Evidence based information on drug use during pregnancy: a survey of community pharmacists in three countries

Objective: To evaluate whether community pharmacists provide evidencebased information to women inquiring about specific drug use during pregnancy.Design: A trained female student posing as a surrogate shopper requested information about the relative safety/risks of medications during pregnancy in two scenarios. Forty randomly selected pharmacies were surveyed in the Netherlands, Canada and Iceland, and pharmacists' recommendations were noted. Main outcome measures included the type of information that was provided, its presentation, and the source of information used. Results: A relatively small proportion of pharmacists surveyed, provided evidencebased information regarding the drugs in question. Only 14% referred to current medical literature, while 60% consulted the product monograph. Over 90% of pharmacists referred the client to a physician. Conclusions: Community pharmacists do not disseminate evidencebased recommendations when counseling women on drug use in pregnancy, and need further education on resources concerning drugs in pregnancy that are currently available.     

Teaching and counselling behaviour: an applied study with community pharmacists.

Continuing education aims at improving practice. In this article, three main research questions are addresssed: Which methodology is optimal to improve counselling behaviour? Are learning outcomes influenced by learning style? Does knowing imply doing? Four educational methods, transferring information on cough medicines, are assessed: a lecture, an interactive workshop, an audiocassette and a textbook. Attendants of the first three methods also received the textbook. Pharmacists completed a learningstyle inventory in addition to a pretest. After the instruction phase, they were interviewed by telephone (posttest). We also evaluated the counselling behaviour by an 'incognito' visit to participants as well as to controls. Seventyeight pharmacists participated. Their learningstyle cannot be related to the results of preor posttest. Each educational method improved the level of knowledge significantly, but none of them proved to be better than the others. The pharmacists who in addition read the textbook, acquired more knowledge than those who did not. Selfstudy at home led to more fundamental rather than practical knowledge. Improving knowledge does not result in better counselling: 75% of the pharmacists asked only one question, especially concerning the type of cough. However 9 out of 10 mentioned how to use the drug. About half of the pharmacists told the patient about the action of the medicine. Other items were hardly ever mentioned. There was no difference in counselling behaviour between the intervention group and a group of pharmacists who did not attend the course. This investigation does not reveal any particular method of inservice training as being more efficient. Active use of selfstudy materials helps to improve pharmacological knowledge. Implementing educational strategies to improve counselling behaviour remains a future aim.     

Pharmaceutical care in Denmark: perceived importance of medicine‐related problems and participation in postgraduate training

Objective: To investigate the readiness of Danish community pharmacists to provide pharmaceutical care. Special focus was on information provided to patients on medicinerelated problems and participation in postgraduate training.Method: National crosssectional survey distributed to all Danish community pharmacies (N = 288). Response rate 75.7%; nonresponders were interviewed by telephone to establish their reasons for not participating.Main outcome measures: Prioritisation of information to patients regarding medicinerelated problems. Postgraduate courses selected by pharmacists during the past three years. Results: In accordance with the profile of Danish community pharmacists, respondents were primarily female and half were below 45 years of age. The main reason given for not responding was lack of time. The prioritisation of information to patients regarding medicinerelated problems resulted in three clusters of answers. The overall topics of the clusters were: information related to the technicalpractical use of medicines; information related to pharmacotherapeutic aspects of medicine use; and information related to the function of the medicine. The clusters accounted for 61.9% of the total variance. The most frequently attended postgraduate courses were on quality assurance and specific diseases. Conclusion: The patient information prioritised by Danish community pharmacists is primarily of a technicalpractical nature. The postgraduate training pursued is primarily technical without much focus on the philosophy of pharmaceutical care. These factors contribute to the lack of proper readiness of pharmacists to practice pharmaceutical care.     

The quality of Dutch hospital drug formularies: Evaluation of technical features and organisational information

Introduction: Hospital drug formularies (HDFs) are widely used tools to help influence clinicians' prescribing behaviour. Besides the therapeutic quality of HDFs, the available information and the way in which this is presented are key factors in HDFs' success or failure to influence prescribing behaviour and enhance prescribing quality. This research evaluates the technical features and organisational information of Dutch HDFs. Methods: Seventytwo (75%) of all Dutch HDFs were evaluated based on criteria retrieved from international literature and additional criteria drafted by occupational groups working with HDFs. Aspects that were studied were physical appearance and layout, practicability with respect to the available information and how easily this could be retrieved from the HDFs, information regarding drug choice policies such as seamless care, and the available type of therapeutic and pharmaceutical information. Results: Thirtythree (46%) of the HDFs were less than 3 years old. Physical appearance of all HDFs was very well looked after. Two (3%) HDFs were diseaseoriented rather than drugoriented. Changes from preadmission therapy were addressed in 30 (42%) of the HDFs, but other seamless care policies were addressed in less than 20% of the HDFs. Finally, less than 50% provided therapeutic information that clinicians indicated as important. Discussion: Although Dutch HDFs are technically practicable with respect to userconvenience, practiceoriented features are capable of improvements. Furthermore, Dutch HDFs lack important clinical information for daily practice. To enhance seamless care across healthcare, generic prescribing and prescribing on admission from and discharge to any other sectors should be addressed more specifically.     

Desire for information about drugs: relationships with patients' characteristics and adverse effects

Introduction: Adverse effects of drugs are known to cause problems both in hospital and general practice settings, contributing to longer stays in a hospital, and increased costs of hospitalisation. By developing both a greater understanding of adverse drug reactions and effects and developing ways to reduce them will assist pharmacists in managing medicines more effectively. The aim of this study was to explore the relationships between patient characteristics, information requirements and perceptions about adverse drug effects to assist pharmacists in identifying patients most at risk of ADRs. Methods: The study took place on medical wards at a London teaching hospital during an eight week period in Autumn 2000. Patients were recruited using convenience sampling during the recruitment period. Once eligible patients consented to take part, standardised interviews were conducted at their bedside. The interviews included the use of the previously validated scale which measures the extent of information desired (EID), patient characteristics including age, gender, socioeconomic status etc and the presence of an adverse drug effect was assessed using the Naranjo algorithm. Patients were also asked semistructured questions to explore past and present experiences of adverse drug effects.Results: 82 patients were recruited, 80 were eligible for adverse effects of drugs assessment. Fifteen percent (12/80) of patients were assessed as having "definite" and "probable" adverse drug effects, based on the Naranjo algorithm. The previously validated EID scale was found to be both valid and reliable in this patient sample. There was an association between high scores on the EID scale and the presence of an adverse drug effect (chisquared = 4.97, p = 0.02). Conclusion: The results show an association between the occurrence of an adverse drug effect on admission (identified by the Naranjo scale), the experience of an adverse drug effect in the past and a patient's desire for information. The EIDscale could be developed into a useful tool for assessing and addressing patients' drug information needs for pharmacists to use when assessing adverse drug effects in everyday practice.     

A longitudinal study of United Kingdom pharmacists' misdemeanours – trials, tribulations and trends

Background: Standards of UK pharmacy practice are maintained by the Royal Pharmaceutical Society of Great Britain, which has the power to take a range of sanctions, including removal of the right to practice, against those found guilty of malpractice. This function is currently under review.Objective: To conduct a longitudinal study in order to define trends and identify areas where remedial or preventative support could be focused.Method: Case analysis of reports of individuals' misdemeanours published in the British Pharmaceutical Journal over a 12year period (September 1988 October 2000). Professional and personal misdemeanours were considered.Main outcome measure: Nature of misdemeanour, conviction or disciplinary proceedings against individual, practising pharmacists in the study period. Reasons offered for committing the misdemeanour and penalties applied.Results: 344 cases, involving a wide range of personal (162) and professional (590) misdemeanours were found. On an annual basis, the maximum incidence of pharmacists found guilty of any misdemeanour was extremely low (<0.1 of 1% on the pharmaceutical register). The most common professional misdemeanour was failure to keep adequate written records. The most common personal misdemeanour was fraud. The most common reason cited for committing any misdemeanour was financial gain. Numbers in individual offence categories were persistent but low and there were few obvious trends with time. The odds of involvement ratio for male versus female pharmacists was 7.36 (CI: 5.2310.35) and for ethnic minority versus Caucasian pharmacists was 3.8 (CI: 3.064.72). The most stringent penalties (either imprisonment or removal of the right to practice and frequently both) were applied to cases involving personal use or trafficking of drugs subject to abuse.Conclusions: The current selfregulation of pharmacy practice in the UK involves a wide range of misdemeanours of varying severity; but the incidence of reports of pharmacists found guilty of malpractice was extremely low. The nature of misdemeanours appeared to change little over the period of the study; this study therefore indicates the spectrum of misdemeanours likely to be encountered by a regulating board in the immediate to mediumterm future. If regulatory changes such as competencebased practice rights are introduced, the spectrum may change.     

The perceived role and skills of pharmacists in asthma management after in‐house training

Objective: To evaluate perceived roles and skills of pharmacists in asthma management before and after a training intervention that consisted of six inhouse training sessions. Method: Altogether 315 pharmacists in the intervention group and 121 pharmacists in the control group participated in the study. The data on study variables were collected by a questionnaire during the first and last training sessions.Main outcome measures: Pharmacists' perceptions of their role, perceived skills, estimates of patients receiving counselling and experienced problems.Results: Based on their ratings for 16 topics, the pharmacists' perceptions about their role in counselling asthma patients remained rather stable. Handling of the inhalers and inhalation technique were considered as the most important aspects of counselling and issues dealing with the disease were regarded as the least important. Using a selfrated scale (410 scale), pharmacists' perceived counselling skills improved in the intervention group (6.5 vs 7.6), but not in the control group (6.5 vs 6.4). In the intervention group, the pharmacists' estimates of the proportion of new users of asthma medicines receiving counselling increased from 48% to 61% and that of old users from 18% to 26%. Before the training, the most commonly experienced problem in counselling was the pharmacists' lack of knowledge and skills. After the training, pharmacists experienced problems mainly with communication. Conclusion: When pharmacists are included in the support system for any patient group, their capabilities of fulfilling their role have to be assessed. In particular, communication skills and outcomeoriented counselling require attention.     

Nursing and residential care for the elderly in Northern Ireland: the contribution of the pharmacist

Aim of the study: To gain more detailed information on the current pharmaceutical service provision in nursing and residential homes in Northern Ireland and to assess the views of care staff on future pharmacy services. Method: A structured questionnaire was developed and mailed to all nursing and residential homes (n=586) in Northern Ireland on two occasions. Results: A response rate of 68% (n=396) was obtained. The most frequent services currently provided by community pharmacists were the supply of medication and the collection of unwanted, discontinued or outofdate medicines. The majority of respondents also reported receiving advice on safekeeping, correct administration of medicines, advice on more appropriate formulations and advice on patient medication records from the community pharmacist. Over a third of all the respondents received advice on compliance devices. A similar proportion stated that their care staff were trained by the pharmacist on broad medication management issues.Over 90% of all homes strongly supported staff training by pharmacists on the recognition of medicationrelated problems as a future service. Over 70% of all respondents thought additional guidelines and advice for missed dosages and the use of home remedies would be beneficial. A review of patient medication records to assess drugdrug interactions and possible adverse drug reactions by pharmacists was supported by over 65% of all respondents. Conclusions: This work has demonstrated that those responsible for care in nursing and residential facilities strongly support further involvement by the pharmacist in these care facilities; pharmacy policy makers must ensure that such services are developed to meet the needs of these vulnerable elderly residents.     

Cost-effectiveness of periconceptional supplementation of folic acid

Background: Supplementation of folic acid prior to and in the beginning of pregnancy may prevent neural tube defects (NTDs) in newborns – such as spina bifida – and possibly other congenital malformations.Objective: To estimate cost effectiveness of periconceptional supplementation of folic acid using pharmacoeconomic model calculation.Method: Probabilities for NTDs, risk reductions through periconceptional supplementation of folic acid and lifetime costs of care for children with spina bifida were estimated using Dutch registrations and international literature.Main outcome measure: Cost effectiveness was expressed in net costs per discounted lifeyear gained. Cost effectiveness was calculated in the baseline and in sensitivity analysis.Results: Estimated cost effectiveness of periconceptional supplementation of folic acid amounts to NLG 3900(D1800) in the base case. In sensitivity analysis cost effectiveness mostly remains below NLG 10.000(D4500).Conclusion: Periconceptional supplementation of folic acid shows a favorable cost effectiveness. From pharmacoeconomic point of view this justifies further stimulation of folicacid supplementation prior to pregnancy. This can be done through targeted education by healthcare workers, such as pharmacists.     

Design and implementation of a common drug information database for a university hospital

Background: Providing high quality problem oriented drug information relies on the ability to easily collect appropriate background information on clinical cases, to access relevant information from published sources by defined search strategies and to store and retrieve previously answered questions. To do this efficiently, an easy to use, flexible and reliable drug information database is necessary. Methods: We designed and implemented an Intranet based drug information database for a major university hospital in Germany. The overall design and the technical details of its design are discussed. We developed a generic, XML based data model for pharmaceutical inquiries including a MeSH oriented system of 99 pharmaceutical qualifiers to enable efficient indexing of questions and the searching of indexed questions.Results: The system provides query statistics and various search algorithms. The software implementation takes into account recent FDA recommendations for software used in clinical trials; internal review for quality control is supported. The database currently consists of 4224 records after 3.5 years of operation. Each inquiry consists of 50 items, 18 of 50 are categorized; 135 text elements support data entry. Our evaluation is focused on technical feasibility, user acceptance and query patterns.Conclusion: The intensive use and widespread acceptance of the database indicates a need for a computerized drug information system and suggests that Intranet technology can perform this task.