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.     

Evaluation approaches,tools and aspects of implementation used in pharmacist interventions in residential aged care facilities: A scoping review

BackgroundThe medication expertise of pharmacists is widely acknowledged and there is ongoing interest in their potential role to reduce medication-related harm amongst residents living in residential aged care facilities (RACFs). An increased understanding of how these interventions are evaluated could support adoption of these interventions in the real world.ObjectiveTo systematically explore the application of evaluation approaches, evaluation tools and aspects of implementation (implementation factors i.e. barriers and facilitators, and assessing implementation fidelity) used in pharmacist intervention in RACF peer-reviewed literature.MethodsA search strategy was applied to MEDLINE, CINAHL, Cochrane Library and Web of Science databases for publications between 1 January 2000 and 27 August 2020 based on defined inclusion and exclusion criteria. Articles that reported on evaluated pharmacist interventions impacting residents in RACFs or which outlined study participant perspectives in relation to these interventions were included.Results2003 published articles were identified, out of which 56 articles met the inclusion criteria. Fifty-three articles reported on outcome evaluations. Four articles used evaluation guidance with 1 article explicitly guided by an evaluation framework. Relationships, trust and respect between pharmacists and RACF health care team members were one of the most reported factors influencing intervention success. None of the 56 articles used a theory or model, assessed implementation fidelity or employed a logic model.ConclusionsTo date there appears to be sparse utilisation of available evaluation approaches, evaluation tools and implementation aspects in pharmacist intervention in RACF peer-reviewed literature. By embracing these evaluation approaches, evaluation tools and aspects of implementation, pharmacy practice researchers have an opportunity to contribute to evaluation research in RACFs and beyond.     

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.     

The role of the community pharmacist in fulfilling information needs of patients starting oral antidiabetics

BackgroundCommunity pharmacy is in the middle of a paradigm shift from provider of medication to provider of care around medication. Much of this care involves giving information to patients so as to maximize pharmacotherapy outcomes; however, this is not necessarily recognized by patients. The initiation of chronic medication for diseases, such as type 2 diabetes mellitus (T2DM), arouses much uncertainty in patients, and it is not certain how information provision roles by pharmacists are viewed.ObjectivesTo obtain insight in the information needs of patients who have recently started treatment with oral antidiabetics and to investigate the opportunities for pharmacy regarding the provision of information for patients with T2DM.MethodsA qualitative study with both semistructured telephone interviews and patient focus group discussions was conducted. Individual patients' comments were categorized and used in a strengths, weaknesses, opportunities, and threats (SWOT) analysis exploring the role of the community pharmacist in the field of providing information at the moment of initiation of T2DM oral medication.ResultsFrom interviews with 42 patients and 2 focus groups, discussions emerged that the general practitioner (GP) does not fulfill all information needs. For the pharmacist, there is an opportunity, as patients feel a need for information and like to discuss drug-related issues. SWOT analysis revealed main strengths of the pharmacy as “expertise” and “service and kindness.” Together with more cooperation with GPs and nurse practitioners, these strengths give the pharmacist the opportunity to further develop pharmaceutical care activities.ConclusionPharmacists are challenged to increase their visibility as health care provider while keeping logistic service on a high level and improving cooperation with other health care providers.     

The role of medication advisory committees in residential aged care services

BackgroundThere is increasing international interest in initiatives to reduce medication-related harm and preventable hospitalizations in residential aged care services (RACS). The Australian Government recommends that RACS establish multidisciplinary Medication Advisory Committees (MACs). No previous research has specifically investigated the structures and functioning of MACs.ObjectivesTo explore the current structures and functioning of MACs, and identify opportunities for MACs to better promote safe and effective medication use.MethodsSemi-structured interviews and focus groups were conducted with a maximum variation sample of health professionals (n = 44) across four health services operating across 27 RACS in rural and regional Victoria, Australia. Qualitative data were analyzed using deductive and inductive content analyses. Results were presented to a multidisciplinary expert panel (n = 13) to identify opportunities for improvement.ResultsDeductively coded themes included composition and functioning of the MAC, education and information needs and support to better manage polypharmacy. Emergent inductively coded themes included general medical practitioner (GP) and pharmacist engagement, collaboration and effectiveness. Participation by GPs and pharmacists was variable, while no MACs involved residents or family carers. Aged care specific and multidisciplinary MACs were generally more proactive in addressing potential medication-related harm. Education to identify and report adverse drug events with high risk medications was identified as a priority. The multidisciplinary panel made 12 recommendations to promote safe and effective medication use.ConclusionDespite all MACs having a strong commitment to medication safety, opportunities exist to improve the composition and structure, proactive identification and response to emerging issues, and systems for staff, resident and family carer training.     

1例瓣膜置换联合冠状动脉旁路移植术后患者抗栓治疗的药学监护

摘 要 目的：探讨临床药师对冠状动脉旁路移植术（CABG）合并瓣膜置换的患者实施药学监护的方法和思路。 方法：临床药师对1例CABG合并瓣膜置换术后的患者进行查房密切观察和药学教育,参与个体化抗栓方案的制定,规范患者用药问题,监测疗效与药品不良反应,给患者提供用药教育。结果：通过药师治疗全过程中细致的药学监护和医嘱干预,确定符合患者特点的抗栓方案,避免不良反应的发生,提高患者治疗的依从性和药物治疗效果。结论：临床药师积极开展药学监护,协同临床医师优化给药方案,有利于患者用药的安全性和有效性。     

Characterizing medication management and the role of pharmacists in caring for people living with cystic fibrosis: A work system approach

BackgroundCystic fibrosis (CF) is an autosomal recessive genetic disease requiring complex, lifelong medication regimens. Given the importance of medication in CF treatment, pharmacists are vital CF care team members in the care of people living with CF (PwCF).ObjectivesThis study aimed to (1) define patients’ CF medication experiences and educational needs and (2) investigate the CF outpatient clinic and community pharmacist’s role in addressing patient challenges.MethodsA work system approach informed by the Systems Engineering Initiative for Patient Safety (SEIPS) model was used to characterize knowledge and perception of CF medication regimens, educational modalities, and pharmacist interactions for PwCF. Semistructured interviews were conducted with adults living with CF at a CF center clinic. Data analyses identified relationships between the themes in the data and 4 SEIPS work system domains: tasks, tools and technology, person, and environment.ResultsThirty PwCF interviews highlighted 4 themes regarding health care experiences: (1) medication use experience, (2) medication education needs, (3) disease experience, and (4) pharmacist and pharmacy interactions. Patients reported complex medication regimens leading to challenges with medication adherence, although the benefit of treatment was recognized. Although a high level of disease-state knowledge was identified among the participants, PwCF desired to learn about CF medication benefits and adverse effects through credible sources using multiple modalities. Many reported a benefit of pharmacist involvement in their care.ConclusionPharmacists are well-positioned to support PwCF in adherence, medication regimen management, and medication education. Opportunities exist for growth in these supportive roles of a pharmacist in both community and outpatient clinic settings.     

Evaluation of a community pharmacy-based medication therapy management programme: A study protocol of a pilot randomized controlled trial with an embedded qualitative study

ObjectivesThe main objectives are: to evaluate the feasibility and effectiveness of a community-pharmacy based medication therapy management programme; to explore patients’ experiences and views towards medication therapy management service delivered by community pharmacists.Research design and methodsA mixed-methods research design consisting of a pilot randomized controlled trial embedded with qualitative study will be used in this study. The study consists of two phases: a 6-month follow-up pilot randomized control trial (quantitative approach) to assess the feasibility and effectiveness of a community pharmacy-based medication therapy management programme. The primary outcome is HbA1C and secondary outcomes include: clinical and health services utilization and process measures, medication adherence, diabetes distress as well as satisfaction with care. Phase two consists of an embedded qualitative study using semi-structured interviews to explore patients’ experiences and views with the medication therapy management programme. Study data collection will be collected between April 2021 and December 2021.Ethics considerationThe study has been approved by institutional review boards from Princess Nourah bent Abdulrahman University (Approval # 20–0240), King Fahad Medical City (Approval # 20-388E) and Birmingham University (Approval # ERN_20-0768).     

Evolution and operation of a pharmacy residency on-call program.

A pharmacy residency on-call program designed to contribute to residents' competence in patient care and to extend the functions of the pharmacy department is described. The program, which was begun at the University of Kentucky Chandler Medical Center in 1984, offers a supportive environment in which the resident is held accountable for pursuing optimal outcomes of drug therapy. The program provides opportunities for the resident to engage in independent decision-making, care for a wide variety of patients, and manage acute illness. On-call services are provided in single 24-hour shifts beginning at 0800 each day. Residents assess and respond to supratherapeutic serum drug concentrations, perform pharmacokinetic monitoring, provide drug information, evaluate patients for specific drug therapy, obtain medication histories for HIV-seropositive patients, and participate in emergency patient management. Residents provide services in the absence of the primary pharmacist on nights, weekends, and holidays and devote a four-hour period to drug distribution. Each pharmacy resident participates in the on-call program, regardless of the chief focus of his or her residency. Residents' activities are documented electronically, and preceptors give feedback via e-mail. The program and its activities have evolved over the years to reflect changes in pharmacy practice. An on-call program for pharmacy residents provides a valuable learning experience while enhancing patient care.     

1例小儿急性骨髓炎的药学监护

目的探索小儿急性骨髓炎抗感染治疗的方案和药学监护方法。方法介绍临床药师参与1例小儿急性血源性骨髓炎的抗感染治疗过程。临床药师从抗感染药物的选择、给药剂量和方法、给药疗程、不良反应监测等方面制定个体化给药方案,同时进行药学监护。结果与结论临床药师利用专业知识,及时发现和解决患者用药期间出现的问题,由临床药师与医师、护士团队协作,能促进合理用药,提高药物治疗水平,保证患者用药的安全有效。     

Clinical medication review by a pharmacist of elderly people living in care homes: pharmacist interventions

Objectives To describe the rate and nature of pharmacist interventions following clinical medication review of elderly people living in care homes. Setting Care home residents aged 65+ years, prescribed at least one repeat medication, living in nursing, residential and mixed care homes for older people in Leeds, UK. Method Analysis of data from care home residents receiving clinical medication review in the intervention arm of a randomised controlled trial. Intervention outcomes for each medicine were evaluated for each resident. Key findings Three‐hundred and thirty‐one residents were randomised to receive a clinical medication review and 315 (95%) were reviewed by the study pharmacist; 256 (77%) residents had at least one recommendation made to the general practitioner. For the 2280 medicines prescribed, there were 672 medicine‐related interventions: medicines for cardiovascular system (167 (25%)), nutrition and blood (121 (18%)), central nervous system (113 (17%)) and gastrointestinal conditions (86 (13%)) accounted for 487 (73%) of medicine‐related interventions. There were 75 non‐medicine‐related interventions. The most common interventions were ‘technical’ (225 (30%)), ‘test to monitor medicine’ (161 (22%)), ‘stop drug’ (100 (13%)), ‘test to monitor conditions' (75 (10%)), ‘start drug’ (76 (10%)), ‘alter dose’ (40 (5%)) and ‘switch drug’ (37 (5%)). Recommendations to stop a medicine were most common for CNS drugs (32 (32%)). The most common medicine to be recommended to be started was calcium and vitamin D (45 (59%)). Following a recommendation to test to monitor a medicine, 23 (14%) medicines required a change. Conclusions This study has demonstrated that clinical medication review by a pharmacist can identify medicine problems in approximately 80% of care home residents, requiring intervention in 1 in 4 of their prescribed medications.     

Deprescribing in nursing homes: Protocol for nested,randomised controlled hybrid trials of deprescribing interventions

IntroductionPolypharmacy and the use of potentially inappropriate medication (PIMs) are frequent among nursing home (NH) residents, and are associated with adverse health outcomes like falls, hospitalisation and death. Deprescribing has been proposed as a way to curtail both problems; however, the best way to implement deprescribing and its real impact are still unclear. This article describes nested trials of two consecutive deprescribing interventions, the first at the NH level, and the second at the resident level.Methods and analysisThe first intervention (QC-DeMo) will be a deprescribing module to be carried out in existing interprofessional quality circles in NHs, with the goal to develop a NH-wide deprescribing consensus. Its effects will be evaluated on the use of PIMs and on patient safety outcomes such as death, hospitalisation and falls. All NHs in the cantons of Vaud and Fribourg with an integrated pharmacy service will be eligible.The second intervention (IDeI), at the resident level, will be a deprescribing-focused medication review, resulting in the implementation of a deprescribing plan. Its effects will be evaluated on the use of PIMs and chronic medications, and on quality of life. This second trial will take place in the NHs allocated to the intervention group of the first trial. All residents of these NHs over 65 years old, living in the NH for at least 4 months, and taking 5 or more medications will be eligible to participate.Both trials will be hybrid effectiveness and implementation trials, aiming to understand the implementation process for the interventions, and to identify barriers and facilitators.Ethics, registration and fundingBoth trials were approved by the relevant ethics committee, registered on ClinicalTrials.gov (QC-DeMo: NCT03688542; IDeI: NCT03655405), and funded by the Swiss National Fund for Scientific Research.     

Clinical and economic impact of clinical pharmacist interventions regarding antimicrobials on critically ill patients

BackgroundIncorporating in the Intensive Care Unit (ICU) a clinical pharmacist who performs interventions on antimicrobials may be cost-effective.ObjectivesTo evaluate the clinical and economic impact of clinical pharmacist interventions on antimicrobials in an ICU. To identify drug related problems and medication errors detected by the pharmacist.MethodsA retrospective observational study was performed to analyze drug related problems, medication errors and clinical pharmacist interventions related to antimicrobials in adults admitted to an ICU in a 5-month period. The economic impact of pharmacist interventions was estimated considering difference in cost derived from antimicrobial treatment, adverse drug events and clinical pharmacist time.ResultsA total of 212 drug related problems were detected in 114 patients, 18 being medication errors. Clinical pharmacist developed one intervention for each problem identified. 204 interventions (96.2%) were considered important with improved patient care and 7 (3.3%) very important. No negative impact of any intervention was identified. Physicians accepted 97.6% of the interventions. A potential saving of 10,905 € was estimated as a result of pharmacist interventions and 4.8 € were avoided per euro invested in a clinical pharmacist.ConclusionsA clinical pharmacist performing interventions on antimicrobials in the ICU has a positive impact on patient care and decreases costs.     

Community health worker perspectives of an academic community medication therapy management collaboration

ObjectiveTo qualitatively assess community health workers’ (CHWs’) perceptions of the challenges and benefits associated with participating in a collaborative, interprofessional medication therapy management (MTM) program for rural, underserved, predominantly Latinx, patients with diabetes and hypertension.MethodsNine CHWs participated in a 1-hour, semistructured focus group that explored their experiences while assisting in the delivery of MTM services through an academic community partnership between an MTM provider and participating rural clinics. Audio recordings of the focus group were transcribed and thematically analyzed by 2 independent reviewers.ResultsAll program-involved CHWs participated in the focus group. Qualitative analysis identified 2 overarching themes: (1) opportunities and (2) challenges. Opportunities were further subcategorized as benefits to (1) CHWs, (2) patients, or (3) academic community MTM research. The CHWs perceived that they served as a liaison among the medical provider (prescriber), patient, and MTM pharmacist. Benefits to the patients focused on the integration of CHWs as essential to patient recruitment, especially for those who were reluctant to participate or receive a phone call from a stranger. The major challenges identified were (1) interruptions in workflow and (2) communication between CHWs and the health care practitioners (physicians, nurse practitioners, pharmacists). Specifically, the CHWs universally agreed that they needed more time after receiving patient report, scheduling a visit with the patient, and communicating with the patient’s health care provider to better understand the individual’s circumstances and needs.ConclusionThis study identified perceived opportunities and challenges faced by CHWs and chronically ill, rural Latinx patients in the acceptance of MTM program. These findings may be useful for all interprofessional health care team members to better understand and appreciate the role of CHWs, while simultaneously enhancing and improving respective medication adherence efforts, and to improve collaborative, academic community programs in the future.     

Stakeholder perspectives on pharmacist involvement in a memory clinic to review patients’ medication management and assist with deprescribing

BackgroundMemory clinics usually involve a team of health professionals who assess and review people with memory impairment. Memory clinic patients are typically older, have multiple comorbidities and potentially inappropriate polypharmacy. Pharmacists are not typically part of memory clinic teams.ObjectiveTo explore stakeholder perspectives on pharmacist involvement in a memory clinic to conduct medication reviews and assist with deprescribing potentially inappropriate/unnecessary medications.MethodsQuantitative and qualitative evaluation of stakeholder perspectives within a deprescribing feasibility study. Patient/carer questionnaires were administered at 6-month follow-up. Fax-back surveys were sent to general practitioners (GPs) shortly after the pharmacist review. A focus group was conducted with memory clinic staff and semi-structured interviews with pharmacists at conclusion of the study. Focus group/interviews were transcribed and thematically analysed.ResultsMost patients/carers found the pharmacist medication review helpful (84%, 31/37) and believed it was important to have pharmacists in the memory clinic (92%, 36/39). Twenty-one (48%) GPs responded to the survey; most found the pharmacist reports useful for identifying inappropriate medication and providing deprescribing recommendations (86% and 81%, respectively), and 90% thought a pharmacist review should be part of the memory clinic service. Feedback from memory clinic staff and pharmacists was largely positive. Questions were raised by some staff about whether deprescribing fell within the clinic's scope of practice. Challenges associated with memory clinic-GP communication were highlighted.ConclusionPatients, GPs and memory clinic staff were receptive to increased pharmacist involvement in the memory clinic. Stakeholder feedback will inform the development and delivery of pharmacist medication reviews and deprescribing in memory clinics.     

An evaluation of pharmacy assessment for geriatric patients

Evaluation of a pharmacy assessment for geriatric patients on a geriatric assessment and rehabilitation unit is described. The assessment has been developed to identify functional, comprehension and therapeutic problems affecting an elderly patient's ability to self-medicate. The pharmacy assessment identified more obstacles to self-medication than the nursing and medical assessments. The detection of obstacles was particularly apparent in the areas of medication knowledge deficit, complicated medication regimes and the inability to follow directions. The pharmacist made more recommendations than the other health professionals for improving the safety and efficacy of drug therapy and medication compliance (p less than .01). Recommendations included simplification of medication regimes, requesting drug levels or specific lab tests, and the use of compliance aids. Seventy-seven percent of the recommendations made by the pharmacist were acted upon by the physician or nurse. Results of the study demonstrate the pharmacy assessment was the most significant predictor of self-medication success.     

Multidisciplinary medication review: evaluation of a pharmaceutical care model for nursing homes

Objective The objective of this study was to assess implementation of a pharmaceutical care model for the multidisciplinary care of elderly patients in nursing homes. Setting Prospective study, medication review, from January 2007 to December 2009 in ten nursing homes affiliated to the Pharmacie interjurassienne (PIJ), Switzerland. Method Medication use data were collected and reviewed by a pharmacist, focusing on drug indication, dosing, side effects, renal/hepatic elimination and interactions. Drug-related problems (DRPs) were discussed face-to-face with the responsible physician and a nurse. The pharmaceutical care issues were formulated and medication interventions proposed during this meeting. DRPs and interventions were documented using the Pharmaceutical Care Network Europe scheme version 5.00 (PCNE V5.00). The economic impact of the service was estimated through a retrospective evaluation of annual drug costs. A satisfaction evaluation was conducted among practitioners and nurses. Main outcome measures DRPs, interventions, treatment changes implemented. Results Drug therapy of 329 patients was reviewed. The number of medicines per patient ranged from 2 to 27 (mean 12.8). A total of 1,225 DRPs were detected and discussed with the physician and the nurse. Medication review led to 343 medical evaluations secondary to drug-drug interactions and 803 treatment adaptations: 373 drugs were stopped, 197 dosages changed, 95 instructions for use amended, 86 drug choices were altered, 35 drug formulations changed and 17 new drugs started. According to the Anatomical Classification System, the main classes involved in interventions were related to Alimentary tract and metabolism (n = 285), Nervous system (n = 189) and Cardiovascular system (n = 115). Since the outset of the PIJ, the annual drug costs decreased in nursing homes with medication review including a pharmacist, whereas it was stable in the other nursing homes. The satisfaction evaluation showed a very positive appreciation by practitioners and nurses. Conclusion The study showed an efficient pharmaceutical care model, well accepted by physicians and nurses. It also indicated that for elderly patients, continuous drug review contributed to improved drug therapy, reduced unnecessary polypharmacy and reduced pharmaceutical costs.