Trajectories of pro re nata (PRN) medication prescribing and administration in long-term care facilities

BackgroundLittle is known about changes in pro re nata (PRN) medication prescribing and administration in residential aged care facilities (RACFs) over time.ObjectiveTo determine the prevalence and factors associated with PRN medication administration in RACFs and examine changes over 12-months.MethodsSecondary analyses utilizing data from the SIMPLER randomized controlled trial (n = 242 residents, 8 RACFs) was undertaken. PRN medication data were extracted from RACF medication charts. Factors associated with PRN medication administration in the preceding week were explored using multivariable logistic regression.ResultsAt baseline, 211 residents (87.2%) were prescribed ≥1 PRN medication, with 77 (36.5%) administered PRN medication in the preceding week. PRN administration was more likely in non-metropolitan areas, and less likely among residents with more severe dementia symptoms and greater dependence with activities of daily living. No significant differences in overall PRN prescribing or administration in 162 residents alive at 12-month follow-up were observed.ConclusionsDespite being frequently prescribed, the contribution of PRNs to overall medication use in RACFs is small. PRN prescribing and administration was relatively static over 12-months despite likely changes in resident health status over this period, suggesting further exploration of PRN prescribing in relation to resident care needs may be warranted.     

Development,validation and evaluation of the Goal-directed Medication review Electronic Decision Support System (G-MEDSS)©

Objectives1) To understand and investigate the experiences of accredited clinical pharmacists (ACP) using computerised clinical decision support systems (CCDSS) during medication reviews for older people, including those living with dementia; 2) To design, develop, validate, and evaluate a CCDSS that incorporates pharmacological and other deprescribing tools to aid person-centred management of high-risk medications in older adults living with and without dementia.MethodsThis study consisted of three phases and was designed on scenario-based methodology: a) the development phase, which included an exploratory survey and prototype building; b) the validation phase, which included qualitative data collection and usability testing with ACPs, general practitioners (GPs) and carers for people living with dementia; and c) the evaluation phase, using mixed-methods analyses.ResultsThe exploratory survey found that ACPs required a flexible, and reliable CCDSS to support them with clinical decisions regarding high-risk medication use in older adults. The Goal-directed Medication review Electronic Decision Support System (G-MEDSS)© was developed and validated using quantitative and qualitative feedback received from ACPs, GPs and carers for people with dementia. The mean (SD) System Usability Scale score was 69.0 (12.9), which indicated fair-good usability.Discussion and conclusionsInvolving end-users in the design process refined and improved the design of G-MEDSS, allowing for a person-centred and goal-directed delivery of pharmaceutical care. G-MEDSS allows healthcare practitioners conducting medication reviews for older adults living with and without dementia to tailor pharmaceutical care to meet their goals and preferences. Future studies may explore integration of G-MEDSS with prescribing or dispensing software.     

Development of a screening tool to identify patients likely to benefit from clinical pharmacist review in a home-based primary care population

ObjectiveTo create a novel screening tool that identified patients who were most likely to benefit from pharmacist in-home medication reviews.DesignSingle-center, retrospective study.Setting and participantsA total of 25 homebound patients in Forsyth County, NC, aged 60 years or older with physical or cognitive impairments and enrolled in home-based primary care or transitional and supportive care programs participated in the study. Pharmacy resident-provider pairs conducted home visits for all patients in the study. Pharmacy residents assessed the subjective risk (high, medium, low) of medication nonadherence using information obtained from home visits (health literacy, support network, medications, and detection of something unexpected related to medications). An electronic medical record–based risk score was simultaneously calculated using screening tool components (i.e., electronic frailty index score, LACE+ index [length of stay in the hospital, acuity of admission, comorbidity, emergency department utilization in the 6 months before admission], and 2015 American Geriatric Society Beers Criteria).Outcome measuresThe electronic medical record–based screening tool numerical risk scores were compared with pharmacy resident subjective risk assessments using tree-based classification models to determine screening tool components that best predicted pharmacy residents’ subjective assessment of patients' likelihood of benefit from in-home pharmacist medication review. Following the study, satisfaction surveys were given to providers and pharmacy residents.ResultsThe best predictor of high-risk patients was an electronic frailty index score greater than 0.32 (indicating very frail) or LACE+ index greater than or equal to 59 (at high risk for hospital readmission). Pharmacy residents and providers agreed that homebound patients at high-risk for medication noncompliance benefited from pharmacist time and attention in home visits.ConclusionIn homebound older persons, this screening tool allowed for the identification of patients at high-risk for medication nonadherence through targeted in-home pharmacist medication reviews. Further studies are needed to validate the accuracy of this tool internally and externally.     

Psychedelic Drug Crises: Toxicity and Therapeutics

Abstract

In a previous article, the authors described the changes initiated by recent health care legislation, and how those changes might affect the practice of medicine and the delivery of addiction services. This article reviews the same changes with respect to how they have the potential to change the practice activities of addiction physicians, addiction therapists, addiction counselors and addiction nurses, as well as the activities of administrators and service delivery financial personnel. Developments in delivery systems and the impact of those developments on professionals who work in addiction treatment are considered; current problems, potential solutions, and opportunities for clinicians under health reform are addressed. The goals envisioned for health system reform and the potential for realization of those goals via changes in addiction service delivery design and clinical practice are discussed.     

Multidisciplinary case conference reviews: improving outcomes for nursing home residents, carers and health professionals

Aim of study: This study sought to determine whether multidisciplinary case conference reviews improved outcomes for nursing home residents, and the effects of this team approach to resident care on carers, including the hands-on carers employed by the nursing home, and health professionals.Method: 245 residents of three Canberra nursing homes were enrolled in this non-randomised controlled trial. The intervention consisted of sessions of three case conference reviews held between 10/4sol;96 and 4sol;12sol;96. These sessions were attended by the General Practitioners (GPs) of the residents discussed, the GP project officer from the ACT Division of General Practice, a clinical pharmacist, senior nursing staff, other health professionals eg physiotherapist, and occasionally the resident concerned or their representative. At each review, a case presentation by the resident's GP was followed by a multidisciplinary discussion of all aspects, medical and non-medical, of the resident's care. The review concluded with a management plan for the resident. In total 75 residents were reviewed.Main outcome measures: Medication use and cost, and mortality.Results: One month after the reviews were completed comparisons between those who were reviewed and those who were not showed non-significant reductions in medication orders, medication cost, and mortality in the reviewed group. Many of the 92 recommendations in the management plans that were carried out benefited the residents (n=37) and/or carers (n=24). The responses of the GPs and the Directors of Nursing to the reviews were overwhelmingly positive.Conclusion: Recommendations arising from multidisciplinary case conferences were carried out to the benefit of patients and carers. Given the support shown by key stakeholders, multidisciplinary conferences should be used more.     

Impact of residential medication management reviews on anticholinergic burden in aged care residents

Objectives:

The primary objective of this study was to investigate the impact of Residential Medication Management Reviews (RMMRs) on anticholinergic burden quantified by seven anticholinergic risk scales.

Design:

Retrospective analysis.

Setting:

Accredited pharmacists conducted RMMRs in aged-care facilities (ACFs) in Sydney, Australia.

Participants:

RMMRs pertained to 814 residents aged 65 years or older.

Measurements:

Anticholinergic burden was quantified using seven scales at baseline, after pharmacists’ recommendations and after the actual GP uptake of pharmacists’ recommendations. Change in the anticholinergic burden was measured using the Wilcoxon sign rank test.

Results:

At baseline, depending on the scale used to estimate the anticholinergic burden, between 36% and 67% of patients were prescribed at least one regular anticholinergic medication (ACM). Anticholinergic burden scores were significantly (p?<?0.001) lower after pharmacists’ recommendations as determined by each of the seven scales. The reduction in anticholinergic burden was also significant (p?<?0.001) after GPs’ acceptance of the pharmacists’ recommendations according to all scales with the exception of one scale which reached borderline significance (p?=?0.052).

Conclusion:

Despite the limitations of the retrospective design and differences in the estimation of anticholinergic burden, this is the first study to demonstrate that RMMRs are effective in reducing ACM prescribing in ACF residents, using a range of measures of anticholinergic burden. Future studies should focus on whether a decrease in anticholinergic burden will translate into improvement in clinical outcomes.     

Pharmacists’ perspectives on medication reviews for long-term care residents with advanced dementia: a qualitative study

Background Medication reviews by pharmacists have been shown to identify and reduce drug-related problems in long-term care residents. Objective To explore pharmacist perspectives of the Australian Government funded pharmacist-conducted residential medication management review and its role improving the quality and safety of prescribing in long-term care, in particular for those living with advanced dementia. Setting Australian Long-term care pharmacists. Method A qualitative research methodology approach using semi-structured interviews was used, with participants pharmacists with Residential Medication Management Review experience. Interviews were recorded, transcribed and coded utilising a meta-model of Physician-Community Pharmacy Collaboration in medication review. Main outcome measure Pharmacists’ perspectives on the Residential Medication Management Review and how to improve the quality of reviews for residents with advanced dementia. Results Fifteen accredited pharmacists participated. The majority believed that the Residential Medication Management Review had the potential to improve the quality and safety of medicines but highlighted systemic issues that worked against collaborative practice. Participants emphasised the importance of three-way collaboration between general practitioners, pharmacists and nursing staff and highlighted key strategies for its optimisation. Conclusion Incorporating avenues for greater communication between team members can improve collaboration between health professionals and ultimately the quality of medication reviews.

     

Utilization of an implementation framework to obtain provider perspectives of pharmacist-led clinical services

BackgroundPharmacist integration into health care teams has been shown to improve patients’ clinical outcomes and satisfaction with care. Medication therapy management (MTM) has been implemented in a variety of pharmacy practice settings. Pharmacist-provided medication reviews, a core element of MTM, have been shown to optimize therapeutic outcomes for patients and identify medication-related problems in a patient’s current regimen. Patients receiving care at Federally Qualified Health Centers (FQHCs) often face a number of challenges, such as multiple health conditions, transportation, and medication costs. Pharmacist-provided services can play an important role in providing patient-centered care in FQHCs. Seeking stakeholder input can be valuable to ensure services will benefit both patients and providers.ObjectiveThe objective of this study was to obtain provider perspectives of psychological, socioeconomic, and practice-based factors to consider before implementing a pharmacist-led medication review services in an FQHC in north central Indiana.MethodsFive nurse practitioners employed by an FQHC in north central Indiana were interviewed. Thirty-four questions within 5 general domains were developed using the Consolidated Framework for Implementation Research. Responses were manually transcribed, coded by 3 reviewers, and then summarized using thematic analysis.ResultsWithin the 5 interviews, a total of 97 codes were identified. The 251 mentions of the 97 codes were then thematically analyzed into 16 different themes. The 5 most referenced themes were feelings (N = 36), roles (N = 28), logistics (N = 26), benefits (N = 25), and communication (N = 21). Study participants noted that team roles, communication of information about the service, team or stakeholder concerns, and logistics should all be kept in mind when designing a new service.ConclusionSemistructured interviews with providers at an FQHC in north central Indiana revealed multiple factors to consider before implementing a new pharmacist-led service in the clinic. Using a systematic approach to seek provider input can be beneficial in the design and implementation of pharmacist-led services.     

Community pharmacists’ interventions and documentation during medication therapy management encounters delivered face-to-face versus via telephone: The devil is in the details

BackgroundTo date, no studies are available comparing in-person versus telephone-administered medication therapy management (MTM) encounters in a community pharmacy setting with respect to medication-related problems, interventions and documentation.ObjectiveThe objective of this study was to evaluate types of medication-related problems, interventions, and documentation among patients receiving MTM face-to-face versus over the telephone.MethodsA retrospective analysis was performed on all completed comprehensive medication reviews (CMR) between 2011 and 2017 in 14 community pharmacies in Western Massachusetts, USA that belong to one district of a national chain. Medication-related problems were classified as: Beers criteria medications, untreated condition, dose too high or low, medication omission, duplicate therapy, drug-drug interaction, non-adherence, complicated dosing. Pharmacist's interventions were classified as education, medication reconciliation, and vaccination. Documentation of assessment, plan, discussion notes, and recommendations were evaluated as being present or absent.ResultsIn total, 297 encounters (56.5% were over the telephone) were included in the analysis. There was no significant differences between clinical and demographic characteristics and types of medication-related problems and pharmacist interventions among patients who received face-to-face versus telephone MTM service. Assessment was documented among 28% of face-to-face and 42% of telephone CMR encounters (p < 0.05). Plan was documented among 27% of face-to-face and 40% of telephone CMR encounters (p < 0.05). Discussion notes were documented among 97% of face-to-face and 98% of telephone CMR encounters (p > 0.05). Pharmacist recommendations were documented among 92% of face-to-face and 95% of telephone CMR encounters (p > 0.05).ConclusionsPharmacists identify medication-related problems and provide education and medication reconciliation interventions independent of the mode of delivery. The overall low frequency of assessment and plan documentation raises concerns. It is imperative for pharmacists to document both instances of provider outreach and follow-up to ascertain resolutions of patients’ medication-related problems.     

Protocol for a pilot and feasibility study of nurse practitioner-pharmacist telehealth collaboration to simplify complex medication regimens

IntroductionNew and flexible multidisciplinary workforce models are needed to address unnecessary medication regimen complexity in residential aged care facilities (RACFs). This study will investigate the feasibility of a nurse practitioner-pharmacist telehealth-based collaborative care model to simplify complex medication regimens.MethodsThis is a pragmatic, non-randomized pilot and feasibility study of up to 30 permanent residents from 4 RACFs in Western Australia. Simplification will be conducted in accordance with a validated 5-step implicit process. Nurse practitioners will identify residents potentially interested in and who may benefit from simplification, including any regulatory or safety imperatives that might preclude simplification. Medication regimens will be assessed by an off-site clinical pharmacist to identify opportunities for simplification in terms of drug–drug, drug–food, or drug–time interactions, and the availability of alternative formulations. The pharmacist will communicate simplification opportunities to nurse practitioners via video case conferencing. Nurse practitioners will then discuss simplification opportunities with the resident, caregiver and the health and care team, including any unintended consequences for the resident or RACF. The primary outcome measure will be feasibility (stakeholder acceptability, protocol adherence, recruitment and retention rates). Secondary outcomes include change in the number of medication administration times per day, medication and behavioral incidents, falls and fractures, hospitalization and mortality at 4 months.Ethics and disseminationEthical approval has been obtained from the Monash University Human Research Ethics Committee. Research findings will be disseminated through industry report, lay summaries, conference presentations and peer-reviewed publications.     

Virtual medication therapy management: The cornerstone to a pharmacy renaissance

ObjectivesTo introduce an innovative clinical service that can be used to reduce medication errors and improve quality of care in the rural environment, in order to assist in eliminating or alleviating disparities in health based on geographical location.SummaryVirtual medication therapy management (MTM) will be a tool to assist underserved populations, specifically residents of rural communities. It will use videoconferencing software to provide MTM services to populations that lack access to care. For virtual MTM to be effective, specific measures must be implemented to comply with the Health Insurance Portability and Accountability Act, and state regulations must be established to standardize the practice.ConclusionThe virtual MTM model is a feasible and promising model for advancing MTM services. With commitment and cooperation from various health care fields, virtual MTM could be the cornerstone of a health care renaissance.     

上海居民对社区药学服务的态度和需求的调查分析

目的：了解目前上海居民对社区卫生服务机构药学服务的态度和需求,为主管部门和基层医疗卫生机构提供参考。方法：采用问卷和访谈相结合的方法,对上海市静安区、长宁区、黄浦区、松江区等9个行政区内的19个社区的居民进行调查,并就调查结果进行统计和分析。结果：共发放664份问卷,回收658份有效问卷,有效回收率为99．1％;共访谈19人次。547名（83．2％）受访者对于社区药学服务满意;573名（87．1％）受访者清楚所提供有关药物方面的知识;364名（55．4％）受访者认为药学服务帮助一般;受访者希望增加更多的社区药学服务内容。128名（19．5％）受访者已签订家庭医生制服务契约,未签约的受访者中有331名（62．4％）表示愿意或可以考虑签订家庭医生制服务契约。受访者认为社区药学服务的优势是便捷和用药指导及时;不足是服务水平参差不齐,药品品种不全、数量不够。结论：上海社区药学服务质量需要提升,服务仍需多样化,且家庭医生制服务未广泛普及。建议均衡提高社区卫生服务机构医务人员业务素质和服务能力;改善社区卫生服务机构药品配备种类,优化药品配送方式;细化社区药学服务内容,注重服务对象的特殊性;丰富家庭医生制服务中的药学服务内容,增强家庭卫生服务作用。     

Impact of medication bedside delivery program on hospital readmission rates

BackgroundSince the establishment of the Hospital Readmission Reduction Program by the Centers for Medicare and Medicaid Services, reducing readmission rates has been a priority for health care institutions. Many institutions have developed services to combat high readmission rates, including bedside medication delivery programs, which have demonstrated reductions in 30-day readmission rates in patients who used these services.ObjectiveTo evaluate the impact of health system–based bedside medication delivery programs on readmission rates in patients at a low to moderate risk of hospital readmission.MethodsA single-center retrospective cohort study conducted on adult patients of low-to moderate–transitions of care (TOC) risk status with unplanned admissions to a large academic medical center between January 1, 2017, and January 1, 2019 who used the medication bedside delivery service or an outside pharmacy. The TOC risk status was defined using historic institutional definitions. Patients with at least a 2-day hospital stay and who were discharged to home from select primary medical services were included. The primary outcome was 30-day readmission rates between the 2 groups. Secondary outcomes included 60- and 90-day readmission rates and readmission rates stratified by primary medical service and TOC status. Coarsened exact matching was used to account for variation between groups.ResultsThe study evaluated 6583 patients discharged with a total of 3905 patients and corresponding index admissions meeting inclusion criteria for analysis. No statistically significant difference between readmission rates at 30 days after the index admission was found between the medication bedside delivery group and the outside pharmacy group, 7.97% and 10.09%, respectively (P = 0.136). However, the readmission rate of the medication bedside delivery group was statistically significantly lower than that of the outside pharmacy group at 60 and 90 days.ConclusionsThis study suggests that bedside medication delivery programs do not significantly reduce readmission rates at 30 days but may do so at 60 and 90 days.     

Exploring stakeholder roles in medication management for people living with dementia

BackgroundTherapeutic decision making, prescribing, administering and managing medications can be difficult for people with dementia.ObjectivesTo explore stakeholder roles in medication management for people with dementia, including barriers and enablers to achieving those roles.MethodsFocus groups were held with stakeholders (consumers, general practitioners, nurses and pharmacists) from both rural and metropolitan communities in two Australian states. Focus groups were audio-recorded, transcribed and thematically analysed using an inductive approach.ResultsNine focus groups were held with 55 participants. Four major themes were identified: supporting the role of the person with dementia, carer roles and challenges, health professional roles, and process and structure barriers to medication management. Stakeholders discussed the importance of advance care planning, and the potential benefits of early implementation of dose administration aids to support patients in self-managing their medication. Carers were seen to have a vital role as patient advocates, but carer burden and changes in the patient-carer roles acted as barriers to this role. General practitioners were perceived as the main care coordinator for a person with dementia, with effective interprofessional collaboration and communication with allied health professionals and specialists further enabling optimisation of medication use. A lack of evidence, guidelines and practitioner training to guide prescribing and deprescribing decisions in people with dementia were mentioned as barriers to medication management.ConclusionMedication management is increasingly challenging for people with dementia and each stakeholder perceives that they have a different role and faces different barriers and enablers. Future research should focus on improving the evidence base to guide prescribing, facilitating stakeholder communication and ensuring early documentation of patient wishes for the future.     

Trends in telephonic comprehensive medication review in the United States from 2000 to present: a scoping literature review

BackgroundAlthough comprehensive medication review (CMR) services have been shown to provide value to patients and payers, the extent of uniformity in service delivery is unknown. A variety of standards and recommendations are available from academic and professional sources, but variation in service provision is an important consideration when attempting to measure or compare service quality nationally.ObjectiveThis study aimed to identify and summarize trends in the peer-reviewed and gray literature describing telephonic CMR delivery and content.MethodsA scoping review of peer-reviewed and gray literature was conducted to quantify and qualify trends in CMR service. Two independent reviewers screened abstracts from 9 bibliographic databases and selected gray literature sources in accordance with the Joanna Briggs Institute guidelines and an internally developed protocol. Inclusion criteria for the review were English language; discussion of telephonic CMR service in the United States; research, legislation, or guidelines that describe CMR content coverage requirements for payment; and publication from the year 2000 to the present. Data relating to publication type, study design, setting, region, and themes of CMR content were collated into a Microsoft Excel data extraction form. Qualitative thematic analysis was conducted, and key findings and concepts were reported contextually.ResultsOf 374 identified documents screened, 15 were included in this scoping review and thematic analysis. The following characteristics of CMRs were identified: content, coverage, eligibility, frequency, process, and responsiveness. All published documents (n = 15, 100%) included a discussion of CMR content, and 14 sources (93%) addressed process elements of providing a CMR. Discussion of other themes varied in frequency across documents, ranging from 3 articles (20%) addressing organizational goals for CMR to 12 articles (80%) including elements of responsiveness. Within-theme variation was also observed for several CMR content areas. CMR process was the most heterogeneous theme with topics ranging from access to patient health records to pharmacist training.ConclusionsAssessment of telephonic CMR comprised a small but steadily increasing portion of the medication therapy management literature. Publications since 2015 have shown an increasing consensus of CMR content and purpose. Per the identified literature, there is an ongoing demand for higher-quality, more holistic CMRs, but there is no consensus on how to measure CMR quality. Future work should include engaging with CMR experts to understand variability in measures of CMR success.     

The development of a taxonomy to support goal setting between mental health consumers and community pharmacists

BackgroundGoal setting is widely used in mental healthcare, yet there is limited information about goal development between community pharmacists and people experiencing mental health conditions.Objectivesi) To review goals developed in partnership between Australian community pharmacists and people experiencing depression/anxiety, and ii) categorize goals and develop a taxonomy.MethodsCommunity pharmacists (n = 142) who had completed a mental health training program provided an individualized medication support service and documented goal planning for 350 people experiencing anxiety and/or depression. Goals were reviewed using a general inductive content analysis to develop themes which were then grouped, categorized, and coded. This involved three researchers in different phases of the coding, repeated review and redrafting of the taxonomy, and inter-rater reliability consistency checks.ResultsThe goals (n = 749) represented a diverse range of health behaviors and outcomes (e.g., medication adherence, relationships, leisure activities). The resulting taxonomy involved five overarching domains: improved health; satisfaction with life; manage physical illnesses; manage mental health; and use of medicines.ConclusionsPharmacists have a role in providing person-centered care and addressing social determinants of health by considering factors that contribute to a person's overall wellbeing. While further testing is necessary, the taxonomy is valuable for pharmacists unfamiliar with supporting goal development with people experiencing anxiety and/or depression.