Telephone Follow-Up of Patients Receiving Antibiotic Prescriptions From Community Pharmacies

Krystel Beaucage, Hélène Lachance-Demers, Thi Thanh-Thao Ngo, Cynthia Vachon, Diane Lamarre, Jean-François Guévin, Andrée Martineau, Danielle Desroches, Joëlle Brassard; Lyne Lalonde

Disclosures

Am J Health Syst Pharm. 2006;63(6):557-563. 

In This Article

Discussion

Telephone follow-up by a community pharmacist proved to be an excellent opportunity for detecting and managing DRPs. However, this did not translate directly into a measurable improvement in the number of infectious symptoms or the infection severity score. Adherence to antibiotic treatment and patient satisfaction were very high in both groups. The cost of the intervention may vary between $5.11 if pharmaceutical advice is not reimbursed and $2.65 if all pharmaceutical advices are reimbursed.

Several aspects of the methodology maximized the internal validity of the results, including randomization, standardization of the PTFI intervention and evaluation process, and modest losses to follow-up. However, a number of factors may have contributed to reducing the impact of the PTFI intervention on the clinical symptoms of infection. Because the access to clinical data was limited, the main study outcome consisted of a patient's subjective evaluation rather than microbiological cultures. In addition, simply counting the number of symptoms at the initial and final evaluations may not have been sufficient. The responsiveness of the scale may have been improved by allowing patients and interviewers at the final evaluation to review the symptoms initially reported. Moreover, a significant proportion of the patients included in the study were probably suffering from viral infections. Because antibiotics are not efficacious against such infections, it is unlikely that optimizing antibiotic treatment would affect the symptoms of these patients.[1] Indeed, in a secondary analysis, by excluding patients suffering from upper- or lower-respiratory-tract infections (the patients most likely to have viral infections), we observed a larger reduction in the number of infectious symptoms among PTFI patients. It is important to note that all patients received high-quality pharmaceutical care; before randomization, all the consultations were standardized and conducted in a private area, with no time limits. This may have reduced the observed difference between the groups. Finally, fewer patients than anticipated were recruited, and we overestimated the expected differences between the groups; the study lacked the statistical power to detect such small differences.

The results show clearly that a telephone follow-up is a simple and inexpensive intervention and can effectively identify opportunities for intervention. This approach allowed pharmacists to detect a greater number of DRPs and consequently to provide more oral recommendations and more written pharmaceutical advices. Compared with the study by Dudas et al.,[7] which reported one DRP for 19% of patients, our study led to the detection of at least one DRP for 53% of patients. Similarly, the telephone follow-up generated 15 more instances of pharmaceutical advices than the usual follow-up, or 5.8 advices per 100 prescriptions (5.8%). Given that the corresponding figure for all Quebecers covered by the government insurance plan was 0.62% in 2003,[18] the impact of telephone follow-up on the care process can only be described as major. It is worth mentioning that we did not measure any indirect positive effects of the program. For example, Westfall and Narducci[9] reported that call-backs frequently prompted patients to discuss other health issues not always related to their antibiotic treatment, including possible pregnancy, uncontrolled asthma therapy, and treatment of depression.

No impact on adherence to antibiotics was detected. In contrast, a recent controlled randomized clinical trial by Urien et al.[19] found improved adherence after telephone follow-up (78.3% versus 54.1% in the control group, p = 0.005) among adults with a prescription for antibiotics. Patients in the intervention group received precise and appropriate oral instructions on how to comply with treatment to avoid the risk of relapse, complications, and bacterial resistance. During a visit to the patient's residence, the investigators counted how many pills the patient had left. In contrast to our study, the patients were not told in advance that such counting would take place; the counting was thus probably more accurate than in our study. However, our results might also be attributed to the effectiveness of the standardized pharmaceutical consultations. Garnett et al.[8] observed an improvement in adherence among patients receiving telephone follow-up compared with a control group (87% versus 77%). However, no difference was observed between patients who received a telephone call and those who received written and oral consultations.

Patient satisfaction was extremely high in both study groups, which underlines not only patients' satisfaction with a high-quality pharmaceutical service but also their receptiveness to greater pharmacist involvement. A telephone follow-up may cost $2.65 to $5.11 per patient. In a system where cognitive services are reimbursed, such calls are relatively inexpensive, particularly when one takes into account additional indirect benefits, such as customer loyalty, which were not considered here. To improve the efficiency of the intervention, it may be relevant to target patients at risk of DRPs in order to maximize benefits and minimize costs.

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