Discussion
pain
DISEASE
This study describes MTM recommendations for participants enrolled in the INCREASE trial. The most common medication categories flagged at baseline included 1) cardiometabolic medications, 2) gastrointestinal medications, 3) pain management medications, 4) anticholinergics, and 5) vitamins/supplements. The most common types of recommendations made at baseline were 1) dose adjustments and 2) switches to more appropriate therapeutic alternatives.Notably, BCGP recommendations were not strictly medication related. In this study, many MTM recommendations did not directly involve a medication change, but rather addressed other potential medical problems (e.g., disease monitoring, referral for diagnostic workup or physical therapy, addition of non-pharmacologic therapies). Each of the top five medication categories identified in the analysis for baseline recommendations included at least some OTC medication options, and one-third of baseline MTM recommendations involved a medication available OTC. OTC products are available without a prescription and were identified frequently as PIMs (13% of all baseline recommendations and 15% of final recommendations). Thus, our study points to the importance of educating patients on the risk–benefit profile of OTCs and the role of pharmacists in OTC stewardship.Among the final MTM recommendations analyzed, 40% underwent revision compared to the baseline MTM recommendation provided. This reflects the potential for several factors to influence recommendations as more information is gathered in a multidisciplinary MTM intervention. Notably, input from the patient on previous therapies, medication tolerability, feasibility/adherence, and condition severity may help inform the MTM team’s final decision-making process. Our results demonstrate that engaging the patient in a team-based intervention may result in patient-motivated revisions to baseline recommendations. This comparison of pre-intervention recommendations to final recommendations after team deliberation has not been discussed in previous literature.Participant responses indicated willingness to make recommended changes about half of the time and a need to confer with a primary care provider or other clinical specialist about one third of the time. This was interpreted as generally positive, since participants were most often willing to either accept the final recommendation as specific, or to further engage with another healthcare provider to seek additional medical advice. While participant refusal to change was generally low, our findings suggest that patients may be less willing to adopt MTM recommendations for certain categories of medications or for certain recommendation types. Previous literature has addressed acceptability of MTM recommendations [Though extensive medication and medical histories were collected from participants, the baseline recommendations were limited to self-reported information before randomization, and complete clinically relevant information was not always available to the BCGP at baseline (e.g., renal function from an electronic medical record). This finding indicates that pharmacists engaged in MTM processes need access to relevant clinical information and an opportunity for direct engagement with prescribers and the patient who have first-hand knowledge of such clinical variables. In addition, chart review may not capture all information necessary to make a patient-centered MTM recommendations, which has not been reviewed in previous literature [There are several limitations to this study. The 2015 Beers Criteria [It is important to note that not all MTM interventions are equivalent. The INCREASE trial modeled its intervention on a foundation of multidisciplinary team interaction with active participant engagement. This is often beyond the scope of traditional, community pharmacy-based MTM models in practice today. The present results suggest that medical advice from a patient-centered team with multiple healthcare perspectives is both appealing to patients and may elicit a stronger patient acceptance of MTM recommendations. Further studies characterizing patient responses to different MTM models are needed to determine whether the qualities such as mode of delivery and multidisciplinary involvement impact long-term recommendation adherence, and/or influences patient outcomes.