Implementation of medication reviews in German community pharmacies.

Michel, Dorothee Elsbeth Andrea

Abstract

Inappropriate polypharmacy can pose a major risk to individuals' health and thus entail unnecessary costs for health systems. With globally ageing societies, polypharmacy is on the rise. The World Health Organization (WHO) and the national German action plan for medication safety suggest performing medication reviews (MRs) for patients with polypharmacy to ensure appropriateness of their entire medication. Despite listing the MR-service in the German action plan as a useful intervention, the plan does not mention any considerations about the implementation of this service. However, successful implementation is a prerequisite for any service to sustainably achieve clinical outcomes. The overall aim of this research programme was to further the implementation of medication reviews in German community pharmacies. The first phase of this research programme was a systematic review (SR) of the literature to critically appraise, synthesise and present the available evidence on experiences with MRs in community pharmacies, including potential barriers and facilitators. The SR was underpinned by the Consolidated Framework for Implementation Research (CFIR) and identified 23 studies from 9 countries reporting mainly on the perspectives of employed pharmacists. Key facilitators were reported to be pharmacists' openness to practice change and patients' satisfaction level after receiving an MR-service. Inadequate remuneration was considered the dominant barrier, as it strongly influenced staffing and provision of additional resources within the pharmacies. Further barriers were collaboration difficulties with medical doctors, little mandate from health authorities along with poor public awareness of the service. The perspective of pharmacy owners was underrepresented in the identified studies. The second phase of this research programme explored German pharmacy owners' views towards and experiences with implementation of MRs. A qualitative interview study, underpinned by the Framework for Implementation of Services in Pharmacy (FISpH), was conducted with 21 owners. Regardless of their experience with MRs, all participants had positive views of MRs but were sceptical if MR-implementation would be feasible for their pharmacies since financial viability of the MR-service seemed uncertain. National awareness campaigns, reduction of excessive bureaucracy, continuing professional education, and including pharmacy technicians in some MR-tasks were identified as potential facilitators. In particular the implementation strategies 'external support' and an additional start-up 'incentive' were suggested by participants as promising to encourage pharmacists to take the first steps towards implementation of an MR-service. Following the Implementation Research Logic Model (IRLM), the third phase of this research programme then went on to involve stakeholders in gathering recommendations for and obtaining consensus on mechanisms of change to realise the two suggested implementation strategies in practice. Four Nominal Group Technique (NGT)-discussions were conducted with 17 participants (pharmacy owners, and employees of regional pharmacy chambers). Highest ranked mechanisms of change were fit-for-purpose software (targeting four implementation outcomes, relative importance rI=154.7), detailed process support (rI=104.9), and the provision of an expert support line (rI=77.7), which were targeting three implementation outcomes each. Both participant groups prioritised these three mechanisms together with ensuring financial viability (rI=40.0). Anecdotal evidence shows that the recommendations made in our publications and talks have already been adopted in practice. Further research is warranted to investigate the effectiveness of the suggested mechanisms of change in a scientific manner, assessing implementation as well as clinical outcomes in a future study.

Citation

MICHEL, D.E.A. 2024. Implementation of medication reviews in German community pharmacies. Robert Gordon University, PhD thesis. Hosted on OpenAIR [online]. Available from: https://doi.org/10.48526/rgu-wt-2795705

• Thesis Type: Thesis
• Deposit Date: Apr 18, 2025
• Publicly Available Date: Apr 18, 2025
• DOI: https://doi.org/10.48526/rgu-wt-2795705
• Keywords: Medication reviews; Health policy implementation; Implementation research; Community pharmacy; Germany
• Public URL: https://rgu-repository.worktribe.com/output/2795705
• Award Date: Dec 31, 2024