General practitioners’ perceptions on home medicines reviews: a qualitative analysis
Amrith Kaur Dhillon
Hendrika Laetitia Hattingh
School of Pharmacy, Curtin University
Bentley, Perth 6845
Background: Home Medicines Review (HMR) is an Australian initiative introduced in 2001 to improve quality use of medicines. Medication management services such as HMRs have the potential to reduce medication related problems. In 2011, changes to the HMR program were introduced to allow for referrals directly to accredited pharmacists in addition to the community pharmacy referral model. These changes were introduced to improve efficiency of the process. This study explored the perceptions of Western Australian general practitioners (GPs) on benefits and barriers of the HMR service and process, including their insights into the direct referral model. Methods: Purposive sampling of GPs who had experience ensured that participants had a working knowledge of the HMR service. Semi structured interviews with 24 GPs from 14 metropolitan Western Australian medical centres between March and May 2013. Transcribing and thematic analysis of data were performed. Results: Most GPs had positive attitudes towards the HMR service. Main perceived benefits of the service were poly-pharmacy reduction and education for both the GP and patient. Strategies identified to improve the service were introduction of a standard HMR report template for pharmacists and better use of technology. Whilst reliability and GPs' familiarity were the main perceived benefits of the direct referral model, a number of GPs agreed that patient unfamiliarity with the HMR pharmacist was a barrier. Conclusions: Despite recognition of the value of the HMR service participating GPs were of the opinion that there are aspects of the HMR service that could be improved. As one of the success factors of HMRs is relying on GPs to utilise this service, this study provides valuable insight into issues that need to be addressed to improve HMR uptake.
There is an increasingly high prevalence of
medicationrelated problems (MRP) in the Australian primary health
care setting [1-5]. The government has therefore
implemented a number of interventions to improve medication
management services. Home Medicines Reviews (HMR)
has been in place since 2001, introduced to improve
quality use of medicines . It is a collaborative medication
review service that involves a referral from a general
practitioner (GP) to a community pharmacy or an
accredited pharmacist. The aim is to facilitate community-based
patients medication therapy and minimise the prevalence
of MRPs . GPs plays a vital role in determining whether
patients are likely to benefit from this service as HMRs
require a referral from a GP. Previous literature indicated
that some GPs believe HMRs potentially improve
medication safety, awareness and management [8,9]. However,
others have expressed concerns regarding the complexity
of the HMR process, time constraints and inconsistency in
the reporting format and quality [6,10,11]. Considering the
variance in GP opinions towards HMRs, an understanding
of their attitudes and beliefs is integral in addressing
potential barriers in order to improve HMR uptake.
Prior to 2011, the only available option to refer a patient
for a HMR was to the patients nominated pharmacy. This
changed in 2011 whereby a second referral model directly
to accredited pharmacists was introduced to improve
efficiency of the process . No research has been
conducted to determine whether this direct referral
model has improved HMR uptake.
Our aim was to explore Australian GPs' perceptions of
the benefits and barriers of the initial HMR process and
service as well as their perceptions of the new model. It
was anticipated that a better understanding of GPs'
attitudes towards the HMR service would inform the
development of strategies to improve the HMR process. The
objectives of this study were to obtain GPs perspectives
and views on:
1) The role and value of HMRs,
2) The most beneficial aspects of the HMR service
3) Strategies to improve the HMR process and
4) The direct HMR referral model to accredited pharmacists.
Low-risk ethical approval was granted by the Human
Research Ethics Committee of Curtin University (Approval
PH-O1-13). This study involved semi-structured interviews
with GPs practising in Perth, Western Australia (WA) who
had utilised the HMR service. Purposive sampling of GPs
who had experience ensured that participants had a
working knowledge of the service which added value to the data.
There were no pre-existing relationships between the
researchers and the participants. This study was carried out
by a final year pharmacy student (AD) under supervision
of three pharmacy practice academics who were also
experienced accredited pharmacists (LH, AS, KH).
Qualitative methodology was selected to allow for
in-depth exploration of participants views . A
semistructured interview guide was developed that addressed
the study objectives consisting of the following nine
1. How involved have you been in HMR program?
2. What do you feel the main aim of the HMR program is?
3. As a GP, describe the process you utilise in identifying whether a patient is likely to benefit from a HMR referral?
4. What aspects do you think are working well for this service?
5. What do you see as barriers that are limiting the uptake of this program?
6. What are your suggestions to improve the HMR process in specific to promote uptake, effectiveness and usefulness?
7. What sort of factors do you feel may influence the extent of service provided by GPs?
8. Explain your thoughts on the recent change that GPs are able to directly refer a HMR request to an accredited pharmacist rather than to a community pharmacy first?
9. Are there any more comments you would like to
make regarding your experience with the HMR
service that you would like to share?
Prompts allowed for re-wording, clarification and
exploring of topics . Open-ended questions encouraged
GPs to discuss their perceptions of the role of HMRs,
benefits, barriers limiting uptake and strategies for
improvement. The final question provided an insight on
their views of the new model. The interview guide was
prepared by the primary researcher (AD) with guidance
from the co-authors. The interview guide was tested on
an academic practitioner for validation purposes.
Interviews were conducted individually for practical reasons
and GP time constraints.
GPs were recruited over a wide geographical area within
Perth. Participant recruitment was initially through
promotion of the project to medical centres and local
practitioner networks. A total of 24 participants were set as the
minimum target for reaching saturation . The majority
of participants were recruited by contacting 44 practice
managers of medical centres. Additional GPs were
approached through a snowball sampling technique 
which involved recruitment through accredited
pharmacists and participating GPs. Interviews were conducted at
each GPs practice. All participants were given an
information sheet about the project and signed a consent form
prior to the interview, also providing approval for audio
recording. Participants received a small gift voucher.
Transcribing and thematic analysis of data were done
manually by the primary researcher (AD) using Word
2010 (Microsoft Corporation, Redmond, United States).
This involved an in-depth process of colour-coding themes
and sub-themes. Data collection ceased when saturation
was achieved. The themes identified emerged from the
indepth analysis of the interview data. All transcribed
interviews and data analysis were reviewed by the research team
members independently to confirm consistency.
A total of 24 GPs (19 male, 5 female) from 14
metropolitan medical centres in Perth were interviewed between
March and May 2013. Interviews ranged from 12- 35
minutes (mean 21 minutes +/- 5.7). Seventeen of the
GPs were aware of the direct referral model and 12 had
utilised this option. Thematic analysis of the interview
transcripts highlighted several areas of interest. There
were four main themes that emerged namely:
Patient and GP benefits
The majority of participants expressed support towards
the HMR service. Table 1 is a summary of selected
Table 1 GP comments about HMR benefits
Education on the need of medication
Preventing interactions between potentially harmful
combination of medicines
Education on medication administration
Preventing confusion with generic medication
Reconfirms current complementary, OTC and
So again advantages for patients, I think its fairly straight forward that the patients become
aware of every medication they are taking. (GP3)
Ever since I started using HMRs, I realised instead of having multi-drug therapy, we can cut it
down to four. From say eight, we can cut it down to six, four and thats fantastic because patient
compliance became much better and our drug interaction became less and patients wellness
became much better. (GP6)
Ensuring no dangerous drug interactions is potentially being missed. (GP10)
What we want to do is to confirm that at home that the patient is taking the regimen we
believe they are so that there is no accidental confusion with the variety of generics medications
which are doubling up on doses. (GP8)
I think it enhances the patients engagement with the health system and they feel like somebody
cares which is good and also I think it enhances the patients feeling of responsibility of self-care.
It also optimises the cost for the patient. (GP19)
It brings to the fore other issues like OTC medication which is a reality of what we live in. People
can get all sorts of medication, some not very good while some are beneficial like complementary
medication, naturopathic medications and so when you conduct a Home Medicines Review; it
brings those things to the fore. (GP19)
Education on side effects of medicines
Just makes the patient more knowledgeable and to look out for any side effects. (GP13)
Preventing interactions between prescribed and
Trying to make sure patients are not taking herbal or other complementary medicines thats
going to interact with what they are taking. (GP5)
Education on side effects associated with current
medication and suggests relevant monitoring tests
Improving dosage knowledge in patients with
chronic renal disease
I can also feel a bit more comfortable that with the support of a pharmacist reviewing whats
happened at home that what Ive heard the pharmacist has identified; we are all on the same
The feedback I get is a learning curve for me because theres a lot of new knowledge gained
from the accredited pharmacist looking at side effects or monitoring. (GP3)
I have had feedback particularly with medicines associated with people with chronic renal
disease as to doses and thats some good stuff. (GP8)
Patient related benefits
The majority of participants agreed that HMRs facilitate
compliance through educating patients about the correct
use of medicines. Participants also indicated that this
service could serve as reassurance for patients, thereby
increasing self-confidence and independence. Additionally,
some participants stated that HMRs could assist patients
in the monitoring for side effects associated with
particular medicines and medication administration. Participants
also indicated that HMRs were specifically useful in
patients with cognitive impairment and immigrants with a
poor command of English. A reduction of costs for
patients was another perceived benefit.
GP related benefits
A number of participants stressed that HMRs improved
their pharmaceutical knowledge, commenting that after
receiving a HMR report they were more informed of
patients complementary, over the counter (OTC) and
prescription medication. Participants highlighted that
HMRs provided insight into potentially harmful
combinations of medicines that patients take without GPs
knowledge. This allowed for concerns regarding
potentially harmful combinations to be addressed. The
decrease in poly-pharmacy through a reduction in unnecessary
medication was addressed by 19 participants. Additionally,
issues pertaining to duplication of therapy due to generic
substitution were also addressed.
Participants mentioned that upon completion of a HMR
they were able to make better judgments as to whether a
patient required any additional medication monitoring.
They were also able to address issues associated with
side effects of medication. Two participants stated that
HMRs improved their knowledge of medication dosing
in patients with chronic renal disease. HMRs were also
found to reassure GPs that patients were being
managed appropriately. Based on previous experience, two
participants reported higher utilisation of HMRs in
retirement villages and country (rural) settings, indicating
specific benefits in these settings.
Patient related barriers
Participants reported that patient discomfort associated
with the HMR being conducted at their residence resulted
in resistance to the service. A lack of patient awareness
regarding the effectiveness of HMRs was also reported.
GP related barriers
A few participants expressed lack of interest in using the
HMR service and one stated that HMRs were not
beneficial. The long convoluted HMR process, tedious
paperwork, time constraints, and low awareness of the HMR
service were identified as the four main barriers limiting
HMR uptake. One participant highlighted the lack of
information available on patient eligibility.
Strategies to improve the HMR process
Participants suggested that the process of HMR could be
improved if accredited pharmacists used a standard HMR
report template and focus on practical recommendations.
The incorporation of an electronic reporting program was
Table 2 GP comments about HMR barriers
Lack of awareness on HMR effectiveness
described by participants as another strategy to improve
HMR uptake. A minority believed that assigning specific
personnel from the practice to be the focal point of the
program could contribute to the efficiency of the process.
Supporting statements are reflected in Table 3.
I think if you establish a rapport with one or a number
of pharmacists that you have confidence in their work
quality and youre happy to use it because you know
what you are getting back will be worthwhile. (GP 8)
However, some GPs had concerns about the fact that
patients may not know the accredited pharmacist
specifically if the accredited pharmacist was not their
community pharmacist. These GPs were more inclined towards
patient preference in the choice of the pharmacist
conducting the HMR.
This study provided insights into GPs opinions towards
HMRs. While a range of views were expressed, most of
the participants had a positive attitude towards the
program. The majority of the GPs were of the opinion that
HMRs were beneficial to patients medication
understanding and management. The GPs highlighted the medication
management advantages from their perspectives as well as
educational benefits for them as well as their patients.
Barriers limiting HMR uptake mainly involved issues with
Sometimes patients may not want to have somebody come to their house and that might be for a whole
range of reasons and it could possibly indicate that there is an issue acting on the domestic front that they
feel uncomfortable and this is something that needs to be concerned about. (GP8)
They dont fully understand why they need a HMR or how it will benefit them; they are then less likely to
go for it. (GP10)
The other scenario is the mindset that is it an administrative nightmare. You have to do the paperwork and
comply with Medicare requirements. Theres a lot of time involved pre and post, you have to read the thing,
a lot of doctors just say oh forget it. I might as well do consults and leave it there. (GP1)
We were not very well exposed to HMRs. Most of our patients are well controlled but we never looked at it
as an option as to why the patient needs a HMR or if a patients illness was not controlled, we always think
of referring to a specialist or well think of other options. (GP6)
For me, its probably just being busy to be honest with you. (GP21)
I think the program has got a lot of merit but Im not doing them because Im time poor. Although I think
it is a great idea and it is beneficial for patients, I just dont seem to be able to incorporate them into my
busy life. (GP 15)
Table 3 GP focused strategies on approaches to improve the HMR process
Ive noticed most of the pharmacists have a very easy to read format. There are one or two
pharmacists write their response in the form of an essay thats a bit difficult to absorb so
obviously if they come out with a universal way of doing this, that will be ideal. (GP3)
Generalised template with the same information but less writing out of information. I think that
would suit doctors better because a lot of the cut and paste we already know. (GP10)
The more that it becomes an online process, it would certainly help the situation cause that just
speeds things up and if they send it back online, I think that process would definitely help. (GP7)
Assigning personnel from practice to be the
focal point of the program
This is why I think its important to have somebody not a GP in the practice to run the HMR process
because GPs are too busy. (GP11)
HMR processes and GPs time constraints. Potential
strategies for improving the HMR process included a standard
HMR report template and an electronic reporting system.
This is the first published study to provide insight into
GPs perceptions of the direct referral model. GPs noted
that reliability and familiarity with the accredited
pharmacist were the main perceived benefits of this model.
However, patient familiarity with the community pharmacist
was considered by some GPs to be of greater importance,
as unfamiliarity with the HMR pharmacist may result in
refusal to participate in the service. Consequently, most
GPs indicated that the referral pathway decision should be
made by the patient. This preference needs to be
considered by pharmacists as many community pharmacists
outsource HMRs to accredited pharmacists who work
on a contract basis.
This study confirmed that HMRs were perceived as
useful educational tools to GPs. GPs also believed that
patients feel reassured and feel more independent as a result
of being educated by the pharmacist during a HMR.
These findings were consistent with the national and
international literature on medication reviews [6,10,11]
and similar services . The results from this study
support previous studies which indicated that HMRs provide
a mechanism to identify MRPs and recommend
alternative treatment options to resolve problems [9,18]. As such,
it provides additional evidence of the perceived value of
HMRs in improving clinical outcomes by facilitating safe
and effective use of medicines and increased GP and
patient knowledge of medicines .
Some of the strategies suggested by the GPs to
improve the HMR process were consistent with previous
studies [6,10,11]. Participants described the HMR process
as being lengthy, with tedious paperwork not conducive to
GPs time constraints. The preferred strategy suggested
to streamline the process was the introduction of an
electronic communication system. This strategy supports
previous findings which indicated that an electronic
system would simplify the GP referral process and improve
the transfer of documents between GPs and pharmacists
[6,10]. GPs supported the concept of a standard HMR
reporting template to improve the consistency of reports
produced by pharmacists. The frequent reporting of these
strategies highlights the lack of awareness on the
availability of these resources including the online HMR referral
and management form which exist within a commonly
used GPs prescribing software . Measures should be
taken to increase awareness and the use of existing HMR
tools. Other strategies included assigning personnel, such
as a practice nurse manager, to be the focal point of the
program to improve efficiency of the process. This finding
is similar to other studies [6,10,11]. GPs were of the
opinion that intrusion into the patients domestic setting could
be a barrier. This raises GP concerns of underlying factors
such as cultural barriers and domestic issues that may be
contributing to a patients resistance towards the service.
However, a previous study that involved a patient survey
indicated that the discomfort patients feel about being
visited in the home by a pharmacist was not significant
whereas their perception of personal benefit from the
HMR was influential in their decision to have a HMR .
As the recruitment was limited to GPs who had
experience with HMRs, those who volunteered or were
recommended may have been biased towards the service.
Nonetheless, previous HMR experience was a requirement
to ensure that participants had a working knowledge of
the service and could provide informed responses. The
low uptake of HMRs in WA made recruitment
challenging, resulting in the utilisation of snowball sampling.
While the findings have confirmed that HMRs improve
GPs knowledge of the medicines their patients are
taking and medication management advantages for patients,
it also raised issues pertaining to GP convenience and
patient familiarity with the accredited pharmacist
conducting the review. Resolving both concerns could
improve the uptake of the HMR service. There is a need for
further research into strategies to overcome these barriers
and establish whether the strategies proposed are
beneficial towards improving the HMR process.
AS, LH and KH designed the study, supervised and confirmed the data
transcription and analysis procedure. AD was responsible for data collection
and analysis with input from LH. All authors contributed to the writing of
the article and critically reviewed the article before the final manuscript was
produced. All authors acknowledged that they had full access to the data
collected in this study. All authors read and approved the final manuscript.
The authors acknowledge the 24 GPs who participated in this study.
This project received a $2400 grant provided by the J M OHara foundation
through the Pharmaceutical Society of Western Australia which contributed
towards the remuneration given to participants. The funding body did not
have a role in the conduct of the research or the decision to submit the
manuscript for publication.