The contribution of patient interviews to the identification of drug‐related problems in home medication review

What is known and Objective: To determine to what extent patient interviews contribute to the identification of drug‐related problems (DRPs) in home medication reviews, in terms of number, type and clinical relevance. Methods: We performed a cross‐sectional study within the intervention arm of a randomized controlled trial. Patients were recruited from 10 Dutch community pharmacies. Patients were eligible if they were home‐dwelling, aged 65 years and over and used five or more different drugs, including at least one cardiovascular or antidiabetic drug. The community pharmacist interviewed the patient at home about the medicines and identified potential DRPs in combination with medication and clinical records. This medication review was assessed and modified by an independent pharmacist reviewers’ panel. Outcomes were the number and type of DRPs and recommendations and percentage of clinical relevant DRPs. Clinical relevance of DRPs was assessed by DRPs assigned a high priority, DRPs followed by recommendations for drug change and DRPs followed by implemented recommendations for drug change. Results: A total of 1565 potential DRPs and recommendations (10 per patient).were identified for 155 patients (median age, 76 years; 54% women). Fifty‐eight per cent of all recommendations involved a drug change; 27% of all DRPs were identified during patient interviews and 74% from medication and clinical records. Compared to DRPs identified from patient medication and clinical records, DRPs identified during patient interviews were more frequently assigned a high priority (OR = 1·8 [1·4–2·2]), were more frequently associated with recommendations for drug change (OR = 2·4 [1·9–3·1]) and were implemented recommendations for drug change (OR = 2·8 [2·1–3·7]). What is new and Conclusion: This study shows that more than a quarter of all DRPs were identified during patient interviews. DRPs identified during patient interviews were more frequently assigned a higher clinical relevance.     

Drug-related problems on hospital admission: relationship to medication information transfer

BACKGROUND: Patients with end-stage renal disease (ESRD) are at risk for drug-related problems (DRPs), especially on hospital admission. OBJECTIVE: To identify and characterize the DRPs experienced by patients with ESRD on admission and investigate how these DRPs could be related to gaps in medication information transfer. METHODS: Patients with ESRD admitted to the hospital were prospectively identified and clinically assessed by a pharmacist to identify and categorize DRPs on admission. Each DRP was evaluated to determine whether it could have been caused by a gap in medication information transfer. For DRPs caused in this manner, the interface in the information transfer process where the gap may have occurred was determined. RESULTS: A total of 199 DRPs were identified in 47 patients with ESRD over a 12 week period. Ninety-two percent of patients had at least one DRP on admission, with an average of 4.2 +/- 2.2 DRPs per patient. The most common DRP identified was indication for drug therapy--patient requires drug but is not receiving it (51.3%). Of the total DRPs, 130 (65%) were related to gaps in medication information transfer, with 21.5% occurring between the inpatient hospital and the ambulatory clinic pharmacists and 17.7% between the admitting physician and the patient. CONCLUSIONS: Results of this study demonstrate that, in patients with ESRD, DRPs on admission are frequently related to gaps in medication information transfer between healthcare professionals and also between healthcare providers and patients. Improved communication is required at medication information transfer interfaces to prevent these DRPs.     

Identification of medication-related attendances at an A & E department

BACKGROUND: The use of medication is the most common medical intervention, but it has associated risks. These have been described as drug-related problems (DRPs). Other non-UK studies have reported DRPs to be the cause of 3-16% of hospital admissions and around 4% of attendances at emergency departments. The size of the problem in the UK has not been quantified. AIM: The aim of this study was to identify the number of patients attending a central London accident and emergency (A & E) department with symptoms or conditions caused by DRPs. METHOD: A 2-week retrospective, case-review study was conducted in the A & E department of St Thomas' Hospital, London, during March 1999. DRPs were identified using recognized criteria. Statistical analysis identified patient characteristics which could be associated with the incidence of DRPs. The types of DRP and the drugs involved were identified. RESULTS: During the study period, 106 patients attended the A & E department with a DRP. This equates to 4% of the A & E population. During this period the demographics of the A & E attenders were no different to the annual A & E cohort. The most common DRPs were adverse drug reactions and overdose. The most frequently involved drugs included analgesics, antibiotics, those with narrow therapeutic indices and illegal drugs. The mean age of this patient group was 38 years (non-significant). They attended significantly more frequently during the early hours of the morning and on Saturdays than the A & E general population (chi-squared P = 0.004 and P = 0.003, respectively). DISCUSSION: The incidence of DRP as a cause of attendance at A & E reflects that in the literature. No statistical association with a specific age group of patients could be made, but the mean age of 38 years is younger than previously reported. The demographic differences which were statistically significant can be explained by the increased incidence of DRP associated with the use of illegal drugs than reported in other studies. Other drug groups identified by this study are representative of other reports. CONCLUSION: DRPs account for 4% of attendances at a central London A & E Department.     

Comparison of drug-related problems in different patient groups

BACKGROUND: There is a lack of knowledge concerning how drug-related problems (DRPs) vary in different patient groups. Possible dissimilarities need to be taken into consideration when guidelines for detecting and preventing DRPs are compiled. OBJECTIVE: To characterize and compare the frequency and categories of DRPs in different groups of hospitalized patients. METHODS: Patients admitted to 4 different types of departments at 5 hospitals in Norway were included consecutively. Medical records and information acquired at multidisciplinary morning meetings were sources for assessing the patients' DRPs. RESULTS: A total of 827 patients were included. Mean age was 70.8 years, 58.6% were female, and 81% had at least one DRP. An average of 1.9, 2.0, 2.1, and 2.3 DRPs per patient were found in the departments of cardiology, geriatrics, respiratory medicine, and rheumatology, respectively. Significant differences in the type of DRPs between the patient groups were found. The most frequent DRPs and the patient group in which they most often occurred were nonoptimal dose (cardiology, respiratory, geriatric) and need for additional drug (rheumatology). CONCLUSIONS: DRPs occurred in the majority of the patients in all departments. The type of DRP differed markedly between the patient groups. Knowledge of these differences is clinically valuable by enabling us to guide efforts toward prevention of DRPs. Antithrombotic agents, loop diuretics, angiotensin-converting enzyme inhibitors, penicillins, antiinflammatory drugs, and opioid analgesics commonly caused DRPs, even in departments where knowledge of these drugs is assumed to be extensive.     

Drug-related problem classification systems

OBJECTIVE: To provide an overview of and critically appraise classifications of drug-related problems (DRPs) for use during the pharmaceutical care process and research in pharmacy. DATA SOURCES: A literature search was conducted using MEDLINE and Yahoo (January 2003) and manually. The search terms included DRP, drug-related problem, drug-therapy problem, and medicine-related problem. STUDY SELECTION AND DATA EXTRACTION: English- and German-language articles on pharmaceutical care and DRPs were reviewed. DATA SYNTHESIS: Most classifications of DRPs were identified through searching publications on pharmaceutical care and DRPs. Fourteen classifications with different focuses were found. Some classifications were hierarchical, categorized into main groups and subgroups. Various terminologies and definitions for DRPs were revealed, as well as guidelines for an optimal DRP classification. Classifications were assessed according to a clear definition, published validation method, and results reflecting process and outcomes, usability in pharmaceutical care practice, and a hierarchical structure with main groups and subgroups. CONCLUSIONS: Finding DRP classifications by computerized search of the biomedical literature with the help of PubMed proved to be difficult. No classification could be found that met all of our criteria for an optimal system. Few classifications have been validated. Three have been tested as to their usability in practice and internal consistency. The Pharmaceutical Care Network Europe system Version 4 comes closest to the defined requirements.     

Societal perceptions of community pharmaceutical services in Malta

Objective: To assess the views of the Maltese general public on services provided by community pharmacies in Malta and their opinions on the proposed extended role for pharmacies Method: An interviewer-administered structured questionnaire was used to interview 912 members of the public (395 males, 517 females) Results: The majority of respondents (70·8%) visited a pharmacy at least once a month, with females visiting more frequently than males ( P< 0·01). Almost 31% stated that the main reason for visiting a pharmacy was to purchase prescribed medication, while 23·3% said that it was to obtain over-the-counter products. Women were more likely than men to be influenced by the pharmacist's advice when selecting an over-the-counter product ( P< 0·05). The majority of respondents (62·8%) said that they usually bought their medicines from the same pharmacy and loyalty to a particular pharmacy increased with age. When treating minor ailments, respondents were more likely to consult their doctor or self-treat rather than seek advice from the pharmacist. The proposed extended role of the community pharmacist found support with the public, e.g. 90·2% felt that the pharmacist should promote health education, with the preferred method suggested being through individual advice; 85·7% were in favour of screening and monitoring services and 85·6% felt that the keeping of patient medication records would be useful. Almost three-quarters (74·6%) of respondents said that they would be willing to participate in pharmaceutical care programmes. When asked to suggest new activities for community pharmacy, respondents were most in favour of the pharmacist offering more advice on the treatment of minor ailments Conclusion: Overall, the results obtained are encouraging and Maltese pharmacists should plan to provide new services to the community in the future     

Uptake and effectiveness of a community pharmacy intervention programme to improve asthma management

What is known and Objective: Pharmacists frequently see patients with asthma in the community who have suboptimal management. This study aimed to compare the uptake and effectiveness of pharmacist‐initiated mailed and face‐to‐face interventions for patients whose asthma may not be well managed. Methods: Seventy‐one community pharmacies in South Australia, Tasmania and Victoria (Australia) installed a software application that data‐mined dispensing records, generating a list of patients who had received six or more asthma reliever inhalers in the preceding 12 months. The pharmacists were randomized, by pharmacy, to perform either a mailed or face‐to‐face intervention, whereby these patients received educational material and a referral to their general practitioner (GP) for an asthma management review. Matching patients from each pharmacy were also randomly assigned to a control group for ‘usual care’. Results and Discussion: A total of 1483 patients were identified and grouped as follows: 510 (34·4%) mailed intervention, 480 (32·4%) face‐to‐face intervention and 493 (33·2%) controls. Significantly fewer face‐to‐face interventions were offered than mailed interventions (66·6% vs. 89·4%, respectively; χ² = 64·2, P < 0·0001). There were significant improvements in the preventer‐to‐reliever ratio after the intervention period (P < 0·0001) in each group. In a per‐protocol analysis, the magnitude of improvement in the face‐to‐face intervention group was greater than in the mailed intervention group. The reverse was true in an intention‐to‐treat analysis. The improvement in the P : R ratios was mainly due to significant decreases in reliever usage. What is new and Conclusion: Community pharmacy dispensing records can effectively identify patients with suboptimal asthma management, who can then be referred to their GP for review. Time constraints in busy pharmacies may limit the uptake and effectiveness of face‐to‐face interventions in the ‘real world’ setting, making mailed interventions an attractive option.     

The comparison of effectiveness of two modalities of mental health nurse follow-up programmes for female outpatients with depression in Taipei, Taiwan

Aims and objectives. This study compares the effectiveness of two modalities of mental health nurse three‐month follow‐up programmes: telephone counselling programme and group therapy programme for female outpatients with depression. Background. The lifetime prevalence of major depression is 15% and is about twice as common in women as in men. Outpatients with depression often discontinue their treatment after the initial visits to their physicians. Methods. This study used a quasi‐experimental, pre–post‐test comparison group design. Twenty‐six female outpatients with depression were assigned to one of follow‐up programmes: telephone counselling programme or group therapy programme. To qualify for group therapy programme, potential participants were required to come to group sessions weekly. To be accepted into telephone counselling programme, potential participants had to be able to be contacted by phone regularly. Mental health nurse three‐month follow‐up programmes included care management and structured psychotherapy. Patients in telephone counselling programme received 10 regular telephone calls of 30–60 minutes each. Patients in group therapy programme received 12 sessions of weekly group meetings of 90–120 minutes each. Results. Wilcoxon signed ranks tests provided evidence that the group therapy programme (S = −52·5, p < 0·001; S = 31·5, p = 0·046) and telephone counselling programme (S = −36, p = 0·002; S = 25, p = 0·050) follow‐up programmes were effective in terms of relieving depressed symptoms and improving quality of life. According to Quade's analysis of covariance, telephone counselling programme and group therapy programme appeared to have similar effects of relieving depressed symptoms (F_(1,24) = 0·06, p = 0·813) and increasing quality of life (F_(1,24) = 0·07, p = 0·792). While there was no significant difference in using emergency services ( = 0·89, p = 0·539) between telephone counselling programme and group therapy programme, the rate of adherence to scheduled outpatient appointments with psychiatrists was higher among patients in group therapy programme than patients in telephone counselling programme ( = 8·67, p = 0·034). Conclusions. Establishing two modalities of mental health nurse follow‐up programmes in Taiwan could benefit patients with different needs. Relevance to clinical practice. Mental health nurses specialized in management of depression could provide not only care management but also structured psychotherapy.