A Randomized Controlled Trial of Pharmacotherapy Specialist Team Consultation Integrated into Primary Care Practice Settings versus Specialty Service Provided in a Hospital Outpatient Clinic

by Lisa Dolovich | Dec 01, 2001

Key Implications for Decision Makers

  • When drug therapy specialists consult with primary care practitioners at the primary care site, rather than doing consultations in a hospital outpatient department, this leads to:

    • drug therapy specialists making more recommendations for patients on complex multiple drug regimens, and
    • family physicians accepting more drug therapy specialist recommendations by 3 months after the consultation.

  • Drug therapy specialist consultations at the primary care practice site with primary care practitioner participation should be considered for complex patients who have multiple medical conditions and are taking multiple medications.

  • There is no difference in the cost of drug therapy specialists seeing patients at the primary care practice site compared with seeing patients in the hospital outpatient department site.

  • The number of participants in this study was too small to determine if this change in process has an effect on quality of life or goals a patient can attain, but the change in process was not associated with any obvious detrimental health effects.

  • Drug therapy specialist consultations at the primary care practice sites took more specialist and family physician time at the initial assessment, as well as travel time for the specialists. Because of this, changes in the financial compensation system and the health care delivery process would be needed to encourage specialist consultation at the primary care practice sites.

Executive Summary

The Specialist Outreach Study evaluated differences in processes, outcomes, and costs of consultations carried out by drug therapy specialists for 22 complex patients at primary care practice sites (including review of patients' primary care charts and review of specialists' recommendations with the family doctor) and for 22 complex patients who saw the specialists as usual in the hospital outpatient department site.

When drug therapy specialists consulted at the primary care practice site compared to the hospital outpatient department site:

  • the specialists made more recommendations, and
  • the family doctors accepted more of the specialists recommendations within 3 months of the initial assessment.

There were trends in favour of patients seen at the primary care practice site for the following:

  • the specialists identified more patient problems, the majority of which were drug related,
  • the specialist made more drug related recommendations per patient for patients seen at the primary care practice site, and
  • patients seen at the primary care practice site had a higher proportion of health goals that improved.

There were no differences in health related quality of life, overall goal attainment score, or number of medications taken by patients three months after the initial consultation for patients seen at the primary care practice site compared with patients seen at the hospital outpatient department site.

It took more time for the specialists to travel to and from appointments and to set up for patients seen at the primary care practice site.

There were no differences in specialist time for initial specialist -patient assessment at the primary care practice site compared with seeing patients at the hospital outpatient department site. It took approximately 2.5 hours to complete an assessment, including research and documentation.

When specialists were at the primary care practice site, family doctors spent approximately 9 minutes talking to the specialists about the patient being seen.

There were no differences in family doctors' ratings for the process of assessment, content of assessment, or overall satisfaction for patients seen at the primary care practice site compared with those seen at the hospital outpatient department site. In general, family doctors rated the specialist service delivered quite highly at both sites.

There were no differences in how patients rated the service given by the specialist physician or specialist pharmacist, their personal knowledge about managing their medication after the consultation, or their access to the specialists for patients seen at the primary care practice site compared with patients seen at the hospital outpatient department site. In general, patients rated the specialist service delivered quite highly at both sites.

More patients preferred seeing the specialists at the primary care practice location, although their ratings could be based only on their experience with one location of service. (This means that more people who received service at the hospital outpatient department site would have preferred seeing the specialist at the primary care practice site.)

There were trends in favour of patients seen at the primary care practice site for the following:

  • family doctors felt that specialist consultations at the primary care practice site provided them with more information about one or more drugs, and
  • family doctors felt that it would be useful to have more outreach services for other medical or surgical consultative services.

Overall, when the costs of the intervention (including travel time) and consequences are taken together from a health care system perspective, there was no statistically significant difference in the costs of specialists seeing patients at the primary care practice site compared with seeing patients in the hospital outpatient department. The results did not change appreciably when patient costs were also considered.