Saturday, November 18, 2006

Medicines Use Reviews

When the new contract for community pharmacy was introduced in 2005 it included medicines use reviews (MURs), designed to get pharmacists out of the dispensary and talking to patients (link opens PDF). MURs are designed to improve patient knowledge, concordance and use of medicines. Pharmacists have been slow to offer MURs, partly because of the copious amount of paperwork required with the new contract and the need for accreditation of both pharmacists and pharmacies. The reaction of some GPs has been less than complimentary. The best way to prove these GPs wrong is to produce some good quality MURs.

As part of a post-grad course I'm doing I had to conduct five MURs. So what came out of them? Well one of them was checking the patient was taking her medication correctly and knew what they were for, but then she was on nine oral medications, five of which were for high blood pressure. To go any deeper in this case would have been far outside the scope of MURs. Another of the MURs was educating a patient about asthma, including the need for regular use of preventer inhalers and allaying fears over long term use of inhlaed steroids. Next up I had an elderly gentleman who was taking diclofenac and omeprazole. Except he wasn't taking the omeprazole, so he had no protection for his stomach from the diclofenac, and he was wasting NHS money. So I explained the reason for taking omeprazole was so that he didn't end up with a nice gastric ulcer, and hopefully he'll take them from now on. I then saw a patient who was being prescribed standard release dipyridamole twice daily, when she should have been on the modified release product if she is taking it twice a day. This patient is also on low-dose aspirin, which increases the risk of gastric ulcers, but is not on anything to protect her stomach, so I suggested her GP start omeprazole 20mg daily. The final patient I saw had some fairly easy things to change to make her life easier, such as changing from simvastatin 20mg 2 at night to simvastatin 40mg 1 at night. This patient was also on co-amilofruse, a combination of furosemide and amiloride. Very few people actually need the amiloride and this patient could not remember having any blood test, so I suggested the GP review the need for the compound product. This patient was also taking Nytol (diphenhydramine) every night without her GP's knowledge so this was passed on to her GP.

From five MURs I found three people that either weren't on a gastroprotective agent or weren't taking it properly, three cases where formulations or strengths should be changed and one case where someone was taking regular over the counter medication that her doctor should have known about. I also had the oppourtunity to educate these patients about the use of their medicines and their disease states which is always beneficial. Hopefully this shows that MURs are beneficial for patients and are not just more paperwork for GPs to read. If anyone in the UK wants to make their pharmacist happy, and probably surprised, go and ask for a MUR.

12 Comments:

Blogger Shinga said...

Some of my elderly neighbours are on a bewildering array of medications for several chronic conditions apiece. I'll recommend that they should ask their pharmacist for an MUR.

Interesting read.

2:28 am  
Anonymous Anonymous said...

OK

1) Not sure you did anything here?
2) & 3) You hope they will take meds correctly? I think you'll find they continue doing what they do. Patients are like that, I think you'll find with more experience.
4) Use of omeprazole as prophylaxis? That's expensive. Tell me why not ranitidine? Not your budget that's why. Notwithstanding the choice of protective, the GP would no doubt start one if the patient gets indigestion symptoms. If all patients get expensive prophylaxis the NHS will be in for a huge bill, for little benefit over a case-selected basis. Not your issue though eh?
5) Mostly irrelevant. Did the patient consent to you passing on info?

What you haven't noted also is the cost of your "intervention". Guess what, your local medical SHO could do this in their own time for a fraction of your cost, and with a much greater degree of skill. It's not just about the pills you know, you have to have CLINICAL knowledge too. You should not be doing these on your own.

8:19 pm  
Blogger UK Community Pharmacist said...

Thanks for the comments, just to address some of the points:

Yes it's possible the patients will carry on regardless, however it's also possible that they will start taking their drugs properly if they know what they are taking them properly.

Re choice of ranitidine vs omeprazole: omeprazole 20mg caps are £4.29 per month, ranitidine 150mg tabs are £1.98 per month, so not a huge price difference. As for choice of prophylaxis, thats something I'll post about in more detail soon as its something I've been reading about. What I can say is that I probably dispense 10 times more PPIs than H2 antagonists.

Good luck trying to get a medical SHO doing this - I think you'll find they have enough of a work load as it is. As for cost, contractors are paid £25 per MUR, which is costed on then taking 30 mins each. Cost for an SHO to do this would be?

I also think you are missing the point of MURs. They are medicines USE reviews, not clinical reviews - look at the service specification in the drug tariff or on PSNCs site. Patient education is key - how many asthmatics don't use their inhaled corticosteroids and what is compliance with bisphosphonates like? Pharmacy could have a huge impact on public health just by doing MURs on these patients, and probably save the NHS vast amounts of money in the process.

As for clinical knowledge, I'm doing a clinical diploma, so am looking at things in more depth than other pharmacists might. Also bear in mind that I can only recommend or suggest changes, the GP still has the final say. With respect to cost, medical SHOs are dire - the amount of scripts from hospitals that are for branded products is ridiculous. I've had scripts for Cipro, Keflex, and even Voltaren which really would be expensive as its not on the uk market.

And what do you do anon?

6:50 pm  
Blogger Pastor Dave said...

Methinks 'Anon' is a patron.
Anon's attitude is certainly patronising.

Pharmacists have never had to be concerned about doctors' budgets - we just are because it's the professional thing to do. We don't write the prescriptions, we simply dispense and support both patient and prescriber.

Anon seems to be very ill-informed too and should probably stick to doing whatever they do when they do it.

My experience of gp prescribing as well as secondary care prescribing has consistently been that 'more thought - less intention' wouldn't go amiss.
I also spent a lot of time over the years gently explaining to SHO's some rather basic pharmacology to counter whatever parrot-rote was stuffed into them on the hoof by the previous generation. Usually this has resulted in a sea-change for the SHO and a good working relationship thereafter.

Anon presumably hasn't had ANY conversation with a ward pharmacist or one of the new generation of clinically oriented community pharmacists.
Perhaps if they have the courage to remove the blinkers they might find they share the high ground with others of competency and integrity.

Still no sign of Anon letting you know just what they do.
Maybe they don't.... so perhaps they should remain silent while others do, and get on with the shared work of doing across professional divisions to mitigate the shocking effects of a decade of miserable political governance.

Maybe Anon is a politico!

5:42 pm  
Anonymous Anonymous said...

Pastor Dave, you really need to make sure that when you deal with bloggers of the like of Anonymous that you provide them with some substance. I’m not particularly experienced in this field but it seems to me that evidence talks & rightly so. Anecdote is all very well but a nice juicy link will works wonders.
How convenient then that our ‘organ’ this very week has published a small article stating that there is a considerable gap between patient ability to understand medication doses and their success in translating said understanding into a practical expression of concordance resulting in satisfactory treatment.

http://www.pharmj.com/Editorial/20061209/news/p681patientswhocanrepeat.html

There is also a link embedded in said article which will lead Anonymous to the US survey. Then they will be able to follow the information trail as far as their “open mind” will take them.

I doubt very much that Anonymous is a ‘politico’ since the field of blogging is still inaccessible to the voting masses and such types require unlimited pr opportunities to massage their ego and further their grubby careers.

Perhaps you need to concentrate on one of your careers and do it well.

12:52 pm  
Anonymous Anonymous said...

hello,
it is really interesting blog.im a pharmacists student and currently doing my researh about MUR.i just wondering if u could help me by emphasizing the difference of tought between pharmacists and GPs?also if possible what could be done to upgrade MUR.thank you so much.

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8:14 pm  
Blogger KGB said...

the use of omeprazole rather than ranitidine has a significant cost difference. the price maybe afew pounds different but omperazole if i am not wrong is the second or third most common drug prescribed on the NHS. Making the total cost for NHS significant if you can reuduce this cost effectivly by prescribing ranitidine then it would save millions for the NHS.
Secondly the benefits of MUR's have not been proven to date. As a pharmacist i do believe they make a difference but this needs to be proven, therfore clear research most prove this, after all this is the rational behind use of " evidence based practice". I mean if in afew years time it is proven not to be cosat effective do we carry on preformnig MUR's or do we develop other services. I n my opinion the changing roles of pharmacists will eventually win over the patients but we as pharmacist must push for this professional development and we must be renumerated appropriatly.

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