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Canadian Pharmacists Journal : CPJ logoLink to Canadian Pharmacists Journal : CPJ
. 2020 Jul 14;153(4):215–223. doi: 10.1177/1715163520929665

Standards in medication review: An international perspective

Olaf Rose 1,2,3,4,5,6,7,8,9,✉, V-Lin Cheong 1,2,3,4,5,6,7,8,9, Sammu Dhaliwall 1,2,3,4,5,6,7,8,9, Karen Eislage 1,2,3,4,5,6,7,8,9, Susanne Erzkamp 1,2,3,4,5,6,7,8,9, Derek Jorgenson 1,2,3,4,5,6,7,8,9, Francisco Martínez 1,2,3,4,5,6,7,8,9, Karen Luetsch 1,2,3,4,5,6,7,8,9
PMCID: PMC7605065  PMID: 33193923

Introduction

Medication reviews (MRs) have become an integral part of pharmacists’ practice in many countries. In this study, MR was defined as a structured assessment of patients’ pharmacotherapy whose aim is to optimize drug use and to improve health outcomes.1 These MR services are typically part of government-funded programs that are not always designed based on published pharmacist intervention studies linked with improvements to patient outcomes.2,3 There is evidence regarding the benefits of pharmacist-led MRs, including improvements in chronic disease management, quality of life, patient knowledge and satisfaction, resolution of drug therapy problems and reduced medication costs.4-8 However, there have been no large multinational randomized, controlled trials measuring the impact of MRs on patient morbidity or mortality, and reviews or syntheses of studies often come to inconclusive results.9,10 This knowledge gap may be, in part, due to a possible lack of standardization regarding the activities performed during an MR in various regions of the world, making it impossible for researchers to combine and analyze MR data from different countries.

A previously published comparison of the standardization or consistency of activities performed by pharmacists during MR in various countries was not identified; however, it is clear that the primary aims of MR programs vary widely around the world.2,11-13 For example, the British Medicines Use Review (MUR) targets adherence,14 whereas comprehensive medication management (CMM) in the United States includes an intensive workup of pharmacotherapeutic and patient-oriented goals.15,16 Several different national or regional guidelines on MR have been developed, tailoring MR activities to individual health systems. Examples include the Pharmacist Guide for the Saskatchewan Medication Assessment Program (SMAP), which has recently been evaluated,17,18 and the Australian guidelines for pharmacists providing Residential Medication Management Reviews (RMMR), Home Medicines Reviews (HMR) and MedsCheck.19 The existence of multiple locally developed guidance documents, funding models and policies suggests that there may be significant inconsistencies regarding the specific activities that are performed by pharmacists during an MR in different countries. The aim of this policy review was to compare the specific activities of pharmacists who provide MRs in a convenience sample of 6 countries. The primary objectives were to determine if there are inconsistencies in how the service is provided internationally and to identify if key components of MRs (based on known best practices) are being omitted.

Knowledge into practice.

  • There are different approaches to medication review. Several tailored guidelines have been developed and provided to clinicians.

  • This study found inconsistencies between medication review approaches from 6 global countries, including the large English-speaking nations. It compiled an inventory of medication review–related activities and agreed on some of them as being indispensable.

  • The recorded inconsistencies imply the need for a standardization of medication review on a procedural and practical level. Defined core activities could lead to a higher quality in clinical practice and to a greater external validity of medication review studies.

Mise En Pratique Des Connaissances.

  • Il existe différentes approches en matière d’examen des médicaments. Plusieurs lignes directrices adaptées ont été élaborées et fournies aux cliniciens.

  • Cette étude a permis de découvrir des incohérences entre les approches en matière d’examen des médicaments dans six pays du monde, y compris les vastes nations anglophones. Dans le cadre de l’étude, on a compilé les activités liées à l’examen des médicaments et convenu que certaines d’entre elles sont indispensables.

  • Les incohérences relevées indiquent qu’il est nécessaire de normaliser l’examen des médicaments, tant sur le plan de la procédure que sur le plan pratique. Des activités de base définies pourraient améliorer la qualité en pratique clinique et accroître la validité externe des études portant sur l’examen des médicaments.

Methods

This study used document analysis to compile an inventory of activities performed by pharmacists according to the policies of each of the selected country’s MR programs. Document analysis is a systematic qualitative methodology for reviewing the contents of various existing official documents.20 The 6 countries that were included in this document analysis were based on a convenience sample of the home countries of the participating authors, who identified their common interest in this work informally during various international meetings. Each author took responsibility for identifying and reviewing his or her home country’s national or regional frameworks, policies, funding criteria and/or practice guidelines regarding MR. Countries included were Australia, Canada (provinces of Ontario and Saskatchewan), Chile, Germany, United Kingdom and the United States. Documents were retrieved from the respective provincial, regional or national pharmacy boards or professional associations. Information regarding the specific activities expected of pharmacists in each program was extracted from each country’s MR documents and was combined into a single document. The lead author (OR) reviewed all of the documents to ensure the accuracy of data compiled by each author.

The relative importance of each MR activity identified during the document analysis was rated and scored in an attempt to further illustrate and compare the differences between each country’s program. Since a previously validated approach to describing the relative importance of each activity was not identified in the literature, the authors used their personal experiences and opinions to rate and score each activity independently on a 3-point Likert scale.21 Although subjective in its nature, the ratings also drew on the authors’ extensive experience in developing, implementing, undertaking or evaluating MR programs. Each author individually assigned a score of 2 points to activities he or she believed to be indispensable in an MR, 1 point to activities that he or she believed to be useful but dispensable and 0 points to activities believed to be nonessential. Since there were 8 authors, the maximum score that any activity could achieve was 16 points. Activities with scores of ≥13 were deemed indispensable, those with scores of 8 to 12 were deemed useful but not indispensable and activities with scores ≤7 were deemed not essential. The consistency regarding the performance of each of these MR activities in the 6 participating countries is described descriptively, with standard deviations for each score calculated.

Results

The following main documents were considered in the document analysis regarding the MR programs in Australia, Canada (provinces of Ontario and Saskatchewan), Chile, Germany, United Kingdom and United States, besides other policy or professional guidance documents identified by the authors.

  • Australian Home Medicines Review (HMR)22; the Australian Residential Medication Management Review (RMMR)23; the Australian MedsCheck,19 as described by the Pharmacy Guild of Australia; and the Australian guiding principles on medication management in the community by the Department of Health and Ageing24,25

  • MedsCheck services (Ontario)26

  • Saskatchewan Medication Assessment Program in Canada (Saskatchewan)17

  • Chilean Seguimiento Farmacoterapéutico (Chile)27

  • Guideline and commentary of the Bundesapothekerkammer (BAK),28 protocol of the AMBER study (Germany)29

  • British Community Pharmacist Medicines Use Review (MUR) Service Specification (United Kingdom)30

  • Centers for Medicare and Medicaid Services (CMS) guidance on Medication Therapy Management (MTM) services (United States)31

The document analysis resulted in a list of 41 activities that are performed by pharmacists during an MR in 1 or more of the 6 participating countries. Tables 1 to 3 show the participants’ rating and valuation of the activities. If the aspect is required according to the analyzed documents on national guidelines or specific standards, it receives a checkmark (✓). If it is not required, the participants rated whether it is “not required but often is done” (↔) or “not required and rarely is done” (o) based on their experience, other available documentation and personal judgement. The participants also expressed their personal valuation of the relevance and importance of each aspect, resulting in a total score per item (with coefficient of variation). The authors’ ratings regarding the perceived importance of each of the 41 activities resulted in 24 being deemed “indispensable” (Table 1), 10 being “useful but dispensable” (Table 2) and 7 being “not essential” (Table 3).

Table 1.

Medication review activities deemed indispensable or mandatory

Activity Australia Canada (Ontario) Canada (Saskatchewan) Chile Germany (BAK) Germany (AMBER) United Kingdom (MUR) United States Score SD
1. Mandatory patient consent form ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 15 0.33
2. Contact patient’s physician before medication review is conducted ✓* ↔ ✓ ↔ o ✓ o o 13 0.43
3. Patient interview: collect patient demographics ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 16 0
4. Patient interview: ask patient for chief complaint/primary concern ✓ ✓ ✓ ✓ o ✓ ✓ ✓ 16 0
5. Patient interview: take a detailed medication history (medication reconciliation) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 16 0
6. Patient interview: collect detailed history of patient’s medical conditions/diagnoses ✓ ✓ ✓ ✓ o ↔ ✓ ✓ 16 0
7. Collect additional patient history from electronic sources* ✓ o ✓ ✓ ✓ ✓ ↔ ✓ 13 0.48
8. Set goals in collaboration with patient ✓ o ✓ ✓ o† ✓ ✓ ✓ 14 0.43
9. Discuss recommendations with patient prior to implementation ✓ ↔ ↔ ✓ ✓ o ✓ ✓ 15 0.33
10. Medication adherence assessment ✓ ✓ ✓ ✓ ✓ o ✓ ✓ 16 0
11. Consider recommending lifestyle changes ✓ ✓ ↔ ✓ ↔ ✓ ✓ ✓ 14 0.43
12. Assess for contraindications ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 16 0
13. Assess for presence of adverse drug events ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 16 0
14. Assess for presence of drug interactions ✓ ✓ ✓ ✓ ✓ ✓ o ✓ 16 0
15. Assess for correct doses, frequencies, dosage forms ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 16 0
16. Assess that all medications are optimal (considering patient’s goals and best evidence) ✓ o ✓ ✓ o o o ✓ 16 0
17. Screen for untreated medical conditions, drugs without an indication and therapeutic duplications ✓ ✓ ✓ ✓ o ✓ ✓ ✓ 16 0
18. Prioritize drug therapy problems identified ✓ ✓ ✓ ✓ o ✓ ✓ ✓ 15 0.33
19. Create a care plan (includes goals of therapy, recommendations to resolve or prevent drug therapy problems and a monitoring plan) ✓‡ ✓ ✓ ✓ o§ ✓ o ✓ 14 0
20. Document findings/recommendations using a standardized format ↔ ✓ ✓ ✓ ✓ ✓ o ✓ 15 0.33
21. Collaborate with other health providers as required ✓‡ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 15 0.33
22. Communicate findings/recommendations with physician ✓‡ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 15 0.33
23. Educate patient regarding findings/recommendations ✓ ✓ ✓ ✓ ✓ ↔ ✓ ✓ 15 0.33
24. Follow up with patient o ✓ ✓ ✓ o ✓ o ✓ 14 0.43
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BAK, Bundesapothekerkammer; MUR, Medicines Use Review; SD, standard deviation.

Required according to the analyzed documents of national guidelines or specific standards (✓), not required but often done (↔) or not required and rarely done (o).

*

From additional sources (e.g., chart, electronic databases, labs, allergies).

†

For Home Medicines Reviews/Residential Medication Management Reviews.

‡

Plus pharmacy chart.

§

Patients should be “actively involved in the solution of problems” only for drug-related problems.

Table 3.

Medication review activities deemed not essential

Activity Australia Canada (Ontario) Canada (Saskatchewan) Chile Germany (BAK) Germany (AMBER) United Kingdom (MUR) United States Score SD (%)
1. Identify and involve patient’s primary caregiver, when applicable ✓ ↔ ↔ ✓ ✓ ✓ ↔ ✓ 6 0.33
2. Assess for correct medication storage ✓ o ↔ ✓ ✓ ✓ ↔ ✓ 6 0.66
3. Assess for correct patient handling of medications ✓ o ↔ ✓ ✓ o o ✓ 7 0.60
4. Use a standardized form to complete the medication review ↔* o ✓ o ✓ ✓ ✓ ✓ 6 0.43
5. Use an electronic tool to enable other health providers to read and/or edit the care plan o o o ↔ o o ↔ o 4 0.50
6. Communication recommendations with patient’s community pharmacist (if medication review not completed by community pharmacist) ✓ ↔ † † † † † † 5 0.70
7. Develop a structured educational plan using method such as motivational interviewing o o o ✓ o o o ✓ 3 0.48
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BAK, Bundesapothekerkammer; MUR, Medicines Use Review; SD, standard deviation.

Required according to the analyzed documents of national guidelines or specific standards (✓), not required but often done (↔) or not required and rarely done (o).

*

For Home Medicines Reviews/Residential Medication Management Reviews.

†

Done by community pharmacists.

Table 2.

Medication review activities deemed useful, but dispensable

Activity Australia Canada (Ontario) Canada (Saskatchewan) Chile Germany (BAK) Germany (AMBER) United Kingdom (MUR) United States Score SD (%)
1. Use specific criteria for patient selection/eligibility ✓ ✓ ✓ ✓ ✓ o ✓ ✓ 8 0
2. Obtain additional patient history from physician/other health providers ✓ o ↔ ✓ ↔ ✓ ✓ ✓ 11 0.48
3. Conduct a comprehensive patient interview face-to-face ✓ ✓ ✓ ✓ ✓ ↔ ✓ ✓ 10 0.49
4. Perform a review of systems assessment ↔ ↔ ✓ ✓ o o o ✓ 10 0.43
5. Measure patient’s vital signs (i.e., BP, HR, RR) ↔ o ↔ ✓ o ✓ o ✓ 8 0
6. Use a systematic thought process to identify drug therapy problems ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 12 0.71
7. Assess for potential cost savings ✓ o ✓ ✓ o o ↔ ✓ 9 0.60
8. Assess vaccination status ↔ ✓ ✓ o o ✓ o ✓ 9 0.33
9. Recommend interventions to support adherence (e.g., adherence aids, Dosetts) ✓ ✓ ✓ ✓ o o ✓ ✓ 8 0
10. Repeat medication review on regular basis ↔ ↔ ✓ ✓ o o ✓ ✓ 11 0.48
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BAK, Bundesapothekerkammer; BP, blood pressure; HR, heart rate; MUR, Medicines Use Review; RR, respiratory rate; SD, standard deviation.

Required according to the analyzed documents of national guidelines or specific standards (✓), not required but often done (↔) or not required and rarely done (o).

Activities such as “assess that all medications are optimal” and “follow up with patient,” which are key steps in the patient care process,32 were found to not be performed in all 6 countries. In the Australian HMR/RMMR, referral by a general practitioner (GP) starts the MR process and in the German AMBER study approach the GP is contacted before the patient interview to ensure a common basis on therapy. This might contribute to the quality of the MR and increase acceptance of recommendations made by the pharmacist. Aspects that signify a more medical approach to patient review, for example, a review of organ systems and their function, were not included in all countries but were believed to be useful in conducting an MR. Standardized forms for communication of MR findings and recommendations to the patient’s physician seemed rather helpful but are used only in some countries. Likewise, a standardized form for patient education was considered only in the American CMM, Saskatchewan and Chile.

Different preconditions and requirements to perform an MR were summarized. The setting, procedural aspects and quality-related standards varied between the 8 analyzed approaches. As expected, the results indicate that MRs are not performed consistently across the 6 countries included in the analysis, with inconsistencies even observed between different MR programs offered within the same country (i.e., Canada, Germany), as shown in Table 4.

Table 4.

Comparison of different national approaches to medication review

Australia—HMR/RMMR Australia—MedsCheck Canada Chile—MR Germany BAK United Kingdom—MUR United Kingdom—clinical MR United States—CMS MTM
Setting Home or ACF CP Any Any Any CP GP Any
Accreditation required? Yes*,† No† No No No Yes‡ No No
Referral from physician required Yes No No No§ No No No No
Inclusion criteria No** No** ≥3 drugs Yes†† No Yes‡‡ Yes‡‡ Yes§§
Patient interview mandatory Yes Yes Yes No No Yes Yes Yes
Defined template for report No No Yes Yes No No No Yes
Communication of findings to GP Yes No No Yes No No Yes No
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ACF, aged care facility; CP, community pharmacy; GP, general practitioner; HMR, Home Medicines Reviews; RMMR, Residential Medication Management Reviews.

*

Accreditation.

†

Provider number required.

‡

Short course.

§

Except cardiovascular patients in primary care centre.

**

Recommendations are to focus on specific criteria.

††

Five or more daily drugs, 65+ years, independent patients; multimorbidity and 7 or more daily drugs regardless of age.

‡‡

Patients taking high-risk medicines, recently discharged from hospital with changes to medicines while in hospital, with respiratory disease, at risk of or diagnosed with cardiovascular disease and regularly being prescribed at least 4 medicines.

§§

Three or more defined chronic health problems; 7 or more daily medicines, annual drug costs of ≥$4044 (Medicare Part D).

Discussion

This is the first analysis of published data that describes the wide range of approaches to pharmacist-led MR across multiple nations. Some of the inconsistencies across programs included elements that we judge to be clinically important, including a comprehensive patient interview and interprofessional collaboration. This study aimed to analyze those discrepancies and propose standards of best practice.

Many of the variations described in this article relate to aspects of MR that authors deemed to be useful but not essential (Tables 2 and 3), suggesting that these inconsistencies may not be clinically important. However, significant inconsistencies were also noted among aspects of MR programs that authors deemed to be essential (Table 1), which is perhaps the most concerning finding.

Medication review programs in many countries were developed as part of contract negotiations between professional pharmacy associations and government payors, with the primary purpose of providing additional nondispensing income to pharmacies. This may explain some of the inconsistencies of approaches identified in this study, as some MR programs may have intentionally omitted certain tasks or aspects that made the service less efficient or profitable. Stated another way, it may be that medication review programs have been designed more for profit rather than considering what patients need and what improves outcomes.

These findings also have potential implications for pharmacy practice researchers. Significant government funds are invested every year in MR programs in many countries, despite the fact that there are no large randomized trials showing that these programs reduce hospitalizations or mortality rates. The variations identified in this study make it very difficult, if not impossible, to perform the large multinational randomized controlled trials that are needed to determine if these programs add real value to health systems. It also makes it difficult to assume that the results of a study performed within one country will be relevant or applicable within the context of any other country. The results of this study should serve as a call to action for pharmacy professional associations around the world to develop standardized processes for this very common pharmacist-led clinical service, and to consider what services will improve patients’ quality of life and outcomes.

Future research is warranted to determine if similar variations exist within countries not included in this study and to define and validate a list of indispensable MR activities that ideally are performed to ensure quality of the MR and patient care. In the meantime, the list of MR activities included in Table 1, which were deemed to be indispensable by the study authors, could be used as a temporary proposed inventory of MR-related activities. The items in Table 1 certainly require further validation but can provide a first stimulus to standardize MR in order to increase quality of care and external validity of future studies.

Limitations

The study was based on the collaboration of a small group, and the analyzed approaches were rated after personal evaluation and opinion, leaving room for bias, as each participant collected information on his or her home nation. Consequently, it is not possible to link the inconsistencies found in this study regarding the “essential” aspects of MR programs and any possible negative effects on the impact of the MR programs on patient outcomes. Indeed, the previously published evidence to support the impact of MR programs on patient outcomes is weak, further limiting the findings of this study. This might be especially true if the chronic nature of medical conditions is not approached with longitudinal management or with a focus on improved patient outcomes. Scoring the relative importance of each MR activity was also based on the individual opinions of the authors, making these definitions prone to rater bias. It is also important to note that the definitions of “essential” and “not essential” were based solely on the authors’ opinions, since no formal definitions of these terms exist as they pertain to MR programs. Nevertheless, this finding provides some context to the potential importance of the inconsistencies identified in this study with respect to MR program approaches across participating countries. Not all readers may agree with all of the authors’ decisions regarding the classification of “essential” MR activities in Table 1; however, most will likely agree that at least some of these items, such as “assessing that all of the patients’ medications are optimal,” are necessary to provide a basic level of patient care. Additional research is required to determine if these inconsistencies actually lead to poor patient outcomes.

Conclusion

This international study confirmed that there is significant variation in regards to the activities performed by pharmacists during MRs within 6 different countries. Future endeavours to standardize this clinical service internationally will likely not only improve the quality of care that pharmacists provide when completing an MR but also facilitate future research and evaluation of MR programs. Standardization of care quality indeed is a basic requirement for future multicentre studies. Additional research is needed to confirm variations in other countries and to define and validate a list of indispensable MR activities. ■

Footnotes

Author contributions:VLC, SD, SE, DJ, FM and OR initiated the project; VLC, SD, KE, SE, DJ, KL, FM and OR were responsible for design and methodology; VLC, SD, KE, SE, DJ, KL, FM and OR were responsible for data collection and extraction; DJ, KL and OR wrote the manuscript; VLC, SD, KE, SE, DJ, KL, FM and OR reviewed the final draft.

Disclaimers:The views expressed in the submitted article are not an official position of the institutions.

Funding:The project was not funded.

Statement of Conflicting Interests:VLC has no conflicts of interest to report; SD is employed by Northwest Telepharmacy Solutions; KE has no conflicts of interest to report; SE has received a speaker honorarium from Merck Sharp and Dohme; DJ has no conflicts of interest to report; FM has no conflict of interest to report; KL has no conflict of interest to report; OR has received speaker honoraria from AbbVie, Bayer, Boehringer Ingelheim, Medac, Merck Sharp and Dohme, Noweda, Novartis and Omnicell.

References

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