Medication reviews provided by general medical practitioners (GPs) and nurses: an evaluation of their quality

Objective To train general medical practitioners (GPs) and nurses in providing medication review services in the primary care setting and to evaluate the reviews provided. Setting One medical practice in Scotland with five whole‐time equivalent (WTE) GP partners, two practice nurses and six community‐based nurses. Method Training for GPs was provided as a group session plus individual supported clinic sessions. Nurse training consisted of a group session only. Patients aged over 75 were invited to attend the medical practice to receive a medication review. Output measures were: number of patients with pharmaceutical care issues (PCIs) documented, changes made to repeat medicines and computer records, monitoring undertaken, number of PCIs, PCIs identifiable from notes and records but not documented (‘missed’ PCIs). A sample of GP reviews provided before training and all GP and nurse reviews during training were evaluated. Key findings In 45 case note reviews provided prior to training, GPs documented PCIs in 20% of patients; average 0.3 per patient, but missed 1.75 per patient. In 56 reviews provided during training, they documented PCIs in 98% of patients; average 3.0 per patient, missing 0.8 per patient. The proportion of patients with changes to drug therapy or monitoring carried out during training increased significantly compared to pre‐training reviews. Nurses documented PCIs in 97% of 33 patients reviewed, average 1.5 PCIs per patient, but missed 0.8. The mean number of repeat drugs prescribed reduced from 4.73 to 4.42 per patient after nurse review, but increased after GP review from 4.07 to 4.18. Conclusion After training, both GPs and nurses identified PCIs appropriate to their expertise. The sustainability of this effect in the longer term is not known. Since all patients should have repeat medication reviewed regularly, involving these professionals in providing routine reviews would allow pharmacist medication review clinics to be optimised.     

Chronic pain management -can we do better? An interview-based survey in primary care

SUMMARY

Background: Persisting pain is demoralising and debilitating for patients and their carers. Most patients with chronic pain do not need the services of a specialised pain clinic and are appropriately managed by their general practitioner (GP).

Method: Interviewers approached 569 GPs to assess their satisfaction with the management of patients with chronic non-malignant (i.e. non-cancer related) pain (CNMP). The survey was carried out from November 2001 to January 2002 in general practices in the UK. GPs were randomly selected as representative of the basic population who treat CNMP. The survey was conducted in a face-to-face interview in the GP surgery using a questionnaire consisting of 35 open questions covering practice information, treatment of CNMP, pain management and multidisciplinary support.

Results: 504 (88.6%) of GPs completed the structured questionnaire. 81% of GPs believed that a significant number of patients received suboptimal management. Optimal control of symptoms was estimated to occur in less than half of patients. The main barriers to achieving good pain control were identified as side-effects of therapies (74%) and patient compliance (58%). 60% of respondents expressed concerns regarding efficacy of available therapies. Although 91% of GPs considered specialised pain services as beneficial, only 14% of patients were referred to hospital for symptom management. 96% of GPs felt that the management of chronic pain could be improved in their locality and 81% expressed an interest in relevant training.

Conclusion: Most GPs believe that the management of chronic pain can be improved. Further education of all healthcare professionals who manage patients in pain is needed to bring about such a change.     

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.     

A qualitative study of physicians' and nurses' experiences of multidisciplinary collaboration with pharmacists participating at case conferences

OBJECTIVES Previous studies have revealed a range of drug-related problems for nursing home and hospital patients. Different attempts to reduce drug-related problems have been tested. Medication reviews performed by pharmacists and subsequent presentation of findings at case conferences is one of these methods. Physicians' and nurses' experiences from multidisciplinary collaboration with pharmacists have to a lesser degree been investigated. This study aims to describe how Norwegian physicians and nurses experience collaborating with pharmacists at case conferences to reduce drug-related problems in elderly patients. METHODS This was a qualitative interview study using systematic text condensation. The setting was nursing homes (long-term care) and hospital wards (gerontology and rheumatology). Four physicians and eight nurses participated and the main outcome was physicians' and nurses' experiences of multidisciplinary collaboration with pharmacists. KEY FINDINGS Organizational problems were experienced including, among others, what professional contribution team members could expect from pharmacists and what professional role the pharmacist should have in the multidisciplinary team. Both professions reported that ambiguities as to when and if the pharmacist was supposed to attend their regular meetings resulted in some aggravation. On the other hand, the participants valued contributions from pharmacists with regard to pharmaceutical skills, and felt that this raised awareness on prescribing quality. CONCLUSIONS Physicians and nurses valued the pharmacists' services and reported that this collaboration improved patients' drug therapy. However, before implementing this service in nursing homes there is a need to make an organizational framework for this collaboration to support the professional role of the pharmacist.     

Referrals made by different health care professionals to community pharmacists for domiciliary visits

Objective — To examine the suitability of referrals made by health professionals to a pharmacist for a domiciliary visiting service. Method — General practitioners (GPs), district nurses and social services carers were contacted to request that they refer patients who they thought might benefit from a home visit by a pharmacist, using a referral form agreed by an expert panel. Information gathered by the visiting pharmacist during the patient interview was compared with the reason for referral by the health care worker. Setting — All GPs, district nurses and social services carers who cared for housebound patients in the Kenton and Stanmore areas of the London Borough of Harrow. Key findings — Ninety patients were visited. Of these, 47 had been referred by GPs, 29 by nurses and 14 by social services. The highest level of incorrectly stated referrals (22 per cent of their referrals) came from nurses. Nurses tended to refer patients for an explanation of the purpose of their medicines, and GPs because patients were taking more than three medications. Six patients, five of whom were referred by GPs, appeared not to have any problems that could be helped by a visit. Conclusion — There may be a need to raise awareness among social services carers about potential medication problems and the role that could be played by community pharmacists in helping these patients. When GPs make referrals, the criterion of patients taking more than three medications may not be sufficiently sensitive; this should be expanded to ensure that the GP has additional clinically related suspicions that there are adherence issues. Generally, little difference was found between the appropriateness of referrals from the three agencies.     

Post-discharge medication reviews for patients with heart failure: a pilot study

Background Medication misadventure is greatest at times of change such as the transition from hospital to community. Patients with heart failure are prone to medication misadventure due to polypharmacy, inappropriate medication use and frequent readmissions. Objective To identify the barriers encountered when implementing a Liaison Pharmacist facilitated post-discharge medication management service for patients with heart failure. Method A Liaison Pharmacist contacted the patient’s General Practitioner (GP), sent them a medication discharge summary and organised an appointment for the patient with the GP approximately 2 days post-discharge to make a Home Medicines Review (HMR) referral. The patient’s community pharmacist was also contacted, sent a medication discharge summary and requested to engage an accredited pharmacist to undertake the HMR. The Liaison Pharmacist arranged for the HMR report to be sent to the outpatient department clinic to enable assessment of outcomes at the outpatient department follow-up 12 weeks post-discharge. Main outcome measure: GP HMR referral rates. Results 90 patients were offered the service. Fifty-nine patients (66%) agreed to have their GP contacted with 56 GPs agreeing to order a HMR and 41 patients having an HMR post-discharge. Barriers to the implementation of a HMR post-discharge included: patient withdrawal, low GP awareness of the HMR process and conducting the HMR in a timely manner. Conclusion This study provides evidence for the feasibility of a post-discharge pharmacy service for patients with heart failure although barriers to implementation have been identified.     

Psychotropic effects of adrenergic β-blockers on agonistic behavior between resident and intruder mice

The present study was conducted to investigate the effect of adrenergic -blockers on agonistic behavior in male mice, using quantitative ethological methods. Agonistic behavior was evoked using a resident-intruder paradigm. The following drugs were administered orally at four dose levels (vehicle, 5, 10 and 20 mg/kg) to either resident or intruder mice: dl-propranolol, practolol, d-propranolol, and l-propranolol. When the resident was treated with either dl-propranol or l-propranolol, aggressive episodes (offensive sideways posture, attack bite, tail rattle) were suppressed significantly in a dose-dependent manner, whereas practolol and d-propranolol were ineffective. All treatments except the high dose of l-propranolol failed to affect the resident's solitary behavior (locomotion). When the intruder was treated with -blockers, agonistic behavior was not altered. Since practolol does not cross the blood-brain barrier, the differential suppression of agonistic behavior is due to the central action of -blockers. d-Propranolol does cross the blood-brain barrier but is devoid of -receptor blocking property; hence l-propranolol suppression of agonistic behavior implies inactivation of brain adrenergic -receptors. The findings seem to indicate that -blockers such as dl-propranolol and l-propranolol have a psychotropic action.     

A Buprenorphine Education and Training Program for Primary Care Residents: Implementation and Evaluation

ABSTRACT. Background: Although substance use disorders are highly prevalent, resident preparation to care for patients with these disorders is frequently insufficient. With increasing rates of opioid abuse and dependence, and the availability of medication-assisted treatment, one strategy to improve resident skills is to incorporate buprenorphine treatment into training settings. Methods: In this study, esidency faculty delivered the BupEd education and training program to 71 primary care residents. BupEd included (1) a didactic session on buprenorphine, (2) an interactive motivational interviewing session, (3) monthly case conferences, and (4) supervised clinical experience providing buprenorphine treatment. To evaluate BupEd, the authors assessed (1) residents’ provision of buprenorphine treatment during residency, (2) residents’ provision of buprenorphine treatment after residency, and (3) treatment retention among patients treated by resident versus attending physicians. Results: Of 71 residents, most served as a covering or primary provider to at least 1 buprenorphine-treated patient (84.5 and 66.2%, respectively). Of 40 graduates, 27.5% obtained a buprenorphine waiver and 17.5% prescribed buprenorphine. Treatment retention was similar between patients cared for by resident PCPs versus attending PCPs (90-day retention: 63.6% [n = 35] vs. 67.9% [n = 152]; P = .55). Conclusion: These results show that BupEd is feasible, provides residents with supervised clinical experience in treating opioid-dependent patients, and can serve as a model to prepare primary care physicians to care for patients with opioid dependence.     

Study of anemia in long-term care (SALT): prevalence of anemia and its relationship with the risk of falls in nursing home residents

ABSTRACT

Objective: The objectives of the current study were twofold. First, this study examined the prevalence of anemia in nursing home residents in the USA and its relationship with key resident characteristics and medical conditions. Second, the study explored whether an association between anemia and falls is evident in this same population.

Research design and methods: Chart review was conducted in 40 nursing homes across the USA. Residents were randomly sampled and considered eligible if they: were ≥18 years of age; had ≥1 hemoglobin (Hb) level reported during the data uptake period of 1/1/04–2/1/05 (first occurrence defined as index Hb); had a recorded serum creatinine level; maintained residency in the facility; and did not receive dialysis during the 6-month post-index follow-up period. Resident demographics, laboratory values, comorbid conditions, medication regimens, falling events, physical functioning measures, and hospitalizations were obtained from chart data. The relationship between selected resident characteristics and comorbidities was explored with index Hb level, using multiple linear regression. Logistic regression was used to analyze the relationship between falling and recurrent falls with anemia (index Hb <13 g/dL and <12 g/dL in men and women ≥15 years, respectively) adjusting for selected variables presumed to be related to falls.

Limitations: Study limitations include the retrospective design and limited follow-up, potential for biased selection of relevant covariates, gaps in time between index Hb levels and falling events, non-random selection of nursing homes, limits to quality and detail in data extracted from residents’ medical charts, and confounding of anemia therapy with index hemoglobin level.

Results: A total of 564 sampled residents met the criteria for data completeness and were retained for analysis; of these, 70% were female. Mean age was 81 ± 12.3 years (±SD). Mean index Hb level was 11.9 ± 1.8 g/dL (12.2 ± 2.0 for males, 11.7 ± 1.6 for females). Of all residents studied, 56% were identified as anemic (64% males, 53% females) from index Hb level. In all, 53% of anemic residents were receiving an identified therapy, with 72% of these treated residents receiving iron. None received an erythropoietic-stimulating agent (ESA). For index Hb level, the regression coefficient was significant for female (p = 0.002), African-American race (p = 0.012), glomerular filtration rate (GFR) <60 mL/min/1.73 m² (p < 0.001), diabetes (p = 0.004), cancer (p < 0.001), asthma (p = 0.002), GI bleeding (p = 0.012), and inflammatory disease (p = 0.039). Except for asthma, these factors were associated with a decrease in Hb. In the regression model for the dependent variable of falling, anemia (OR = 2.26, p < 0.001), psychoactive medication use (OR = 2.18, p = 0.001), and age 85+ years (OR = 2.08, p = 0.016) were associated with more than twice the risk of falling.

Conclusions: Anemia in nursing home residents appears to be under-recognized. For residents over 70 years, the prevalence of anemia in both male and female residents was approximately four times the rate reported in a study of older community dwellers (Salive et al., 1992). Both anemia and the use of psychoactive medications are potentially modifiable factors strongly associated with falling. Since falls and related fractures are events associated with high morbidity and mortality, each of these factors deserves special consideration for potentially reducing the risk of such events in the nursing home.     

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.     

Inter-rater reliability of scales and tests used to measure mild cognitive impairment by general practitioners and psychologists

SUMMARY

Background: This study was conducted to assess whether general practitioners (GPs) can be trained to use a simple battery of functional scales and neuropsychological tests to detect people likely to develop dementia as reliably as neuropsychologists in clinical practice.

Methods: Fifty GPs with medium-sized practices in the Bordeaux area of France were recruited by monitors and trained to use a battery of tests (Mini-Mental State Examination (MMSE), Isaacs Set Test (IST), Benton Visual Retention Test (BVRT) and Zazzo's Cancellation Test (ZCT)). Each GP was required to recruit one patient. The tests were administered first by the GP, and then by a trained psychologist.

Results: Overall, the GPs showed interest in participating in the study. They had no difficulty

in recruiting patients according to the inclusion and exclusion criteria and none reported any difficulty in using the scales and tests battery. In total, 35 subjects were interviewed by both a trained GP and a psychologist. The scores obtained by the GPs and psychologists did not differ statistically for two of the four tests (IST, p?=?0.6; BVRT, p?=?0.7), but were statistically different for the other two tests (MMSE, p?=?0.04; ZCT; p?<?0.002).

Conclusions: The results confirm the feasibility of conducting a study for detecting cognitive deficit in general practice. The GPs were interested and participated well, patient adherence was good, and the concordance correlation coefficients between the GPs' and psychologists' scores were satisfactory.     

Chronic pain management--can we do better? An interview-based survey in primary care

BACKGROUND: Persisting pain is demoralising and debilitating for patients and their carers. Most patients with chronic pain do not need the services of a specialised pain clinic and are appropriately managed by their general practitioner (GP). METHOD: Interviewers approached 569 GPs to assess their satisfaction with the management of patients with chronic non-malignant (i.e. non-cancer related) pain (CNMP). The survey was carried out from November 2001 to January 2002 in general practices in the UK. GPs were randomly selected as representative of the basic population who treat CNMP. The survey was conducted in a face-to-face interview in the GP surgery using a questionnaire consisting of 35 open questions covering practice information, treatment of CNMP, pain management and multidisciplinary support. RESULTS: 504 (88.6%) of GPs completed the structured questionnaire. 81% of GPs believed that a significant number of patients received suboptimal management. Optimal control of symptoms was estimated to occur in less than half of patients. The main barriers to achieving good pain control were identified as side-effects of therapies (74%) and patient compliance (58%). 60% of respondents expressed concerns regarding efficacy of available therapies. Although 91% of GPs considered specialised pain services as beneficial, only 14% of patients were referred to hospital for symptom management. 96% of GPs felt that the management of chronic pain could be improved in their locality and 81% expressed an interest in relevant training. CONCLUSION: Most GPs believe that the management of chronic pain can be improved. Further education of all healthcare professionals who manage patients in pain is needed to bring about such a change.     

Consumers'' perceptions of community pharmacy in Portugal: a qualitative exploratory study.

Objective: Pharmacists are health professionals who are ideally positioned to perform a primary health care role. However, the definition of professional value needs to be considered not just as professional education and skills, but also in terms of how consumers perceive it. The main aim of this work was to explore the publics perceptions and attitudes towards community pharmacy in Portugal. Methods: A pure qualitative approach was undertaken. The data were collected through a semi-structured interview, conducted with a snowball like sample. First, individuals (n = 15) were interviewed, allowing for adjustment and validation of the interview schedule, followed latter by group interviews with adults in rural and urban areas. Group participants (n = 25) were asked about their behaviour and beliefs, resulting from their perceptions of community pharmacies, pharmacists and medicines. Future expectations regarding the community pharmacy service were also explored. The interviews were tape recorded and transcribed verbatim. An iterative, reflexive coding process was applied, assisted by the qualitative software package QSR NUD*IST v4. The inductive analysis of the extracted codes assembled those codes into themes. Results and discussion: This article will mainly focuses on community pharmacy service representations and cognitions (theme A) and community pharmacy evaluative perceptions and behaviours (theme B). Participants displayed general and contradictory ideas about the actual functions of the pharmacist, including weak conceptualizations and a positive demand for services in relation to product supply. This superficial understanding is in line with previous results from satisfaction studies, confirming a low expectation level. The publics poor knowledge and low expectations can justify a reduced desire for an extended role of the pharmacist in the community. This uncertain service conceptualization does not define the professional responsibility from a consumers perspective. Conclusions: Although these results allow for the development of a framework to describe the perceptions of community pharmacy users, further research is needed to determine the prevalence of these and other possible results.     

Restricted Intestinal Absorption of Some β-Lactam Antibiotics by an Energy-Dependent Efflux System in Rat Intestine

Purpose. The purpose of this study was to examine factors limiting the intestinal absorption of orally inactive -lactam antibiotics. Methods. Permeation behaviors of various -lactam antibiotics across rat intestinal segments were evaluated in vitro using diffusion cells. Results. Poorly absorbed -lactam antibiotics, like cephaloridine and cefoperazone, commonly exhibit greater serosal-to-mucosal permeation than mucosal-to-serosal permeation, while cephalexin permeation was greater in the mucosal-to-serosal direction. In the absence of D-glucose, secretory-oriented permeation of cephaloridine and cefoperazone disappeared. Addition of sodium azide into an experimental buffer including D-glucose significantly and selectively enhanced mucosal-to-serosal permeation of cephaloridine and cefoperazone. Although benzylpenicillin, ampicillin, and amoxicillin all showed secretory-oriented permeation, the tendency to permeation was greatest with benzylpenicillin and least with amoxicillin. Probenecid stimulated mucosal-to-serosal permeation of cephaloridine, but verapamil and p-aminohippuric acid had no significant effect on it. Conclusions. It has been suggested that mechanisms which induce secretory-oriented permeation of orally inactive -lactam antibiotics are factors limiting intestinal absorption of such antibiotics. This energy-demanding efflux system was distinct from P-glycoprotein-mediated transport. A free -amino group in the molecule is an important factor for reducing an affinity with the efflux system.     

Patient sources of drug information and attitudes to their provision: a corticosteroid model

Aim: To determine patients' preferred sources of drug information and their attitudes to how this is provided.Design: A quantitative evaluation via personal interviews using a formal questionnaire.Subject and settings: A group of 101 inpatients in a chest ward at the Royal Devon & Exeter Healthcare NHS Trust.Outcome measures: Preferred sources for medication advice; personal involvement in own treatment; adequacy of consultation period; medication compliance; post discharge sources of drug information; recalled benefits and side effects of corticosteroids.Results: Preferred source of drug information was: doctor (35%), pharmacist (11%) and nurse 4%. Sixty percent of patients wanted to be involved in the choice of their medication, thirtynine percent leaving it totally to the doctor and one patient who wanted the final word in what was prescribed. Sufficient discussion time with GPs was reported by 66% of patients (12%, insufficient) and 53% with hospital doctors (19%, insufficient). Noncompliance with medication was reported by 66% and compliance by 24%. Medication advice sources used when at home were; community pharmacists (22%), GPs/books & magazines/specialist societies (all 18%), nurses (10%) and others less than 8%. Benefits of corticosteroids recalled by patients were: 'improving breathing' (14), 'general improvement' (9) and 'improved mobility'/'greater appetite' (both 5) 'with little change' reported by 13. Knowledge of side effects was much more comprehensive with; oedema/weight gain (50), skin/hair problems (33), osteoporosis (33), bruising (12) and mood changes (10) most commonly featured in responses. Almost all patients confirmed they liked to be given printed information about their medication.Conclusion: Patients sought their medication advice from a variety of sources and armed with this almost two thirds of patients wished to exercise their rights to be involved with their treatment planning. Sufficient discussion time appeared to be available to about half of the interviewees though only a few understood the intended benefits of prescribed corticosteroids used as an example in this work. A much better knowledge of drug side effects might have partly explained the high level of declared noncompliance. Although pharmacists featured as the preferred source of drug information for some patients, a much more detailed investigation is needed of patients' attitudes to the profession and to individuals' consultation and communication skills.