Development and implementation testing of a medication review service blueprint for community pharmacy practice in Malaysia

Abstract

Medication review services are evidenced based practices in which a systematic assessment of a patient's medication is conducted, with the primary aim of optimizing drug therapy and minimizing adverse drug events through pharmacist interventions. In Malaysia, medication review services have been established in public hospitals and home setting. However, implementation in community settings is still pending due to various challenges. Using an implementation science approach that guides healthcare services' uptake, success, and sustainability, this study aimed to develop a medication review service blueprint for implementation in the community setting in Malaysia. The specific objectives are to identify the barriers, facilitators, and tailor strategies through developing a medication review service blueprint and testing the implementation at the community pharmacy settings. Utilizing the Triple Diamond Service Design method to visualise the process, this study consists of four main projects. The first study involves a qualitative study design using focus group discussions and individual interviews to investigate community pharmacists’ perceptions of the barriers, facilitators and strategies related to implementation of medication review services in the community setting. The Framework Analysis approach with the Consolidated Framework for Implementation Research (CFIR) was utilized in this study. Study two involved content analysis of previous literature on established services overseas to develop a priori medication review service blueprint. A modified two round e-Delphi survey to seek an expert consensus-based medication review services blueprint was utilized in study three. Study four is an effectiveness-implementation hybrid type 3 study to evaluate the implementation outcomes while observing the effectiveness of the medication review service. In study one, interviews with 20 community pharmacists identified several barriers and facilitators to service implementation. The prioritised strategy analysis included identifying and preparing champions, conducting local consensus discussions, organizing educational meetings, and promoting adaptation. Through content analysis a priori medication review blueprint was developed in study two and a consensus on the model was achieved in study three, with 26 experts in the field. The consensus-based medication review blueprint consisted of two types: 1) Medication review-consultancy (MR-C) and 2) Medication review-clinical (MR-Clin) that differ in terms of services’ aims, complexity, and activities. In study 4, 78.5% (n=11) of community pharmacies reached the testing phase, and 36% (n= 4) achieved the implementation phase. A total of 54 patients were recruited, resulting in an implementation reach of 70%, with high competence fidelity, and most patients expressed satisfaction. A total of 133 drugrelated problems were identified, resulting in 64 interventions. The main barriers reported by community pharmacists during the pilot study were "inability to plan for change" and "lack of individual alignment with the change". Facilitation strategies included "engaging stakeholders by creating ownership of the change" and "equipping stakeholders with training". The dissemination and implementation of the Medication Review Service in the community setting in Malaysia have marked a positive start. To leverage the medication review service's effectiveness, multi-level, multi-component, collaborative strategies with continuous monitoring, feedback, refinement, and adaptation are required.