Pharmacists' and Pharmacy Students' Ability to Identify Drug-Related Problems Using TIMER (Tool to Improve Medications in the Elderly Via Review)

Article excerpt

INTRODUCTION

Medicare Part D requires MTM for enrollees who use a high proportion of financial resources in the program. (1) Pharmacists are challenged to find ways to effectively and efficiently provide MTM services, given the high volume of prescriptions that they dispense. While there are MTM plans that assist pharmacists, these services are not always available. (2-3) Community pharmacists, who fill the vast majority of prescriptions, are in a unique position to provide important medication reviews. (4-6) An MTM tool may provide pharmacists with a systematic approach for conducting medication reviews and improve efficiency.

MTM services can be especially valuable to older adults. (7-8) The presence of polypharmacy and age-related physiological changes cause this population to experience more drug-related problems (DRPs). (9) Medication errors consist of overuse, underuse, and misuse, and lead to more than 5% of hospital admissions in older adults. (9-11) Between 14% and 23% of older adults receive a medication that should not have been prescribed for them, (12-14) and 10% to 25% of patients have an adverse drug reaction or adverse drug event. (15,16) However, some medications, such as statins and angiotensin-converting enzyme (ACE) inhibitors, are under prescribed among older adults. (17-21)

In order to simplify medication reviews, screening tools have been developed. Available tools include Beer's list, Assessing Care of Vulnerable Elders guidelines, and the Medication Appropriateness Index. (22-28) These tools can rarely accommodate patients with multiple chronic diseases, multiple drug interactions, and/or organ-system insufficiency that may cause patient-specific medication problems. Medication reviews need to be done in a way that encompasses the whole patient, not just a particular disease, medication, or drug interaction. This complexity makes it nearly impossible to create a tool that is sufficiently specific and sensitive to identify drug therapy problems. (28)

In addition to practicing pharmacists, pharmacy students are trained to provide MTM, (29,30) but there is currently no standardized approach used to provide MTM services or to identify DRPs. (31,32) A tool may make the task of learning how to provide these services easier for pharmacy students and practicing pharmacists who are new to MTM. Having such a tool may also facilitate and improve the efficiency of identifying DRPs.

The objective of this study was to evaluate the Tool to Improve Medications in Elderly via Review (TIMER), a systematic approach to conducting medication reviews and improving pharmacists' ability to identify important drug-related problems among older adults. The specific aim of this 2-part study was to compare the number and types of drug-related problems identified by practicing pharmacists (part 1) and pharmacy students (part 2) with and without using the TIMER.

METHODS

Development of the TIMER

TIMER is a guide for pharmacists and pharmacy students to follow when conducting medication reviews. TIMER was developed by 2 of the authors (KF and EC), with input from a consensus panel of 4 regional experts who reviewed the tool and provided feedback. Using a scale ranging from strongly agree to strongly disagree, reviewers rated each section of the TIMER on whether the content was evidence-based, important, helpful/useful, and understandable. Feedback from reviewers resulted in several improvements to TIMER, for example, including drug-drug interactions based on both prevalence and severity rather than just on severity, and reducing the symptom timeframe to several months.

An important assumption made in developing TIMER was that its users have conducted a patient medication history so that a complete medication list is avail able. TIMER has 4 sections including cost-effective drug selection, adherence, medication safety, and attaining therapeutic goals, and covers the most common medication issues that affect older adults. …