Background
Methods
Study design and setting
Research team
Selection of participants
The interview guide
The interviews
Qualitative analysis
Presentation of results
Results
Sample size and response rate
Characteristic of the participants
Characteristics | N | % |
---|---|---|
Gender | ||
Female | 22 | 92 |
Male | 2 | 8 |
Age [years] | ||
below 40 | 8 | 34 |
41–50 | 7 | 29 |
51–60 | 7 | 29 |
over 60 | 2 | 8 |
Education | ||
Specialist of family medicine | 23 | 96 |
Resident of family medicine | 1 | 4 |
Working experience as GP [years] | ||
less than 5 | 1 | 4 |
5–10 | 5 | 21 |
10–20 | 5 | 21 |
20–30 | 6 | 25 |
more than 30 | 7 | 29 |
Position | ||
Primary GP (practice licence holder) | 20 | 83 |
Substitution GP | 3 | 13 |
Elderly resident home | 1 | 4 |
Experience with CMR (N of referred patients) | ||
Less than 10 | 10 | 42 |
10–30 | 11 | 46 |
More than 30 | 3 | 12 |
Results of the qualitative content analysis
Structure
Categories under structure domain | Statement | GP |
---|---|---|
Competencies of clinical pharmacist | We are GPs and we practice family medicine. CP has its own role as he has much more knowledge and information about medicines pharmacokinetics, pharmacogenomics, interactions, adverse reactions, … We have some knowledge, but it is not that deep. It is a role that is irreplaceable in my opinion. We will always have the need for. | GP 1 |
… we see different things and maybe don’t think the problems could be related to medicine. The pharmacist looks at the patients from a different perspective … | GP 2 | |
The main advantage is that patients tell them a lot of things, they do not tell me. | GP 3 | |
CP has more time for a more in-depth review. | GP 4 | |
Access to clinical pharmacist | If I have any questions, I know CP is available also via email or via telephone for urgent matters … | GP 5 |
It practical – in the same house, we know when she’s here. | GP 6 | |
Collaboration between health-care professionals | We do not judge each other work, we work from two different perspectives, what is synergistic and positive for the patients. | GP 1 |
It is an add on, to community pharmacists and to us. We all work together in satisfaction of the patients. | GP 7 | |
Implementation of clinical decision support systems | There is something …. computer is throwing out something, but in my case it does not even work, I can read it and even if I could there is usually no time for that. | GP 8 |
Process
Categories under process domain | Statement | GP |
---|---|---|
Reasons for referral of patients to clinical pharmacist by general practitioner | The patient came to the nurse for prescription renewal and muttered about taking to many medicines. The nurse proposed the CMR. | GP 3 |
The patient takes a lot of medicines, has kidney insufficiency and is sensitive to medicines changes. So, I wished that we lower the risk in prescribing as much as possible. | GP 9 | |
… patients with many Rx medications and adverse reactions. They present the biggest challenge. | GP 10 | |
… special patients’ groups like kidney insufficiency, liver insufficiency, pregnant women …. We don’t know much about new biological target medicines or patients on chemotherapy... Groups of patients with unusual therapy for a GP office … | GP 9 | |
I think the patient was referred to the CMR via anticoagulation office … It was not done by me … | GP 11 | |
Communication of general practitioner with the patients after clinical medication review | Yes, we were in contact via telephone and email. The patient was not here in person though, which is of course different. | GP 12 |
In this case we will need some more time to explain everything to the patient as she is very attached to her medicines. We didnot explain it by phone, we invited her to come in. | GP 13 | |
We have not yet scheduled the next visit and the things are also not of the serious nature …. So, in few months we will talk about it. | GP 14 | |
Sometime in May [CMR was performed mid-March], when medicines run out. We can’t even make appointments earlier … | GP 10 | |
Patient care based on clinical pharmacist recommendations | The patient has the control visit already scheduled, so we will start with the implementation then. | GP 15 |
We will check cholesterol … He won’t be taking statins for 6 weeks not, so we will see what the starting point will be. And then how much it will be decreased … | GP 16 | |
… if the values will raise three times above the upper reference limit …. We will send the patient to the diabetes clinic prematurely to change the medication … | GP 3 | |
Follow up of patients by a clinical pharmacist | It depends how successful will I be with the implementation. If it will be ok, I don‘t see the need. If it doesn‘t work out, then probably. | GP 10 |
Clinical medication review service performance challenges | It looks like we [GPs] are not interested, however when you have 70 patients a day … | GP 17 |
It’s all about time, to critically assess every patient in front of you and decide if you need to refer him. And then I guess there would be more referrals. | GP 18 | |
We will see … The patient has multiple medicines for this condition, I believe we could discontinue that one …. However, we need time to do that, and we don’t have it … | GP 10 | |
You know, there is a lot of work with this. If you want to refer someone, its additional workload … | GP 19 | |
I believe that when we get used to each other it will be better … we got used to it already [during the pilot project] and then there was the gap and it got out of routine …. | GP 13 | |
Sending medical documentation around is risky, I might need it in between, … | GP 20 | |
The CP was able to talk with this patient … But with many others it is not possible – dementia, decreased cognitive function … they are not able to communicate. | GP 21 | |
Potential improvements of clinical medication review service | When I get the reports, I see how useful they are. And then more time you refer, more time you remember. Because you are satisfied with the feedback information and then you recall referring more times … | GP 17 |
We had the idea for the CP to come during office hours to select patients … but currently the CP is not allowed to do that. | GP 15 | |
We need to be more aware that we have a CP in the house and be reminded more times. | GP 9 | |
… when they will see how good this is … every novelty is at first “phaa” … why would anybody stick around my patient records … but then …. | GP 6 | |
It would be nice if the CP could notify us about changes of medicines at the market … It is done once a month, at the meetings, but sometimes it would be useful to notify us right away by email so that we don’t send patients up and down. | GP 13 | |
To cite and reference more of clinical studies … like she did in this case … | GP 14 | |
It would be nice to personally talk with the CP sometimes … | GP 22 |
Outcomes
Categories under outcomes domain | Statement | GP |
---|---|---|
Evaluation of clinical pharmacists’ recommendations by general practitioners | This about lercanidipine was useful, that if we would titrate the dosing slower, the patient might have not had problems. Its good warning for the next time. | GP 6 |
The advice was to try ezetimibe and I really haven’t tried it yet. So yes, I will try that. | GP 16 | |
It’s interesting … the CP suggested to decrease the number of medicines with introduction of three active substances in one pill … I found the advice very suitable. | GP 3 | |
The patient has diabetic polyneuropathy, which was untreated until now as the patient was not showing or talking about any problems. The CP recommended duloxetine … We will check the symptoms and start duloxetine if needed. | GP 12 | |
I prescribed trazodone; the patient didn’t take it out of fear for adverse reactions. The CP proposed mirtazapine or quetiapine instead … The problem is how to convince the patient … I am willing to prescribe any of the options. | GP 4 | |
The patient will take this report to a pulmonologist. It ‘s theophylline in high doses and roflumilast, which I don‘t really know. The medicines were prescribed by pulmonologist, so we will see what he has to say. | GP 10 | |
For this recommendation we decided the patient will consult with the cardiologist. | GP 8 | |
We didn‘t accept this recommendation as her asthma is under control, she practically never uses salbutamol. Therefore, I don‘t feel its necessary. And I prefer to do only one to two changes in therapy at once. | GP 4 | |
I don’t think it’s reasonable to turn whole therapy around to have one medicine less at this high number of medicines. ... we [GP together with the patient] have decided not to switch … The patient is very sensitive about his medicines … he was not very keen on the proposed switch. | GP 19 | |
Sometimes you accept the recommendation, and it confuses the patient. I had cases when it didn‘t work out. He was fine on previous medication when we changed it was not ok. | GP 20 | |
I prescribed the medicine already and wanted to know if it is appropriate. I got confirmation. | GP 9 | |
The report responds directly to the question. First, second and third line of treatment together with dosing are suggested. Even more, the CP proposed combination for other medicines to be joined in one pill. | GP 9 | |
Perfect. Short, to the point, important thing underlined … | GP 14 | |
Barriers for the implementation of clinical pharmacists’ recommendations | The patient is reluctant to take warfarin from the start, he is actively looking for changes at the skin. And we talked about it several times … but still insists … | GP 11 |
When it comes to the unfortunate zolpidem … there nothing we can do … This is the therapy from which the patient will not back down … | GP 13 | |
Clinical medication review service benefits | ||
Assurance of evidence-based pharmacotherapy | Having a lot of medicines means comorbidity, large number of hurt organ systems and therefore it is always good with such large number of medicines to have professional, evidence-based assessment, and recommendations if we can discontinue some of the medicines. | GP 21 |
Benefits for the patients | It’s a way to get closer to the patients, give them the medicines that suits them and discontinue those, which cause them problems … . | GP 14 |
It was important to decrease the number of daily doses. The patient was taking medicines four times a day and it was decreased to two. | GP 7 | |
The patient was satisfied and was reassured the medication are not causing any harm and are appropriately chosen. | GP 1 | |
It helps them with adherence as they know how to take the medicines, they discuss and side effects … | GP 17 | |
The CP asks them also about OTCs, food supplements, … We usually don’t ask about it and secondly, we don’t know much about these medicines. The CP counsels them about it – what is reasonable and appropriate to use, what is not, if there are any interaction with regular prescription medicines, … | GP 7 | |
Benefits for the GPs | It means the quality of patient care from pharmacological aspect is higher. It gives us confirmation of our work. | GP 10 |
… for me especially management of patients with multimorbidity. For us, young doctors, these are the biggest challenge to manage … The patients are new to you, with already several prescribed medicines … | GP 16 | |
Even if it’s only medical record review and the CP doesn’t see the patient … I can prescribe the medicines safely. | GP 14 | |
I believe in personal referrals. Sometimes it’s easier just to review records. But when there is conversation with the patient …. more information is gathered. | GP 3 | |
I personally learned a lot and I use the knowledge in everyday practice. | GP 7 | |
It useful because the CP warns us about some things that are maybe not reasonable or recommended, especially in elderly population. | GP 13 | |
Patients are more honest about their medicine taking habits. And about OTCs and food supplements, it‘s new information for us. | GP 15 | |
I heard the last CP’s lecture was a big success. I was unfortunately not there, but colleagues told me it was very good, useful. | GP 8 | |
It happened few times, I detected an issue that the specialist hasn’t and then patients brought them the CMR report, and they implemented recommendations. | GP 10 | |
General practitioners’ satisfaction | I am very, very satisfied. It‘s a precise, concise review. And it’s simple. It just read it and I don‘t have any reasons not to prescribe as its recommended, because it makes it so simple | GP 20 |
Patients’ satisfaction | Patients say great things about it, that she [CP] takes the time for them, she really listens, and they get useful information. | GP 12 |
Acceptance | Implementation | N | % |
---|---|---|---|
ACCEPTED | 55 | 61% | |
Yes | implemented | 22 | 24% |
Yes | to be implemented | 33 | 37% |
PARTIALLY OR CONDITIONALLY ACCEPTED | 23 | 26% | |
Partially | implemented | 3 | 3% |
Partially | to be implemented | 2 | 2% |
Partially | implemented as needed | 7 | 8% |
Conditionally | implementation depending on the specialist’s decision | 7 | 8% |
Conditionally | implementation depending on the patient response | 4 | 4% |
NOT ACCEPTED | 12 | 13% | |
No | n/a | 9 | 10% |
No, although the recommendation is valid | n/a | 3 | 3% |