Discrepancies between physician-documented and patient-stated drug regimens are a potential risk to both medication effectiveness and patient safety. Patients with chronic heart failure (CHF) are especially prone to drug-related problems (DRPs) like discrepancies due to a high number of drugs. Interdisciplinary consolidation between physicians and pharmacists after a medication review may improve the quality of drug regimens. 

To analyze the changes from the physician-documented medication plan (MP) to the interdisciplinary consolidated MP (CMP) after pharmacists reviewed the current medication used by CHF patients.

As part of the PHARM-CHF randomized controlled trial, community pharmacists conducted a medication review with CHF patients over 60 years in the intervention i.e., pharmacy care group. They compared the physician-documented MP with the current drug regimen stated by the patient and checked for DRPs. Pharmacists consulted with physicians on identified discrepancies and other DRPs to develop the CMP. This CMP was used by the pharmacist to provide the medication in weekly dosing aids for the patient. 

We analyzed 93 patients (mean 74.0 ± 6.6 years, 38% female), with a median of ten (IQR 8–13) drugs in total. Overall, 81% of the patients had at least one change from the physician-documented MP to the CMP. We identified changes in 33% (303/926) of all drugs. The most common change was the addition of a drug into the CMP (43% [131/303]). For example, 10% (8/80) of agents acting on the renin-angiotensin system were added to the CMP. We also determined frequent changes in the dosing regimens (38% [114/303]), such as the change of the daily dose in 12% (11/90) of beta-blockers and 17% (16/94) of diuretics. The omission of a drug accounted for 19% (58/303) of the changes. Of all identified changes, 68% (207/303) originated from patients’ reports at the medication review with the pharmacist. The other changes (n=96) were based on agreements within the process of consolidation between physicians and pharmacists. Of those, 22% (21/96) resulted from identified DRPs, such as drug/drug-interactions. Fifty-nine drugs identified during the medication review by the pharmacist but not documented in the MP, were not considered in the CMP.

The medication review and interdisciplinary consolidation of the medication plan resulted in changes of the drug regimen in the vast majority of the patients. The changes affected one third of their medication. Structured physician-pharmacist interdisciplinary care is able to harmonize and optimize the drug treatment of patients with CHF substantially.