A stepped wedge randomised controlled trial assessing the efficacy and patient acceptability of virtual clinical pharmacy in rural and remote Australian hospitals
Authors: Nott Shannon , Fleming Cristen , Hawthorn Gerard , Luscombe Georgina , Allan Julaine , Webster Emma , Coleman Clare , Palazzi Kerrin , Dizon Joshua , Munro Alice , Chambers Brett 
Published: October 2023

Background
Despite medications being the most common healthcare intervention and medication-related incidents being common in hospitals, many rural and remote hospitals in Australia lack onsite pharmacy services due to resource constraints. A Virtual Clinical Pharmacy Service (VCPS) was implemented in rural and remote facilities to determine whether the intervention increased adherence to National Safety & Quality Health Service Standards (NSQHS).
Methods
A stepped wedge cluster randomised controlled trial design was employed to sequentially implement a telehealth pharmacy service at one-month intervals in eight hospitals (clusters). The primary outcomes were patient-level medication reconciliation completion rates on admission and discharge. Secondary measures evaluated compliance with other NSQHS standards (including Best Possible Medication History), patient outcomes, and detection of potential medication-related harms. Patients were invited to complete a patient-reported experience measure questionnaire. Data was collected from electronic medical records and analysed using mixed logistic regression models to estimate the effectiveness of the interventions. Antimicrobial usage, falls, and medication errors were analysed at the facility level, while other data was analysed at the patient level.
Results
Compared to control (n = 535), patients in the intervention period (n = 527) were more likely to have an admission medication reconciliation completed (Odds Ratio (OR) 11.16, 95% confidence interval (CI) 5.59–22.30) in models adjusted for the study period. A similar improvement was observed for discharge medication reconciliation completion (OR 4.07 CI 2.38–6.95), whereas a 33-fold improvement was seen in Best Possible Medication History completion (OR 33.27, CI 17.53–63.14). The VCPS identified 879 medication interventions, with 61% of patients had at least one medication-related intervention documented by a pharmacist. There was no change in length of stay, falls, readmission rates or reported medication error rates; however, the study was not powered to detect these changes. Patient feedback was positive and comparable to in-person care, with 95% (179/189) reporting overall pharmacist experience as ‘good’ or ‘very good.’ No unintended harms were reported.
Conclusions
The VCPS improved compliance with national standards for medication safety, had high patient acceptability and resulted in the detection of clinically relevant medication-related issues in rural and remote settings. The applicability of virtual pharmacy should be explored in other settings, including metropolitan locations with no onsite clinical pharmacists.
Ethics number:
GWHREC 2019/ETH13355
Trial registration:
ANZCTR registration number ACTRN12619001757101. Registered on 11/12/2019. Publish trial protocol: A stepped wedge trial of efficacy and scalability of a virtual clinical pharmacy service (VCPS) in rural and remote NSW health facilities | BMC Health Services Research | Full Text (biomedcentral.com)