This study is probably the first large scale trial conducted in Malaysia which involved collaboration between various healthcare professionals in the management of diabetes, hypertension or hyperlipidaemia at primary care level. More than half of the participants encountered at least one PCI, with a total of 706 PCIs identified.
Drug-use problems (especially non-adherence to medication), ADRs, therapeutic failure and drug-choice problems constituted the main PCIs encountered by participants in this study, followed by insufficient awareness or knowledge of participants. Wermeille and colleagues
 reported similar results. The high number of PCIs encountered by the participants indicates the importance of pharmacists working in collaboration with other healthcare providers to identify and resolve such problems. These include educating participants on the purpose and side effects of medications to clear their doubts and misconception, which would lead to better understanding and hence better medication adherence
Participants were taking their medications incorrectly in terms of dose, frequency and timing in relation to meals (8.2% of the PCIs). This again indicates that the provision of pharmaceutical care is essential to identify and resolve such problems in order to achieve optimal clinical outcomes and also to reduce side effects such as gastrointestinal disturbances.
Therapy failure constitutes 13.9% of the PCIs. The usual recommendations for such issues were to increase the dose or frequency of existing medication or to add another medication. Patients were also advised to monitor their BP or blood glucose level where appropriate. Constant monitoring of BP, blood glucose levels and lipid profile is crucial to ensure that these clinical conditions are within target levels in order to prevent complications and to reduce morbidity and mortality
[26, 27]. In addition, lifestyle modification was also often recommended.
The 11 dispensing issues identified in this study are not reflective of the incidence of dispensing problems encountered as this study was not designed specifically to determine dispensing errors, hence no direct observation of the dispensing process was carried out. Examples of dispensing errors noted in this study only served to alert the healthcare professionals, especially those involved in dispensing of medications at the primary care clinics, that such errors may occur and measures should be taken to minimize such risk.
Drug choice and dosing problems are usually detected via double-checking by an independent person. Pharmacists can act as a safety net to prevent or minimize any potential medication errors. These included a case of contraindication which involved a woman planning to get pregnant but was prescribed an angiotensin-receptor blocker which carries a potential risk of teratogenesis if the woman did get pregnant
. Again, the number of prescribing discrepancies that were identified is not indicative of the incidence of such problems as prescriptions issued to participants of this study were not screened individually.
Most of the PCIs were considered to be of no direct potential clinical significance (52%), especially non-adherence to medications and some minor side effects, but they could cause inconvenience and prolongation of the issues may lead to complications and increased cost of treatment. Incorrect timing of drug administration were considered to have minimal clinical significance, except for aspirin which has a higher risk of causing gastrointestinal complications and thus was classified as definitely clinically significant.
The main causes of PCIs were deterioration or improvement of disease state which led to therapy failure, and also presentation of new symptoms or indication. This indicates the role of pharmacists in monitoring patients with chronic diseases. The manifestation of side effects such as cough, gastrointestinal problems and symptoms of hypoglycaemia as well as patients’ concerns with drugs and undue worries about side effects were also common causes of PCIs. In these aspects, counselling of patients by the pharmacist is important to resolve some of the preventable side effects and also to assure and increase patients’ confidence concerning their medications. Consequently, educating and counselling patients on their medications and disease states were the main interventions made by the pharmacists (50.8%) in this study. Often, patients were referred to the prescribers (20.8%) especially if adjustment to patients’ prescribed medication regimens were deemed necessary.
In this study, most of the recommendations made by the pharmacists (87.3%) were carried out accordingly. This indicates the effectiveness of the pharmacist interventions in resolving PCIs as well as the doctor and patients’ confidence in following the recommendations made by pharmacists. Other studies have also shown that pharmacist interventions produced positive outcomes
[13, 28, 29] and well accepted by the doctors and patients
This study has several strengths. The CORFIS trial was performed in private primary care settings in Malaysia, highlighting the feasibility of collaboration between pharmacists, GPs, dietitians, nurses and patients in diabetes, hypertension and hyperlipidaemia risk management. The study had an adequate sample size and follow-up duration. It is probably the first study in Malaysia, which involved the collaboration of various healthcare professionals in managing primary care patients with chronic diseases.
There are also several limitations in this study. The process of detecting and resolving PCIs is very time consuming since there is a time-lag between identification and subsequently communicating the PCI to the caregiver involved, especially in a community setting. Potential bias in the detection and resolving of PCIs may exist since this depended heavily on the experience of the pharmacist performing the medication review. The classification of the PCIs, causes and outcomes were performed by two pharmacists based on the information recorded by the service pharmacist. Although care has been taken to be as accurate as possible in the classification, some ambiguities could not be ruled out. In addition, the classification of the clinical significance of the PCIs identified was not re-tested.