Differences between patients'', physicians'' and pharmacists'' preferences for treatment products in haemophilia: a discrete choice experiment

The provision of health care to patients with haemophilia through replacement of the deficient coagulation factor is the result of a complex interaction between patients, physicians and policy makers, each carrying their individual sets of preferences. Preferences of patients, physicians and pharmacists towards perceived viral safety, risk of inhibitor development, infusion frequency during prophylaxis, pharmaceutical dosage form, distribution modes and price were evaluated by conjoint analysis, using a discrete choice experiment. Overall 178 patients', 69 physicians and 58 pharmacists completed the study. Patients, physicians and pharmacists displayed preferences: (i) similar in direction and strength for risk of inhibitors and frequency of prophylaxis, (ii) similar in direction, but not in strength for perceived viral safety and price, with patients showing lower strength compared with physicians and pharmacists, and (iii) dissimilar in direction and/or strength for: (i) dosage form, which tested important only for pharmacists and (ii) distribution mode, which tested important for patients and physicians only. Our study provides evidence of the differences between different stakeholders in the preferences towards haemophilia replacement therapy, indicating that different opinions should be taken into account when planning optimal care.     

Pharmacists’ contributions to the delivery of pharmaceutical care to patients with type 2 diabetes in Kuwait

This study was designed to identify pharmacists’ potential contributions to the delivery of pharmaceutical care to patients with type 2 diabetes in Kuwait, and to identify and explore barriers that were preventing them from providing care to this specific group. A pretested self-administered questionnaire was distributed to all pharmacists registered in the Kuwait Pharmaceutical Association’s email registry (N?=?250). Invitations to a focus group interview were then sent to all pharmacists (N?=?50) who had responded to the questionnaire. Seven pharmacists accepted the invitation and participated in the focus group interview. Of the 50 respondents to the questionnaire, 31 (62.0 %; 95 % CI: 47.2–75.4) indicated that they were “comfortable” and “extremely comfortable” in discussing patient’s blood pressure target and annual screening with physicians rather than discussing smoking cessation advice or specific medication-related care issues. More than 75 % of the respondents were “comfortable” and “extremely comfortable” in sharing and verifying the patient’s drug history, blood pressure, cholesterol and stability of blood glucose with the healthcare team, and to maintain a pharmaceutical care plan for patients with diabetes. Overall, pharmacists indicated that they were more comfortable in undertaking clinical activities than discussing care issues with physicians. The focus group interview identified issues related to pharmacist-physician interaction, pharmacists’ confidence, pharmacists’ image by patients and physicians and barriers to implementing pharmaceutical care. This study shows that pharmacists in Kuwait perceive that their contribution to the delivery of pharmaceutical care could develop further with increased partnership between pharmacists and physicians and provision of further education, training and continuing professional development support.     

Effects of computerized guidelines for managing heart disease in primary care

BACKGROUND: Electronic information systems have been proposed as one means to reduce medical errors of commission (doing the wrong thing) and omission (not providing indicated care). OBJECTIVE: To assess the effects of computer-based cardiac care suggestions. DESIGN: A randomized, controlled trial targeting primary care physicians and pharmacists. SUBJECTS: A total of 706 outpatients with heart failure and/or ischemic heart disease. INTERVENTIONS: Evidence-based cardiac care suggestions, approved by a panel of local cardiologists and general internists, were displayed to physicians and pharmacists as they cared for enrolled patients. MEASUREMENTS: Adherence with the care suggestions, generic and condition-specific quality of life, acute exacerbations of their cardiac disease, medication compliance, health care costs, satisfaction with care, and physicians' attitudes toward guidelines. RESULTS: Subjects were followed for 1 year during which they made 3,419 primary care visits and were eligible for 2,609 separate cardiac care suggestions. The intervention had no effect on physicians' adherence to the care suggestions (23% for intervention patients vs 22% for controls). There were no intervention-control differences in quality of life, medication compliance, health care utilization, costs, or satisfaction with care. Physicians viewed guidelines as providing helpful information but constraining their practice and not helpful in making decisions for individual patients. CONCLUSIONS: Care suggestions generated by a sophisticated electronic medical record system failed to improve adherence to accepted practice guidelines or outcomes for patients with heart disease. Future studies must weigh the benefits and costs of different (and perhaps more Draconian) methods of affecting clinician behavior.     

A prospective, randomized trial to assess the cost impact of pharmacist-initiated interventions.

BACKGROUND: Hospital pharmacists make many recommendations that improve patients' quality of care and/or reduce drug costs. While the impact of quality-of-care interventions is difficult to quantify, those limited to cost savings could be assessed in a prospective, randomized fashion. OBJECTIVE: To assess the impact of pharmacist-initiated interventions on cost savings. METHODS: Six pharmacists at a large university hospital recorded patient-specific recommendations for 30 days. All quality-of-care interventions were completed by the pharmacists, but those strictly aimed at reducing costs were stratified by drug class and randomized to an intervention or control group. Pharmacists contacted physicians with cost-saving recommendations in the intervention group, while control group patients were simply observed. MAIN OUTCOME MEASURE: Drug costs after randomization. RESULTS: Most (n=967 [79%]) of the 1226 interventions recorded were aimed at improving quality of care. The remaining 259 (21%) provided equivalent quality of care, but at less expense. These cost-saving interventions typically involved streamlining therapy to less expensive agents (39%), discontinuing an unnecessary medication (25%), or modifying the route of administration (24%). The group randomized to receive a pharmacist's intervention had drug costs that were 41% lower than those in the control group (mean, $73.75 vs $43.40; P<.001). Interventions involving anti-infective agents had the greatest cost savings (mean, $104.08 vs $58.45; P<.001). For our institution, this extrapolates to an annual savings of approximately $394,000 (95% confidence interval, $46,000-$742,000). As expected, these interventions had no impact on length of hospital stay, in-hospital mortality, 30-day readmissions, or the need to readminister the targeted medication or restart intravenous therapy. CONCLUSIONS: While interventions solely aimed at reducing costs represent a small portion of a pharmacist's activities, they can result in significant savings for an institution.     

Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: diagnosis and management

Heart failure remains a common diagnosis, especially in older individuals. It continues to be associated with significant morbidity and mortality, but major advances in both diagnosis and management have occurred and will continue to improve symptoms and other outcomes in patients. The Canadian Cardiovascular Society published its first consensus conference recommendations on the diagnosis and management of heart failure in 1994, followed by two brief updates, and reconvened this consensus conference to provide a comprehensive review of current knowledge and management strategies. New clinical trial evidence and meta-analyses were critically reviewed by a multidisciplinary primary panel who developed both recommendations and practical tips, which were reviewed by a secondary panel. The resulting document is intended to provide practical advice for specialists, family physicians, nurses, pharmacists and others who are involved in the care of heart failure patients. Management of heart failure begins with an accurate diagnosis, and requires rational combination drug therapy, individualization of care for each patient (based on their symptoms, clinical presentation and disease severity), appropriate mechanical interventions including revascularization and devices, collaborative efforts among health care professionals, and education and cooperation of the patient and their immediate caregivers. The goal is to translate best evidence-based therapies into clinical practice with a measureable impact on the health of heart failure patients in Canada.     

Primary care physicians’ experience with disease management programs

OBJECTIVE: To examine primary care physicians' perceptions of how disease management programs affect their practices, their relationships with their patients, and overall patient care. DESIGN: Cross-sectional mailed survey. SETTING: The 13 largest urban counties in California. PARTICIPANTS: General internists, general pediatricians, and family physicians. MEASUREMENTS AND MAIN RESULTS: Physicians' self-report of the effects of disease management programs on quality of patient care and their own practices. Respondents included 538 (76%) of 708 physicians: 183 (34%) internists, 199 (38%) family practitioners, and 156 (29%) pediatricians. Disease management programs were available 285 to (53%) physicians; 178 had direct experience with the programs. Three quarters of the 178 physicians believed that disease management programs increased the overall quality of patient care and the quality of care for the targeted disease. Eighty-seven percent continued to provide primary care for their patients in these programs, and 70% reported participating in major patient care decisions. Ninety-one percent reported that the programs had no effect on their income, decreased (38%) or had no effect (48%) on their workload, and increased (48%)) their practice satisfaction. CONCLUSIONS: Practicing primary care physicians have generally favorable perceptions of the effect of voluntary, primary care-inclusive, disease management programs on their patients and on their own practice satisfaction.     

Geriatrics medication management rounds: a novel approach to teaching rational prescribing with the use of the medication screening questionnaire

Prescribing for older adults has become increasingly complex as treatment regimens have intensified, and the use of herbal and over-the-counter medications has increased. This article describes an educational intervention called Geriatrics Medication Management Rounds, which uses a new and comprehensive assessment tool called the Medication Screening Questionnaire (MSQ). This case-based interactive session is aimed at teaching trainees and postgraduate physicians and pharmacists to examine the pharmacology, potential drug and disease interactions, efficacy, adherence issues, and goals of care for a geriatric patient's medication regimen. Twenty-three sessions were held from January 2008 to January 2009, with 241 participants overall and an average of 10.4 participants per session. Of the 163 participants who completed an evaluation, all agreed or strongly agreed that the learning goals were clearly established, and 99% agreed or strongly agreed that the overall quality of the session was excellent. Participants described the sessions as excellent, interactive, informative, and educational. Teaching medication management through a case-based format with the MSQ is an effective format that is interactive and informative, as demonstrated by positive quantitative and qualitative evaluations. These sessions may be replicated in other settings and with other disciplines.     

Encounters with pharmaceutical sales representatives among practicing internists.

BACKGROUND: Although pharmaceutical sales representatives provide physicians with information on new products, these encounters have rarely been studied in practice settings. We examined these interactions among practicing internists and assessed whether prior residency policies limiting pharmaceutical sales representative access affected the subsequent behavior of practitioners. METHODS: We conducted a mail survey of the internal medicine staffs of a medical school hospital and two affiliated community hospitals. A second request was sent to nonresponders. After the second mailing, a random sample of nonresponders was compared with a similar sample of respondents. Multivariate odds ratios (OR) and 95% confidence intervals (CI) were estimated with logistic regression. RESULTS: Of the 346 (40%) internists who responded, 22% were women and 60% were trained in university hospitals. There were no differences in gender, subspecialization, or type of training when survey responders and nonresponders were compared. Two hundred eighty-seven (83%) physicians had met with pharmaceutical sales representatives within the previous year, of whom 248 (86%) had received drug samples. Having had a policy that limited access to pharmaceutical sales representatives during residency did not affect the subsequent likelihood of seeing these representatives (P = 0.20) or accepting samples in practice (P = 0.99). Those describing themselves as busy practitioners were significantly less likely to abstain from meeting pharmaceutical sales representatives (OR = 0.2, 95% CI: 0.1 to 0.6, P <0.001). Those with very frequent contacts (>10 times/month) were virtually all busy practitioners. CONCLUSIONS: Encounters between physicians and pharmaceutical sales representatives are common in internal medicine practice, especially in busy offices. Policies designed to limit pharmaceutical sales representative access during residency do not appear to affect the subsequent likelihood of meeting with pharmaceutical sales representatives or accepting samples.     

Unsaid but not forgotten: patients' unvoiced desires in office visits

OBJECTIVES: To examine patient, physician, and health care system characteristics associated with unvoiced desires for action, as well as the consequences of these unspoken requests. PATIENTS AND METHODS: Patient surveys were administered before, immediately after, and 2 weeks after outpatient visits in the practices of 45 family practice, internal medicine, and cardiology physicians working in a multispecialty group practice or group model health maintenance organization. Data were collected at the index visit from 909 patients, of whom 97.6% were surveyed 2 weeks after the outpatient visit. Before the visit, patients rated their trust in the physician, health concerns, and health status. After the visit, patients reported on various types of unexpressed desires and rated their visit satisfaction. At follow-up, patients rated their satisfaction, health concerns, and health status, and also described their postvisit health care use. Evaluations of the visit were also obtained from physicians. RESULTS: Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician. Patients with unvoiced desires evaluated the physician and visit less positively; these encounters were evaluated by physicians as requiring more effort. Holding an unvoiced desire was associated with less symptom improvement, but did not affect postvisit health care use. CONCLUSIONS: Patients' unvoiced needs affect patients' and physicians' visit evaluations and patients' subjective perceptions of improvement. Implications of these findings for clinical practice are examined.     

The undertreatment of LDL-cholesterol: addressing the challenge

Patients with dyslipidemia are at increased risk of coronary heart disease (CHD), while treatment to reduce low density lipoprotein cholesterol (LDL-C) concentrations lessens this risk. Consequently, the Lipid Treatment Assessment Project (L-TAP) was undertaken in the US to determine the extent to which primary care practitioners utilize lipid-lowering therapy and to evaluate the success of current therapeutic regimens, using the National Cholesterol Education Program (NCEP) guidelines as therapeutic targets. The L-TAP study, initiated in 1996 and completed in February 1997, recorded LDL-C levels in 4888 patients from 619 US practices. All patients had received lipid-lowering therapy for at least 3 months. The primary care practitioners involved in the study were questioned about the NCEP guidelines and the results confirmed that these physicians were representative of primary care practitioners in the USA. The 4888 patients were categorized according to risk: patients with <2 risk factors (RFs) but no CHD, those with >/=2 RFs but no CHD and patients with confirmed CHD. Overall, only 38% of the patients attained LDL-C target levels or had values lower than these goals. The greater the number of RFs, the lower the proportion of patients achieving target levels. LDL-C targets were less often attained in patients receiving dietary therapy only compared with those receiving lipid lowering drug treatment. However, there was good correlation between the success of treatment and both receipt of and compliance with dietary instruction. In conclusion, a large proportion of dyslipidemic patients who are being treated in primary care are not achieving NCEP target LDL-C levels.     

Patterns of hypertension management in Italy: results of a pharmacoepidemiological survey on antihypertensive therapy. Scientific Committee of the Italian Pharmacoepidemiological Survey on Antihypertensive Therapy

OBJECTIVE: To collect statistically significant information on patterns of antihypertensive therapy in medical practice, with particular attention to the drugs used in the pharmacological management of hypertensive patients and the reasons for the limited achievement of therapeutic goals during treatment DESIGN: A survey conducted among general practitioners, specialists, and hypertensive patients. METHODS: A total of 28,000 physicians were contacted by letter and 3,394 declared their willingness to participate and received a questionnaire. Subsequently, 1,255 questionnaires suitable for analysis (corresponding to 37.0% of adhering physicians) were received. In addition, 4,612 questionnaires completed by patients were pooled and evaluated. The prevalence of hypertension was calculated from a base of 254,192 patients, seen by general practitioners. RESULTS: The prevalence of hypertension, defined as systolic blood pressure > or = 160 mmHg or diastolic blood pressure > or = 95 mmHg, or current treatment, was 19.7%. The average number of hypertensive patients in each general practitioner's file, covering the previous 12 months, was approximately 230. Physicians reported a 66% rate of discontinuation of treatment or switching to another drug. Physicians and patients both considered inadequate blood pressure control and side effects to be the two main reasons for switching antihypertensive therapy, but in opposite order. Furthermore, physicians indicated a prevalence of drug side effects between 10 and 20%, according to class of drug used, whereas 69% of patients reported to have experienced side effects. In the doctors' opinions, there were many reasons for poor patient adherence: complexity of the drug regimen, appearance of side effects, forgetfulness, reduced patient understanding of the need for long-term continuation of treatment, and refusal to accept a chronic pathological condition. CONCLUSIONS: The survey showed awareness of the disease among physicians and provides a representation of the experiences of both general practitioners and specialists, in addition to that of their patients. During antihypertensive therapy, a disconcerting degree of discontinuation and switching of drugs occurred. Insufficient blood pressure control and side effects accounted for most of the observed treatment changes. This survey revealed the existence of a gap between the physicians' perception of tolerability and the real experience of patients, a clear need for greater tolerability of treatments, and a need for an enhancement of patient-physician communication.     

Difficult end-of-life treatment decisions: do other factors trump advance directives?

BACKGROUND: Advance directives are widely promoted as a means to plan for patients' decisional incapacity, yet there is little evidence of their effectiveness. We devised a study to assess physicians' compliance with hypothetical advance directives and further examine their clinical reasoning. METHODS: The study consisted of an analysis of a mailed written survey containing 6 hypothetical cases of seriously ill patients. Each case contained an explicit advance directive with potential conflict between the directive and (1) prognosis, (2) wishes of family or friends, or (3) quality of life. Data were collected on the clinical treatment decisions made by physicians and the reasons for those decisions. Study participants were all internal medicine faculty and resident physicians from a single academic institution. RESULTS: A total of 47% analyzable surveys (117/250) were returned. Decisions by faculty and residents were not consistent with the advance directive in 65% of cases. This inconsistency was similar for faculty and residents (68% and 61%, respectively; P>.05). When physicians made decisions inconsistent with the advance directive, they were more likely to list reasons other than the directive for their decisions (89%; P<.001). CONCLUSIONS: Internists frequently made treatment decisions that were not consistent with an explicit advance directive. In difficult clinical situations, internists appear to consider other factors such as prognosis, perceived quality of life, and the wishes of family or friends as more determinative than the directive. Future work needs to explore the generalizability of these findings and examine how strictly patients desire their advance directives to be followed.     

Medication education of acutely hospitalized older patients

OBJECTIVES: To determine the amount of time spent providing medication education to older patients, the impact of medication education on patients' knowledge and satisfaction, and barriers to providing medication education. DESIGN: Telephone survey of patients within 48 hours of hospital discharge and direct survey of physicians and pharmacists. SETTING: Internal medicine ward in a tertiary care teaching hospital. PARTICIPANTS: Patients 65 years of age and over regularly taking at least one medication. MEASUREMENTS: Patient demographics, medication use, time spent receiving or providing medication education, and satisfaction scores. MAIN RESULTS: Forty-seven respondents with a mean age of 77.1 years reported that physicians spent a mean of 10.5 minutes (range, 0-60 minutes) and pharmacists spent a mean of 5.3 minutes (range, 0-40 minutes) providing medication education. Fifty-one percent reported receiving no education from either physician or pharmacist, and only 30% reported receiving written medication instructions. Respondents were generally quite satisfied with their education. Physicians identified one or more barriers to providing education 51% of the time and pharmacists 80%. Lack of time was the most common barrier (18%) identified by physicians, but pharmacists cited lack of notification of discharge plans (41%) and lack of time (39%) as the main barriers. Respondents made many medication errors and knew little about their medications. CONCLUSIONS: Although older hospitalized patients received little medication education or written information and made many medication errors with and without medication education, approximately one half of physicians perceived no barriers to providing education.     

Treatment of mild hypertension in primary health care: results of a physicians' inquiry, Stuttgart, 1986

One of the most widely discussed problems in the field of hypertension is the treatment of mild hypertension: 90-104 mmHg diastolic BP. Organizations like the WHO recommend caution with respect to drug therapy. To investigate the actual treatment of hypertension by primary health care services, a standardised questionnaire, based on the study protocol of the WHO-coordinated HYRAP project, was sent to all private practitioners, internists and gynaecologists in private practice in Stuttgart in 1986 (n = 480). The response rate among the general practitioners and internists was 68%. The data indicate that a major part of the physicians favour treatment by health counselling. In contrast, the vast majority (89%) of the physicians report treating mild hypertension exclusively by drug therapy. This wide use of drug therapy may be due to the influence of certain reference groups and the health care system itself. The results support recommendations that special attention be given to the training of physicians in health counselling.     

Initiation of the pharmacist-delivered antidiabetic medication therapy management services in a tertiary care hospital in Nepal

The medication therapy management (MTM) pharmacists follow the philosophy of pharmaceutical care to address individualistic medication therapy requirements in their practice settings.The present study aimed to introduce the pharmacist-delivered MTM services among type 2 diabetes mellitus patients at a tertiary care hospital in Nepal.Cross-sectional study was conducted at Patan Hospital, Lalitpur, Nepal, among 200 patients with type 2 diabetes mellitus from July to December 2019. The intervention included maintenance of medication profile for individual patients, and then MTM service was proposed based on 5 core elements of MTM services proposed by the American Pharmacists Association. Both antidiabetic and non-antidiabetic medicines were coded as per the anatomic, therapeutic, and chemical classification and defined daily dose assignment 2020 for documentation. The Charlson Comorbidity Index was used to index comorbidities. The drug interaction profile was checked with the Medscape Drug Interaction Checker.Both fasting and postprandial blood sugar levels were significantly associated with age (P-values <.000 for both), baseline symptom (P-values .012 and .003 respectively), and diet plan proposed (P-values .049 and .011 respectively). Maximum cases of drug interactions requiring close monitoring were between metformin and insulin regular (i.e., 11, 5.5%).This was a novel initiative of the MTM services in a resource constraint country like Nepal and can show a clue for the pharmacists targeting such services in other similar settings.     

Goals for the care of frail older adults: do caregivers and clinicians agree?

PURPOSE: Establishing shared treatment goals for patients may improve the quality of care by facilitating achievement of appropriate and desired outcomes. The purpose of this study was to describe types of family caregiver and physician treatment goals for frail elderly patients who had a high prevalence of cognitive impairment, and to ascertain the level of agreement between family caregivers and physicians on principal treatment goals. SUBJECTS AND METHODS: We surveyed family caregivers and physicians for 200 consecutive older adults who were initially evaluated at the outpatient geriatric assessment center of a major teaching hospital. Treatment goals for patients were measured after a comprehensive geriatric assessment. RESULTS: Goals commonly chosen as most important by family caregivers and physicians pertained to day-to-day functioning (61 [31%] family caregivers, 81 [41%] physicians), behavior and emotional health (56 [28%] family caregivers, 50 [25%] physicians), and safety (40 [20%] family caregivers, 29 [15%] physicians). Although a substantial proportion of family caregiver and physician pairs shared at least one goal (157 [79%] of 200), agreement on presence or absence of individual categories of goals was poor (kappas from -0.19 to 0.28), and agreement on the most important goal was also poor (kappa 0.20). CONCLUSIONS: Agreement on treatment goals between family caregivers and physicians for patients at the study site was low. These results suggest that encounters between family caregiver and physician may need improvement. Further research is needed to assess whether lack of agreement is found in other settings, persists over time, and affects achievement of goals and optimal health outcomes.