Community pharmacies and patients
Sixty-four community pharmacies participated, most of them were suburban pharmacies (59.4%), followed by rural (20.3%), transit (17.2%) and coastal (3.1%) pharmacies. A total of 495 patients were enrolled. Table 1 shows the sociodemographic characteristics of the participating patients. A slight predominance of women (56%) was noted, with a mean age of 66.09 ± 14.71 years and a mean consumption of 5.68 ± 2.97 medicines. More than half of the patients were married (62.6%), most were retired (53.9%), and most were highly educated (81.4%). Additionally, 62.2% of the patients were aged 65 years or older, and 61.2% were polypharmacy patients, but only 45.3% of patients met both conditions.
Table 1 Patient sociodemographic characteristics
Variable
|
Categories
|
Value
|
Gender
|
Female
|
279 (56.4)
|
|
Male
|
216 (43.6)
|
Age in years
|
Mean + SD
|
66.1 ± 14.7
|
|
<65
|
187 (37.8)
|
|
≥65
|
308 (62.2)
|
Marital statusa
|
Single
|
50 (10.1)
|
|
Married
|
310 (62.6)
|
|
Separated/divorced
|
37 (7.5)
|
|
Widow
|
94 (19)
|
Education levela
|
None
|
92 (18.6)
|
|
Elementary
|
183 (37)
|
|
Secondary
|
104 (21)
|
|
University
|
102 (20.6)
|
|
Other
|
3 (0.6)
|
Occupationa
|
Employed
|
91 (18.4)
|
|
Unemployed
|
31 (6.3)
|
|
Retired
|
267 (53.9)
|
|
Homemaker
|
67 (13.5)
|
|
Other
|
14 (2.8)
|
Cohabitationb
|
Alone
|
81 (16.4)
|
|
Partnered
|
273 (55.2)
|
|
Children
|
99 (20)
|
|
Caregiver – part-time
|
13 (2.6)
|
|
Caregiver – full-time
|
7 (1.4)
|
|
Other
|
30 (6.1)
|
Number of medicines prescribed
|
Mean + SD
|
5.68 ± 2.97
|
|
≤4
|
192 (38.8)
|
|
5-9
|
250 (50.5)
|
|
10-14
|
46 (9.3)
|
|
≥15
|
7 (1.4)
|
Help with medicationa
|
None
|
397 (80.2)
|
|
Children
|
25 (5.1)
|
|
Caregiver
|
13 (2.6)
|
|
Others
|
20 (4.0)
|
Country of origina
|
Spain
|
481 (97.2)
|
|
Other
|
12 (2.4)
|
Notes: Data are expressed as n (%) or mean ± SD; aThere are missing values for these variables; bAnswers were not mutually exclusive. SD: Standard deviation.
In total, 2,811 medicines were reviewed, over 90% were from the following six groups of the first ATC classification system (anatomical level): A. Alimentary tract and metabolism: 495 medicines (17.6%); B. Blood and blood-forming organs: 230 medicines (8.2%); C. Cardiovascular system: 900 medicines (32%); M. Musculo-skeletal system: 157 medicines (5.6%); N. Nervous system: 566 medicines (20.1%); R. Respiratory system: 210 medicines (7.5%).
Medicine use evaluation
Before starting the MUR service, the pharmacist asked patients the following: “How are you managing with your medicines? Is there anything you are worried about?”. For 2,541 medicines (90.4%), the patients reported that they were doing well.
Table 2 shows the medicine use evaluation. Notably, an inappropriate pattern was observed for 11.6% of the medicines evaluated, suboptimal administration was noted in 7.2% of cases, and a lack of knowledge of the indication for the medicine was found in 10.3% of cases. The pharmacists detected suspected adverse drug reactions for 8.8%, interactions for 4.4%, duplicity for 1.6% and contraindications for 0.7%.
Table 2 Medicine use evaluation
|
Yes
|
No
|
DK
|
Inappropriate dose
|
146 (5.2)
|
2,617 (93.1)
|
48 (1.7)
|
Inappropriate pattern
|
325 (11.6)
|
2,445 (87.0)
|
41 (1.4)
|
Inappropriate duration
|
125 (4.5)
|
2,643 (94.0)
|
43 (1.5)
|
Suboptimal administration
|
203 (7.2)
|
2,563 (91.2)
|
45 (1.6)
|
Inappropriate conservation
|
115 (4.1)
|
2,640 (93.9)
|
56 (2.0)
|
Inappropriate disposal
|
273 (9.7)
|
2,415 (85.9)
|
123 (4.4)
|
Difficulty with use
|
110 (3.9)
|
2,651 (94.3)
|
50 (1.8)
|
Concerns about use
|
193 (6.9)
|
2,548 (90.6)
|
70 (2.5)
|
Patient does not know the drug indication
|
289 (10.3)
|
2,446 (87.0)
|
76 (2.7)
|
Suboptimal treatment of illness
|
170 (6.1)
|
2,550 (90.7)
|
91 (3.2)
|
Inappropriate dose or duration (deliberate)
|
179 (6.4)
|
2,447 (87.0)
|
185 (6.6)
|
Suspected adverse drug reactions
|
246 (8.8)
|
2,516 (89.5)
|
49 (1.7)
|
Patient requests further information
|
176 (6.3)
|
2,584 (91.9)
|
51 (1.8)
|
Duplicity
|
44 (1.6)
|
2688 (95.6)
|
79 (2.8)
|
Contraindication
|
20 (0.7)
|
2714 (96.6)
|
77 (2.7)
|
Interactions
|
124 (4.4)
|
2601 (92.5)
|
86 (3.1)
|
Other
|
116 (4.1)
|
2492 (88.7)
|
203 (7.2)
|
Data are expressed as n (%). DK: Don´t know.
The pharmacists provided tailored information for 2,073 medicines (73.8%) and 1,316 suggestions for improving use (46.8%). At the patient level, the pharmacists provided personalized information to 473 patients (95.6%), suggestions for improvement to 423 patients (85.5%) and basic health education information (vaccinations, healthy lifestyle—diet and exercise, etc.) to 417 patients (84.2%).
As results of MUR, a total 550 referrals were made in 334 patients: 164 (29.8%) to Primary Care, 19 (3.5%) to Specialized Care and the remaining referrals were to professional pharmaceutical services: 154 (28%) to the blood pressure monitoring service; 56 (10.2%) to the nutritional status assessment service; 55 (10%) to the personalized medication dosage systems service; 42 (7.6%) to the pharmaceutical care service with follow-up; 31 (5.6%) to the smoking cessation service; and 29 (5.3%) to other pharmaceutical services. Fourteen drug notifications were also made using the “yellow card” system.
Non-adherence with the medication, polypharmacy and help with medication were the main factors associated with referrals (Table 3).
Table 3 Predictors of referrals
Factor
|
OR (95% CI)
|
P value
|
Between-group difference
|
P value
|
All referrals
|
|
|
|
|
Non-adherence
|
1.74 (1.17 to 2.58)
|
0.006
|
0.39 (0.19 to 0.58)
|
<0.001
|
Polypharmacy
|
1.50 (1.02 to 2.20)
|
0.038
|
0.25 (0.06 to 0.44)
|
0.01
|
Help with medication
|
3.03 (1.45 to 6.34)
|
0.003
|
0.62 (0.35 to 0.89)
|
<0.001
|
Primary Care and Specialized Care
|
|
|
|
|
Non-adherence
|
1.80 (1.18 to 2.75)
|
0.006
|
0.13 (0.04 to 0.22)
|
0.01
|
Polypharmacy
|
1.59 (1.07 to 2.34)
|
0.021
|
0.10 (0.02 to 0.19)
|
0.02
|
Help with medication
|
2.05 (1.20 to 3.53)
|
0.009
|
0.17 (0.05 to 0.30)
|
0.008
|
Pharmaceutical services
|
|
|
|
|
Non-adherence
|
1.36 (0.93 to 1.99)
|
0.11
|
0.08 (-0.02 to 0.17)
|
0.11
|
Polypharmacy
|
1.47 (1.02 to 2.11)
|
0.038
|
0.10 (0.01 to 0.19)
|
0.038
|
Help with medication
|
3.12 (1.69 to 5.76)
|
<0.001
|
0.26 (0.13 to 0.39)
|
<0.001
|
Adherence
Adherence for the 2,811 medicines was analysed. Some patients claimed they had never forgotten to take their medication (80.6%), took it at the right times (88.4%) and did not stop taking it even if they felt well (87.2%) or felt ill (93.4%). Therefore, the patients were adherent for 68.3% of their medicines. Differences were found in the degree of adherence based on the group in the first level of the ATC classification system: A (72.4%); B: (80.3%); C: (74.3%); M: (60%); N: (65%); R: (64.3%); for the drugs in other groups: 73.8% (p<0.001).
However, the results varied at the patient level and only 156 patients (31.5%) were adherent. Polypharmacy was associated with non-adherence. Percentages of non-adherence were 71.0% and 64.6% among polypharmacy and non-polypharmacy patients respectively (OR=1.34; 95% CI: 0.91 to 1.97). Likewise, among polypharmacy patients older than 65 years, the degree of non-adherence was higher (73.7%) than that of the remaining patients (64.2%) (OR=1.56; 95% CI: 1.06 to 2.30).
MUR-related time and costs
The mean time employed by the pharmacists in the MUR was 52.80±31.52 minutes: 27.34±15.15 in the interview and 25.39±21.32 for registering the MUR forms and reports.
There was a significant correlation between the MUR time and number of medicines (r=0.54; p<0.001). MUR time increased significantly for polypharmacy patients (62.27±33.92 vs 37.98±19.77; p<0.001), patients aged 65 years or older (55.57±32.95 vs 48.17±28.48; p=0.013) and non-adherent patients (54.94±33.29 vs 48.17±26.84; p=0.029).
The mean costs associated with the time the pharmacists spent on each patient interview and MUR form registration were €8.98±€4.99 and €8.29±€7.01, respectively, resulting in a mean MUR service cost of €17.27±10.31.
Health-related quality of life
At least half of the patients reported having no health problems on most of the dimensions: 58.4% for mobility, 77.0% for personal care, 68.7% for usual activities, 38.6% for pain/discomfort and 56.2% for anxiety/depression.
The mean VAS score was 66.06±17.81. Quality of life reduced significantly for polypharmacy (63.39±17.72 vs 70.25±17.17; p<0.001), age older than 65 years (64.59±17.53 vs 68.57±18.06; p=0.02) and help with medication (57.12±16.86 vs 66.97±17.66; p<0.001). No differences were detected according non- adherence with the medication (65.62±17.48 vs 67.01±18.53; p=0.45).
Satisfaction and willingness to pay
98.5% of patients expressed a high level of satisfaction with the MUR service (68.9% and 29.5% of patients were very satisfied and satisfied respectively). Among the main benefits of the MUR service that patients highlighted were better understanding of the medicines used (97.2%), effective resolution of health problem(s) (93.6%), learning the need to comply with the prescribed treatment (91.0%), learning the undesirable effects of the drugs used (87.7%), and reducing the undesirable effects of the drugs used (83.6%).
Prior to estimating their willingness to pay for the MUR service, the patients were asked whether they would use this service again and if they would recommend the service to a friend or family member. Very similar percentages were obtained for both questions: 90.7% and 91.1% respectively. Additionally, 90.7% of patients indicated that they would likely use the service again, 8.4% of patients were undecided, and only 0.9% stated that they were unlikely to use the service again. Moreover, 90.5% of patients would recommend the service without hesitation, 7.8% would recommend it with reservations, and only 1.1% would not recommend it.
Four hundred nineteen patients expressed interest in receiving the MUR service. The willingness to pay was: 17 patients (4.1%) more than 30€; 35 patients (8.4%) between 21€-30€; 91 patients (21.7%) between 11€-20€; 113 patients (27.0%) between 6€-10€, 96 patients (22.9%) until 5€, 61 patients (14.6%) were not willing to pay anything for it and 6 patients (1.4%) don´t know.