International Journal of Clinical Pharmacy

, Volume 35, Issue 5, pp 763–771 | Cite as

Effects of a three party healthcare network on the incidence levels of drug related problems

  • Thomas FißEmail author
  • Claudia Meinke-Franze
  • Neeltje van den Berg
  • Wolfgang Hoffmann
Research Article


Background Drug related problems (DRPs) are impairing patients’ health and cause high costs. Neither delegation of home medication review nor regular pharmaceutical care are common in Germany. Objective We aimed to reduce several DRP by the implementation of a three party healthcare team [AGnES-practice assistant, pharmacist, general practitioner (GP)] and adherence supporting strategies (using a medication reminder chart, medication compliance aid). Setting The setting was ambulatory primary healthcare in German rural areas with a cohort of home-dwelling, elderly, mostly multimorbid patients with limited mobility (study period: 06/2006–12/2008). Methods We conducted a prospective non-randomized implementation cohort study with home medication review (home medication review module; mean participation time: 9 months). Data collection was delegated to additionally qualified AGnES-practice assistants (AGnES: GP-supporting, community-based, e-health-assisted systemic intervention). The intervention comprised pharmaceutical care by the local pharmacy in addition to medical interventions by the GP. 408 patients (mean age: women: 80.7 years; men: 75.3 years) received both pharmaceutical care and at least one follow-up visit. Main outcome measurement Outcome measurements comprised self-reported DRPs, objectively evaluated DRP, and prevalence of adherence supporting strategies. Results The three party healthcare team approach reduced self-reported forgetfulness (7.7–3.2 %; p = 0.001), the proportion of patients with intermittent drug intake (5.3–1.3 %; p < 0.001), and the proportion of patients with potentially clinical relevant drug–drug interaction (61.6–51.2 %; p < 0.001). Self-reported adverse drug reactions decreased non-significantly (5.4–4.6 %; p = 0.564; all tests χ2-McNemar). The median number of active substances taken was reduced from 8 to 7 (p < 0.001; Wilcoxon signed rank test). The proportions of patients using medication charts and compliance aids increased significantly (75.2–90.3 %; p < 0.001) and (70.0–80.1 %; p > 0.001), respectively. Conclusion This is the first study evaluating effects of a three party team on DRPs in a primary healthcare setting in Germany. This approach led to reduction in the occurrence of several DRPs and improved adherence supporting strategies. However, the study is a pre-post analysis, and had no control group.


Adverse drug events Drug–drug interaction Drug related problem Germany Health services research Home medication review Interprofessional cooperation Potentially inappropriate medication 



We are grateful to all local pharmacies, GPs, and AGnES-practice assistants for their active role in the implementation of pharmaceutical care. We are grateful to the GSF scientific centre Neuherberg for licensing the IDOM database and the AOK Research Institute (WidO) for licensing the German Drug Index.


The AGnES-projects were funded by the following institutions: Ministry of Health of the Federal State of Mecklenburg-Western Pomerania, the Ministry for Labour, Social Affairs, Health and Family of the Federal State of Brandenburg, the Saxony State Ministry of Social Affairs, the Ministry of Health and Social Affairs of the Federal State Saxony-Anhalt, the Regional Association of Statutory Health Insurance Physicians, various regional Statutory Health Insurances and the European Social Fund. The first author (TF) was supported by a research fellowship granted by the German National Academic Foundation (Studienstiftung des Deutschen Volkes).

Conflicts of interest



  1. 1.
    Schaefer M. Discussing basic principles for a coding system of drug-related problems: the case of PI-Doc. Pharm World Sci. 2002;24(4):120–7.PubMedCrossRefGoogle Scholar
  2. 2.
    Schneeweiss S, Hasford J, Gottler M, Hoffmann A, Riethling AK, Avorn J. Admissions caused by adverse drug events to internal medicine and emergency departments in hospitals: a longitudinal population-based study. Eur J Clin Pharmacol. 2002;58(4):285–91.PubMedCrossRefGoogle Scholar
  3. 3.
    Eickhoff C, Schulz M. Pharmaceutical care in community pharmacies: practice and research in Germany. Ann Pharmacother. 2006;40(4):729–35.PubMedCrossRefGoogle Scholar
  4. 4.
    Hessel A, Gunzelmann T, Geyer M, Brahler E. Utilization of medical services and medication intake of patients over 60 in Germany–health related, social structure related, socio-demographic and subjective factors. Z Gerontol Geriatr. 2000;33(4):289–99.PubMedCrossRefGoogle Scholar
  5. 5.
    Beitz R, Dören M, Knopf H, Melchert HU. Self-medication with over-the-counter (OTC) preparations in Germany. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2004;47(11):1043–50.PubMedCrossRefGoogle Scholar
  6. 6.
    Nolan L, O’Malley K. The need for a more rational approach to drug prescribing for elderly people in nursing homes. Age Ageing. 1989;18(1):52–6.PubMedCrossRefGoogle Scholar
  7. 7.
    George J, Elliott RA, Stewart DC. A systematic review of interventions to improve medication taking in elderly patients prescribed multiple medications. Drugs Aging. 2008;25(4):307–24.PubMedCrossRefGoogle Scholar
  8. 8.
    Schulz M, Verheyen F, Muhlig S, Muller JM, Muhlbauer K, Knop-Schneickert E, et al. Pharmaceutical care services for asthma patients: a controlled intervention study. J Clin Pharmacol. 2001;41(6):668–76.PubMedCrossRefGoogle Scholar
  9. 9.
    Royal S, Smeaton L, Avery AJ, Hurwitz B, Sheihk A. Interventions in primary care to reduce medication related adverse events and hospital admissions: systematic review and meta-analysis. Qual Saf Health Care. 2006;15(1):23–31.PubMedCrossRefGoogle Scholar
  10. 10.
    Dreier A, Rogalski H, Oppermann RF, Terschueren C, van den Berg N, Hoffmann W. A curriculum for nurses in Germany undertaking medically-delegated tasks in primary care. J Adv Nurs. 2010;66(3):635–44.PubMedCrossRefGoogle Scholar
  11. 11.
    Fiss T, Dreier A, Meinke C, van den Berg N, Ritter CA, Hoffmann W. Frequency of inappropriate drugs in primary care—analysis of a sample of immobile patients who received periodic home visits. Age Ageing. 2011;40(1):66–73.PubMedCrossRefGoogle Scholar
  12. 12.
    Hoffmann W, van den Berg N, Thyrian JR, Fiss T. Frequency and determinants of potential drug–drug interactions in an elderly population receiving regular home visits by GPs—results of the home medication review in the AGnES-studies. Pharmacoepidemiol Drug Saf. 2011;20(12):1311–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Fiss T, Ritter CA, Alte D, van den Berg N, Hoffmann W. Detection of drug related problems in an interdisciplinary health care model for rural areas in Germany. Pharm World Sci. 2010;32(5):566–76.PubMedCrossRefGoogle Scholar
  14. 14.
    Terschüren C, Fendrich K, van den Berg N, Hoffmann W. Implementing telemonitoring in the daily routine of a GP practice in a rural setting in northern Germany. J Telemed Telecare. 2007;13(4):197–201.PubMedCrossRefGoogle Scholar
  15. 15.
    Von EE, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344–9.CrossRefGoogle Scholar
  16. 16.
    van den Berg N, Kleinke S, Heymann R, Oppermann RF, Jakobi B, Hoffmann W. Transfer of the AGnES concept to the regular german health-care system: legal evaluation, reimbursement, qualification. Gesundheitswesen. 2010;72:285–92.PubMedCrossRefGoogle Scholar
  17. 17.
    Bullinger M, Kirchberger I. SF-36 Fragenbogen zum Gesundheitszustand. Göttingen: Hogrefe-Verlag GmBH & Co. KG; 1998.Google Scholar
  18. 18.
    Kalbe E, Kessler J, Calabrese P, Smith R, Passmore AP, Brand M, et al. DemTect: a new, sensitive cognitive screening test to support the diagnosis of mild cognitive impairment and early dementia. Int J Geriatr Psychiatry. 2004;19(2):136–43.PubMedCrossRefGoogle Scholar
  19. 19.
    Shulman KI. Clock-drawing: is it the ideal cognitive screening test? Int J Geriatr Psychiatry. 2000;15(6):548–61.PubMedCrossRefGoogle Scholar
  20. 20.
    Schaefer M, Schulz M, Emmermann A, Mühlbauer K, Verheyen F. Manuale zur Pharmazeutischen Betreuung-Band 1: Grundlagen der Pharmazeutischen Betreuung (manual of pharmaceutical care: part I: basics). ABDA-Bundesvereinigung Deutscher Apotheker GOVI-Verlag Eschborn; 2000.Google Scholar
  21. 21.
    Zagermann-Muncke P. ABDA-Datenbank als Wegweiser im Wechselwirkungsdschungel (The ABDA-database). Pharm Ztg. 2009;154(1):26–8.Google Scholar
  22. 22.
    Karopka T, Bruder I, van den Berg N, Hoffmann W, Heuer A. ICT architecture for a community medicine nurse project. Healthinf. In: Proceedings of the first international conference on health informatics, vol. 2; 2008. pp. 26–30.Google Scholar
  23. 23.
    Mühlberger N, Behrend C, Stark R, Holle R. Datenbankgestützte Online-Erfassung von Arzneimitteln im Rahmen gesundheitswissenschaftlicher Studien, Erfahrungen mit der IDOM-Software. Informatik, Biometrie und Epidemiologie in Medizin und Biologie. 2003;2003(4):601–11.Google Scholar
  24. 24.
    Vonbach P, Dubied A, Krahenbuhl S, Beer JH. Evaluation of frequently used drug interaction screening programs. Pharm World Sci. 2008;30(4):367–74.PubMedCrossRefGoogle Scholar
  25. 25.
    Zagermann-Muncke P. ABDA-Datenbank: Welche Interaktionen werden aufgenommen? Pharm Ztg 2003 Jan. Available from: URL:
  26. 26.
    Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163(22):2716–24.PubMedCrossRefGoogle Scholar
  27. 27.
    Roughead EE, Barratt JD, Ramsay E, Pratt N, Ryan P, Peck R, et al. Collaborative home medicines review delays time to next hospitalization for warfarin associated bleeding in Australian war veterans. J Clin Pharm Ther. 2011;36(1):27–32.PubMedCrossRefGoogle Scholar
  28. 28.
    Salter C, Holland R, Harvey I, Henwood K. “I haven’t even phoned my doctor yet.” The advice giving role of the pharmacist during consultations for medication review with patients aged 80 or more: qualitative discourse analysis. BMJ. 2007;334(7603):1101.PubMedCrossRefGoogle Scholar
  29. 29.
    Schaefer M. Systematic drug documentation. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2005;48(7):736–41.PubMedCrossRefGoogle Scholar
  30. 30.
    van den Berg N, Meinke C, Heymann R, Fiss T, Suckert E, Pöller C, et al. AGnES: Hausarztunterstützung durch qualifizierte Praxismitarbeiter (AGnES: supporting general practitioners with qualified medical practice personnel: model project evaluation regarding quality and acceptance). Dtsch Arztebl Int. 2009;106(1–2):3–9.PubMedGoogle Scholar
  31. 31.
    Simpson SH, Eurich DT, Majumdar SR, Padwal RS, Tsuyuki RT, Varney J, et al. A meta-analysis of the association between adherence to drug therapy and mortality. BMJ. 2006;333(7557):15.PubMedCrossRefGoogle Scholar
  32. 32.
    Sabate E. Adherence to long-term therapies. World Health Organization; 2003.Google Scholar
  33. 33.
    Hämmerlein A, Griese N, Schulz M. Survey of drug-related problems identified by community pharmacies. Ann Pharmacother. 2007;41(11):1825–32.PubMedCrossRefGoogle Scholar
  34. 34.
    Holt S, Schmiedl S, Thürmann PA. Potenziell inadäquate Medikation für ältere Menschen. Deutsches Aerzteblatt. 2010;107(31–32):543–51.Google Scholar
  35. 35.
    Holland R, Lenaghan E, Harvey I, Smith R, Shepstone L, Lipp A, et al. Does home based medication review keep older people out of hospital? The HOMER randomised controlled trial. BMJ. 2005;330(7486):293.PubMedCrossRefGoogle Scholar
  36. 36.
    Fiss T, Schaefer M, van den Berg N, Hoffmann W. Time required and associated costs for implementation of home medication review with associated pharmaceutical and medical evaluation in the ambulatory health care sector. Gesundheitswesen. 2012;74(5):322–7.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2013

Authors and Affiliations

  • Thomas Fiß
    • 1
    Email author
  • Claudia Meinke-Franze
    • 2
  • Neeltje van den Berg
    • 2
  • Wolfgang Hoffmann
    • 1
    • 2
  1. 1.German Center for Neurodegenerative Diseases (DZNE)GreifswaldGermany
  2. 2.Department of Epidemiology of Health Care and Community Health, Institute for Community MedicineErnst Moritz Arndt University of GreifswaldGreifswaldGermany

Personalised recommendations