Show me the Evidence
Bad Drug Reactions Jeopardize Patient Safety
Pharmacists on health care teams reduce adverse drug events and improve health and safety of seniors
At a Glance
Who: Dr. Lisa Dolovich, Faculty of Medicine, McMaster University
Issue: 51.5% of all emergency department visits each year are due to adverse reactions to medications in adults aged 50 and over, according to a study by the US Substance Abuse and Mental Health Services Administration. Among seniors, 62% are on 5 or more drugs, while almost 30% aged 85 or older are taking 10 or more drugs daily.1
Research: Dr. Dolovich's study, a two-year project named IMPACT (Integrating family Medicine and Pharmacy to Advance primary Care Therapeutics), involved 1,554 patients being referred to a pharmacist for a comprehensive assessment of their prescribed medications.2
Impact: The study caught and averted adverse drug reactions for 241 patients. The research has also been used as evidence to support new pharmacist positions in family medicine teams in Ontario and Saskatchewan.
Sources: Integrating Family Medicine and Pharmacy to Advance Primary Care Therapeutics. Clinical Pharmacology and Therapeutics. 2008; 83 No.6: 913–17.
Seventy-one-year-old Rhoda Malone (a pseudonym) was experiencing dizziness, fatigue and swollen ankles when a pharmacist working with McMaster University pharmacy professor Lisa Dolovich took a look at her medications.
Diagnosed with low blood pressure, Malone was having an adverse drug reaction as a result of the two drugs she had been prescribed to treat the problem. Once the pharmacist worked with Malone's doctor to lower the dose of one drug (metoprolol) and switch from one kind of medication used to control blood pressure (a calcium channel blocker) to a different kind of medication (a diuretic), Malone started feeling better. Her dizziness disappeared, her energy improved and the swelling in her ankles went down.
Because of the pharmacist's knowledge of drug interactions and teamwork with Malone's doctor, she was saved from a fall or another potentially serious effect resulting from the drug interaction and adverse effects.
The Evidence: Improved Quality of Life
The study identified problems in an incredible 93% of cases studied, or nearly 4,000 drug-related problems overall. The study caught and averted adverse drug reactions for 241 patients.
Thanks to the study that Dolovich was working on when her team examined Malone, thousands of seniors in Ontario, Saskatchewan and Alberta are getting the same benefits from having a pharmacist as part of their health care team right in their doctor's office or clinic.
Dolovich, an associate professor at McMaster University in Hamilton, Ontario, and a scientist and associate director with the Centre for Evaluation of Medicines at St. Joseph's Healthcare in Hamilton, studied seven pharmacists working with 70 doctors at family practices in Ontario to see how they affected prescribing and medication practices among 14,000 patients.
The two-year project, named IMPACT (Integrating family Medicine and Pharmacy to Advance Primary Care Therapeutics), led to 1,554 patients being referred to a pharmacist for a comprehensive assessment. The pharmacists identified at least one drug-related issue in 93% of the patients, finding 3,974 drug-related problems in total. Those problems included adverse drug reactions in 241 patients (26.5%) and 315 adverse drug reactions or potential reactions in total.
The research is particularly important because people aged 75 and over take an average of six to eight medications every day. The potential for adverse drug reactions increases with every medication they add to their regimen, since drug interactions account for 15–20% of those adverse events.
Working closely with pharmacists enabled the doctors participating in the IMPACT study to correct the problems and prevent serious adverse reactions in the seniors. The project also provided the evidence for placing pharmacists on family health care teams, something Ontario, Saskatchewan and Alberta have all done on the basis of Dolovich's work.3
"You can find research going back about 20 to 25 years ago where some pharmacists were doing this," says Derek Jorgenson, an assistant professor of pharmacy at the University of Saskatchewan. "But it was never studied on a large scale, using quality research methods."
Once Dolovich's work was published (13 studies emerged from the IMPACT project), Jorgenson stopped being the only pharmacist in Saskatchewan working in a primary health care setting. He used the McMaster research to help persuade the province to pay 25 pharmacists to work on health care teams. "I wouldn't say IMPACT is the only reason this model has expanded, but it's been a big reason why health ministries around the country have bought into it and supported it," Jorgenson said.
Ontario took note. Dolovich's work provided the evidence that was needed to include pharmacists on health care teams. When new proposals now come to the Ontario Ministry of Health and Long-Term Care, "we want to make sure pharmacists are included in the design," says Mary Fleming, director of the Ministry's Family Health Teams unit. "Right now we have 170 teams in various stages of implementation," she said. Most have pharmacists on them, 4 including those that participated in the IMPACT study.
The research also changed the way medical students at McMaster are trained. Their professors now teach doctors to encourage patients to contact them about any side effects they experience from medication, and to discuss with patients ways to improve the way they take medication by using organizers, reminders and other tools.
"In Ontario, it's moved from evidence to implementation," says Dolovich. In Rhoda Malone's case, the intervention of a pharmacist not only prevented a serious adverse event from occurring as a result of her medication, it also improved her overall quality of life. During the assessment, the pharmacist answered Malone's questions about whether she would become too dependent on over-the-counter pain relievers if she took them at night. The pharmacist let Malone know it was okay to take acetaminophen at bedtime for pain, which helped her sleep and improved her overall quality of life. That experience is consistent with Dolovich's subsequent research, which has shown that pharmacists working in these family health care settings improve not only medication management, but also monitoring for chronic diseases, and blood pressure and cholesterol control.
The Evidence: Cost Savings
The costs of preventable, medication-related incidents and deaths in seniors alone are estimated at $11 billion annually in Canada.
Overall, Dolovich's research has provided evidence for the increased involvement of pharmacists on health care teams and community intervention programs as a way of improving health outcomes for seniors in Canada.
The costs of preventable, medication-related incidents and deaths in seniors alone are estimated at $11 billion annually in Canada.5 Given that family doctors are hard-pressed to keep up with the adverse events associated with new medications and most are not trained to identify drug interactions, a team approach that allows them to work closely with pharmacists in their practices seems a cost-efficient and effective change whose worth is demonstrated by this groundbreaking research.
For Further Reading:
- Seniors and Prescription Drug Use.
- Pharmacist's identity development within multidisciplinary primary health care teams in Ontario; qualitative results from the IMPACT project. Res Social Adm Pharm. 2009 Dec;5(4):319–26. Epub 2009 Apr 25.
- Ontario began including pharmacists on teams in 2004, Alberta in 2006 and Saskatchewan in 2008.
- As of August 2010, the number of Family Health Teams totals 200.
- A Status Report on The National Pharmaceuticals Strategy: A Prescription Unfilled.