Table 1 Implementation dimensions and determinants of a discharge medicines review service a [51, 52, 60]
Timeline | Aim | Implementation dimensions b | Interventions (and identification of their determinants of practice) b | Outcomes |
|---|---|---|---|---|
2006 - 2012 | Identify resolve and prevent medicine-related problems (MRPs) to improve medicine management in older patients. Reduce inappropriate medicine use. | ----Context National failure to reduce medicine related harm in older Australians; national review of safety and quality governance recommended development of national standards for safety and quality in health care; strong desire by hospital board and medical executive committee to improve patient care; absence of remuneration for clinical pharmacy services; known increased likelihood of MRPs occurring at transitions of care. ----Reach All patients over 65 years old taking five medicines or more. ----Implementer engagement Proactive experienced medicines-review trained pharmacist, enthusiastic and co-operative nursing, medical and administrative staff. ----Fidelity Collaboration with the University of Sydney for clinical pharmacy, research methods and service development facilitation. Participatory action research approach. ----Intervention quality A list of Australian specific prescribing appropriateness criteria to be applied to inpatients did not exist. | Private hospitals were invited to apply for a research grant by a major private health insurer, to improve any aspect of patient care. A proposal was submitted to develop and apply a list of Australian prescribing appropriateness criteria to inpatients (payer or funder policy). The hospital board met and determined that application of prescribing appropriateness criteria was practical (feasibility). University of Sydney researchers agreed to oversee the development of criteria and their application (source of the recommendation, assistance for organisational changes). A scoping review to examine applicability of the criteria to detect DRPs and their incidence was designed (quality of evidence supporting the recommendation). The hospital’s medical executive committee met and agreed that the application of such criteria was appropriate and would likely provide information necessary to progress a medicines review intervention. Cooperation was sought from attending doctors (feasibility, implementer engagement, expected outcome, knowledge about own practice). Ethics approval for application of criteria to patients was obtained from the Human Research Ethics Committee of the University of Sydney (quality assurance and patient safety systems). The director of nursing and the pharmacist liaised with all staff to explain the project and seek cooperation and feedback (mandate, authority, accountability; team processes, implementer engagement). The criteria had not been validated (quality of evidence supporting the recommendation). | A research grant of AU$30,000 was awarded by an Australian Private Healthcare Insurer to improve patient care. A list of Australian specific prescribing appropriateness criteria was developed [43] The prescribing appropriateness criteria were applied to a cohort of older inpatients. On average, each patient had seven unmet indicators of appropriateness [44] The prescribing appropriateness criteria were validated [93] |
2012 -2015 | Improve medicine management for older patients: Assess the impact of applying our self-developed, validated criteria-set, during medicine review at discharge, on change in the number of criteria met, health related quality of life and implementation rate of review recommendations at follow-up. Reduce inappropriate medicine use. | ----Context Implementation of national safety and quality health service standards mandating systems and strategies to ensure appropriate use of medicines. Australian health service accreditation scheme introduced. Expectation by hospital board and medical executive committee of a high standard of compliance by pharmacy. Absence of remuneration for clinical pharmacy services. Increased frequency of MRPs at transitions of care. ----Dose delivered/Reach Patients over 65 years old taking 5 medicines or more, English speaking, living within a 15 km radius of the hospital, with no cognitive impairment. ----Implementer engagement Proactive experienced medicines-review trained pharmacist, enthusiastic and co-operative nursing, medical and administrative staff. ----Fidelity Collaboration with the University of Sydney for clinical pharmacy, research methods and service development facilitation. Participatory action research approach. ----Intervention quality Validated list of Australian specific prescribing appropriateness criteria. ----Adaptation Test impact via randomised controlled trial after previous scoping review. | The medical executive committee considered the results of the previous review required corrective action (Mandate, authority, accountability; capacity to plan change, implementer engagement). University of Sydney researchers agreed to oversee a randomised controlled trial (RCT) (source of the recommendation, assistance for organisational changes). The medical executive committee decided that an in-depth study to improve medicine management was needed (Feasibility; Quality of evidence supporting the recommendation). Attending doctors agreed (agreement with the recommendation, implementer engagement). Ethics approval for application of criteria to patients was obtained from the Human Research Ethics Committee of the University of Sydney (quality assurance and patient safety systems). The pharmacist worked part-time and researched part-time (unpaid) to perform the study (payer or funder policy, implementation cost). The director of nursing and the pharmacist liaised with all staff to explain the project and seek cooperation and feedback (mandate, authority, accountability: team processes: capacity to plan change, implementer engagement). Patients/caregivers were recruited (Patient beliefs and knowledge). Regular research progress reports and discussion occurred at the hospitals two-monthly Clinical Care committee meetings (adaptation, capacity to plan change, fidelity; implementer engagement, mandate, authority and accountability; patient needs, reach, team processes). | A randomised controlled trial was conducted [45]. There was no significant difference in the number of criteria applicable and met in intervention patients, compared to control patients. GPs implemented a relatively low rate (42%) of medicine management recommendations. |
2015 - 2020 | Improve medicine management for older patients: Identify resolve and prevent MRPs by changing strategy and making the patient rather than the GP or specialist doctor the driver for implementation of medicine management recommendations. Reduce inappropriate medicine use. | Context Failure to improve patient care. Absence of remuneration for clinical pharmacy services (framing the problem). ----Dose delivered/Reach Patients over 65 years old taking 5 medicines or more. Exclusion criteria present. ----Implementer engagement Proactive experienced medicine-review pharmacist, enthusiastic and co-operative nursing, medical and administrative staff. ----Fidelity Collaboration with the University of Sydney for clinical pharmacy, research methods and service development facilitation. Participatory action research approach. ----Intervention quality Validated list of Australian specific prescribing appropriateness criteria. Discharge medication form required redesigning. ----Adaptation Alter focus from the GP to the patient for implementation of recommendations. - Participant engagement/Reach Engage patients in their own medicines management. All patients over 65 years old, with no exclusion criteria. | The hospital board and medical executive supported efforts to exceed compliance with Australian accreditation standards in patient care after the results of the above RCT were considered (mandate, authority, accountability: capacity to plan change, feasibility). This included the establishment of paid clinical pharmacy services (payer or funder policy, implementation cost), resulting in positive patient feedback (Patient needs, patients’ beliefs, and knowledge). Pharmacist applied to the hospital for a research grant to enable payment to follow up patients after discharge; $15,000 was granted (payer or funder policy, implementation cost). University of Sydney researchers agreed to oversee a follow-up audit of a different strategy to improve the results of the unsuccessful RCT above (source of the recommendation, assistance for organisational changes). Ethics approval was obtained from the Human Research Ethics Committee of the University of Sydney (quality assurance and patient safety systems). The director of nursing and the pharmacist liaised with all staff to explain the project and seek cooperation (mandate, authority, accountability: team processes: capacity to plan change, implementer engagement). Verbal and written information about individual medicine needs and risks were made to patients in ways that were meaningful to them. The reverse side of the discharge medication list was redesigned and dedicated to medication review findings (patient needs, patient motivation, patients’ beliefs, and knowledge). Regular research progress reports and discussion occurred at the hospitals two-monthly Clinical Care committee meetings (adaptation, capacity to plan change, fidelity; implementer engagement, mandate; authority and accountability; patient needs, reach, team processes). | Current study: A cohort of older patients and/or caregivers received discharge counselling supported by written information and were asked to discuss any recommendations they thought were important with their GPs. See Results Table 2. |