Effectiveness and sustainment of a tailored over-the-counter medication safety intervention in community pharmacies: A randomized controlled trial

IntroductionThe Senior Section is a continuation of a previous intervention that aims to address a gap in medication safety, specifically related to older adult selection and use of over-the-counter medications. The purpose of this paper is to describe the protocol of this study.MethodsThis study will occur in three phases: an adaptation phase, an effectiveness phase using a randomized controlled trial, and a sustainment phase. This study will take place in conjunction with administrative leadership and pharmacy sites of a regional Midwest integrated health system. Eye tracking technology will inform the adaptation of the intervention and demonstrate effectiveness in the randomized controlled trial. Following the randomized controlled trial, the health system will implement the intervention without research team support. Fidelity and long-term effectiveness outcomes will be collected to demonstrate sustainment.DiscussionThe potential implications of this study are a complete and sustained redesign of the pharmacy setting to include educational and directional materials on medication safety, leading to a decrease in over-the-counter medication misuse in older adults. This project could provide a road map for pharmacy organizations to tailor and adopt the Senior Section, to ultimately reduce inappropriate over-the-counter medication use in older adults.     

Structured pharmacist-led intervention programme to improve medication adherence in COPD patients: A randomized controlled study

Background

COPD is characterised by a progressive airflow limitation in the lungs. However, adherence to therapy improves management of symptoms and delays disease progression. Therefore, patients' knowledge and awareness about the disease are important. Hence, pharmacist-led educational interventions could achieve this and improve medication adherence.

The effect of hospitalization on potentially inappropriate medication use in older adults with chronic kidney disease

Objectives: Potentially inappropriate medication (PIM) use is associated with increased morbidity and mortality in chronic kidney disease (CKD). However, there is a paucity of data on how hospitalization affects PIM use in older adults with CKD. Therefore, we aimed to measure the impact of hospitalization on PIM use in older CKD patients, and identify factors predicting PIM use.

Methods: A retrospective cohort study was conducted in older adults (≥65 years) with CKD admitted to an Australian tertiary care hospital over a 6 month period. PIM use was measured, upon admission and at discharge, using the Medication Appropriateness Index (MAI) and Beers criteria (2015 version) for medications recommended to be avoided in older adults and under certain conditions.

Results: The median age of the 204 patients was 83 years (interquartile range (IQR): 76–87 years) and most were men (61%). Overall, the level of PIM use (MAI) decreased from admission to discharge (median [IQR]: 6 [3–12] to 5 [2–9]; p?<?.01]). More than half of the participants (55%) had at least one PIM per Beers criterion on admission, which was reduced by discharge (48%; p?<?.01). People admitted with a higher number of medications (β 0.72, 95% CI 0.56–0.88) and lower eGFR values (β???0.11, 95% CI ?0.18 to ?0.04) had higher MAI scores after adjusting for age, sex and Charlson’s comorbidity index.

Conclusions: PIMs were commonly used in older CKD patients. Hospitalization was associated with a reduction in PIM use, but there was considerable scope for improvement in these susceptible individuals.     

Incorporation of pharmacist pre-surgical calls to improve medication history completion rates

BackgroundThe accuracy and timeliness of documenting a medication history is an important aspect to ensure appropriate medication reconciliation during transitions of care. Surgical patients often have their medication history recorded just moments before surgery which may be rushed, incomplete or missed entirely. Between January and May 2020, 76.7% of surgical patients admitted to our institution had a medication history completed by a pharmacist prior to surgery.ObjectiveThe objective of this work is to improve the pharmacist medication history completion rates for pre-surgical patients before surgery by integrating pharmacist-led medication histories into the pre-operative pathway.MethodsThrough interdisciplinary collaboration, the pre-operative pathway for surgical patients was evaluated for opportunities to complete medication histories days prior to their scheduled procedure. Plan-Do-Study-Act (PDSA) cycles were utilized to make incremental improvements in practice.InterventionsThrough an iterative process, the pathway for cardiovascular surgery (CVS) patients was modified to include a scheduled pharmacist phone appointment in the days leading up to their surgical procedure. Utilizing these phone appointments, pharmacists complete patient medication history reviews and share a feedback loop to cardiovascular and peri-operative health care providers.ResultsThe iterative PDSA cycles revealed challenges to completing pre-surgical medication history calls without advance notice. Patient responsiveness to pre-surgical medication history calls improved with the incorporation of scheduled phone appointments. Between January 18 and May 31, 2021, pharmacists completed 359 of 376 scheduled CVS appointments (95.5%), improving the medication history completion rates for cardiovascular surgery patients from 84.8 to 93.0% (p = 0.000025). The completion rate for all surgical patients also improved from 76.7 to 85.1% (p < 0.00001).ConclusionsIncorporating scheduled pharmacist medication history appointments as a part of the pre-operative pathway was shown to expand the capacity for pharmacists to complete medication histories for patients prior to surgery. By reducing pharmacist workload on the morning of surgery, fewer patients were admitted to surgery without having their medication history reviewed by pharmacy. Future investigation should be considered to evaluate the impact on patient outcomes.     

Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults

BackgroundMobile health technology can improve medication safety for older adults, for instance, by educating patients about the risks associated with anticholinergic medication use.ObjectiveThis study's objective was to test the usability and feasibility of Brain Buddy, a consumer-facing mobile health technology designed to inform and empower older adults to consider the risks and benefits of anticholinergics.MethodsTwenty-three primary care patients aged ≥60 years and using anticholinergic medications participated in summative, task-based usability testing of Brain Buddy. Self-report usability was assessed by the System Usability Scale and performance-based usability data were collected for each task through observation. A subset of 17 participants contributed data on feasibility, assessed by self-reported attitudes (feeling informed) and behaviors (speaking to a physician), with confirmation following a physician visit.ResultsOverall usability was acceptable or better, with 100% of participants completing each Brain Buddy task and a mean System Usability Scale score of 78.8, corresponding to “Good” to “Excellent” usability. Observed usability issues included higher rates of errors, hesitations, and need for assistance on three tasks, particularly those requiring data entry. Among participants contributing to feasibility data, 100% felt better informed after using Brain Buddy and 94% planned to speak to their physician about their anticholinergic related risk. On follow-up, 82% reported having spoken to their physician, a rate independently confirmed by physicians.ConclusionConsumer-facing technology can be a low-cost, scalable intervention to improve older adults’ medication safety, by informing and empowering patients. User-centered design and evaluation with demographically heterogeneous clinical samples uncovers correctable usability issues and confirms the value of interventions targeting consumers as agents in shared decision making and behavior change.     

Measuring drug burden in older adults with intellectual disabilities: Critical issues for consideration in finding the optimal measure to improve safety of medicines use

ABSTRACT

Older adults with Intellectual Disability have been described as among the most medicated groups in society, with rates of polypharmacy significantly exceeding that of the general population. They are at heightened risk of medication-related harm and have high exposure to high-risk medications, for example, anticholinergic ad sedative medicines. There has been significant controversy internationally relating to the inappropriate use of antipsychotics for challenging behavior, often in the absence of a psychiatric diagnosis. Despite this, the evidence base of the safety of use of medicines in this population is lacking, the provision of healthcare is often suboptimal and this population is often excluded from Randomized Controlled Trials. In this editorial, we describe the unique challenges in ensuring safe and appropriate medicines in this population. We describe tools to date that has been used in this population to measure the burden of medicines that increase the risk of adverse outcomes. We outline current and future developments required to improve the quality and safety of medicines use in this population, for example, longitudinal cohort studies.     

Contextual factors influencing medication management by rural informal caregivers of older adults

BackgroundManaging medications is an important part of the rural informal caregiver's role in the community setting, and the context within which care is provided plays an important role in shaping the work they perform. However, little is known about the intra- and interpersonal factors that impact the rural caregiver's involvement in and performance of medication management.ObjectivesTo identify contextual factors influencing medication management by rural informal caregivers of older adults.MethodsFour separate focus groups with rural caregivers of older adults were conducted with 5–9 caregivers per group. Participants were asked to describe the medication management activities performed and problems they encountered while providing assistance. Focus groups were recorded, transcribed verbatim, and analyzed for themes using an inductive approach.ResultsCare recipient independence, or their ability and preference to perform medication-related activities without supervision, was a key factor driving the caregiver's involvement in medication management and how it was performed. Many caregivers used a team-based approach to medication management that supported the care recipient's independence. Care recipient health and function was a driver behind the need for caregiving, and declines in physical and mental health led to changes in how medication management was carried out over time. Caregiver location also impacted the ways in which medication management was performed by caregivers.ConclusionsInterventions and pharmacy services to support medication management by rural informal caregivers should be designed in a way that preserves and promotes the care recipient's independence, and should be tailored to the context within which caregiving is performed.     

医院信息系统在安全用药管理中的作用探讨

目的探讨完善医院信息系统,加强用药安全管理的方向和措施。方法结合实际工作情况,阐述运用信息技术加强用药安全管理的方法。结果应从药学信息服务、用药安全管理、合理用药监控三方面对医院信息系统加以完善。结论医院可以通过完善医院信息系统以加强用药安全的管理。     

Instruments for evaluating medication use and prescribing in older adults

ObjectiveTo describe primarily implicit instruments for assessing medication use in older adults.Data sourcesLiterature was identified via PubMed (1966–2014) and Google Scholar using the following search terms: geriatric/medication use, implicit criteria, inappropriate medication use, inappropriate prescribing, older adults/medication use, and polypharmacy. Reference citations from identified publications were also reviewed.Study selectionAll articles in English identified from data sources were evaluated. Instruments applicable to pharmacy and multiple medication classes were included. We excluded instruments developed for a single medication or medication class, for a single condition or disease state, as primarily an academic instrument, using primarily explicit criteria, for use primarily by health care practitioners other than pharmacists, or for regulatory purposes.Data synthesisSeven instruments were reviewed by evaluating characteristics, components of prescribing and medication use addressed, and settings in which they have been evaluated and validated. Screening Medications in the Older Drug User (SMOG) is a six-question instrument developed specifically for community pharmacists. The Medication Appropriateness Index (MAI); Assess, Review, Minimize, Optimize, Reassess (ARMOR) tool; and Tool to Improve Medications in the Elderly via Review (TIMER) are more comprehensive instruments, but they require clinical judgment and are time intensive. Assessing Care of Vulnerable Elders-3 (ACOVE-3) and the Good Palliative–Geriatric Practice Algorithm (GPGPA) are useful in determining need for medication continuation in older adults who are closer to the end of life. The Assessment of Underutilization (AOU) is an implicit tool to guide medication initiation.ConclusionEach instrument is unique in design, which may be beneficial in some pharmacy practice settings and present barriers in others. The use of multiple instruments may be necessary to optimize therapy in this vulnerable patient population.     

Evaluation of a community pharmacy-based medication therapy management programme: A study protocol of a pilot randomized controlled trial with an embedded qualitative study

ObjectivesThe main objectives are: to evaluate the feasibility and effectiveness of a community-pharmacy based medication therapy management programme; to explore patients’ experiences and views towards medication therapy management service delivered by community pharmacists.Research design and methodsA mixed-methods research design consisting of a pilot randomized controlled trial embedded with qualitative study will be used in this study. The study consists of two phases: a 6-month follow-up pilot randomized control trial (quantitative approach) to assess the feasibility and effectiveness of a community pharmacy-based medication therapy management programme. The primary outcome is HbA1C and secondary outcomes include: clinical and health services utilization and process measures, medication adherence, diabetes distress as well as satisfaction with care. Phase two consists of an embedded qualitative study using semi-structured interviews to explore patients’ experiences and views with the medication therapy management programme. Study data collection will be collected between April 2021 and December 2021.Ethics considerationThe study has been approved by institutional review boards from Princess Nourah bent Abdulrahman University (Approval # 20–0240), King Fahad Medical City (Approval # 20-388E) and Birmingham University (Approval # ERN_20-0768).