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Social Psychiatry and Psychiatric Epidemiology

, Volume 45, Issue 11, pp 1071–1079 | Cite as

An expert panel assessment of comprehensive medication reviews for clients of community mental health teams

  • Natasa Gisev
  • J. Simon BellEmail author
  • Claire L. O’Reilly
  • Alan Rosen
  • Timothy F. Chen
Original Paper

Abstract

Background

Few studies have investigated strategies to identify and resolve drug-related problems among clients of community mental health teams (CMHTs).

Objective

The objective of this study was to evaluate the clinical impact and appropriateness of comprehensive medication reviews for clients of CMHTs.

Methods

Trained pharmacists conducted interviews (30–45 min each) with clients of CMHTs to identify actual and potential drug-related problems. The pharmacists prepared medication review reports that detailed their findings and recommendations to optimize drug therapy. An expert panel comprising a psychiatrist, general medical practitioner, mental health pharmacist and medication review pharmacist evaluated reviews for 48 clients of 5 CMHTs. Panelists independently assessed review findings, review recommendations, likelihood of recommendation implementation and the overall expected clinical impact.

Results

Two hundred and nine medication review findings and 208 medication review recommendations were evaluated. Panelists agreed with 76% of findings and considered that 81% of recommendations were appropriate. Collectively, 69% of recommendations were considered likely to be implemented. Thirty-seven (77%) reviews were deemed potentially to have a positive clinical impact. The agreement between panelists was statistically significant (P < 0.01) for the assessment of the findings, recommendations and likelihood of recommendation implementation.

Conclusions

Pharmacists’ findings and recommendations to optimize drug therapy were considered appropriate and likely to result in improved clinical outcomes. Comprehensive medication reviews may be a valuable strategy to identify and resolve drug-related problems among clients of CMHTs.

Keywords

Medication review Medicines management Psychotropic drugs Community mental health services Community pharmacy services 

Introduction

Psychiatric drugs are frequently implicated as a cause of adverse drug events and drug-related problems [3, 31]. In spite of an increased emphasis on medication safety following the Institute of Medicine report “To err is human” [17], relatively little has been published regarding drug-related problems among psychiatric patients [22]. Of those studies that have been conducted, most relate to hospital inpatients and many address the clerical aspects of prescribing rather than clinical decision-making. This is a concern because people with schizophrenia, schizotypal and delusional disorders increasingly receive care in community settings. Fragmentation associated with the transition from hospital to community care has created numerous interfaces; including between primary and secondary providers, community and hospital care, and between different components of the community mental health service [9, 21]. Psychiatric drugs are commonly dispensed by community pharmacists who may be unfamiliar with the mental health care system [4], primary care records often omit drugs prescribed by community mental health teams (CMHTs) [26], clients of CMHTs often have physical comorbidities, and psychiatrists may fail to screen for the metabolic effects of second-generation antipsychotic drugs [2].

Clinical pharmacy services are a well-established and evidence-based strategy to prevent and detect drug-related problems in hospitals [18]. While the value of interdisciplinary teamwork in community psychiatry is widely recognized [33, 34], few CMHTs employ a clinical pharmacist. Working with community pharmacists has been described as a future role for community psychiatrists [33]. Comprehensive medication reviews are one promising strategy to promote medication safety in community settings [7]. When conducted among general older populations medication reviews have proved useful in identifying and resolving drug-related problems [11], reducing the use of sedative-hypnotics in long-term care facilities [29], and been associated with a trend toward decreased mortality [32]. While medication reviews were associated with higher rates of hospital readmission in one study [16], other studies have demonstrated positive clinical outcomes [19, 27, 37, 43]. Few studies have addressed the potential benefits of comprehensive medication reviews in community psychiatry. In two pilot studies conducted in UK, between 35 and 60% of pharmacists’ medication review recommendations for clients of CMHTs were judged clinically significant by expert review panels [10, 13]. The objective of this study was to evaluate the overall clinical impact and appropriateness of comprehensive medication reviews as a strategy to identify and resolve drug-related problems among clients receiving case management by CMHTs.

Methods

Study design and data collection

This descriptive study involved a secondary analysis of 48 comprehensive medication reviews conducted by 5 pharmacists contracted to work with 5 out of the 13 CMHTs in the Northern Sydney Central Coast Area Mental Health Service in Sydney, Australia. The medication reviews were performed as part of an initiative to identify and resolve drug-related problems among clients of CMHTs. Case managers working at the CMHTs recruited clients to the study who they believed would benefit from the service. This recruitment method was utilized to mimic possible future implementation of the service in practice. In order to be recruited to the study clients needed to be aged 18 years or older, receiving case management by the CMHT, and take at least one medication for a mental illness. Clients also had to be able to read and understand English sufficiently to provide informed consent to participate. The study was approved by the Human Research Ethics Committee at The University of Sydney and written informed consent was obtained from each of the participants.

The methods for the initiative have been described elsewhere [12]. Each of the pharmacists were contracted to work with one CMHT for the duration of the initiative. The pharmacists were already familiar with the medication review process and had participated in an educational program designed to improve skills and knowledge in the provision of pharmaceutical services to people with mental illness [6].

Pharmacists conducted interviews with each client (30–45 min each) to assess knowledge and beliefs about drug therapy, and to identify actual and potential drug-related problems. Pharmacists had access to clients’ medical and medication histories held by the CMHT and also community pharmacy dispensing records. A written referenced medication review report was prepared for each client outlining the pharmacist’s findings and recommendations in relation to any drug-related problems identified. The number of reviews completed for each CMHT was 13, 5, 10, 9 and 11. These reports were presented at face-to-face multidisciplinary case conference meetings conducted by the CMHTs. Copies of the written reports were also provided to the client’s general medical practitioner if he or she was unable to attend the case conference.

Data coding and extraction

De-identified copies of the written medication review reports were provided to the research team. The drug-related problems identified by the pharmacists were coded using an adaptation of the framework developed by Gilbert et al. [11]. This framework included five categories designed to capture the range of issues identified in comprehensive medication reviews. These categories were management issues (e.g. need for an additional pathology test), problems related to medication selection (e.g. prescribing of an NSAID in the presence of a contraindication), problems related to the medication regimen (e.g. suboptimal dose), problems related to patient knowledge and skills (e.g. adherence issues) and other problems. The coding of the drug-related problems was performed by one member of the research team. To ensure consistency, a second member of the research team coded a random selection of 20 (10%) of the drug-related problems. Medical diagnoses were classified according to the International Classification of Diseases and Related Health Problems (ICD) Version 10 [47]. Drugs taken by the clients were coded using the Anatomical Therapeutic Chemical (ATC) classification system [46]. For the purpose of this study, psychiatric drugs were defined as those belonging to ATC categories N03 antiepilepsy drugs, N04 antiparkinson, N05 psycholeptics and N06 psychoanaleptics. Propranolol (C07AA05) and atropine eye drops (S01FA01) were also defined as psychiatric drugs when the documented indication for use was to treat an adverse drug reaction of another psychiatric drug. Medication review findings and recommendations for each client were extracted from the written medication review reports and recorded on a purpose-designed pro forma for use by the four expert panelists.

Assessment by expert panel

A four-member expert panel comprising a consultant psychiatrist, general medical practitioner, specialist psychiatric pharmacist and medication review accredited pharmacist was convened to individually evaluate the findings and recommendations. Multidisciplinary panels are commonly utilized in studies evaluating interventions made by pharmacists. The multidisciplinary panels in the pilot studies conducted in UK consisted of two mental health pharmacists and a psychiatrist [10, 13]. Given that approximately half of the drug-related problems identified by the pharmacists were not related to mental health, the panel in our study was formulated to include professionals with both generalist and specialist expertise.

For each client the four panelists were provided with the pro forma, a list of current medications, a medication history, a list of current medical diagnoses, a medical history and demographic details. Using this information the four panelists were asked to independently rate:
  1. 1.

    Agreement with each of the pharmacists’ findings (finding agreement)

     
  2. 2.

    Appropriateness of each of the pharmacists’ recommendations (recommendation appropriateness)

     
  3. 3.

    The probability that each of the pharmacists’ recommendations would be implemented by the treating clinician (implementation probability)

     
  4. 4.

    The overall expected clinical outcome for each client.

     

Five-point Likert-type scales were used to evaluate the first three aspects. The level of agreement with the finding, defined in terms of clinical importance, was measured on a scale with endpoints ranging from strongly disagree to strongly agree. The appropriateness of the recommendation was rated on a scale with endpoints of most inappropriate to most appropriate. A recommendation was considered appropriate if it was relevant to the client and would not adversely affect the client’s health. The probability that the recommendation would be implemented by the treating clinician was measured on a scale with 20% increments, ranging from 0 to 100%. The overall expected clinical outcome was assessed using a scale adapted from an earlier study which evaluated the impact of pharmacists’ interventions to correct dispensing errors in community pharmacy [14]. An additional item “no change in the management of the client” was added to this scale. Panelists were also asked to provide written comments if they disagreed with a particular finding or recommendation or if they felt a finding and/or recommendation were missing. The scales and assessment criteria were pilot tested for face validity by an independent pharmacist prior to being utilized in the study.

Data analysis

All data were entered into the Statistical Package for the Social Sciences Version 15.0 (SPSS Inc., Chicago, IL, USA). The frequency of responses for each of the four scales was computed. The drugs taken by the clients, their medical diagnoses, and the types of drug-related problems identified in relation to the clients’ drugs and diagnoses were cross-tabulated.

The inter-rater agreement between panelists’ responses was assessed using the Kendall coefficient of concordance (W) with MINITAB 15 (Minitab Inc., Pennsylvania, USA). This statistic is used to determine the inter-rater agreement of responses for ordinal variables by multiple raters [40]. It provides an indication of the strength of agreement and is tested for statistical significance. W scores range between 0 and 1, with 1 signifying complete agreement. The Kendall coefficient of concordance can therefore be interpreted in the same way as a correlation coefficient [39], and a score of 0.3 or greater is generally desirable in the context of social research, indicating a moderate association [8, 15]. When testing for statistical significance the null hypothesis is that panelists’ ratings are independent of one another. Therefore, rejection of the null hypothesis indicates that any agreement between the panelists’ responses is statistically significant.

Results

Study population

The mean age of the 48 clients was 46.8 (SD 15.1) years and 22 clients (46%) were female. The mean number of medical diagnoses per client was 3.5 (SD 2.1). Thirty-four clients (71%) had a principal diagnosis of a schizophrenia, schizotypal or delusional disorder. Twelve clients (25%) had a principal diagnosis of an affective disorder. Two clients (4%) had a principal diagnosis of a neurotic, stress-related somatoform disorder. Comorbid mental and physical illness was common. The mean number of drugs taken per client was 7.0 (SD 4.6). The mean number of psychiatric drugs taken per client was 3.0 (SD 1.5), representing 43% of the total number of drugs.

Drug-related problems

In total, 209 findings and 208 recommendations were extracted from the 48 written medication review reports. The mean number of drug-related problems per client was 4.4 (SD 2.0). The mean number of drug-related problems related to a mental illness was 2.3 (SD 1.4), representing 52% of the total number of drug-related problems identified during the medication review process (Table 1). Problems related to medication selection, including adverse drug reactions, were the most frequent. Drug-related problems were most frequently associated with antipsychotic drugs (34.4%), antiepileptic drugs (9.6%) and antidepressants (9.6%) (Table  2).
Table 1

Classification of drug-related problems by ICD-10 (n = 209)

International statistical classification of diseases and related health problems (version 10)

Management issuesa

Medication selectiona

Medication regimena

Patient knowledge and skillsa

Othera

Total

Percentage (%)b

I

Infectious and parasitic diseases

1

0

0

0

0

1

0.5

III

Blood, blood-forming organs

0

0

1

0

0

1

0.5

IV

Endocrine, nutritional, metabolic

13

5

5

1

0

24

11.5

V

Mental and behavioral

F10–F19 Psychoactive substance use

0

1

0

0

0

1

0.5

F20–F29 Schizophrenia, schizotypal, delusional disorders

9

34

10

2

2

57

27.3

F30–F39 Mood (affective) disorders

15

26

10

2

2

55

26.3

F50–F59 Behavioural syndromes

0

2

1

0

1

4

1.9

F60–69 Personality disorders

0

0

0

0

0

0

0.0

VI

Nervous system

2

2

0

0

2

6

2.9

VII

Eye and adnexa

0

0

0

0

1

1

0.5

IX

Circulatory system

0

2

0

0

0

2

1.0

X

Respiratory system

1

1

1

0

0

3

1.4

XI

Digestive system

1

3

4

0

1

9

4.3

XII

Skin and subcutaneous tissue

1

1

1

0

0

3

1.4

XIII

Musculoskeletal system

0

1

0

1

0

2

1.0

XIV

Genitourinary system

0

1

1

0

0

2

1.0

XVIII

Other signs, symptoms, findings

2

2

1

0

0

5

2.4

XXI

Factors affecting health status

0

0

0

7

4

11

5.3

 

Total

45

81

35

13

13

187c

89.7

Percentage (%)

21.5

38.8

16.7

6.2

6.2

89.5

aCategories based on coding framework by Gilbert et al. [11]

bPercentage of all 209 drug-related problems

cTwenty-two of the issues identified were not related to a particular disease state, including, for example, adherence issues

Table 2

Classification of drug-related problems by ATC (n = 209)

Anatomical therapeutic chemical classification

Management issuesa

Medication selectiona

Medication regimena

Patient knowledge and skillsa

Othera

Total

Percentage (%)b

A Alimentary tract and metabolism

1

4

8

1

3

17

8.1

B Blood and blood-forming organs

0

2

2

1

0

5

2.4

C Cardiovascular

3

4

1

0

1

9

4.3

D Dermatologicals

0

1

1

0

0

2

1.0

G Genitourinary and sex hormones

0

1

1

0

1

3

1.4

H Systemic hormonal preparations

4

1

0

0

0

5

2.4

M Musculoskeletal system

0

2

0

0

0

2

1.0

N Nervous system

 N02 Analgesics

0

0

0

0

1

1

0.5

 N03 Antiepileptics

11

6

2

0

1

20

9.6

 N04 Antiparkinson drugs

0

1

2

0

0

3

1.4

 N05A Antipsychotic drugs

12

41

13

5

1

72

34.4

 N05B Anxiolytics

0

1

0

0

0

1

0.5

 N05C Hypnotics and sedatives

0

1

1

0

1

3

1.4

 N06A Antidepressants

0

13

5

1

1

20

9.6

 N07 Other nervous system drugs

0

1

1

0

0

2

1.0

R Respiratory system

1

1

1

0

0

3

1.4

S Sensory organs

0

0

0

0

1

1

0.5

Total

32

80

38

8

11

169c

80.9

Percentage (%)

15.3

38.3

18.2

3.8

5.3

80.9

 

aCategories based on coding framework by Gilbert et al. [11]

bPercentage of all 209 drug-related problems

cForty of the issues identified were not related to a particular drug, including, for example, lifestyle issues

Expert panel assessments

Panelists agreed or strongly agreed with 76% of the medication review findings (91.1% response rate). The responses between panelists were moderately consistent, although the psychiatrist expressed more neutral responses (50%) (Fig. 1). The W score of 0.33 confirmed that there was moderate agreement between the panelists’ responses (P = 0.007). Panelists considered that 81% of the medication review recommendations were appropriate or most appropriate (99.6% response rate) (Fig. 2). There was a moderate level of consistency between the responses from the four panelists, confirmed by a W score of 0.41 (P < 0.001). Panelists judged that 69% of the medication review recommendations had a greater than 60% probability of being implemented (99.6% response rate) (Fig. 3). Less than 11% of the recommendations were considered unlikely to be implemented. Again, the W score of 0.40 (P < 0.001) indicated that the agreement between the panelists was moderate and statistically significant. Collectively 37 (77%) of the 48 medication reviews were considered likely to have had a positive impact on the overall health of the client (improving management, preventing harm or preventing a hospital admission) (Fig. 4). The psychiatrist, general medical practitioner and medication review accredited pharmacist considered that between 83 and 93% of the reviews would result in a positive impact on the client’s health. However, the mental health pharmacist believed that a greater proportion (30%) of the reviews would not have had an impact on the client’s therapeutic management.
Fig. 1

Panelists’ responses for the assessment of finding agreement for the 209 findings

Fig. 2

Panelists’ responses for the assessment of recommendation appropriateness for the 208 recommendations

Fig. 3

Panelists’ responses for the assessment of implementation probability for the 208 recommendations

Fig. 4

Panelists’ responses for the assessment of the overall expected clinical outcome for the 48 clients

Discussion

This was the first study which assessed the overall clinical impact of comprehensive pharmacist-led medication reviews for people with mental illness. Thirty-seven (77%) of the reviews in our study were deemed to have had an overall positive clinical impact. This result compares favorably to two pilot studies conducted in UK, in which 35–60% of interventions in two CMHTs were assessed to be of clinical significance [10, 13]. This also compares favorably to medication review studies conducted among general older populations, in which 40–90% of recommendations were judged to result in patient benefits [19, 27]. One of the reviews (2%) in our study was assessed by the two panel pharmacists to have potentially prevented a hospital admission. As a result of receiving the medication review this client was found to be taking 24 acetaminophen tablets each day. At the opposite end of the scale, each panelist identified a small number of drug-related problems which were not identified by the reviewing pharmacists. This led two panelists to deem one review (2%) may have had a detrimental clinical impact. In this review, the client had symptoms suggestive of serotonin toxicity which was not detected by the reviewing pharmacist.

A total of 43% of the drugs being taken by the clients were to treat a mental illness. The proportion of central nervous system drugs taken by clients in other medication review studies has ranged from 10 to 17% [19, 36], and psychiatric drugs represent 11% of all subsidized drugs prescribed by medical practitioners in Australia [1]. Another point of differentiation between our study and previous medication review studies was the mean age of clients. The mean age of clients in our study (46.8 years) was lower than in other medication review studies, in which mean ages have ranged from 66 to 86 years [5, 16]. Nevertheless, adverse drug reactions and suboptimal monitoring have also been among the top five drug-related problems identified in previous medication review studies [11, 19, 36, 43]. Psychiatric drugs were also associated with the greatest risk of drug-related problems in a previous medication review study [27]. This is consistent with the results of our study in which psychiatric drugs were the highest contributor to drug-related problems.

Previous studies evaluating medication reviews have focused on the recommendations made by pharmacists without addressing the relevance of findings [10, 13, 19, 27, 28]. The panelists agreed or strongly agreed with 75% of the findings, however, the psychiatrist indicated more neutral responses than the other panelists. This may have been because many of the findings were not related to mental health. The psychiatrist may have been less confident rating the relevance of findings in therapeutic areas that extended beyond psychiatry. In addition, the psychiatrist questioned the relevance of several findings related to polypharmacy with antipsychotic drugs. Although supported by little research evidence, and contrary to treatment guidelines, polypharmacy with antipsychotic drugs is common among clients of CMHTs [12, 45]. The psychiatrist disagreed with a small number of findings related to the use of psychiatric drugs at higher than recommended doses. The routine use of high doses of antipsychotic drugs is also common among clients of CMHTs [12, 24].

A total of 81% of the recommendations were considered appropriate or most appropriate. This rate is similar to the rates of appropriateness reported in other studies for people with mental illness (from 91 to 100%) [10, 13], and coronary heart disease (94.6%) [20]. However, the definition of appropriateness differed between studies and thus the results may not be directly comparable. Interestingly, there was greater disparity in the assessment of findings than recommendations for the psychiatrist. This may have been because pharmacists’ findings were often specific (e.g. stating a client’s current statin dose and their most recent cholesterol level) whereas pharmacists’ recommendations were often general (e.g. recommending routine monitoring of cholesterol levels); enabling a panelist to agree with a recommendation and not the corresponding finding. While several reviewing pharmacists made recommendations to simplify clients’ medication regimens in an attempt to improve adherence (e.g. to prescribe a controlled-release formulation), some panelists believed changing clients’ medication regimens would create unnecessary confusion. Illness severity and lack of insight have been identified as factors linked to medication non-adherence [25]. Several pharmacists recommended that clients receive additional drug education and counseling. This is a role that could be successfully performed by a designated CMHT pharmacist [4].

While 81% of the recommendations were considered appropriate, only 69% of the recommendations were considered likely to be implemented. This result was not unexpected, because implementing recommendations is more challenging than accepting recommendations on theoretical grounds. Rates of recommendation acceptance in previous medication review studies have ranged from 50 to 90% [5, 23, 41, 42], however, rates of documented recommendation implementation have ranged from 42 to 77% [11, 42, 43]. Many of the recommendations the panelists considered unlikely to be implemented related to the need to monitor clients for signs of symptoms of common physical health conditions. These recommendations were likely to have addressed an important public health need [38]. This finding was consistent with research in UK which highlighted confusion and uncertainty in relation to the routine monitoring of clients of CMHTs for signs and symptoms of physical health conditions [2]. Comprehensive medication reviews may act as a prompt for clinicians to monitor for signs and symptoms of physical health conditions.

The agreement in responses between panelists was statistically significant for the findings, recommendations and implementation probability assessments. The composition of the panel reflected the diversity of health care professionals who provide care for clients of CMHTs. It was encouraging that in many cases panelists were able to independently agree in relation to clinical decisions. Clients often have several mental and physical comorbidities requiring treatment from different health care professionals. In this study, over half of the drug-related problems identified by the reviewing pharmacists were for non-mental health-related conditions. This was similar to the findings of a previous study that revealed one-third of preventable adverse drug events in a psychiatric hospital were not related to mental health [35].

Study strengths and limitations

The expert panel methodology was well suited to the in-depth analysis of the 48 comprehensive medication reviews. This method allowed for an implicit or judgment-based assessment of the appropriateness and clinical impact of the medication reviews. An advantage of this method was that it considered client-related factors and, therefore, was more relevant than explicit criterion measures of appropriateness [44]. The challenge of measuring clinical outcomes in community psychiatry has been presented [30], and many of the medication review findings and recommendations in our study were not related to mental health. However, a limitation of our method was that the opinions of the panelists may not have corresponded to actual client clinical outcomes. The large workload required for each panelist to review each client case and then evaluate each medication review made it impractical to analyze a larger number of medication reviews using this method. However, further studies with larger sample sizes using alternative methodologies are required to confirm the actual clinical impact and appropriateness of comprehensive medication reviews for clients of CMHTs.

Clients were recruited to receive a medication review on the basis they were likely to benefit from the service. However, because clients and CMHTs were not recruited randomly, it is likely that those clients who received a medication review were not representative of all clients of CMHTs. This limits the generalizability of the study results to all clients of CMHTs.

Conclusions

Pharmacists’ findings and recommendations to optimize drug therapy were judged appropriate and likely to result in improved clinical outcomes. Comprehensive medication reviews may be a valuable strategy to identify and resolve drug-related problems among clients of CMHTs. Comprehensive medication reviews represent a promising strategy to address the morbidity and mortality associated with adverse drug events and drug-related problems among psychiatric patients.

Notes

Acknowledgments

The authors are grateful to the reviewing pharmacists, staff and clients of the CMHTs for their enthusiastic participation. The authors thank the four panelists for their contribution to the study. The study was supported by a research grant from the Pharmacy Research Trust of New South Wales.

Conflict of interest statement

The authors declare that they have no direct conflict of interest.

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Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Natasa Gisev
    • 1
  • J. Simon Bell
    • 1
    • 2
    • 3
    Email author
  • Claire L. O’Reilly
    • 1
  • Alan Rosen
    • 4
    • 5
    • 6
  • Timothy F. Chen
    • 1
  1. 1. Faculty of PharmacyUniversity of Sydney SydneyAustralia
  2. 2.Kuopio Research Centre of Geriatric CareUniversity of KuopioKuopioFinland
  3. 3.Department of Pharmacology and ToxicologyUniversity of KuopioKuopioFinland
  4. 4.Greater Western Area Health ServiceDubboAustralia
  5. 5.School of Public Health, Faculty of Health and Behavioural SciencesUniversity of WollongongWollongongAustralia
  6. 6.Department of Psychological MedicineUniversity of SydneySydneyAustralia

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