Barriers and enablers to safe medication management

“The battle that we have as a credentialed pharmacist is the doctor is too terrified to stop medication, because if they have a heart attack or a stroke then they’re going to get blamed for it,” says one study participant…

Pharmacy researchers recently conducted focus groups with consumers, GPs, nurses and pharmacists from both rural and metropolitan communities across Western Australia and Victoria, exploring roles in caring for people with dementia.

Nine focus groups were held with 55 participants, including 14 consumers (two people with dementia and 12 carers), 22 GPs, nine registered nurses and 10 pharmacists.

Results published in the journal Research in Social and Administrative Pharmacy found consumers and health professionals alike identified daily management of medications as “challenging”.

One carer explained: “My mother was extremely stubborn about her medication and the way she dealt with it. Sometimes she was quite good and other times she was all over the place. She would keep going back for more and more scripts and she would have hundreds of pills in her bag.”

Dose administration aids (DAAs) were cited as one potential solution to assist in the organisation of a person’s medication, ranging from self-packed to pharmacy-packed—for example, Webster packs.

Meanwhile, interprofessional collaboration and communication between GPs, nurses and pharmacists was highlighted as crucial.

“Health professionals spoke about the importance of having positive interdisciplinary relationships and ongoing two-way communication to help optimise patient-centred care,” lead author Dr Amanda Cross, from the Centre for Medicine Use and Safety at Monash University, told AJP.

For example, one nurse stated: “We have consultant pharmacists that we use as well and I think they’re very powerful in being on the nurse’s side. So with a nurse’s assessment as well as the pharmacist, ‘tick tick’. Then presenting to the GP you can often get that relationship built. But it’s those struggles getting there … it’s getting that GP on board [and] you’re half way there.

But where you’re not having good pharmacist interaction and consultation you’re having difficulty. It’s a real battle.

Co-author Dr Amy Page, also from the Centre for Medicine Use and Safety, emphasised that pharmacists play a “crucial” role as part of the multidisciplinary team looking after people with dementia.

“Our research showed that health professionals and consumers value a multidisciplinary team and a consistent message being delivered across all of their providers,” Dr Page told AJP.

“All stakeholder groups acknowledged the important role that pharmacists have in supplying medication to reduce confusion and ensure clarity around what is taken to avoid unintentional administration errors.”

A pharmacist participant shared an example of how they cared for people who have dementia.

“I’m involved in de-prescribing, not just antipsychotics and the benzodiazepines, but other medicines – particularly the statins – and having a conversation with the GPs and the registered nurse about what to do and at different stages, particularly with patients who are in the home who want to stay home.”

However another added: “The battle that we have as a credentialed pharmacist [is] that the doctor is too terrified to stop [medication] because if they have a heart attack or a stroke then they’re going to get blamed for it.”

One GP admitted: “Doctors are always now practising defensive medicine, too scared that someone’s going to sue them for not doing something that they felt should have been done.”

“It’s so easy to just chug along as per the current protocol and not think about reducing medications,” said another GP.

More evidence-based deprescribing guidelines were identified as potential facilitators for deprescribing.

“I think it would be useful if there was a guideline, particularly if we are talking about stopping medication. If there was a back-up, that there was evidence that [deprescribing] was the appropriate thing to do, then I think there would be a greater confidence in withdrawing medication at certain points in someone’s life,” said a GP participant.

Just last week pharmacist researcher Dr Emily Reeve, from the University of South Australia, was awarded a $1.5 million Federal Government grant to create processes for developing deprescribing recommendations and implementing them into aged care facilities.

Meanwhile a further barrier to patient care cited by participants was restrictions on frequency of government-funded pharmacist medication management reviews.

“Medication reviews are most important for this group of people, regardless of who initiates them,” explained Dr Page.

“The progressive nature of the condition means that medication needs can change over time as priorities and symptoms change,” she said.

“The consumers spoke about a desire for health professionals to initiate more frequent reviews, and to initiate difficult conversations around priorities and changing needs.”

Dr Cross added: “This research was conducted prior to recent changes that allow for pharmacists to conduct two paid follow-ups after the initial medication management review, and it will be interesting to see the impact and benefit of these changes in the months and years to come.”

See the full study in RSAP here (login required)

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