pharmacists embedded in primary care medical practices , such as those modeled on the patient - centered medical home , are playing increasing roles in interdisciplinary primary healthcare teams.13 however , with limited pharmacist resources and high patient to pharmacist ratios , it is important to identify which patients would benefit most from consultation with a primary care pharmacist .
we have previously completed a similar assessment of patient requirements for dietician services in primary care.4 while commonly used approaches to identify patients for pharmacist care include physician referrals , drug- or disease - specific programs ( eg , chronic disease management ) , and patients recently discharged from hospital , an alternative strategy is to focus on patients at increased risk of medication - related problems ( mrps).2,57 mrps are events or circumstances involving drug therapy that actually , or potentially , interfere with an optimum outcome for the patient.8,9 several studies have identified factors associated with an increased risk of mrps,1014 and short , self - administered surveys have been developed to help identify patients at risk of mrps.12,15 our objective was to determine the feasibility of using a locally adapted , self - administered , paper - based , patient survey , to identify patients at risk of mrps , in a convenience sample of patients at a single academic family medicine clinic .
we conducted a cross - sectional pilot study based on a convenience sample of 100 completed surveys at the university of alberta hospital family medicine clinic in edmonton . at the time of the survey ,
seven family physicians , two family medicine resident doctors , two full time clinic nurses ( one dedicated to chronic disease management ) , and two academic clinical pharmacists ( each working ~0.2 full - time equivalent ) provided service to approximately 7,000 patients .
all patients registered to be seen by one of the clinic physicians were eligible to participate in this survey , unless they were less than 18 years old , could not read english , or were not responsible for self - management of their medications .
after registration at the reception desk , a medical office assistant asked eligible patients if they would be willing to participate .
those who expressed interest were given an information letter and a copy of the survey as they were placed in an examination room , and asked to complete the survey while waiting to be seen by their physician .
the university of alberta health research ethics board ( reb ) approved the study protocol .
we used the previously validated , ten - item mrp questionnaire , developed by barenholtz levy , and the modified five - item questionnaire , developed by langford et al , to create an adapted ten - item questionnaire ( figure 1).12,15 to adapt the questionnaire for the primary care ambulatory population , several changes were made .
the two most significant changes made were : 1 ) the focus of question 3 ( present in both surveys ) was changed from high risk medications to a chronic diseases focus , and 2 ) question 9 ,  does someone else bring any of your medications to your home for you ?  was replaced ( as all patients attending the family medicine clinic were ambulatory ) with  do you sometimes worry about the long - term effects of your medications ?  to determine feasibility , we recorded patient - reported time to complete the questionnaire , and we solicited opinions from the medical office assistants and physicians about the impact of the questionnaire on clinic flow . to estimate the number of patients at high risk for an mrp , we calculated a summary risk score .
responses , after collapsing question 3 into a single  yes  or  no  response .
as done by others in the literature , we defined patients who answered  yes  to three or more questions as being at high risk for a mrp.11,15,16 to allow further comparisons , we did a sensitivity analysis , in which we examined the number of patients who were at risk , while restricting analysis to the five questions developed by langford et al.15
we conducted a cross - sectional pilot study based on a convenience sample of 100 completed surveys at the university of alberta hospital family medicine clinic in edmonton . at the time of the survey ,
seven family physicians , two family medicine resident doctors , two full time clinic nurses ( one dedicated to chronic disease management ) , and two academic clinical pharmacists ( each working ~0.2 full - time equivalent ) provided service to approximately 7,000 patients .
all patients registered to be seen by one of the clinic physicians were eligible to participate in this survey , unless they were less than 18 years old , could not read english , or were not responsible for self - management of their medications .
after registration at the reception desk , a medical office assistant asked eligible patients if they would be willing to participate .
those who expressed interest were given an information letter and a copy of the survey as they were placed in an examination room , and asked to complete the survey while waiting to be seen by their physician .
the university of alberta health research ethics board ( reb ) approved the study protocol .
we used the previously validated , ten - item mrp questionnaire , developed by barenholtz levy , and the modified five - item questionnaire , developed by langford et al , to create an adapted ten - item questionnaire ( figure 1).12,15 to adapt the questionnaire for the primary care ambulatory population , several changes were made .
the two most significant changes made were : 1 ) the focus of question 3 ( present in both surveys ) was changed from high risk medications to a chronic diseases focus , and 2 ) question 9 ,  does someone else bring any of your medications to your home for you ?  was replaced ( as all patients attending the family medicine clinic were ambulatory ) with  do you sometimes worry about the long - term effects of your medications ? 
to determine feasibility , we recorded patient - reported time to complete the questionnaire , and we solicited opinions from the medical office assistants and physicians about the impact of the questionnaire on clinic flow . to estimate the number of patients at high risk for an mrp , we calculated a summary risk score .
responses , after collapsing question 3 into a single  yes  or  no  response .
as done by others in the literature , we defined patients who answered  yes  to three or more questions as being at high risk for a mrp.11,15,16 to allow further comparisons , we did a sensitivity analysis , in which we examined the number of patients who were at risk , while restricting analysis to the five questions developed by langford et al.15
demographic characteristics , summary risk scores , and time to complete the questionnaire are presented in table 1 . from patient reports in answer to the questionnaire ,
the median time to complete the questionnaire was 2 minutes ( interquartile range : 1.53 minutes ) .
there were no comments from the medical office assistants , or physicians approached during regular staff meetings , to suggest that the questionnaire was intrusive on the clinic s workflow .
the questionnaire was not distributed by medical office assistants to consecutive patients , because research was not considered to be a priority in their responsibilities , and clinical tasks sometimes intervened .
forty - three respondents had three or more risk factors identified by the full ten - point questionnaire , and 26 respondents met this criterion in the sensitivity analysis . in view of the limited data , and bearing in mind that this was a pilot study , no further mining of the data was undertaken .
the findings of this pilot study suggest that distribution of a mrp questionnaire at the point of care is feasible in a busy family medicine clinic , and that there was a strong signal for potential mrps in the sample studied .
however , there may have been a selection bias introduced by the office assistants , in terms of who they approached to participate , especially when they were busy .
we have identified issues relating to the efficiency of this approach ( consecutive patients were not all approached ) , and we suggest that asynchronous methods to systematically screen larger numbers of patients , such as the use of electronic medical record data , should also be explored to supplement the direct approach .
this anonymous pilot study , as approved by the reb , did not permit the pharmacists to act upon the mrps identified , whereas a chart survey would allow this .
this study adds to existing literature that demonstrates in practice the clinical utility of a mrp screening tool , and demonstrates its potential to generate pharmacist referrals .
while our overall estimate of patients at high risk for an mrp was double that obtained by langford et al15 ( 43% versus 18% , respectively ) , our sensitivity analysis , using only langford s questions , demonstrated more similar proportions ( 26% versus 18% ) .
the difference is likely related to the change in focus of one question , from high risk medications to the presence of common chronic diseases . in view of the differences between the two studies ,
unfortunately , comparisons with the sample studied by barenholtz levy are not possible , as they did not report summary risk scores , nor use a cut - off to define patients as being at high risk.12 perhaps one of our study s biggest strengths was its use of medical office assistant staff to screen patients , rather than using research personnel or clinic pharmacists . from a practical standpoint , part - time clinic pharmacists are not available to screen all patients attending clinics . despite this strength ,
since our study was an uncontrolled , single site , cross sectional survey based on a convenience sample , the time taken to achieve 100 completed surveys , as well as our estimates of the proportions of patients at high risk of mrps , may be unreliable . framing the survey as 
research  to the office assistants ( rather than quality improvement ) may have contributed to the prolonged recruitment period ; this was also contributed to by the deliberate  arms length 
policy of the investigators , to test the feasibility of the intervention in the practice context .
volunteer bias or preselection by medical office assistants could have led to overestimation of those at high risk . finally ,
as demonstrated by our sensitivity analysis , the reliability of this estimate is influenced by the number of questions included in the survey , and the arbitrary nature of the cut - off points to define high risk .
future study is required to compare different methods of patient identification for primary care pharmacists , determine what threshold accurately defines high risk of an mrp , and , ultimately , the effect of pharmacist intervention on risk of mrps . in conclusion ,
our results suggest that screening patients at the point of care , using a self - administered mrp questionnaire , was feasible , and that a large proportion of those who complete the questionnaire will have multiple risk factors for mrps .
this is similar to the opportunity found in our dietician study.4 however , other strategies , including electronic medical record screening or focusing on patients attending the chronic disease management nurse , may represent complementary methods to increase screening efficiency , and allow for more systematic screening of clinic patients for risk of mrps .
our findings support the integration of a pharmacist into family medicine practices , as a member of the patient - centered medical home .
future work will include further content and construct validation of the revised tool and its predictive ability for measures of health care utilization .
additionally , we plan to compare the predictive accuracy and feasibility of an automated electronic medical record medication list screening approach for identifying patients at high risk of mrps .
 background and objectivespharmacists working in primary care clinics are well positioned to help optimize medication management of community - dwelling patients who are at high risk of experiencing medication - related problems . 
 however , it is often difficult to identify these patients . 
 our objective was to test the feasibility of a self - administered patient survey , to facilitate identification of patients at high risk of medication - related problems in a family medicine clinic.methodswe conducted a cross - sectional , paper - based survey at the university of alberta hospital family medicine clinic in edmonton , alberta , which serves approximately 7,000 patients , with 25,000 consultations per year . 
 adult patients attending the clinic were invited to complete a ten - item questionnaire , adapted from previously validated surveys , while waiting to be seen by the physician . 
 outcomes of interest included : time to complete the questionnaire , staff feedback regarding impact on workflow , and the proportion of patients who reported three or more risk factors for medication - related problems.resultsthe questionnaire took less than 5 minutes to complete , according to the patient s report on the last page of the questionnaire . 
 the median age ( and interquartile range ) of respondents was 57 ( 4569 ) years ; 59% were women ; 47% reported being in very good or excellent health ; 43 respondents of 100 had three or more risk factors , and met the definition for being at high risk of a medication - related problem.conclusionsdistribution of a self - administered questionnaire did not disrupt patients , or the clinic workflow , and identified an important proportion of patients at high risk of medication - related problems . 
Background
Methods
Design and setting
Survey
Data analysis
Results
Discussion