Problem-oriented drug information: physicians’ expectations and impact on clinical practice

Purpose  Problem-oriented drug information (POD) is a service in which health professionals provide evidence-based answers to clinical questions posed by physicians. The objective of this study was to evaluate the user satisfaction and clinical impact of POD, to investigate predictors for use and to examine the kind of sources physicians search before applying for POD. Methods  To evaluate POD, a questionnaire was distributed with problem-oriented answers sent from a drug information centre to physicians during the period of April 2006 to March 2007. Results  Of 197 questionnaires, 183 (93%) were returned. The information from the POD service was highly valued by the physicians, and 90% of the answers led to reported impact on clinical practice in the specific clinical situation. Furthermore, 74% of the answers were intended to be used in a wider context either for future patients (67%) or for dissemination to colleagues (51%). Secondary-care physicians more often than general practitioners (GPs) used the information for dissemination to colleagues (63 vs. 39%, P = 0.0008), while GPs more often used the answer to support patient information (88 vs. 70%, P = 0.0029). The most prominent motive for applying for POD was a request for evidence-based information (78%), and the service was used to overcome barriers to practicing evidence-based medicine such as lack of time (36%), skills for searching (26%), and appraising the literature (13%). Before inquiring, 74% of the physicians had tried other information sources; the most frequent sources used were a drug reference (68%) and consulting a colleague (24%). Secondary-care physicians reported fewer barriers than GPs when seeking information, and secondary-care physicians searched other sources more often than GPs before contacting the service (81 vs. 67%, P = 0.031). Conclusion  POD represents a useful source for acquiring evidence-based drug information by physicians. POD is highly valued by the users. It was reported to have an impact on clinical practice for the specific patient but is also intended to be used in a wider context for future patients or for dissemination to colleagues. GPs’ and secondary-care physicians’ use of POD differs with GPs having more focus on patient information and secondary-care physicians having more focus on dissemination of the information to colleagues.     

Prioritising the prevention of medication handling errors

Objective Medication errors are frequent in a hospital setting and often caused by inappropriate drug handling. Systematic strategies for their prevention however are still lacking. We developed and applied a classification model to categorise medication handling errors and defined the urgency of correction on the basis of these findings. Setting Nurses on medical wards (including intensive and intermediate care units) of a 1,680-bed teaching hospital. Method In a prospective observational study we evaluated the prevalence of 20 predefined medication handling errors on the ward. In a concurrent questionnaire survey, we assessed the knowledge of the nurses on medication handling. The severity of errors observed in individual areas was scored considering prevalence, potential risk of an error, and the involved drug. These scores and the prevalence of corresponding knowledge deficits were used to define the urgency of preventive strategies according to a four-field decision matrix. Main outcome measure Prevalence and potential risk of medication handling errors, corresponding knowledge deficits in nurses committing the errors, and priority of quality improvement. Results In 1,376 observed processes 833 medication handling errors were detected. Errors concerning preparation (mean 0.88 errors per observed process [95% CI: 0.81–0.96], N = 645) were more frequent than administration errors (0.36 [0.32–0.41], N = 701, P < 0.001). Parenteral drugs (1.10 [1.00–1.19], N = 492) were more often involved in errors than enteral drugs (0.32 [0.28–0.36], N = 794, P < 0.001). Of the 833 observed medication errors 30.9% concerned processes of high risk, 19.0% of moderate risk, and 50.1% of low risk. Of these errors 11.4% were caused by critical dose drugs, 81.6% by uncomplicated drugs, and 6.9% by nutritional supplements or diluents without active ingredient. According to the decision matrix that also considered knowledge deficits two error types concerning enteral drugs (flaws in light protection and prescribing information) were given maximum priority for quality improvement. For parenteral drugs five errors (incompatibilities, flaws in hygiene, duration of administration, check for visible abnormalities, and again prescribing information) appeared most important. Conclusion We successfully applied a newly developed classification model to prioritise medication handling errors for prevention strategies.     

Impact of pharmacist prescribing through direct pharmacy access policies on access to hormonal contraception

Background/ObjectiveThis study assesses the impact of direct pharmacy access (DPA) policies that allow pharmacists to prescribe hormonal contraceptives on women’s access by comparing access among 3 groups: (1) women in a state without DPA (Indiana), (2) women in a state with DPA, but not using DPA, and (3) women in a state with DPA and using DPA.MethodsThis cross-sectional survey, including a scale to measure access to contraceptives, perception items, and demographics, was distributed through Amazon Mechanical Turk (Amazon.com, Inc). Kruskal–Wallis tests and linear regression analysis were used.ResultsThe sample size was 316. When controlling for education, income, and age, the women not using DPA (in Indiana and a DPA state, respectively) reported significantly higher levels of approachability (P < 0.001 and P < 0.001, respectively), acceptability (P < 0.001 and P < 0.001, respectively), availability and accommodation (P < 0.001 and P = 0.009, respectively), affordability (P < 0.001 and P < 0.001, respectively), and appropriateness (P < 0.001 and P < 0.001) access than the women using DPA. The women using DPA reported significantly lower levels of privacy access than those not using DPA in a DPA state (P = 0.004) when controlling for education, income, and age. However, 78.9% of women using DPA agreed DPA made obtaining contraceptives easier. Most of the women who had never used DPA were previously unaware of DPA (81.1% in DPA states and 86.2% in Indiana) but felt that it would improve access (82.8% and 80.0%, respectively).ConclusionUnderstanding the effects of DPA policies on women’s access to contraceptives can inform future policies and support implementation. Lower levels of access across all dimensions among those using DPA may be influenced by imperfect implementation and failure to legislatively enable the sustainability of this service rather than pharmacists’ ability to improve women’s access.     

Pharmacogenomics and Efficacy of Risperidone Long‐Term Treatment in Thai Autistic Children and Adolescents

The purpose of this study was to evaluate the association of pharmacogenomic factors and clinical outcome in autistic children and adolescents who were treated with risperidone for long periods. Eighty‐two autistic subjects diagnosed with DSM‐IV and who were treated with risperidone for more than 1 year were recruited. Pharmacogenomics and clinical outcome (CGI‐I, aggressive, overactivity and repetitive score) were evaluated. Almost all patients showed stable symptoms on aggressive behaviour (89.02%), overactivity (71.95%), repetitive (70.89%) behaviour and all clinical symptoms (81.71%). Only 4.48% of patients showed minimally worse CGI‐I score. Patients in the non‐stable symptom group had DRD2 Taq1A non‐wild‐type (TT and CT) frequencies higher than the clinically stable group (p = 0.04), whereas other gene polymorphisms showed no significant association. Haplotype ACCTCAT (rs6311, rs1045642, rs1128503, rs1800497, rs4436578, rs1799978, rs6280) showed a significant association with non‐stable clinical outcome (χ² = 6.642, p = 0.010). Risperidone levels showed no association with any clinical outcome. On the other hand, risperidone dose, 9‐OH risperidone levels and prolactin levels were significantly higher in the non‐stable compared to the stable symptom group (p = 0.013, p = 0.044, p = 0.030). Increased appetite was the most common adverse drug reaction and associated with higher body‐weight, whereas it was not significantly associated with genetic variations and non‐genetic information. In conclusion, risperidone showed efficacy to control autism, especially aggressive symptoms in long‐term treatment. However, Taq1A T – carrier of dopamine 2 receptor gene – is associated with non‐stable response in risperidone‐treated patients. This study supports pharmacogenomics testing for personalized therapy with risperidone in autistic children and adolescents.     

Safety of an injection with a mixture of extracts from Herba Artemisiae annuae, Fructus Gardeniae and Flos Lonicerae

Objective This study aimed to evaluate the safety for an injection with a mixture of extracts from Herba Artemisiae annuae, Fructus Gardeniae and Flos Lonicerae and to determine the risk factors that may affect its adverse drug reactions. Methods A drug-oriented prospective observational study was performed. Physicians filled in clinical observation forms with detailed information of the patients including general information, drug information, therapeutic effects and adverse drug events. The adverse drug reaction factors were analyzed by both mono-factor and multiple-factor logistic regression methods. Results From April to July 2007, we collected 12,427 observation forms from 46 hospitals in Jiangsu Province of China. Among the 11,707 observation forms we analyzed, 8,074 patients were children younger than 14 years old (69%). Among 51 reported adverse drug events, 45 cases were adverse drug reactions. The total adverse drug reaction incidence of the injection was 0.38%. While most adverse drug reactions were previously known (e.g., rash, pruritus, vomiting and diarrhea), we observed three new ADR symptoms: shiver, phlebitis and anhelation. All the adverse drug reactions were controlled very well through the follow-up therapy, and none of them was life threatening. The mono-factor analysis showed that adverse drug reactions of the injection were significantly correlated with total medication dose (P = 0.0049) and combination medication (P = 0.0143), especially with antimicrobial drugs (P = 0.0079) and macrolides (P = 0.0017). The multiple factor analysis confirmed these results: medication dosage and combination medication had a crucial impact on adverse drug reactions of the injection; the risk was increased by 24.8% (the estimated value of relative risk was 1.248, 95% confidence interval: 1.054–1.479) and 89% (1.890, 1.001–3.566), respectively. Conclusion The total adverse drug reaction incidence of the injection was 0.38% and lower than we expected. Moreover, we observed three new adverse drug reactions, none of which was severe.

Plasma Levels of 25‐Hydroxyvitamin D3 and In Vivo Markers of Cytochrome P450 3A Activity in Swedes and Koreans: Effects of a Genetic Polymorphism and Oral Contraceptives

In vitro studies have shown that vitamin D may induce several cytochrome P450 (CYP) enzymes in general and CYP3A4 in particular. The primary aim of this study was to investigate the relationship between plasma levels of 25‐hydroxyvitamin D₃ and suggested in vivo markers of CYP3A activity in healthy volunteers from Sweden and Korea. Plasma concentrations of 25‐hydroxyvitamin D₃ were analysed in samples from three previously performed studies, and the correlation between these levels and suggested in vivo markers of CYP3A activity was investigated by means of nonparametric correlation. In addition, we studied the modulating effects of three vitamin D receptor promoter polymorphisms on the association between 25‐hydroxyvitamin D₃ and CYP3A enzyme activity in Swedish subjects. The plasma levels of 25‐hydroxyvitamin D₃ were not significantly associated with CYP3A phenotypes in any of the three studies, but after accounting for the vitamin D receptor polymorphism rs4516035, there was a significant positive association between 25‐hydroxyvitamin D₃ and CYP3A activity (p = 0.004). Swedes (n = 65) had significantly higher 25‐hydroxyvitamin D₃ levels than Koreans (n = 67), 75 nM compared with 31 nM (p < 0.001). Swedish women taking oral contraceptives (OC) (n = 19) had somewhat higher plasma levels of 25‐hydroxyvitamin D₃ compared with Swedish women not taking oral contraceptives (n = 21), 89 and 72 nM, respectively (p = 0.02). In conclusion, our results suggest that the overall influence on the CYP3A activity by 25‐hydroxyvitamin D₃ is of marginal importance.     

Drug information centre queries and responses about drug interactions over 10 years—A descriptive analysis

Many people are treated with ≥1 drug, implying that risks of drug interactions need to be considered. The aim of this study was to describe drug interaction queries from healthcare professionals to a drug information centre in Sweden over 10 years focusing on drugs frequently asked about and the advice provided. Advice was recorded in mutually exclusive groups: Avoid, Adjust dose, Separate intake, Vigilance or No problem. For queries with Avoid, Adjust dose or Separate intake advice, alerts were extracted from an interaction database (Janusmed). Of 4335 queries to the centre in 2008‐2017, 589 (14%) concerned interactions. Most were posed by physicians (91%) and concerned a specific patient (83%) before treatment initiation (76%). Sertraline, warfarin and methotrexate were the most frequently asked about, whereas queries about cyclophosphamide and rifampicine occurred most often in relation to the number of exposed patients. Advice provided in 557 (95%) replies comprised Avoid: n = 85 (15%), Adjust dose: n = 57 (10%), Separate intake: n = 17 (3%), Vigilance: n = 235 (42%) or No problem: n = 163 (29%). In all, 113 (71%) of 159 queries with Avoid/Adjust dose/Separate intake advice elicited an action alert on Janusmed, whereas 31 (20%) did not result in any alert at all. Summarized, seven in ten replies from the drug information centre recommended an explicit drug treatment action, regarding either specific prescribing aspects, for instance dose adjustments, or active follow‐up including monitoring potential adverse reactions and/or laboratory results. Readily accessible decision support regarding drug interactions often provides relevant action alerts, but cannot be solely relied on.     

An evaluation of consumers’ knowledge, perceptions and attitudes regarding generic medicines in Auckland

Objectives The aim of this project was to evaluate the perceptions, knowledge and attitudes regarding generic medicines. Methods A cross-sectional study, with self administered questionnaires, was conducted to survey consumers visiting pharmacies in four regions of Auckland (North Shore, Waitakere, Central Auckland and South Auckland). Through stratified random sampling, approximately 10% of pharmacies from each region were selected, which turn out to be 30 pharmacies. Every alternate customer coming to the pharmacy, who was eligible to participate in the study, was asked by the researchers to complete the questionnaire. Results A total of 441 questionnaires were included in the analysis. Different response rates were obtained in different regions of Auckland. Of all respondents, 51.6% had previous knowledge of generic medicines. Pharmacists were the main source of information regarding generic medicines followed by doctors and media. A higher level of education had a direct relationship with having correct knowledge of generics (P = .002). Attitude of participants toward the use of generic medicines was determined by their knowledge of generics, whether it was recommended by a pharmacist and their type of illness. Participants were more prepared to change to a generic for a minor illness (79%) than for a major illness (58.7%). Those who had better knowledge were more likely than those with poor knowledge to say they would to use a generic in major illness (P = .001) as well as minor illness (P < .0001). Previous positive experiences with generics also determined consumers’ willingness to use generics. Conclusion Many consumers have misconceptions regarding generic medicines. Having knowledge about generics and the advice by doctors and pharmacists are key indicators to improve the quality use of generic medicines.     

Which factors predict the time spent answering queries to a drug information centre?

Objective To develop a model based upon factors able to predict the time spent answering drug-related queries to Norwegian drug information centres (DICs). Setting and method Drug-related queries received at 5 DICs in Norway from March to May 2007 were randomly assigned to 20 employees until each of them had answered a minimum of five queries. The employees reported the number of drugs involved, the type of literature search performed, and whether the queries were considered judgmental or not, using a specifically developed scoring system. Main outcome measures The scores of these three factors were added together to define a workload score for each query. Workload and its individual factors were subsequently related to the measured time spent answering the queries by simple or multiple linear regression analyses. Results Ninety-six query/answer pairs were analyzed. Workload significantly predicted the time spent answering the queries (adjusted R ² = 0.22, P < 0.001). Literature search was the individual factor best predicting the time spent answering the queries (adjusted R ² = 0.17, P < 0.001), and this variable also contributed the most in the multiple regression analyses. Conclusion The most important workload factor predicting the time spent handling the queries in this study was the type of literature search that had to be performed. The categorisation of queries as judgmental or not, also affected the time spent answering the queries. The number of drugs involved did not significantly influence the time spent answering drug information queries.     

Opinion comparison concerning future information technology in Finnish community pharmacies

Objective To compare the opinions of community pharmacy owners, managers and personnel concerning the key features of the future information technology system needed in Finnish community pharmacies. Setting The study was targeted to the pharmacists working in community pharmacies as managers (owners and staff pharmacists with M.Sc. degree) or personnel responsible for dispensing and patient counselling (pharmacists with B.Sc. degree). Method A national cross-sectional survey to all of Finnish community pharmacy owners (n = 580) and staff pharmacists (B.Sc. and M.Sc. degrees, n = 1709) working in community pharmacies, was conducted in order to determine differences in opinions between these occupation groups with different professional duties. The response rates were 53% for pharmacy owners (n = 308) and 22% for staff pharmacists (n = 373). Main outcome measure The main outcome measure was the perceived importance of 89 potential features for a new IT system ranked by using a five-point Likert scale. Results The responding community pharmacy managers and staff pharmacists had differences in their ranking of more than half (52%) of the potential features listed in the survey questionnaire. The features related to the pharmacy’s internal processes, such as financial management, sales and marketing management and stock holding, were ranked significantly higher by the managers, while the personnel prioritized the features supporting pharmaceutical service provision and personnel management. The managers and personnel shared their opinion on the importance of features supporting drug information and patient counselling, medication safety and interprofessional collaboration. Conclusion The managers and staff pharmacists have different views of the importance of IT features, reflecting their different professional duties in the community pharmacy. A high priority was given for the features familiar to the users and needed in their daily practice. This indicates the need for involving different occupation groups in planning the new IT systems for community pharmacies.     

Moxifloxacin is non-inferior to combination therapy with ceftriaxone plus metronidazole in patients with community-origin complicated intra-abdominal infections

Management of community-origin complicated intra-abdominal infections (cIAIs) requires surgical intervention and antimicrobial therapy. This multinational, randomised, double-blind clinical trial carried out in Asia compared the efficacy and safety of moxifloxacin monotherapy and ceftriaxone/metronidazole combination therapy in adults with confirmed or suspected cIAI. Patients received surgical intervention and either intravenous (i.v.) moxifloxacin 400 mg once daily or i.v. ceftriaxone 2 g once daily plus i.v. metronidazole 500 mg twice daily. A total of 364 patients were randomised [intent-to-treat (ITT), moxifloxacin N = 180, comparator N = 181; per-protocol (PP), moxifloxacin N = 174, comparator N = 171]. The most common cIAI diagnosis was complicated appendicitis. Moxifloxacin was non-inferior to ceftriaxone/metronidazole in terms of clinical response at test-of-cure in the PP population [clinical cure, 90.2% for moxifloxacin vs. 96.5% for ceftriaxone/metronidazole; 95% confidence interval (CI) of the difference −11.7 to −1.7] and in the ITT population (87.2% for moxifloxacin vs. 91.2% for ceftriaxone/metronidazole; 95% CI −10.7 to 1.9). Bacteriological cure rates in the microbiologically evaluable population support the clinical results (89.4% for moxifloxacin vs. 95.9% for ceftriaxone/metronidazole; 95% CI −13.3 to −0.6). The incidence of treatment-emergent adverse events was similar for both treatment groups (moxifloxacin 31.7% vs. comparator 24.3%). These results confirm previous findings that moxifloxacin plus adequate source control is an appropriate treatment of cIAI.     

Media exposure and tobacco product addiction beliefs: Findings from the 2015 Health Information National Trends Survey (HINTS–FDA 2015)

BackgroundAddiction beliefs about tobacco use are associated with intentions to use and use of tobacco products. Exposure to information about tobacco products in media sources may affect addiction beliefs.PurposeTo examine the relationship between media exposure and tobacco product addiction beliefs.MethodsA nationally representative sample of US adults (n = 3738) from the 2015 National Cancer Institute's Health Information National Trends Survey was used to examine addiction beliefs about cigarettes, cigars, smokeless tobacco, electronic cigarettes, hookah/waterpipe tobacco, and roll-your-own cigarettes. We used logistic regression to examine the relationship between media exposure and addiction beliefs. We defined media exposure by hours exposed, as well as exposure to tobacco use health effects information through media sources including social media. We categorized media sources by whether respondents actively or passively engaged with the source.FindingsA majority (60.6% to 87.3%) of respondents believed that cigarettes, cigars, roll-your-own cigarettes and smokeless tobacco are addictive. Less than half of respondents believed that electronic cigarettes or hookah/waterpipes are addictive (45.2% and 49.8%, respectively). Respondents exposed to messages about tobacco use health effects on active media channels (e.g., social media) had greater odds of believing that smokeless tobacco (adjusted odds ratio [AOR] = 1.48), hookah/waterpipe (AOR = 1.69), and roll-your-own cigarettes (AOR = 1.61) are addictive. Respondents exposed to tobacco use health effects messages on passive media channels (e.g., television), had greater odds of believing that cigarettes (AOR = 2.76) and electronic cigarettes (AOR = 2.12) are addictive.ConclusionsUS adult exposure to information about the health effects of tobacco use was associated with addiction beliefs about tobacco products.     

Combined hormone contraceptive choice experience in Czech Republic

The aim of the prospective, multicenter project was to evaluate the effect of standardized information on the decision of woman when selecting application routes for combined hormonal contraceptives (CC). Selection the route of CC’s administration before and after consultation with the physician was evaluated on the group of 1326 women in 125 centres in the Czech Republic using a questionnaire. Analysis of the difference between the intended (4,1%) and selected (33,9%, CI 95% 31%–38%, 451 women) contraception shows that the vaginal ring preference increased by 29,8% (CI 97,5% 26,9%–32,8%, p < 0,0001). The difference for the weekly patch after (5,7%) and prior (4,2%) to the counseling of 1,4% was borderline statistically significant (CI 97,5%–0,002%–3,0%, p = 0,05). Preference of COC remained practically unchanged at 53,5%. Vaginal ring was selected by 45,2% of undecided women and 28,0% of women, who considered other than combined hormonal contraception. Easibility of application, efficacy and cycle control are the most important predictors for contraception choice. Following expert advice, including information on all forms of combined oral contraceptives, more than 33% of women chose the latest application form of combined hormonal contraceptives - vaginal ring.     

Extracellular proteomic analysis for degradation of PAHs in source of drinking water with fusant strains

Extracellular proteomic expressions of two fusant strains were analyzed to observe their abilities to degrade polycyclic aromatic hydrocarbons (PAHs) in the source of drinking water from Yangtze River. The extracellular proteomes for the hybrid strains, Fhhh and Xhhh, and one of their parental strain Phanerochaete chrysosporium were measured by the two-dimensional electrophoresis and MS/MS. The similarity of proteome expression was 34.7% between Fhhh and P. chrysosporium and that was 28.6% between Xhhh and P. chrysosporium. PAHs degeneration performance for Fhhh, Xhhh and the native bacterium NJ2007 was studied by biological activated carbon reactor. The specific degradation rate of Fhhh for PAHs was 3.05 × 10⁻⁵ day⁻¹ which was significantly higher than that of the NJ2007 and Xhhh (P < 0.05). The results indicate that the fusant strain could not express the same proteome as that of its parental strain but could degrade PAHs in the source water with higher efficiency.     

Dynamics of antiviral-resistant influenza viruses in the Netherlands, 2005–2008

In the Netherlands, influenza specific antivirals are used for the therapy of influenza in nursing homes and hospitals, for prophylaxis in high risk groups and neuraminidase inhibitors are stockpiled as part of pandemic preparedness plans. To monitor the antiviral susceptibility profile, human influenza virus isolates derived from the Dutch influenza surveillance in 2005–2006 (n = 87), 2006–2007 (n = 58) and 2007–2008 (n = 128) were analyzed with phenotypic assays and sequencing. For adamantanes, a high proportion (>74%) of A(H3N2) viruses had the S31N mutation in M2 protein, while variation in the HA₁ region of adamantane-sensitive viruses suggested that adamantane-sensitive variants were reseeded into the Dutch population and re-emerged as drug-sensitive due to M-segment reassortment. For neuraminidase inhibitors oseltamivir and zanamivir, 98% of types A and B influenza viruses prior to 2007–2008 were sensitive for both, whereas 24% of the A(H1N1) viruses obtained in 2007–2008 were oseltamivir-resistant while retaining sensitivity to zanamivir and adamantanes. Furthermore, oseltamivir-resistant A(H1N1) or adamantane-resistant A(H3N2) virus infections were not associated with differences in clinical symptoms compared to infections with sensitive variants. Our data show the dynamic nature of emergence of drug-resistant influenza viruses, stressing the need for surveillance of resistance trends as part of influenza monitoring programs.