Exposure to potential drug interactions in primary health care

OBJECTIVE: To analyse the prevalence of potential drug interactions, and to identify patients particularly prone to drug interaction. DESIGN: Database study (Odense University Pharmacoepidemiologic Database). SETTING: Individuals exposed to polypharmacy in 1999 were examined for potential drug interactions. SUBJECTS: Inhabitants of the County of Funen (n = 471 732). MAIN OUTCOME MEASURES: Prevalence of potential drug interactions. RESULTS: One-third of the population were exposed to polypharmacy and among these 15% were exposed to drugs carrying a risk of harmful interaction. Among the elderly with polypharmacy, 25% aged 60-79 years and 36% over 80 years received drugs carrying the risk of interaction. Among individuals exposed to potential drug interaction, 62% were exposed only to one drug interaction and 38% to two or more different drug interactions. The drugs accounting for the highest number of potential interactions were diuretics, NSAIDs, ACE-inhibitors, digoxin, oral antidiabetics, calcium channel blockers, anticoagulants and beta-blockers. When focusing only on major drug interactions, potassium-sparing diuretics and oral anticoagulants were the most frequently involved drugs. CONCLUSION: Elderly patients exposed to polypharmacy should be kept under intensified monitoring as they are at increased risk of clinically significant drug interactions.     

Assessment of cardiovascular risk in primary health care

The aim of this study was to determine the frequency of audit and the proportion completed in a group of practices. Data obtained by interviewing a member of each practice and inspecting practice records were independently coded by researchers. Practices initiated an average of 3.5 (range 1-7) audits in 2 years, of which an average of 0.9 (range 0-3) were completed. Ten of 16 completed audits were externally funded or facilitated. Few audits are com pleted in general practice and practices require continuing support for audit.     

Developing a social perspective in mental health services in primary care

The influence of Primary Care Trusts (PCTs) on the reorganisation of UK health and social care provision is already considerable. As well as challenging institutionalised processes of care, PCTs are encouraging innovation. This article reflects on a service pioneered by a small group of mental health social workers, which has been reconfigured within a new PCT, illuminated by examples of direct therapeutic work and service user feedback. In the new service, the practical application of a social perspective in mental health provision is demonstrated by eligibility criteria based on social context as well as psychological adversity. Possible developments arising from the prospective, multidisciplinary team membership and interface with secondary care are anticipated.     

Factors associated with self-rated health in primary care

Background: Self-rated health (SRH) measures one’s current general health and is a widely used health indicator. Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships are suspected to influence SRH, but studies in primary health care settings are sparse.

Objective: To examine the associations between patients’ self-rated health and their sleep problems, somatic health complaints, and unmet needs in interpersonal relationships.

Design: We collected data via questionnaires for this cross-sectional study from general practice.

Setting: Primary health care in Norway.

Subjects: 1302 consecutive patients participated.

Main outcome measures: The questionnaire included a single question about SRH, the Bergen Insomnia Scale (BIS), five questions on somatic health complaints, and three questions from the Basic Psychological Needs Scale (BPNS) pertaining to the relationships domain. We analyzed our data using ordinal logistic regression models.

Results: Our response rate was 74%. The prevalence of fair/poor SRH was 26%, with no gender differences. We revealed a significant association between increasing age and reduced SRH. The study showed that sleep problems and somatic health complaints were strongly associated with SRH, and unmet needs in relationships were also significantly and independently associated with reduced SRH in a full model analysis.

Conclusion: Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH. These factors are all modifiable and could be managed both within and outside a primary care setting in order to improve SRH.

• Key Points

• There was a high prevalence of reduced SRH in clinical general practice

• Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH

• These predictors are all modifiable with a potential to improve SRH

     

Potential drug interactions in cancer patients receiving supportive care exclusively

Cancer patients at the end of life often take many medications and are at risk for drug interactions. The purpose of this study was to describe the epidemiology of potential drug interactions in cancer patients receiving supportive care exclusively. We retrospectively reviewed the charts of consecutive adult cancer outpatients attending palliative care clinics at the Princess Margaret Hospital, Toronto, Canada. Drugs were screened for interactions by the Drug Interaction Facts software, which classifies interactions by levels of severity (major, moderate, and minor) and scientific evidence (1–5, with 1 = the strongest level of evidence). Among 372 eligible patients, 250 potential drug interactions were identified in 115 patients (31%, 95% confidence interval 26%–36%). The most common involved warfarin and phenytoin. Most interactions were classified as being of moderate severity (59%) and 42% of them were supported by Levels 1–3 of evidence. In multivariable analysis, increasing age (P < 0.001), presence of comorbidity (P = 0.001), cancer type (brain tumors, P < 0.001), and increasing number of drugs (P < 0.001) were associated with risk of drug interactions. Potential drug interactions are common in palliative care and mostly involve warfarin and anticonvulsants. Older patients, those with comorbid conditions, brain tumor patients, and those taking many medications are at greater risk of drug interactions.     

Implementation of guidelines in primary health care. A challenge for the municipal health centres in Finland

Objective - To assess the implementation of guidelines in Finnish primary health care units. Design - A semi-quantitative analysis of a cross-sectional interview survey. Setting - All municipal health centres in a selected region in Finland. Subjects - Head physicians and head nurses of the 31 participating units. Main outcome measures - Number of guidelines adopted; methods used in the implementation; and the unit's estimated purposefulness in the implementation of guidelines. Results - All health centres had adopted at least one guideline in the defined task areas, but only one-third of the units had implemented several guidelines. The implementation methods utilised were usually directive and passive rather than co-operative and problem-solving. Half of the units used training and methods involving active partici pation of the personnel, and in one-third a multiprofessional approach was applied. Clients' representatives were hardly ever involved in the adaptation of guidelines. A quarter of the health centres were assessed as purposeful in their policy to implement guidelines, the large units being more goal-oriented than the smaller ones. Conclusions - A minority of health centres are goal-oriented in the adoption of guidelines and use versatile methods to support the implementation; this presents an important managerial challenge for national health care development in Finland.     

Poisonings requiring admission to the pediatric intensive care unit: A 5-year review

Background. Poisonings represent a significant number of preventable admissions to the pediatric intensive care unit (PICU), but data about poisonings requiring PICU-level care are limited. Objectives. To identify the demographics of patients admitted with poisonings and characterize their clinical courses related to their poisoning. Methods. All poisonings over a 5-year period (2008–2012) at an academic medical center in New England were retrospectively reviewed using electronic medical records in an observational case series. Poisonings were identified using key search terms within an admissions database. Results. There were 273 admissions for poisonings, which represent 8% of total PICU admissions over this time period. The poisonings were unintentional in 148 (54%) cases and intentional in 125 (46%). The vast majority of poisonings occurred in patients either 3 years or below (N = 121, 44%) or 13 years or above (N = 124, 45%). Most (96%) admissions were for less than 48 h and 41% were for less than 24 h. Mean PICU length of stay was 1.2 + 0.7 days. A total of 468 substances were ingested in 54 different drug classes, with analgesics and antidepressants being the most common. Eighty-five (31%) poisonings were polypharmaceutical. The most commonly used therapies were naloxone, activated charcoal, and benzodiazepines. Twenty-seven patients (10%) received mechanical ventilation. There was one fatality, an adolescent with a polypharmacy overdose in a suicide attempt. Conclusion. Pediatric poisonings are a significant percentage of admissions to the PICU. The majority of poisonings are non-fatal, require supportive care, close monitoring, and some specific treatment. Drug classes causing poisonings have changed to a higher percentage of opioids in younger patients and atypical antidepressants in adolescents.     

Lessons from eleven primary health care nursing innovations in New Zealand

Introduction:  In New Zealand in 2003, 11 primary health care (PHC) nursing innovation projects and an evaluation of the initiative were funded by the Ministry of Health to develop and explore the ways new models of nursing practice could help address health inequalities and contribute to PHC.
Design and Methods:  A research-and-development approach was used in the evaluation. Data were gathered from interviews with national stakeholders, workshops with personnel from all projects, visits to each project site and case studies of four projects. Analysis involved assessing each project individually as well as the projects as a whole.
Context:  The initiative was one of many international and local PHC developments in this period designed to reduce health inequalities and improve patient care and health outcomes.
Findings:  Each project was developed from a different starting point; was located in different parts of the health system; and had different levels of funding. Some were principally focused on leading nursing development; others focused on developing nursing practice. Each involved influencing or providing nursing services, nurse education, leadership and service integration. Most projects progressed well, but some had limited success.
Lessons:  Lessons are on many levels, and include those related to: developing successful innovation; the importance of nursing leadership; developing the nursing workforce; and advancing nursing practice.
Conclusion:  The funding of the innovative projects enabled nurses to pioneer developments. Such funding is important, as it paves the way for change and provides an opportunity for reflection and new learnings.     

Interactions between family members and staff in intensive care units--an observation and interview study

BACKGROUND: Research about interactions between family members and staff are sparse, although family members' needs and experiences in intensive care units are well researched areas. AIM: The aim was to describe and interpret interactions between family members and staff in intensive care units. METHODS: Interviews (n=24) with family members and repeated observations of interactions of family members and staff in intensive care units were performed and analysed together by means of content analysis. RESULTS: The initial interactions between staff and family members had a substantial effect on family members and influenced their further interactions with the staff. Two kinds of interactions were revealed; mutual understanding and mutual misunderstanding. Family members, who understood the explicit information and the implicit messages were open in communication with the staff, adjusted well to the system, were acknowledged by the staff and sometimes consoled. Family members, who had difficulties understanding information and implicit messages drew back from communication with staff, did not adjust to the system and were sometimes insulted by the staff. CONCLUSIONS: Unambiguous information from the staff is important for developing interactions of mutual understanding. The results may be a starting point for intensive care unit staff to reflect on how all family members are initially met and further informed and treated. Further research of family members' experiences of interactions with staff in a longitudinal perspective and the influence of critical illness on families are needed.     

Guidelines accompanied by changes in reimbursement rules Effects on lipid-lowering drug prescribing

Objective - To study the medical situation and health-related quality of life (HRQOL) in foreign- and Swedish-born diabetic patients. Design - A cross-sectional, questionnaire survey of diabetic patients registered with primary health services, compared with the general Swedish population. Setting - Three community health centres in Stockholm County. Subjects - 62 foreign- and 351 Swedish-born subjects, aged 18-84 years. Age- and sex-matched controls from a standard population sample of 2500 individuals. Main outcome measures - Medical data extracted from the medical records. HRQOL assessed by the Swedish Health-Related Quality of Life Survey. Results - Differences were found for foreign- vs Swedish-born patients regarding diabetes duration, 7.9 vs 10.9 years, p&;lt;0.01; BMI, 31.9 vs 28.8, p&;lt;0.05; tablet treatment, 64.5% vs 46.4%, p&;lt;0.01; and diabetic complications, 37.5% vs 54.9%, p&;lt;0.05. HRQOL was decreased on nine of the 13 scales in foreign-born patients, and eight in Swedish-born. Foreign-born patients were also at larger risk to be among the third with worst health at seven of the scales. Conclusions - Foreign-born diabetic patients are at higher risk of experiencing bad health.     

Access to primary health care in urban Iceland

The accessibility by telephone of primary health care was studied in Reykjavik and its surrounding municipalities. Comparison was also made between community run health centres and private practices. About 60% of the total population of Iceland live within the study area. The study used medical secretaries as patient substitutes. During the prescribed telephone time, all "patients" were able to make telephone contact with their practice facilities, and 80% reached their doctor within 10 min. The waiting time for non-acute appointments was never more than three days. The study did not detect any difference in accessibility between community run health centres and privately owned GP practices.     

Preventing potential drug interactions in community pharmacy

With ongoing debate on health care reform including improved pharmaceutical care, there is much current concern about drug interactions and their prevention. Many patients visit more than one doctor for their different diseases and receive more than one drug at a time, and often doctors are unaware of all the medications their patients are taking and the risks to which their patients are exposed when treated with multiple drugs. Pharmacists in the community setting or hospital are the most accessible health care providers able to intervene when faced with potential drug interactions that may occur during patients' multiple drug therapy. A few selected examples of potential drug-drug interactions and interventions instituted are presented in this paper. Possible mechanisms for the drug interactions are also discussed. It is hoped that more documentation of pharmacists' involvement in such interventions will demonstrate the true value of pharmaceutical care.     

Integrated education of health care professionals applied to social medicine in primary health care

A Regional Health University is planned at the University of Link?ping, Sweden. To evaluate new educational principles, a trial project was carried out in which medical and nursing students trained together in a two-week full-time course aimed at patient-oriented clinical social medicine and epidemiological field work in primary health care and involving a high degree of group activity and responsibility. The students' expectations concerning improvement in theoretical and applied knowledge and motivation for co-operation in future work situations were fulfilled. The students also enjoyed the way of working. The programme requires more time in planning and supervision than a traditional one.