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Summary of the Medicine-Use Review (MUR) Audit
[April 2010]
1.0 Aim
The PCT determined multi disciplinary audit involved three groups; community
pharmacy, general practice, and patients who have recently had a Medicines-
Use Review (MUR). The aim of the audit is to review the effectiveness of
MURs from the different perspectives of the participating groups, and where
appropriate, to improve the quality of MURs.
2.0 Criteria
The pharmacist performing the MUR must be accredited to do so, and it must
be conducted in a private room where patient confidentiality is upheld. For the
purpose of this audit, there is no specific criteria on which patients should be
selected for an MUR, although the national criteria states that the MUR must
be conducted with patients on multiple medicines, have a long-term condition,
and have received prescriptions from that pharmacy for the previous 3
months.
3.0 Standards
Due to the nature of the audit it would not be possible to achieve 100% for all
the criteria. However, the following criteria should have a 100% standard:-
Patients understanding why they were having an MUR 100%
This standard is 100% as a lack of understanding of why it is being carried out
would defeat the purpose and therefore could reduce the effectiveness from
the outset.
Patients who found the MUR useful with a rating of 3 or above 100%
This standard should be 100% as the reviews should be deemed as a useful
service by patients.
4.0 Methodology
A total of three different data collection sheets were used for each group
which included patients, pharmacists, and GPs. GPs were sent a brief outline
of the audit, and a form to capture their views of the service (appendix 1).
Pharmacists were sent two data collection forms; one for patients (appendix
2), and the other for pharmacists to complete (appendix 3). The pharmacists
were briefed on how to complete the forms.
Each patient that had an MUR was given their data collection form after this to
help gather information on their experience of the MUR. The patient was
requested to complete the form on site or take it away to be returned later. If
the patient needed support completing the questionnaire, the pharmacy staff,
excluding the pharmacist, could assist in this.
The pharmacist had to complete their form after each MUR to help gather
information which included reasons for undertaking the MUR, and to record
any recommendations made to the GP.
The data from each MUR performed by the pharmacist and their patients was
collected over a 30-day period for each MUR conducted from 1st April to 30th
April 2010. This was to ensure consistency across the city. It was decided not
to perform the audit during February or March as some pharmacies had
already reached their allocation of 400 and would be unable to conduct any
more.
5.0 Improvements to the MUR service
The audit process will allow pharmacists and prescribers to become aware of
current practice, where this practice works well, and how it can be improved to
ensure the service is utilised to allow the best possible outcomes for patients.
6.1 Benefits to Pharmacists
Review and improve patients’ understanding of their medication.
Improve patient care and safety
Help reduce medicine waste
Improve patient adherence to their medication
Support GP prescribing
Help build a good rapport with the patient
Promote healthy lifestyle choices
Builds on services they can offer to the community
To utilise their skills and knowledge effectively
6.2 Benefits to Prescribers
Highlights difficulties patients may have in taking their medicines
Improve patient care and safety
Improve patient adherence to their medication
Support from allied healthcare professionals
Help reduce waste
6.3 Benefits to Patients
Improved understanding of their medication
Improved adherence to medication
Address any concerns regarding their medication
Help build a good relationship with their pharmacist
Help improve medication efficacy so they can get the most out of their
drug therapy
7.0 Results
Leeds had a vast response for this audit. The following numbers of
submissions were received from the following participants:-
- 1161 patient responses;
- 1221 pharmacist responses;
- 65 GP practice responses.
When an MUR was completed, a total of 95% of patients understood the
purpose of the MUR.
No of Patients with Changes Recommended to the Way they take
their Medication
1.21%
1.12%
41.17% Yes
No
Not sure
56.50% Not recorded
The pharmacist had recommended changes to a total of 41% of patients with
regards to the way the patient should take their medication. From these
patients, 89% had said they were likely to implement the recommendations.
Number of Patients who felt their Knowledge had been
Improved
7.84% 0.69%
15.68%
Yes
No
Not sure
Not recorded
75.80%
A total of 76% of patients felt their knowledge about their medication and how
to take them had been improved after the MUR.
Rating Scale Indicating Patients' Perception of Usefulness of
MUR
0.69%
1.03%
13.44%
1 - Not useful
2
3
54.52% 4
30.32%
5 - Very useful
On the rating scale that indicated how useful patients found the MUR, a total
of 98% had rated the service on a scale of 3 and above, therefore indicating
patients found the service useful.
Percentage of GP Practices who find the MUR Service Beneficial
1.71%
37.71%
Yes
No
Not Recorded
60.57%
Most GP practices see a benefit from the MUR service.
Saves GP time in sorting out medicine
MUR Benefits to the Practice issues with patient
Supports the relationship between
patient and GP
Improves patients' understanding of
their medicines
79.55% 34.09%
38.64%
Improves patients' compliance with
medicine regime
50.00%
95.45% Improves patients' concordance by
40.91% giving them the opportunity to play an
81.82%
active role in decisions regarding their
condition/treatment
Supports management of long-term
conditions
Increases patient safety e.g.multiple
medicines management
The greatest benefit deemed by GPs for the MUR service was improving
patient understanding of their medicines, improving patient compliance, and
increasing patient safety.
Practice Partcipation in the MUR Service
Noting and filing MUR forms
8.62% received
Scanning MUR forms received
3.45%
13.79%
36.21% Read coding MUR forms and
68.97% entering them
Considering recommendations
as appropriate
Providing feedback to
84.48%
43.10% pharmacist as appropriate
Refering patients for MURs
Others
The majority of GPs consider the recommendations made by the pharmacist.
Primary Reason for Conducting an MUR
8.27%
0.41%
2.62%
4.01%
Long-term condition(s)
4.67%
Multiple medicines
1.23% Hospital discharge
Particular age group
PCT suggested group
66.42%
Other health problem
42.59%
Not recorded
Other reason
Patients with long-term conditions were the primary reason for conducting an
MUR, followed by a patient taking multiple medicines. This is in line with
national criteria on patient selection for the MUR service.
From the MURs conducted, 75% of patients had recommendations made.
The areas in which recommendations were made are highlighted in the graph
below.
Areas where Recommendations were Made
12.46%
Lifestyle recommendations
0.11%
2.84% Interactions/contraindications
6.01% Adherence
16.61%
61.86% Synchronisation of repeats
8.31%
Patient to talk to GP
Signposting for other services
42.84% 21.53%
Signposting for further information
Not recorded
Other
Lifestyle advice was the most common recommendation made, followed by
medication adherence, and interactions or contraindications.
8.0 Discussion
Due to the nature of the audit, it would be difficult to have most of the criteria
meeting a standard of 100%. However, the two criterions that should have
had a standard of 100% were patients understanding why they were having
an MUR, and if they found the MUR useful. A total of 95% of patients
understood why they were having an MUR, and only 5% of patients did not
know. The reasons why this may have been was not gathered in the data
collection form but if patients did not know why they were having the review,
then any subsequent understanding and advice may not have been as
valuable. However, when it came to patients rating the usefulness of the
service, 98% had rated it above 3 which was a positive result. The reason for
this can be explained by looking at the other results. Approximately, 3 in 4
patients had a better knowledge of their medicines after the MUR, and 89% of
patients said they were likely to implement the recommendations made by the
pharmacist. As these were both positive outcomes from the MUR, it would be
likely that patients would find the service useful.
Additional comments made by patients were also positive. Patients found the
service helpful, and some commented that they felt they could clarify issues
with their medication that their doctor may not have time for. In addition, some
felt they were more confident with their medication regime after speaking to
the pharmacist and felt they were a useful resource. The patients were given
their form immediately after the MUR, but had the option of completing it at
home. The accuracy of their answers may therefore have been affected by
this, as they would most likely answer positively especially if they were
handing the form back straight away. To help reduce any bias, a separate
sealed envelope could have been provided for each patient so they could seal
their form in this, and therefore give the patient reassurance that their
answers would be kept confidential. It would also be useful to see if these
recommendations were implemented and were beneficial to the patient, as
some patients that said they would implement the changes, may not have
done so in practice.
The majority of GPs find the MUR service useful, with a total of 84% of GPs
considering the recommendations made by the pharmacist. The most
frequent benefits of the service deemed by GPs are improving patient
understanding of their medicines, improved patient compliance, and increased
patient safety. However, the most common recommendation made by
pharmacists was related to lifestyle advice. One of the reasons for this maybe
because most patients would benefit from lifestyle advice, even if there was
no issue with their medication. Medication adherence, interactions and
contraindications were the second and third most frequent recommendation or
intervention, which is an expected result as this is one of the areas where
pharmacists can utilise their expertise, and be an additional safety mechanism
in the pathway.
Long-term conditions were the primary reason for conducting the MUR,
followed by the patient being on multiple medicines. Patients in these groups
are most likely to have issues with their medication and so providing an MUR
service appears to be most beneficial here.
Some GPs expressed criticisms of the service, which included duplication of
work and increasing their workload. Some also felt that suggestions made by
pharmacists were inappropriate particularly where this related to changes in
therapy which were not evidence-based. The MUR service is designed to
check patients understand their treatment, use their medication effectively and
identify any potential adverse effects. Therefore recommending changes to
patients’ therapy that are not in line with the service is something that would
understandably cause friction and pharmacists should avoid suggesting
changes that are out of the remit of the service unless clinically significant and
prior agreement between the pharmacist and GP has been made.
Furthermore, if GPs are to act on a recommendation of a pharmacist
undertaking an MUR, the information needs to be well structured and provide
the relevant details.
The MUR service represents an additional component in the patient care
pathway, and this is where the benefits of the service will be more apparent to
all parties concerned. Some pharmacists expressed that they would find it
useful if they understood priorities for the local surgeries regarding
prescribing. Improving communication between the pharmacist and the GP
would address any initial concerns that both parties may have, and an action
plan could be implemented which covered priorities for both to ensure
maximum benefit from the service is achieved. A further audit to establish
best practice and sharing this information may help all pharmacists to provide
a more consistent and valuable service.
9.0 Conclusion
In conclusion, the vast majority of patients found the MUR service useful, and
most commented that it was helpful to have a service that helped clarify any
issues they had with their medication. The service helped build a good rapport
between the pharmacist and patient, and highlighted the pharmacists’ role as
experts in medicines. GPs reinforced this expertise by ranking patients
understanding and compliance with their medication, and improving safety, as
key benefits of the service. However, better communication between the GP
and pharmacist in determining initial key priorities may help ensure the
service is used to maximum effect.
Positive comments by patients were given when the pharmacist had made
recommendations and interventions. However, further research is needed to
determine what the specific recommendations are, if these recommendations
and interventions are improving patient outcomes, helping to reduce
medication-related errors, and ultimately providing a cost-effective service.
10.0 Recommendations for future work
Currently, the PCT does make recommendations for the type of patient that
would most benefit from an MUR.1 These include those with one or more long
term conditions; if recently diagnosed with a long term condition; patients on
four or medicines; frail/elderly; recently discharged from hospital or secondary
care; those with recent changes to their medication; patients aged over 75
years; patients with evidence of poor compliance; or those attending a
number of GPs/ specialists. Whilst it is encouraging from the audit that
pharmacists are focused on groups of patients that will benefit from MURs,
such as those with long-term conditions, it may be more useful to break this
down further, and target those groups of patients that maybe more vulnerable.
Domiciliary patients and patients recently discharged from hospital with
changes to their medication are groups of vulnerable patients who may
require a greater pharmaceutical input than other patients. Adequate referral
pathways should be in place so the pharmacist is aware of whom they need to
refer the patient to should any issues arise.
Other target groups for MURs include patients who may have concordance
issues with their medication. These include those patients with respiratory
disease that are prescribed inhalers, and checking the correct inhaler
technique by a competent healthcare professional is important before
changes to drug therapy are made.2 An additional benefit of having targeted
MURs is that evidence of its’ effectiveness can be captured more easily,
thereby proving if the MUR service is cost-effective.
Specific target patient groups for MURs are to be introduced by the
government in 2011. These target groups will focus on those patients who will
benefit the most including those patients taking high risk medicines, patients
recently discharged from hospital who had changes to their medicines, and
patients with respiratory disease. Outcome measures for each target group
and measures which will improve post-payment monitoring will be introduced.
These changes will help ensure that MURs are delivered to a high quality, and
provide greater value for money and benefit to patients.3
Finally more collaborative working between different healthcare professionals
will help provide more positive outcomes that can be sustained in the long-
term. Ultimately to gain maximum value and benefit from any service,
effective communication is vital. Future changes in information technology
systems may also help in supporting this.
References
1. NHS Leeds. MUR Policy. January 2008
2. SIGN. British Guideline on the Management of Asthma. British Thoracic
Society. Updated May 2011.
3. PSNC and NHS Employers. NHS Community Pharmacy Contractual
Framework. 16/06/2011.
Appendix 1
Medicines Use Review (MUR) – General Practice Survey
The following survey forms part of a multidisciplinary audit of Medicines Use
Reviews (MURs) in which Community Pharmacies, the PCO and patients who
have had an MUR are participating. Answers to the following questions will help
to inform the audit results with the aim of improving the quality of MURs. The
views of general practice are an important aspect of this audit and are being
sought to help understand practices’ experience of and their approach to MURs.
For each question, please tick all boxes that apply.
Name of Practice
Which PCO are you part of? NHS LEEDS
(1) Are you aware of the MUR service provided by local pharmacies?
Yes
No (*see below)
* If you answered “No” to Q1, there is no need to continue with the survey. If
you would like more details relating to MUR’s you can download guidance via
www.nhsemployers.org/SiteCollectionDocuments/MUR-
_guidance_aw_170209.pdf.
(2a) Is the practice participating in MUR Service?
Yes (please go to Q2b)
No (please go to Q3)
(2b) How is practice participating in the MUR service?
Nothing and filing MUR forms received
Scanning MUR forms received
Read coding MUR forms and entering them
Considering recommendations as appropriate
Providing feedback to Pharmacist as appropriate
Referring patients for MUR’s
Other, please state below
(3) Has there been a meeting between the local Pharmacist(s) and the
practice GP(s) and/or Practice Manager to discuss MURs?
Yes – all local Pharmacists
Yes – some local Pharmacists
Yes – one local Pharmacist
No meetings taken place
(4a) Does the practice see any benefits from the MUR service?
Yes (please go to Q4b)
No (please go to Q5)
(4b) Please select any benefits to the practice of MURs:
Saves GP time in sorting out medicines use issues with patients
Supports the relationship between the patients and GP
Improves the patients’ understanding of their medicines
Improves the patients’ compliance with medicine regime
Improves patients’ concordance by giving them the opportunity to
play an active role in decisions regarding their condition/treatment
Supports management of long-term conditions
Increases patient safety e.g. multiple medicines management
Other, please state below
(5) Please list any problems you have experienced with the MUR
service:
(6) Please suggest ways in which MUR service could be improved:
Appendix 2
Appendix 3
Medicines Use Review (MUR) – Community Pharmacist Data
Collection Tool
Please complete one of these forms after each MUR that you complete during
the audit data collection period. Please answer all the questions ticking the
boxes that apply.
SECTION 1: Pharmacy demographics: to be completed by the pharmacy
Pharmacy ID Number (PPD or OCS Code)
Which PCO are you part of? NHS LEEDS
Please state what type of pharmacy you are?
Independent (if yes, tick box)
Small multiple: 2 to19 pharmacies (if yes, tick box)
Large multiple: 20 pharmacies+ (if yes, state which multiple you are part of)
SECTION 2: Details of MUR
(1) Who initiated the MUR?
Patient
Pharmacist
GP
Other, please state
(2a) Is this a first or subsequent MUR?
First (please go to Q3)
Subsequent (please go to Q2b)
(2b) If it was a subsequent MUR was it the same issues again?
Yes
Some
No
Don’t know
(3) What was the primary reason for undertaking this MUR?
Long-term condition(s)
Multiple medicines
Hospital discharge
Particular age group
PCT suggested group
Other health problem
Other reason, please state
(4) Please state how many medicines the patient was on
(prescribed and OTC) when he/she attended for this MUR
(5a) Were recommendations made to the patient during the MUR?
Yes (please go to Q5b)
No (please go to Q6a)
(5b) In which areas were recommendations made during the MUR?
Please select all that apply.
Lifestyle recommendations
Interactions/contraindications
Adherence
Synchronisation of repeats
Patient to talk to GP
Signposting for other services
Signposting for further information
Other area, please state
(6a) Did you contact the patient’s GP as a result of something identified
during the MUR?
Yes (please go to Q6b)
No (please go to Q7)
GP details not known (please go to Q7)
(6b) If the GP was contacted (see Q6a) what was the reason(s) for this?
(7) If an interpreter was needed were you able to obtain one?
Interpreter not required
Yes
No
(8) Did the patient ask questions during the MUR?
Yes
No
(9) Overall do you think that the MUR improved the patient’s
understanding of his/her medicines?
Yes
No
I’m not sure
(10) Did you identify any learning needs for yourself from this MUR?
Yes
No
I’m not sure
(11) Please use the box below to share any learning needs that this MUR
highlighted for you, or to make any additional comments.
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