Prescriptions, practitioners and pharmacists

Better communication and teamwork for improved patient outcomes

MJA 1998; 168: 317-318  

Medicines are clearly an important component of healthcare. In Australia, prescriptions are written in 63.8% of general practitioner consultations,1 and in 1996 approximately 178 million prescriptions were dispensed. With the potential for adverse reactions and reported suboptimal use of drugs,2-5 it is important to work towards the best possible use of medicines. There are a number of indicators of inappropriate drug use in Australia, including the large quantities of unused medicines collected in the Return of Unwanted Medicines campaign,6 and studies showing that between 5.7% and 16.6% of all hospital admissions are drug-related events.7,8 Further, a recent report of the South Australian Community Pharmacy Model Practices Project showed that, at entry to the project, 90% of patients at high risk of medication misadventure (usually those taking more than four medications) had unresolved health or medication problems, two-thirds of which were medication related.3 Medication care can be improved by enhancing communication between doctors, pharmacists, other health professionals and consumers. Indeed, a number of intervention studies have found that quality of medication care can be improved through further building of the healthcare team, academic detailing (promotion of rational prescribing through detailing visits from pharmacists), medication review by pharmacists and doctors and feedback of prescribing patterns to doctors.2-5,9 In this vein, the Royal Australian College of General Practitioners (RACGP) and the Pharmaceutical Society of Australia (PSA), in their draft joint statement about communication between GPs and pharmacists,10 proposed a range of conventions and abbreviations aimed at improving the prescription as a communication medium. In this issue of the Journal Liddell and Goldman report the findings of the pilot study11 on which the final version of the joint statement, published in 1996, was based.12 In their study, Liddell and Goldman11 trialled the use of certain prescription notations by GPs as a means of providing the pharmacist with information for enhancing patient understanding and medication care. A modified prescription form was preprinted with the abbreviations recommended in the draft RACGP-PSA joint statement.10 These abbreviations were intended to alert the pharmacist to patient needs for counselling and assistance, and to the existence of written instructions given to the patient by the GP to enable the pharmacist to label the medicine accordingly and reinforce the patient's understanding. The prescription conventions trialled were (i) writing the general purpose for which a medication was prescribed on the form, (ii) indicating when this should not be written on the label, (iii) underlining and initialling unusual dosages, (iv) indicating that an unusual pack size was intended, and (v) noting that therapy with an ongoing medication had been stopped. Liddell and Goldman11 examined the use of and attitudes towards these new notations and found that at least one of the new notations was used on 45% of the 3464 prescription items, and that one in particular -- the general purpose of the medication -- was noted on 35%. Some preprinted notations were used so rarely that they were excluded from the final joint statement,12 and the "cease" notation was also so rarely used (14 times) that it was relatively ineffective. However, consumers felt that writing the purpose of a medication on its label was generally appropriate and helpful. Participating GPs and pharmacists were positive about the notations, especially the indication of a medication's purpose. Effective communication and collaboration between specialists, GPs and pharmacists, beyond simply changing the way prescriptions are written, are likely to result in advances in medication care. A range of collaborative interdisciplinary primary care models have been developed and trialled both here3,5,13 and in the United Kingdom.14 In the Community Pharmacy Model Practices Project (mentioned above), protocols were defined by pharmacists, with input from GPs and consumers, to optimise quality pharmaceutical services for patients with a high risk of medication misadventure; more than 80% of consumers felt that the pharmacists' service had made a significant contribution to their health and there was an estimated net societal saving to the health system of $110 per patient.3 The Commonwealth Department of Veterans' Affairs has attempted to facilitate communication in its medication management program through written referrals between specialists, general practitioners and pharmacists, with the consent of veterans, and through education programs.13 In the UK, models of pharmacists' input to primary care include (i) review of repeat prescriptions, (ii) total medication review, (iii) drug use evaluation, (iv) development of drug formularies (or drug lists) for general practices, (v) development of prescribing policy, and (vi) audit of prescribing by disease or condition.14 Not surprisingly, it was found that rational and cost-effective prescribing was best achieved when pharmacists and general practitioners worked together.14 Successful models of interdisciplinary collaboration need to be implemented cautiously, as rapid imposed change can create conflict and resistance. Relationship building, stakeholder involvement (at both "grass roots" and organisational levels) and communication between the professions have been key components associated with Australian studies of medication care.3-5,9 There are dangers in ignoring these components and other recommendations in translating trials into practice. For example, selective implementation of recommendations in providing consultant pharmacist services to nursing homes without the recommended involvement of and support to GPs,4 has resulted in some justifiable concern by GPs (personal, unpublished data). Clearly, any national effort to facilitate optimal medication care should mandate the involvement of all key stakeholders. Communication and relationships are the keys to balancing collaboration and optimal patient care with autonomy and privacy issues. Effective communication depends both on its being a two-way process, and on how the relationship between the two parties influences the interpretation of "messages" by each. Trust, confidence, involvement and a mutual respect for each professional's role and competence are therefore essential in any functioning team. The development of these elements should start during interdisciplinary undergraduate (and postgraduate) clinical education of doctors, pharmacists and other health professionals.15 Interdisciplinary clinical teaching, recognition of emerging practice models and the need for interprofessional student interaction are sadly lacking in Australia. With the introduction of the four-year pharmacy course and the graduate medical courses nationally, now is the time to grasp the opportunity offered for interdisciplinary development. Further, electronic prescribing links16 and newer avenues of interprofessional communication, such as regular joint medication reviews,9 consumer medicine information and the National Prescribing Service, are opportunities for overcoming the barriers to communication and information sharing, and to nurturing professional relationships. Facilitating information sharing between specialists, medical practitioners and pharmacists through interprofessional collaboration and better communication (including through the prescription form10-12) should lead to improved patient care and outcomes, easier and more effective communication between health professionals, and high quality, cost-effective use of medicines. The Australian healthcare system must build and maintain relationships between professionals and with consumers if it is to improve. Michael S Roberts NHMRC Senior Principal Research Fellow, and Professor Julie A Stokes Research Scholar Department of Medicine, University of Queensland, Princess Alexandra Hospital Brisbane, QLD Bridges-Webb C, Britt H, Miles D, et al. Morbidity and treatment in general practice in Australia 1990-1991. Med J Aust 1992; 157 Suppl Oct 19: S1-S56. Parkes AJ, Coper L. Inappropriate use of medications in the veteran community. How much do doctors and pharmacists contribute? Aust N Z J Public Health 1997; 21: 469-476. Gilbert A. Final report of the Community Pharmacy Model Practice Project. Canberra: Federal Department of Health and Family Services, 1997. Roberts MS, Stokes J, Bonner C, et al. Clinical pharmacy intervention and resident outcomes in Australian nursing homes. Proc Austral Soc Clin Exp Pharmacol Toxicol 1995; 2: 158. McNeece J. The drug and therapeutics information service. Aust J Hosp Pharm 1994; 24: 28-31. Goodman M, Lazzarini R. Examination of the feasibility of an ongoing strategy for disposal of unwanted and outdated medicines [abstract]. The Pharmaceutical Education Program 1995 Work in Progress Conference; Sydney Aug 24-26. Canberra: Commonwealth Department of Health and Family Services, 1995. Dartnell JG, Anderson RP, Chohan V, et al. Hospitalisation for adverse events related to drug therapy: incidence, avoidability and costs. Med J Aust 1996; 164: 659-662. Blackbourn J. Readmission to Fremantle Hospital. Part 2. Drug-related readmissions. Fremantle Hosp Drug Bull 1991; 15: 13. ACT Division of General Practice. Managing medication in nursing homes -- GP involvement in medication reviews. A report of the outcomes of the "Aged Care Assessment Project". Canberra: ACT Division of General Practice, 1998. In press. Ruth R, Constable V, Dammery D, et al. General practitioners' and pharmacists' interprofessional communication. Aust Fam Physician 1994; 23: 1544-1546. Liddell MJ, Goldman SP. Attitudes to and use of a modified precription form by general practitioners and pharmacists. Med J Aust 1998; 168: 322-355. Bollen M. Improving communication between general practitioners and pharmacists. Aust Fam Physician 1996; 25: 1011-1013. Coper L. Pharmaceutical Management Program. Canberra: Commonwealth Department of Veterans' Affairs, 1997. Bradley CP, Taylor RJ, Blenkinsopp A. Developing prescribing in primary care. BMJ 1997; 314: 744-747. Greene RJ, Cave I, Jackson SMD. Interprofessional clinical education of medical and pharmacy students. Med Educ 1996; 30: 129-133. Getting connected. Newslet Nat Pharm Intranet Demonst 1997; 1: 1-8.