Participants

Members of 40 PTAM groups, either pharmacists (35) or GPs (5) were asked to participate. Seven groups agreed to participate. Characteristics are shown in Table D1 (Supplementary Material D).

One group did not start because the GPs were ultimately not willing to change the process of conducting CMRs. One group withdrew after implementing the questionnaire and task delegation to pharmacy technicians after the CP indicated it was too much effort, and in one group the CP expert left the pharmacy halfway through the project. Four groups were ongoing with Opti-Med2 until the end of the study. Although participating groups were asked to record details about the CMRs conducted, only sufficient data from one group was received. Reasons for not providing data were: forgotten to register; forms were lost; considering recording data an additional task; data only being recorded digitally in the GP information system, but not on the study forms.

CMRs performed

Six participating groups conducted on mean 28 ± 31 CMRs during their participation. One PTAM reported to have conducted 22 CMRs with 54 proposed interventions, of which 39 (72.2%) were implemented.

InterviewsCharacteristics of interviewees

Fifteen HCPs were interviewed separately at their workplace. Their characteristics are shown in Table 2. The interviews lasted 10 to 34 min with an average of 21 min.

PotentialIndividual intentions

Most CPs and GPs stated that conducting CMRs is important. A CPA and a GP mentioned that CMRs could improve the quality of the PT treatment of patients. Patient involvement was considered as an important quality asset. The HCPs also believed that the contact between GPs and CPs went more smoothly as the result of an intensified level of collaboration. Showing the patient that CPs and GPs actively collaborate was seen as positive and promoting patient adherence was also mentioned as a positive point.

Nearly all HCPs recognised that participating in the study was an opportunity to improve the CMR process. An advantage mentioned by many HCPs was the gain in efficiency, which allowed for an increase in the number of CMRs conducted. Both GPs and CPs saw a possibility to achieve continuity in the conductance of CMRs. Several CPs hoped that their appointments with GPs to perform PT analyses would be cancelled less often and that they would be able to better embed CMRs in their daily activities. A GP was motivated to try a new approach because of dissatisfaction with the current outcomes of CMRs.

“And we already do, let’s say, medication reviews. And, every year we end up with the same people with the same things (…) so maybe it would be interesting to try this once, to see if we can change things this way.” – General Practitioner Expert, group 7, participant 1 (GPE7.1).

Shared commitment

Jointly conducting the project was mentioned by HCPs as a success factor. In one group, the intervention did not materialise because too few GPs appeared willing to participate.

“However, the doctors want to keep it separate for each doctor. They don't want one doctor to discuss the reviews for the other doctors.” – Community Pharmacist Expert, group 1, participant 1 (CPE1.1).

CapacitySocial norms

A pharmacy technician reported that most patients were open to discussing their medication or to complete a questionnaire, but that some patients only wanted to discuss these matters with their doctor. On the other hand, a GP mentioned that patients spontaneously remarked that they appreciated being contacted and counselled by the CP.

“Yes, I thought that was excellent. So the pharmacy starts, and I notice from the patients that they also like it very much.” – General Practitioner non Expert, group 2, participant 4 (GPnE2.4)

Social roles

Several GPs and CPs had reservations about other HCPs reviewing their patients. A CP mentioned that it might be confusing for the patient and another CP was concerned about potential competition between the pharmacies. A GP felt somewhat uncomfortable about giving feedback to his colleagues, while another GP and a CP expected that the approach in which other HCPs were involved in PT analyses could lead to new insights.

“Of course, you’re a little bit under a magnifying glass. If your colleague assesses it, and you get an advice about it, yes. Yes, it has to be safe for that, I think, but I dare to do that.” – GPE7.1

Some CPs appreciated the contribution of pharmacy technicians and GP practice nurses in conducting CMRs. Pharmacy technicians were enthusiastic about these extended responsibilities (Table 3). A pharmacy technician mentioned she was able to deepen the relationship with the patient.

Table 3 Characteristics of interviewed healthcare professionals

A CP was concerned that by having patients reviewed by other HCPs, the individual relationship with the patient as well as with the other HCP could be harmed. Another fear was that the centralisation of CMRs could give healthcare insurers an incentive to impose centralisation on a larger scale. This could lead to bypassing local HCPs and more-table top reviews which are cheaper but certainly much less patient-oriented.

“If one pharmacist for the whole city starts reviewing then, as far as I'm concerned it's really theoretical paper reviews and, is not patient-centred.” – CPE2.3

Material resources (instruction manual, invitation letter, questionnaire)

All groups used the patient questionnaire. A CP sent the questionnaire but additionally invited patients for a face-to-face interview. Other CPs and pharmacy technicians only invited patients when they were unable to fill in the questionnaire themselves. Some CPs and pharmacy technicians remarked that the questionnaire was used as a discussion aid during the anamnesis with the patient and helped to time manage the interview. A GP considered some questions too difficult for older people.

“Yes, the questions have become more difficult for many people. Most of them are over the 80s. (..) My advice would be (..), fill that in with their child. – GPE7.1

The invitation letter inviting patients to complete the questionnaire was deemed useful. Patients appreciated that it was signed by both GP and CP, which made clear that it was a joint effort.

CapabilityWorkability

Several HCPs remarked they had to find a practical way to deal with the questionnaire. Most GPs, CPs and pharmacy technicians were satisfied with using a questionnaire. Some mentioned that conveying the expert teams’ PT advice to the patients’ GP took additional time and led to impoverishment of information. GPs who received PT advice, mentioned that it took little effort to implement the advice.

“I can only write it down very briefly for a colleague. If you've been there, then you know exactly what it's about and then you also know the reason why something might be changed.” – GPE2.1

HCPs were satisfied with the expert team. CPs appreciated that they had one contact for multiple practices, which simplified the organisation of CMRs. A GP feared that the organisation would be problematic and difficult to fit into the busy practices of GPs, but it all went smoothly.

“We really did ten each session. And then GPE5.2 also ten, approximately. So that's twenty patients per month, so that's a lot more than we expected.” – GPE5.3

Integration

GPs and CPs mentioned that having fixed appointments was crucial to keeping the review process going. A CP described that in case an appointment was cancelled, it was difficult to get back on track. Another CP described that collaboration came to a standstill after an expert team member went on leave.

"Well, particularly in that, we have really, now, started planning it. So every time we meet, we plan a new date." – GPE5.3

A GP said that a simple procedure was introduced by placing the PT advices in their physical mailbox, which made implementing PT advices a part of routine.

ContributionCoherence

Not knowing the patient was mentioned as an obstacle by many HCPs, because patient records often lacked information required for conducting CMRs. GPs receiving PT advices reported that interventions were not always appropriate.

Other HCPs mentioned it was easier to look at the medication more objectively and critically when a patient is unknown.

“And that did make it a bit easier to look at the matter from a distance, actually. And then fewer emotions come into play, because I don't know all those people. So then you come to very clear conclusions.” – GPE7.1

GPs experienced that by performing more PT analyses, they became more efficient because they had learned from previous sessions. A GP mentioned that GPs interested in CMRs and who conduct them regularly, can develop expertise which is otherwise difficult to develop.

Most GPs noticed changes in medication after a CMR. Some were deemed important, such as stopping medicines, others as minor.

“We observed things that had gone very wrong which I had not expected. Indeed, medicines that should have been stopped a long time ago and things like that.” – GPE5.3

Cognitive participation

GPs and CPs noted that the intensive collaboration during the project improved interprofessional collaboration. A CP remarked that the project also increased job satisfaction. Another CP was happy about the more frequent appointments for the analyses. A CP also noted that GPs increasingly apply the skills and knowledge acquired during CMRs in daily practice.

A GP appreciated the additional value of the perspective of the CP in the quality of the CMRs. A CP noted the importance of mutual respect for each other’s profession and expertise.

Collective action

Each group took their own approach to setting up the expert group. In most groups, GPs reviewed their own patients as well as those of their colleagues, whereas the CPs only reviewed their own patients. In one group, a GP only reviewed patients from his colleagues in the GP group practice.

Several GPs and CPs made clear agreements on performing patient selection. Some delegated administrative tasks to pharmacy technicians or GP practice assistants.

A GP remarked that they had adopted and implemented PT advices for interventions in most cases. It was mentioned that some recommendations were not followed up by the GP and were noticed to be open-ended after several months. This seemed more common when GPs were not involved in an expert team. Sometimes this is caused by the high time demands of daily practice. In other occasions, interventions proposed by the expert team in the medical record of the patient's own GP could be missed, because newer entries covered the earlier ones. This problem was circumvented by adding a pop-up appearing on the GP's screen when accessing the patient’s file.

"But especially those things that then also need to be discussed with the patient, when further explanation is needed, in the day-to-day, hecticness is not picked up. Then three months later, these questions are still open." – CPE2.3

Reflexive monitoring

Several HCPs reported continuing conducting CMRs using expert teams. HCPs in one group expressed their plans to create multiple expert teams within the group, one per GP practice instead of one for all practices, and maintain the questionnaires, task delegations and appointment structure.

Several groups shortened and/or adapted the questionnaire. Most CPs and pharmacy technicians considered the shortened questionnaire more useful.

"By a coincidence I used the short version and my colleague in the other pharmacy the long version. It turned out that, that with us the questionnaires were sent in better than with my colleague." – CPE2.2

One CP considered the questionnaire the most valuable intervention element. Some CPs mentioned to have used the questionnaire for patients reviewed outside the expert team, while the use of the questionnaire as a valuable tool also spread to other partner pharmacies.

Barriers and facilitators for the implementation of Opti-Med2

An overview of the barriers and facilitators for the implementation of Opti-Med2 classified according to the eNPT framework is presented in Table 4. Facilitators include: 1. the structured approach based on the PTAM framework allowed for achieving the required number of CMRs; 2. the intensified HCP collaboration contributed to good relationships between CPs and GPs; 3. pharmacy staff members expressed enthusiasm about their newly-assigned tasks and 4. the use of the Opti-Med2 method reduced the time investment to conduct CMRs.

Table 4 Barriers and facilitators according to the eNPT-framework

Main barriers include: 1. Not wanting any other GP than their own GP to perform the PT analysis, 2. Searching files of patients who the GP does not know is time-consuming. 3. The questionnaire is less suitable for people with impaired cognition.