Community pharmacists can play a major role in helping patients navigate complex medication regimens. However, given the busy work environment of most retail pharmacies, time constraints limit the pharmacist's ability to be fully engaged. In order to have the greatest impact, pharmacists should target their efforts for those patients most at risk. Unfortunately, determining risk stratification in the community setting is difficult as data are limited.

The Medication Regimen Complexity Index (MRCI) is a tool that had been used in previous studies to address polypharmacy and comorbidities in which medication complexity is based on the number of drugs, dosage frequency, administration instructions, and prescribed dosage forms. However, the MRCI is labor-intensive because scores have to be manually calculated.

Given the difficulty associated with use of the MRCI, investigators from an independent community pharmacy conducted a study to develop and assess a medication-regimen complexity score for reliability and validity; to design and implement a Less Complex Program (LCP) to tailor medication management services to the complexity of the medication regimens; and to evaluate the impact that the LCP has on the identification and resolution of medication-related problems (MRPs).

The LCP utilized the Iowa Medication Complexity Score (IMECS), which was calculated based on five components, including the number of prescribers, the number of different medications dispensed, the number of dosage forms being taken, the number of high-risk medications (based on the Beer's criteria of potentially inappropriate medications), and the number of dates medications were dispensed to a patient. Each occurrence of a component was assigned one point. The intent was to program this LCP into an electronic clinical documentation platform for community-based patients, to integrate it into the pharmacists' workflow, and to use it routinely to target pharmacists' interventions in this population.

Towncrest Pharmacy in Iowa City, Iowa, patients aged 50 years were eligible for enrollment in the LCP. The intensity of the pharmacist's interventions was based on the complexity of the medication regimen. Patients with low-medication complexity regimens (i.e., IMECS <24) were managed with continuous medication monitoring (CoMM); those with a moderate-complexity regimens (i.e., IMECS 25-40) had targeted interventions along with CoMM; and those with a high-medication complexity regimens (i.e., IMECS >41) underwent CoMM and case management involving comprehensive medication reviews.

Targeted interventions were interventions that focused on specific conditions or medications taken by the study patient. The cut-offs utilized aligned with the percentages in the pyramid of medication management, where the base of the pyramid refers to population-based care and the top of the pyramid is patient-centered care.

The key measures for evaluation of the LCP were the types and numbers of MRPs identified in the pharmacists' notes and interventions and the IMEC scores. The reliability and validity of the IMECS met face, content, and criterion validity compared with the MRCI.

Baseline and postintervention data were available for 661 community pharmacy patients (mean age: 72.6 years) out of a total of 1,019 patients. The mean number of medications ranged from 18.2 in the high-intensity group to 5.8 medications in the low-intensity group. Overall, the mean IMECS score dropped from 28.6 at baseline to 27.3 postintervention. This was attributed to a decrease in the number of medications utilized and the number of fill dates. Almost one-half (49.0%) of patients showed a decrease in IMECS, 28.9% showed no change, and 22.1% demonstrated an increase in IMECS. The P value was <.05 across the three complexity groups.

Among the 1,019 patients, there were a total of 10,535 care notes logged by pharmacists that documented 10,535 MRPs and 10,482 interventions. Over 40% of MRPs identified involved medication nonadherence, followed by an indication for patient counseling (17.1%), the presence of therapeutic duplication (16.8%), and the need for additional therapy (8.9%). Those in the low-complexity group had approximately one-half of the annual rate of MRPs compared with the high-complexity group. The "needs additional medication" MRP was most common in the low-complexity group. Fall risk rates were similar between the three complexity levels as this had just been the focus of a pharmacy resident's project. Of the 10,482 interventions, the most common were the need for continued monitoring (35.6%) and patient counseling (16.6%).

This community-based study demonstrated the feasibility of a population health management approach to identifying and targeting MRPs based on the complexity of a patient's medication regimen.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

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