Implementation of type 3 medication review in Flanders: obstacles and opportunities: Implementatie van type 3 medication review in Vlaanderen: obstakels en oppurtuniteiten

Medication reviews type 3 (MR3s) represent a collaborative initiative involving both healthcare providers and patients, with the overarching goal of attaining optimal medication therapy and enhancing overall health outcomes. On a global scale, there is a growing interest in medication review practices, evident in the initiation of pilot projects and subsequent widespread implementation efforts. This thesis mainly focused on the questions related to the sustainable deployment of MR3s in community pharmacies in Belgium. This involved an exploration of the factors influencing successful implementation like quality assessment, potential challenges encountered, and strategies to ensure the enduring and effective incorporation of MR3 practices in the Belgian healthcare system.
Chapter 1 provides a general introduction. In a first part we endeavoured to clear up the confusion surrounding the different definitions, classifications, and historical underpinnings of MR. Subsequently we directed our attention to the evolution, in Belgium, of pharmaceutical care with a focus on medication review. This part also described the origin and local context of this project as part of the training and professional development initiatives of KAVA and the subsequent academic involvement.
Chapter 2 provides an overview of the aims and structure of this doctoral thesis.
Chapter 3 discusses the perspectives and experiences of community pharmacists and general practitioners (GPs) active in a MR3 pilot project. This startup affirmed the preparedness of Belgian healthcare professionals to participate in MR3 and generated positive feedback from GPs and pharmacists. The input from these healthcare professionals indicated a positive outlook on the potential benefits of MR for patients and informed the subsequent training initiatives. This enthusiasm for MR during the pilot study points to its future potential, but further efforts will be needed to realize the widespread adoption of this service in Belgian community pharmacies.
Chapter 4 examines the views and experiences of patients who took part in a MR3 pilot project. They generally appreciated the attention and time invested by pharmacists during MR3s. However, some patients were not fully aware of the service's purpose and goals, making it crucial to offer them a thorough explanation of MR3. This strategy is expected to alleviate potential stress for patients when they are invited to engage in MR3 and during subsequent inquiries about their medications. Patients overwhelmingly expressed positive feedback regarding this new service, providing valuable insights for its further development and implementation. Improved communication by pharmacists and GPs to patients regarding the goals and components of this type of MR is, however, crucial.
Ensuring a high level of quality is essential for the effective implementation of MR3 in community pharmacies. Currently, there is, however, no tool or instrument available that can thoroughly evaluate the overall quality of MR3. This led to research into the creation of quality criteria (as detailed in Chapter 5) and the formulation of a scoring table (as described in Chapter 6), both specifically designed for MR3.
To establish the quality criteria, a ranking questionnaire was developed and deployed as described in Chapter 5. A panel of pharmacists from Belgium and the Netherlands, were tasked with ranking distinct quality criteria based on their perceived importance. Our investigation unveiled a broad consensus on the key elements crucial for evaluating the quality of MR3. Eight key statements emerged as integral components to be incorporated into a comprehensive MR3. Minor differences, related to the participants' level of experience, were noted.
Building upon the empirical evidence gathered from the study described in Chapter 5 and incorporating a small number of additional criteria proposed by participants, we initiated the creation of a streamlined and effective quality instrument for medication reviews as outlined in Chapter 6. This process included the development of a scoring table, called BRANT-MERQS, with a thorough examination of all the quality criteria identified in the preceding study. Data from two subsequent projects were examined, one involving patients with rheumatoid arthritis (RA) and another involving patients with type 2 diabetes mellitus (T2DM). This evaluation method clearly demonstrated its viability for assessing MR3 reports submitted by the community pharmacists, through requiring some improvements in the handling of the scoring table.
The reports received favourable to very favourable scores, although it is premature to establish a definitive benchmark value for the MR3 quality. Certain criteria were not directly quantifiable from the reports, and BRANT-MERQS may be further enhanced through combination with Patient-Reported Outcome Measures (PROMs) and Patient-Reported Experience Measures (PREMs). In this regard, we observed the additional benefit of incorporating patient experiences in the initial pilot project, as demonstrated by a qualitative survey. The quality criteria established in the Chapter 5 study are crucial, illustrating the diversity in conducted MRs and underscoring the necessity for rigorous control before initiating outcome studies. The BRANT-MERQs scoring table serves as both a self-assessment tool for pharmacists initiating the process and a peer assessment tool. It also provides insight for other stakeholders and third payers into the specific elements addressed during MR3. Nevertheless, this research underscores the significance of practical elements, such as the availability of a template or the provision of telephone feedback opportunities.
Chapter 7 presents a comprehensive discussion and exploration of future perspectives. Furthermore, the thesis's strengths and weaknesses are highlighted. Finally, the section includes recommendations for the implementation of MR3 in Belgian community pharmacies, accompanied by a delineation of areas that deserve further research.
In conclusion, we demonstrated the feasibility of implementing MR3 in pilot projects and identified key elements for the quality assessment of MR3. In addition, we demonstrated a remarkable level of enthusiasm for MR3 among both healthcare providers and patients. This research not only opens up new areas for further study, but also provide practical recommendations for enhancing clinical practice and patient care through the implementation of MR3.