Development, implementation, and evaluation of medication therapy management in Saudi Arabia

Albabtain, Basmah Abdulaziz ORCID: 0000-0001-6467-263X (2023). Development, implementation, and evaluation of medication therapy management in Saudi Arabia. University of Birmingham. Ph.D.

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Abstract

Background: Despite global evolution of the role of pharmacists, community pharmacy (CP) practice in the Kingdom of Saudi Arabia (KSA) is still in infancy and in need of substantial upgrades. Under the Vision 2030, the Saudi healthcare system is undergoing a significant transition. In this regard, the CP sector has benefited from ongoing initiatives that aim to introduce a new approach to healthcare. This PhD work aims to develop, implement and evaluate of CP-based medication review service in KSA.

Methods: This thesis was conducted using multiple methodologies. First, a systematic review and meta-analysis were conducted to evaluate the effectiveness of community-pharmacist-led medication review services with a wide range of targeted outcomes. Second, a mixed-methods study using an embedded design was conducted to assess the impact of a CP-based medication therapy management (MTM) service on patients’ outcomes. The embedded design consisted of two components, a pilot randomised control trial (RCT) and a qualitative descriptive study. The data were collected sequentially and independently. Glycated haemoglobin (HbA1c) was the primary outcome. Secondary outcomes included: clinical parameters, drug-related problems, health services utilisation, medication adherence, distress and satisfaction. Participants’ experience and views about the service was evaluated using face-to-face, semi-structured qualitative interviews. The final stage involved the process evaluation, quantitative and qualitative methods were utilised to understand the processes and conditions surrounding MTM service development and implementation.

Results: Forty RCTs were included in the systematic review and twelve in the meta-analysis. Compared to the control, a significant improvement was noted in the community-pharmacist-based medication review group for the following outcomes: blood pressure (BP) in patients with diabetes (mean difference (MD) in systolic blood pressure (SBP): -6.8 [95% CI -11.3, -2.3]; MD in diastolic blood pressure (DBP): -2.1 [95% CI -3.4, -0.9]) and in the hypertension patients (MD in SBP: -6.2 [95% CI -13.3, 0.9]; MD in DBP: -2.1 [95% CI -6.5, 2.3]), HbA1c in patients with diabetes (MD -0.6; 95% CI -0.9, -0.3), and total cholesterol (TC) in patients with hyperlipidaemia (MD -0.2; 95% CI -0.3, -0.1).

One hundred sixty patients with a mean age of 50 years (standard deviation (SD) ±11.9) took part in the RCT study. One hundred twenty-nine patients completed the RCT. Compared to standard care group, improvement was noted in MTM service group for all outcome measures. For the primary outcome, the mean HbA1c level was 0.21% (p=0.503) lower in the intervention arm at six-month. Additionally, the MTM service reduces the odds of healthcare utilisation by 93.1% (p=0.7) at six-month. Participants in the intervention group were 8 times more likely to be adherent compared to the participants in the standard group (p=0.0001). Finally, the MTM service group had a significantly higher median satisfaction score 4 [IQR 4, 4] than the standard care group 1.4 [IQR 1.3, 1.9]. For second phase, sixteen patients participated in the interview. Patients’ responses were classified into three broad themes: perceived benefits from the service, factors contributing to positive patient experiences and barriers and suggestions.

Finally, the findings of the process evaluation concluded that the service delivery was achieved as initially planned in the study protocol. Although most of the MTM service components achieved high fidelity, there were challenges in implementing the personal medication record (PMR), monthly follow-up and referral. A number of facilitating factors for service implementation were explored such as: availability of qualified and enthusiastic pharmacists to run MTM clinic, choice of the pharmacy location and utilisation of collaborative agreement. On other hand, barriers to implementation included: lack of manpower and interprofessional setup.

Conclusions: CP-based MTM service was deemed to be a ‘pioneer’ and serve the patient considerably, connected all health practitioners with all specialties in one clinic. The service is a potentially successful opportunity in the Saudi CP setting. The MTM service can improve clinical and patient-health outcomes. The findings from this thesis have useful clinical implications that could guide future research and clinical practice.

Type of Work:

Thesis (Doctorates > Ph.D.)

Award Type:

Doctorates > Ph.D.

Supervisor(s):