Effect of clinical pharmacist intervention on medication discrepancies following hospital discharge

Background Medication discrepancies may occur at transitions in care and negatively impact patient outcomes. Objective To determine if involving clinical pharmacists in hospital care, medication reconciliation and discharge medication plan communication can reduce medication discrepancies with a prospective, randomized, blinded, controlled trial. Setting A large, tertiary care, academic medical center. Method The intervention consisted of clinical pharmacist medication reconciliation, patient education and improved communication of the discharge medication plan, as devised by the hospital physician and care team, to primary care physicians and community pharmacists. Medication discrepancies were identified by blinded research pharmacists who reviewed primary care physician and pharmacy records at discharge through 90 days post-discharge to create 30- and 90-day medication lists. Main outcome measure Rate of medication discrepancies compared across groups. Results A total of 592 subjects from internal medicine, family medicine, cardiology and orthopedic services were evaluated for this study. Clinically important medication discrepancies in the primary care physician record were different between groups 30 days after hospital discharge following a clinical pharmacist’s intervention. The mean number of medication discrepancies per patient for the enhanced group being nearly half the number in the control group. However, this effect did not persist to 90 days post-discharge and did not extend to community pharmacy records. Conclusion The present study demonstrates the involvement of pharmacists in hospital care, medication reconciliation and discharge medication plan communication may affect the quality of the outpatient medical record.     

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.     

Combined intervention programme reduces inappropriate prescribing in elderly patients exposed to polypharmacy in primary care

Purpose  To evaluate the effect of a combined or a single educational intervention on the prescribing behaviour of general practitioners (GPs). The primary endpoint was effect on inappropriate prescribing according to the Medication Appropriateness Index (MAI). Methods  General practitioners were randomised to either (1) a combined intervention consisting of an interactive educational meeting plus feedback on participating patients’ medication, (2) a single intervention with an interactive educational meeting or (3) a control group (no intervention). Elderly (>65 years) patients exposed to polypharmacy (≥5 medications) were identified and approached for inclusion. Data on medications prescribed over a 3-month period were collected, and the GPs provided detailed information on their patients before and after the intervention. A pre- and post-MAI were scored for all medications. Results  Of the 277 GPs invited to participate; 41 (14.8%) volunteered. Data were obtained from 166 patients before and after the intervention. Medication appropriateness improved in the combined intervention group but not in the single intervention group. The mean change in MAI and number of medications was −5 [95% confidence interval (CI) −7.3 to −2.6] and −1.03 (95% CI −1.7 to −0.30) in the combined intervention group compared with the group with the educational meeting only and the no intervention group. Conclusions  A combined intervention consisting of an interactive educational meeting plus recommendations given by clinical pharmacologists/pharmacists concerning specific patients can improve the appropriateness of prescribing among elderly patients exposed to polypharmacy. This study adds to the limited number of well-controlled, randomised studies on overall medication appropriateness among elderly patients in primary care. Important limitations to the study include variability in data provided by participating GPs and a low number of GPs volunteering for the study. The trial is not registered in a publicly available database of clinical trials. The trial was conducted in a period prior to June 1, 2007.     

Influence of a ward-based pharmacist on the medication quality of geriatric inpatients: a before–after study

Background Despite several international studies demonstrating that ward-based pharmacists improve medication quality, ward pharmacists are not generally established in German hospitals. Aim We assessed the effect of a ward-based clinical pharmacist on the medication quality of geriatric inpatients in a German university hospital. Method The before-after study with a historic control group was conducted on the geriatric ward. During the control phase, patients received standard care without the involvement of a pharmacist. The intervention consisted of a clinical pharmacist providing pharmaceutical care from admission to discharge. Medication quality was measured on admission and discharge using the Medication Appropriateness Index (MAI). A linear regression analysis was conducted to calculate the influence of the intervention on the MAI. Results Patients in the intervention group (n?=?152, mean 83 years) were older and took more drugs at admission compared to the control group (n?=?159, 81 years). For both groups, the MAI per patient improved significantly from admission to discharge. Although the intervention did not influence the summated MAI score per patient, the intervention significantly reduced the MAI criteria Dosage (p?=?0.006), Correct Directions (p?=?0.016) and Practical Directions (p?=?0.004) as well as the proportion of overall inappropriate MAI ratings (at least 1 of 9 criteria inappropriate) (p?=?0.015). Conclusion Although medication quality was already high in the control group, a ward-based clinical pharmacist could contribute meaningfully to the medication quality on an acute geriatric ward.

     

药师参与是减少用药错误的关键环节

用药错误严重影响医疗质量水平,不仅可加重患者病情、浪费宝贵医疗资源,而且极易导致医疗纠纷,恶化医患矛盾。本文通过CNKI、SCI数据库和互联网资源,检索与用药错误有关的文献,从而对用药错误相关概念、分类、危害进行总结,进一步综述药师参与对减少用药错误的重要作用。希望借此促使医务工作者、社会及政府认识到药师是承担减少用药错误不可替代的力量。目前药师队伍数量缺乏、质量不高是目前药师保障用药安全的瓶颈。希望多方协力壮大医院药师队伍、减少用药错误,构建安全、可信赖的医院诊疗环境。     

Development and validation of criteria to identify medication‐monitoring errors in care home residents

Aim The identification of medication‐monitoring errors requires a validated definition. This paper describes the development and validation of a definition which includes criteria for specific medicines to determine whether a medication‐monitoring error has occurred in the care home setting. Setting Criteria were developed for older people (aged 65 years or older) living in care homes. Methods Criteria were developed by two clinical pharmacists using published guidelines. The criteria were divided into those relating to initiation of therapy and maintenance monitoring. The study steering group, made up of clinical pharmacists, a general practitioner (GP) and pharmacy academics, then reviewed the criteria and a consensus was achieved. The criteria were then reviewed by a sample of 21 GPs and 11 clinical pharmacists. The threshold for acceptance for each criterion was set at 70% by agreement of all participants. Key findings The definition of a medication‐monitoring error was accepted as ‘when a prescribed medicine is not monitored in the way which would be considered acceptable in routine general practice. It includes the absence of tests being carried out at the frequency listed in the criteria for each medicine, with tolerance of +50%’. Seventy per cent agreement was reached on all criteria for the initiation of therapy, except warfarin (69%), and on all criteria for maintenance monitoring, except penicillamine (63%) and potassium (63%). Conclusions To our knowledge, this is the first study to define a medication‐monitoring error, and to determine and validate specific criteria to identify such errors in older people living in care homes.     

Impact of the Pharmacy Practice Model Initiative on Clinical Pharmacy Specialist Practice

This paper describes the goals of the American Society of Health‐System Pharmacists' Pharmacy Practice Model Initiative (PPMI) and its recommendations for health‐system pharmacy practice transformation to meet future patient care needs and elevate the role of pharmacists as patient care providers. PPMI envisions a future in which pharmacists have greater responsibility for medication‐related outcomes and technicians assume greater responsibility for product‐related activities. Although the PPMI recommendations have elevated the level of practice in many settings, they also potentially affect existing clinical pharmacists, in general, and clinical pharmacy specialists, in particular. Moreover, although more consistent patient care can be achieved with an expanded team of pharmacist providers, the role of clinical pharmacy specialists must not be diminished, especially in the care of complex patients and populations. Specialist practitioners with advanced training and credentials must be available to model and train pharmacists in generalist positions, residents, and students. Indeed, specialist practitioners are often the innovators and practice leaders. Negotiation between hospitals and pharmacy schools is needed to ensure a continuing role for academic clinical pharmacists and their contributions as educators and researchers. Lessons can be applied from disciplines such as nursing and medicine, which have developed new models of care involving effective collaboration between generalists and specialists. Several different pharmacy practice models have been described to meet the PPMI goals, based on available personnel and local goals. Studies measuring the impact of these new practice models are needed.     

The effect of training and service provision on the self‐assessed competence of community pharmacists

Objective The purpose of this study was to explore self‐assessed competence of community pharmacists who had completed additional clinical pharmacy training at certificate level and were accredited to provide a clinical medication review service to primary care patients (the ‘trained’ group). The self‐assessed competence of these pharmacists was compared with others who had not undertaken the training (the ‘untrained’ group). Method A postal questionnaire was sent to 179 community pharmacists in both groups across four primary care trusts in the east of London. The questionnaire comprised two parts: characteristics of the respondents; and 81 behavioural statements divided into four competency clusters. Key findings The response rate was 50% (n = 90). While pharmacists who possessed a postgraduate qualification were more likely to assess themselves to be more competent in the ‘Delivery of patient care’ competency cluster, there was no difference in self‐assessed competence between ‘trained’ and ‘untrained’ groups. Conclusion Training and experience in providing clinical medication reviews did not seem to influence the self‐assessed competence of community pharmacists: indeed, the ‘trained’ pharmacists seemed to have become more aware of their competence gaps. As the roles of community pharmacists expand, pharmacists need greater targeted support to face new challenges and to deliver the new services in chronic medicines management.     

Drug-related problems identified in post-discharge medication reviews for patients taking warfarin

Objective To characterise the nature of the drug-related problems with warfarin therapy identified in pharmacist-conducted medication reviews during a collaborative post-discharge warfarin management service, with a focus on potentially serious drug interactions. Setting Australian community pharmacy practice. Method Medication review reports submitted by pharmacists to patients?? general practitioners as part of the service were reviewed and the type and clinical significance of the warfarin-associated drug-related problems, and the pharmacists?? recommendations were classified. The prevalence of prescribing of ??potentially hazardous?? warfarin drug interactions was investigated and compared with the frequency of documentation of these interactions in the medication review reports. Main outcome measure The number and nature of warfarin-associated drug-related problems identified and the rate of documentation of ??potentially hazardous?? warfarin drug interactions in the reports from pharmacist-conducted medication reviews. Results A total of 157 warfarin-associated drug-related problems were documented in 109 medication review reports (mean 1.4 per patient, 95% CI 1.3?C1.6, range 0?C5). Drug selection and Education or information were the most commonly identified warfarin-associated drug-related problems; most drug-related problems were of moderate clinical significance. Eight of 23 potentially serious warfarin drug interactions (34.8%) were identified in the medication review reports. Conclusion Pharmacists addressing drug selection and warfarin education drug-related problems during medication reviews may have contributed to the positive outcomes of the post-discharge service. Warfarin drug interactions were frequently identified; however, well-recognised potentially hazardous interactions were under-reported. Improved communication along the continuum of care would permit improved targeting of drug-related problem reporting, especially in relation to preventable drug interactions.     

临床药师开展用药教育对老年高血压合并高胆固醇血症患者的影响

目的：探讨临床药师开展用药教育对老年高血压合并高胆固醇血症患者用药依从性及治疗达标率的影响。方法：依据是否实施用药教育将老年高血压合并高胆固醇血症患者分为试验组和对照组,分别在用药教育前和教育后半年对2组患者进行用药依从性和治疗达标率的调查。结果：临床药师通过用药教育可提高老年高血压合并高胆固醇血症患者的用药依从性和降压调脂治疗达标率。结论：影响老年高血压合并高胆固醇血症患者用药依从性的因素是多方面的,临床药师可通过个体化的用药指导,提高药物治疗的依从性及治疗达标率。     

Pharmacists’ perspectives on medication reviews for long-term care residents with advanced dementia: a qualitative study

Background Medication reviews by pharmacists have been shown to identify and reduce drug-related problems in long-term care residents. Objective To explore pharmacist perspectives of the Australian Government funded pharmacist-conducted residential medication management review and its role improving the quality and safety of prescribing in long-term care, in particular for those living with advanced dementia. Setting Australian Long-term care pharmacists. Method A qualitative research methodology approach using semi-structured interviews was used, with participants pharmacists with Residential Medication Management Review experience. Interviews were recorded, transcribed and coded utilising a meta-model of Physician-Community Pharmacy Collaboration in medication review. Main outcome measure Pharmacists’ perspectives on the Residential Medication Management Review and how to improve the quality of reviews for residents with advanced dementia. Results Fifteen accredited pharmacists participated. The majority believed that the Residential Medication Management Review had the potential to improve the quality and safety of medicines but highlighted systemic issues that worked against collaborative practice. Participants emphasised the importance of three-way collaboration between general practitioners, pharmacists and nursing staff and highlighted key strategies for its optimisation. Conclusion Incorporating avenues for greater communication between team members can improve collaboration between health professionals and ultimately the quality of medication reviews.

     

医院药学部开展微信用药咨询的SWOT分析及发展策略

目的：探讨医院药学部开展微信用药咨询的实践模式。方法：采用SWOT分析法分析药学部开展微信用药咨询具有的优势、劣势、机会与威胁,并结合已开展的工作探讨微信用药咨询的实践模式。结果：药学部开展微信用药咨询具有药物咨询工作已有多年经验、药物咨询团队人员分布合理、全程信息化管理、硬件设施齐全、检测项目丰富、微信公众平台关注度高、具有开放性和共享性等优势,也有药师需要加强临床医学知识的学习,微信互动及时性有待提高、需安排专职微信咨询药师而造成人力资源紧张等劣势,面临开展微信用药咨询有临床和社会需求等机会,也面临社会对微信咨询知晓度不够、微信咨询不能产生直接经济效益,投入产出严重不平衡,难以长期持续等威胁。结论：药学部开展微信用药咨询可以发挥药师的专业特长,促进药师参与患者用药全过程的管理,提高患者依从性,从而促进合理用药。     

Medication reviews

Recent years have seen a formalization of medication review by pharmacists in all settings of care. This article describes the different types of medication review provided in primary care in the UK National Health Service (NHS), summarizes the evidence of effectiveness and considers how such reviews might develop in the future. Medication review is, at heart, a diagnostic intervention which aims to identify problems for action by the prescriber, the clinican conducting the review, the patient or all three but can also be regarded as an educational intervention to support patient knowledge and adherence. There is good evidence that medication review improves process outcomes of prescribing including reduced polypharmacy, use of more appropriate medicines formulation and more appropriate choice of medicine. When 'harder' outcome measures have been included, such as hospitalizations or mortality in elderly patients, available evidence indicates that whilst interventions could improve knowledge and adherence they did not reduce mortality or hospital admissions with one study showing an increase in hospital admissions. Robust health economic studies of medication reviews remain rare. However a review of cost-effectiveness analyses of medication reviews found no studies in which the cost of the intervention was greater than the benefit. The value of medication reviews is now generally accepted despite lack of robust research evidence consistently demonstrating cost or clinical effectiveness compared with traditional care. Medication reviews can be more effectively deployed in the future by targeting, multi-professional involvement and paying greater attention to medicines which could be safely stopped.     

Impact of domiciliary pharmacy visits on medication management in an elderly population

This paper describes medication management by elderly patients living in their own homes, and the effects of patient counselling during five domiciliary pharmacy visits on patient compliance and medication management. The 190 subjects who completed the 12-month study were randomly allocated to either an intervention group (receiving counselling on the correct use and storage of their drugs during five domiciliary visits), a control (V) group (receiving visits but no counselling), or a control (NV) group (having no contact between an initial visit and the end of the study). The patients' drug knowledge, dexterity and cognitive functioning were assessed, and patients in all three groups were well matched at baseline. At each follow-up visit, patient compliance was measured using pill counts and interviews. After the initial visit, patients in the intervention group demonstrated better compliance, better drug storage practices and a reduced tendency to hoard drugs, and required fewer GP consultations, than patients in either of the control groups. The provision of the domiciliary pharmacy service was effective in detecting drug-related problems in a potentially high risk patient group. The effectiveness of such a service may be improved by increased transfer of patient information between community pharmacists and general medical practitioners.     

General practitioners' and pharmacists' perceptions of the role of community pharmacists in delivering clinical services

BackgroundBecause community pharmacists are encouraged to provide clinical services, there is a need to determine the role perceptions of both community pharmacists and general practitioners (primary care physicians). Differing role perceptions are likely to result in barriers to pharmacists expanding their roles in health care.ObjectivesThe purpose of this study was to investigate whether community pharmacists' and general practitioner's perceptions of the role of community pharmacists may be a barrier to pharmacists increasing their role in medication management. Other potential barriers were also explored that could provide a framework for future research.MethodsA postal survey to 900 and 1000 randomly selected community pharmacists and general practitioners, respectively, elicited the perceptions of these groups toward the role of community pharmacists. Likert scales were used to quantify the results.ResultsThe results revealed a gap in perceptions regarding the role of the community pharmacist, with general acceptance of the technical roles but less acceptance of clinical roles by general practitioners. Barriers to increased involvement of community pharmacists in clinical services included a perceived lack of mandate, legitimacy, adequacy, and effectiveness by both groups. Also observed was a lack of readiness to change by community pharmacists.ConclusionsThis study suggests that there are significant barriers to community pharmacists increasing clinical services, both from the community pharmacists themselves and from the general practitioners. Attention to change management in a complex environment will be necessary if community pharmacists are to change their role toward more clinical services.