Pharmacy practice in hospital settings in GCC countries: Dispensing and administration

PurposeTo outline dispensing and administration practices in hospital pharmacy across the Gulf Cooperation Councils (GCC) countries’ hospitals. Paucity of data in appraising hospital pharmacy practice in GCC regions motivated us to conduct this study.MethodsA modified survey questionnaire was prepared from the American Society of Health-System Pharmacist (ASHP) survey questions. Three major domains of questions for general characteristics of the medication use process for dispensing and administration were identified. These were, (1) medication distribution system, and medication distribution technology, (2) technology used to compound sterile preparations, compounding I.V. medication and method of compounding nutrition support preparations, (3) medication administration practices, medication orders, medication administration records (MARs), and technician activities. A list of hospitals was obtained from the Ministry of Health of the targeted GCC countries. A secure invitation link containing a survey questionnaire was sent to the participants directly.ResultsSixty-four hospitals responded to this survey. The overall response rate was 52%. Most surveyed hospitals have centralized inpatient medications distribution system (75.0%). About 37.5% of hospitals used automated dispensing cabinets (ADCs) in their patient care areas. Compounding sterile preparations in the pharmacy, barcode verification technology, workflow management technology, and robotic technology were used by 17.2%, 15.6%, and 4.7% of hospitals, respectively. In using safety technology for medication administration, almost all hospitals have partially or completely implemented an electronic health record (EHR). About 40.6% of hospitals used electronic medication administration records (e-MARs), 20.3% used bar-code-assisted medication administration (BCMA), and 35.9% used smart infusion pumps.ConclusionThe results of this survey revealed an opportunity to improve the medication use management process on dispensing and administration practices in hospitals in GCC countries.     

Pharmacy practice in hospital settings in GCC countries: Prescribing and transcribing

PurposeTo outline hospital pharmacy practices across the Gulf Cooperation Councils (GCC) countries’ hospitals.MethodsA modified survey questionnaire was prepared from the original 2019 American Society of Health-System Pharmacist (ASHP) survey questions. Survey details were discussed with some pharmacy directors for clarity and relevance. A list of hospitals were obtained from the Ministry of Health of each of the targeted GCC countries. A secure invitation link containing a survey questionnaire was sent to the participants directly.ResultsSixty four hospitals responded to this survey. The overall response rate was 52%. About 47% of the surveyed hospitals considered their drug formularies as closed, and strict. Additionally, only 44% of hospitals compare the effectiveness of products, when taking formulary decisions for drug inclusion. Forty-four percent of hospitals have computerized prescriber order entry (CPOE / EHR) system functionality for formulary system management. At about 39.1% hospitals, pharmacists have the responsibility for managing medication therapies, majority were engaged in providing anticoagulation therapies. About 61% of hospital pharmacies in GCC countries receive medication orders electronically, through CPOE/EHR. Majority (66%) of the hospitals in GCC countries have an active Antimicrobial Stewardship Program (ASP) while only 40% of pharmacists have a key role in providing clinical support. About 57.8% of hospital pharmacy directors reported that pharmacists do not provide ambulatory care clinical pharmacy services in their hospitals.ConclusionIn GCC countries’ hospitals, there are major areas for improvement to patient care of which pharmacists are uniquely qualified as the medication experts to have the most meaningful outcomes in all of the domains of safe medication use, medication therapy management, antimicrobial stewardship program and participation in outpatient clinics.     

Experiences of key stakeholders with the implementation of medication reviews in community pharmacies: A systematic review using the Consolidated Framework for Implementation Research (CFIR)

BackgroundThough medication reviews have shown positive patient outcomes, they are still not widely implemented in community pharmacies. Published reviews on their implementation often include several other pharmacy services, making them non-specific. Using the Consolidated Framework for Implementation Research (CFIR) to focus solely on the experiences of different stakeholders with the implementation of medication reviews will help to better understand relevant facilitators and barriers.ObjectivesTo critically appraise, synthesise and present the available evidence on experiences of key stakeholders with the implementation of medication reviews and to identify barriers and facilitators to its implementation in community pharmacies.MethodsA systematic literature search was conducted in four databases for studies published in English, Spanish or German. Key search terms included: implementation, pharmac*, medication review, facilitator, barrier. Study selection, quality assessment and data extraction were performed by two independent reviewers. Findings were mapped directly against the constructs of the CFIR.ResultsOut of 924 retrieved records 24 articles from 9 countries met the inclusion criteria. Key facilitators identified included pharmacists' openness to practice change and a high degree of patient satisfaction post medication review. Attracting patients to the service was stated as challenging due to an unawareness of the scope and potential benefit of a medication review. The dominant barrier was inadequate remuneration, as it impacted all additional resourcing and ultimately the viability of the service. Further barriers included difficult professional relationships with doctors and little mandate from health authorities. Most reports were from the employed pharmacists’ perspective and concerned the inner setting, other perspectives were under-reported.ConclusionsResults of this systematic review illustrate different stakeholders' experiences and add to the understanding of challenges in the implementation process. Nevertheless, findings also highlight how scarce reporting of external stakeholders’ views is and that filling this gap can unveil hidden barriers and facilitators.RegistrationPROSPERO register (CRD 42019122836)     

Claims-based pharmacy markers for comprehensive medication management program case identification: Validation against concurrent and prospective healthcare costs and utilization

BackgroundThree claims-based pharmacy markers (complex, costly and risky medications) were developed to help automatically identify patients for comprehensive medication management.ObjectiveTo evaluate the association between newly-developed markers and healthcare outcomes.MethodsThis was a two-year retrospective cohort study using PharMetrics Plus patient-level administrative claims in 2014 and 2015. We included all claims from 1,541,873 individuals with: (1) 24-month medical and pharmacy enrollment in 2014 and 2015, (2) aged between 18 and 63 in 2014, and (3) known gender. Independent/control variables came from 2014 while outcomes came from 2014 (concurrent analysis) and 2015 (prospective analysis). Three pharmacy markers, separately or together, were added to four base models to predict concurrent and prospective healthcare costs (total, medical, and pharmacy) and utilization (having any hospitalization, having any emergency department visit, and having any readmission). We applied linear regression for costs while logistic regression for utilization. Measures of model performances and coefficients were derived from a 5-fold cross-validation repeated 20 times.ResultsIndividuals with 1+ complex, risky or costly medication markers had higher comorbidity, healthcare costs and utilization than their counterparts. Nine binary risky category markers performed the best among the three types of risky medication markers; the Medication Complexity Score and three-level complex category both outperformed a simpler complex medication indicator. Adding three novel pharmacy markers separately or together into the base models provided the greatest improvement in explaining pharmacy costs, compared with medical (non-medication) costs. These pharmacy markers also added value in explaining healthcare utilization among the simple base models.ConclusionsThree claims-based pharmacy indicators had positive associations with healthcare outcomes and added value in predicting them. This initial study suggested that these novel markers can be used by pharmacy case management programs to help identify potential high-risk patients most likely to benefit from clinical pharmacist review and other interventions.     

A narrative review of approved and emerging anti-obesity medications

BackgroundRecently, many drugs have been approved for halting overweight and obesity—few types of research shifted to using Anti-obesity medications (AOM) solely for well-being and shape-keeping.ObjectiveThis narrative review's objective was to explore the use of AOM in relation to their medical indications, efficacy, and cardiovascular safety.Methods and materialsWe have conducted a narrative review of the literature on approved/non-approved AOM used for obesity and overweight. We have shed light on the emerging trials of therapies and evolving remedies.ResultsRecently, there has been an enormous change in the use of AOM with high consumption that deserves extensive surveillance for the long-term consequences and impact on social, mental, and physical health. Nearly six AOMs and combined therapy are approved by the Food and Drug Administration. The recent guidelines for obesity management have shifted the focus from weight loss to goals that the patient considers essential and toward targeting the root cause of obesity.ConclusionThe use of AOM increased enormously despite its sometimes-dubious safety and ineffectiveness. The public and medical professionals should be vigilant to the real-world benefits of anti-obesity drugs and their achieved effectiveness with an improved safety profile.     

Pharmacist-led medication reconciliation at patient discharge: A scoping review

BackgroundOne of the strategies to promote patient safety in care transitions is medication reconciliation (MR), which is conducted by the pharmacist at the patient's discharge from hospital. However, there are divergences about this process and about the pharmacist's role in conducting such intervention.ObjectiveTo systematically review the literature that reports the MR process led by pharmacists at patient discharge and map the different methods, strategies and tools used in the process.MethodsRelevant studies were searched in the following databases: EMBASE, MEDLINE (PubMed), The Cochrane Library, and LILACS. No language restriction or publication date was applied. The studies considered eligible were those involving and describing pharmacist-led MR processes at acute patient discharge from hospital, with an experimental, quasi-experimental, or observational design. The characteristics of the studies and the MR processes were identified and then a qualitative synthesis was performed.ResultsFifty studies were included. The majority of them were observational ones (82%), and the main outcome was medication discrepancies (42%). The studies were mostly conducted in university hospitals (70%) and in internal medicine wards (54%). Pharmacists were responsible mainly for gathering medication histories (72%), and identifying (96%) and solving (98%) pharmacotherapeutic problems. The main sources of information on pre-admission medications were patient/caregiver interviews (66%) and records from other care providers (40%). Only 30% of the studies described a patient discharge plan, and 14% shared information of the patient's pharmacotherapy with community pharmacists.ConclusionThe concept of MR and the pharmacist-led activities in the process varied in the literature, as well as the pharmacotherapy assessment focus and the communication strategies towards patients and other care providers, showing that standardization of the process and concepts is necessary.     

How do elderly outpatients manage polypharmacy including DOAC - A qualitative analysis highlighting a need for counselling

BackgroundPatients with polypharmacy are challenged with the management of their daily medication. Medication management strategies for direct oral anticoagulants (DOAC) are especially important to guarantee medication adherence and to prevent thromboembolic events. Patients are often left alone with finding an appropriate strategy.Objective(s)To explore medication management strategies, to measure adherence to DOAC with the aim of deducing recommendations for practice.MethodsFace-to-face semi-structured interviews were conducted at the home of outpatients who were taking ≥4 medications daily including a DOAC, and self-managing their medication. A small electronic device (Time4Med?) was given to record medication intake during the four following weeks. During a second home visit, participants saw a graph of their medication intake as dot chart, and obtained a feedback. Interviews were transcribed verbatim and thematically analysed. Medication adherence was calculated with electronic data.ResultsEighteen individuals (61.1% female; median age 77.5 years) were interviewed and reported 30 different medication management strategies, together with triggers, advantages and limitations. They combined at least five strategies, composed of internal (memory-based) and external (packaging-based or intake-based) strategies. The number of strategies was neither associated with the number of medications nor with medication adherence. Taking adherence was <100% for eight patients (44.4%). The inability of any medication management strategy to adapt to ageing and cognitive decline emerged as its most dramatic limitation, especially because individuals would fail to notice when their strategy became unsuited.ConclusionsElderly patients develop manifold medication management strategies, which can inspire future medication users. Limitations are present such as forgetting medication intake in spite of a management strategy. The moment to adapt the strategy to ageing or cognitive decline is crucial and often goes unnoticed. It is therefore decisive that healthcare professionals regularly re-evaluate the appropriateness of the medication management strategies during counselling or ideally during home visits.     

Clinical and economic impact of medication reconciliation by designated ward pharmacists in a hospitalist-managed acute medical unit

BackgroundMinimizing unintended medication errors after admission is a common goal for clinical pharmacists and hospitalists.ObjectiveWe assessed the clinical and economic impact of a medication reconciliation service in a model of designated ward pharmacists working in a hospitalist-managed acute medical unit as part of a multidisciplinary team.MethodsIn this retrospective observational study, we compared pharmacist intervention records before and after the implementation of a medication reconciliation service by designated pharmacists. The frequency and type of intervention were assessed and their clinical impact was estimated according to the length of hospital stay and 30-day readmission rate. A cost analysis was performed using the average hourly salary of a pharmacist, cost of interventions (time spent on interventions), and cost avoidance (avoided costs generated by interventions).ResultsAfter the implementation of the medication reconciliation service, the frequency of pharmacist interventions increased from 3.9% to 22.1% (p < 0.001). Intervention types were also more diverse than those before the implementation. The most common interventions included identifying medication discrepancies between pre-admission and hospitalization (22.7%) and potentially inappropriate medication use in the elderly (13.1%). The median length of hospital stay decreased from 9.6 to 8.9 days (p = 0.024); the 30-day readmission rate declined significantly from 7.8% to 4.8% (p = 0.046). Over two-thirds of interventions accepted by hospitalists were considered clinically significant or greater in severity. The cost difference between avoided cost and cost of interventions was 9838.58 USD in total or 1967.72 USD per month.ConclusionsThe implementation of a designated pharmacist-led medication reconciliation service had a positive clinical and economic impact in our hospitalist unit.     

Barriers to the use of patient safety information sources by community pharmacies

BackgroundWhen patient safety information is communicated across a regulatory jurisdiction or country, the potential to enhance the safety of community pharmacy practice is significant. While there currently exists a number of sources for patient safety information (e.g., websites, safety bulletins, online tools), knowledge of the barriers that may inhibit the use of such information sources within community pharmacies is limited.ObjectiveThis research explores community pharmacy manager use of Canadian patient safety information sources and the barriers that may limit the use of such sources.MethodsA qualitative research study design using semi-structured interviews was conducted with 15 community pharmacy managers in the Halifax Regional Municipality of Nova Scotia, Canada. The study explored how pharmacists access and engage a variety of information sources, including corporate intranets, websites, and tools provided by third party data base repositories. Interview data were analyzed using thematic analysis.ResultsFive general barriers were identified: lack of time to access information sources and its contents; too many sources of available information; too much information not relevant to community pharmacy practice; complexity navigating online information sources; and lack of community pharmacy involvement in source design.ConclusionWhile pharmacies do use safety information sources to enhance practice safety, their ability to incorporate this information is inhibited by their general lack of time available to access and read safety information, lack of knowledge about where to get this information, and lack of tailored information for the community pharmacy context. Future initiatives should address increasing information awareness of available sources, consolidating and reducing information overload of such sources, and packaging information to better fit with pharmacists’ needs.     

Pharmacists’ roles in emergency and disasters: COVID-19 as an example

BackgroundEmergencies and disasters are major threats to health care systems. Coronavirus Disease 2019 (COVID-19) is at the center of a recent emergency situation that requires increased attention from health care professionals, including pharmacists. This study was aimed at providing an overview of pharmacists’ roles in disasters and formulating a definition of expected roles and tasks through which they can perform these roles properly.MethodsA systematic review was conducted utilizing a literature search performed on the Medline, EMBASE and PubMed databases. The last search occurred on 14 July 2020. Data were extracted and recorded on a data extraction sheet by the reviewers, then categorized using the prevention, preparedness, response, and recovery (PPRR) model. Study quality was evaluated using the Critical Appraisal Skills Program (CASP) checklist.ResultsFifteen articles addressing pharmacists’ roles in disasters were included. Of these, three addressed pharmacists’ roles during the COVID-19 pandemic. Pharmacists’ roles in the prevention of emergencies, including COVID-19, are focused on chronic disease medication supply and education. Regarding pharmacists’ preparedness to perform their roles in disasters, they were more focused on health policy and population health planning, especially regarding the COVID-19 pandemic. Direct patient care continues to support patients through medication availability, and pharmacists’ clinical roles are examples of their response to disasters. In addition, pharmacists have an important role in disaster recovery that involves several activities, such as restocking emergency kits and reestablishing normal stock. Studies were generally of a reasonable quality. However, some limitations were noted among studies, and higher quality studies that contribute to existing knowledge are needed.ConclusionHealth care systems’ utilization of pharmacists’ new roles can result in a well-prepared disaster response, as observed during the COVID-19 pandemic. Pharmacists’ engagement in decision-making processes and adequate demonstration of pharmacists’ nontraditional roles in the literature can facilitate the health care community’s acceptance of such roles.