Are interventions recommended by pharmacists during Home Medicines Review evidence‐based?

Introduction Over the past decade medication review services have been implemented in many countries, including Australia, UK and USA. Although, the attitudes and barriers to the implementation of evidence‐based medicine have been investigated, the extent to which medication review recommendations are evidence‐based is not known. Objective To determine (1) the extent to which pharmacist's recommendations during medication review services were consistent with the evidence‐based guides at the time of the review; and (2) the nature and extent of drug‐related problems (DRPs) and the actions recommended by pharmacists to resolve DRPs. Method A retrospective review of Home Medicines Review cases performed on 224 community‐dwelling older people (65 years or older). The chi‐squared test for categorical variables was used to compare the proportion of recommendations that were evidence‐based and recommendations for which no evidence could be identified in the most common Australian information sources. DRPs and the actions recommended to resolve the DRPs were classified according to previously employed criteria. Results Pharmacists made a total of 1114 therapeutic recommendations to general practitioners, of which 964 required supporting pharmacotherapeutic evidence. The majority (94%) of the pharmacists' recommendations were in accordance with the evidence‐based guides, as compared with the recommendations for which no evidence could be identified (P < 0.001). Pharmacists reported that 98% of the patients had at least one problem with use of their medication detected. Conclusion The majority of the actions recommended by pharmacists during the medication review process were consistent with the literature embedded in key Australian information sources. Medication management in older people is complex and challenging, as highlighted by the DRPs identified in 98% of our patients. A suitably trained pharmacist, with full access to the patient, medical record and supporting resources, can help to improve the quality use of medicines in this at‐risk population.     

Computerized physician order entry system combined with on-ward pharmacist: analysis of pharmacists' interventions

Rationale, aims and objectives To analyse pharmacists' interventions in a setting where a computerized physician order entry system (CPOE) is in use and a pharmacist works on the ward. Method A prospective cohort study was conducted in seven wards of a French teaching hospital using CPOE along with the presence of a full‐time on‐ward pharmacy resident. We documented the characteristics of pharmacists' interventions communicated to physicians during the medication order validation process whenever a drug‐related problem was identified. Independent predictors of the physician's acceptance of the pharmacist's intervention were assessed using multiple logistic regression analysis. Results The 448 pharmacists' interventions concerned: non‐conformity to guidelines or contraindications (22%), too high doses (19%), drug interactions (15%) and improper administration (15%). The interventions consisted of changes in drug choice (41%), dose adjustment (23%), drug monitoring (19%) and optimization of administration (17%). Interventions were communicated via the CPOE in 57% of cases and 43% orally. The rate of physicians' acceptance was 79.2%. In multivariate analysis, acceptance was significantly associated with the physician's status [higher for residents vs. seniors: OR = 7.23, CI 95 (2.37–22.10), P < 0.01], method of communication [higher for oral vs. computer communication: OR = 12.5, CI 95 (4.16–37.57), P < 0.01] and type of recommendation [higher for drug monitoring vs. drug choice recommendations: OR = 10.32, CI 95 (3.20–33.29), P < 0.01]. Conclusions When a clinical pharmacist is present on a ward in which a CPOE is in use, the pharmacists' interventions are well accepted by physicians. Specific predictors of the acceptance by physicians emerge, but further research as to the impact of CPOE on pharmacist–physician communication is needed.     

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 in medical wards with a computerized physician order entry system

Objective:  Identification and estimation, by clinical pharmacists participating in routine medical rounds, of drug-related problems (DRPs), arising despite the use of a computerized physician order entry (CPOE) system.
Methods:  An 18-month prospective study of DRPs through a CPOE was conducted by seven clinical pharmacists participating in ward activity. DRPs were identified by two independent pharmacists using a structured order review (French Society of Clinical Pharmacy instrument).
Results:  A total of 29 016 medication orders relating to 8152 patients were analysed, and 2669 DRPs, involving 1564 patients (56% female; mean age 72·6 years), were identified representing 33 DRPs per 100 admissions. The most commonly identified DRPs were non-conformity to guidelines or contra-indication (29·5%), improper administration (19·6%), drug interaction (16·7%) and overdosage (12·8%). There were 429 different drugs associated with these DRPs. Cardiovascular drugs were the most frequently implicated (22·2%), followed by antibiotics/anti-infectives (13·3%) and analgesics/antiinflammatory drugs (11·3%). Different types of DRPs were closely associated with specific classes of drugs.
Conclusions:  Drug-related problems are common even after implementation of CPOE. In this context, routine participation of clinical pharmacists in clinical medical rounds may facilitate identification of DRPs. Pharmacists should be able to enhance patient safety through such involvement.     

Assessment for chronic kidney disease service in high-risk patients at community health clinics

BACKGROUND: Chronic kidney disease (CKD) poses significant public health concerns. Early identification and interventions can help prevent or slow progression to end-stage renal disease. OBJECTIVE: To characterize CKD in high-risk indigent patients in a primary care setting and evaluate opportunities for pharmacists to work collaboratively with physicians to improve medication use and CKD patient outcomes. METHODS: Medical records of 200 patients with diabetes mellitus and/or hypertension were reviewed by the clinical pharmacist. Estimated glomerular filtration rate (creatinine clearance [Cl(cr)]) and urinalysis were used to identify and stage CKD according to published guidelines. Glycosylated hemoglobin concentrations and blood pressures were recorded. The pharmacist evaluated medications for possible drug-related problems (DRPs), made therapeutic recommendations, and evaluated the acceptance rate by physicians. RESULTS: One hundred nineteen patients met inclusion criteria, and a total of 68.9% met CKD criteria: stage 1, 16.0%; stage 2, 20.2%; stage 3, 25.2%; stage 4, 1.7%; stage 5, 0.8%; and not stageable, 5.0%. A total of 381 DRPs were identified, averaging 3.2 (1.7) per patient (range 0-11). The number of DRPs correlated with Cl(cr) (r = -0.25; p = 0.007). Therapeutic recommendations included change of drug, dose and/or interval adjustment of the current drug, discontinuation of nonsteroidal antiinflammatory drugs, additional laboratory monitoring, meeting goal blood pressure and glycosylated hemoglobin, adding renoprotective drug and/or low-dose aspirin, and nephrologist referral. Fewer than half (40.9%) of the recommendations were accepted or accepted with modifications, and an approximately equal percentage were not accepted by the physicians. CONCLUSIONS: CKD prevalence was high among the patients evaluated here. New guidelines are available to assist in managing CKD ambulatory patients. Pharmacist collaboration with physicians may optimize CKD screening in high-risk patients and improve medication usage.     

The impact of medication therapy management in older oncology patients

Purpose

This project aimed to identify common drug-related problems (DRP) among elderly cancer patients, to determine the effectiveness of medication therapy management (MTM) service in resolving DRP, to determine the clinical significance of pharmacist interventions, and to determine patients’ satisfaction level of MTM service.

Method

Elderly cancer patients (age ≥65) who were at least on one chronic medication would be eligible for the MTM service. Any DRP that was detected would be recorded and steps to resolve it were taken. Pre- and post-service patient satisfaction surveys (PSS) were conducted before and after MTM. All interventions performed by MTM pharmacists were subjected to independent evaluation by a panel of three judges.

Results

One hundred eighteen patients received at least one session of MTM. We identified and attempted to resolve 361 DRPs, and the most common DRPs were drug interactions (117 cases, 32.4 %), adverse effects (114 cases, 31.6 %), and non-adherence (48 cases, 13.3 %). Forty-four interventions were performed by pharmacists and forty cases (91 %) were accepted by physicians. Almost two third of these interventions were deemed significant (or higher) by the judges. Seventy-two patients completed PSS. There was statistically significant improvement in patients’ satisfaction level after the service was provided.

Conclusion

MTM is an important platform in identifying and managing DRPs. Patients are generally satisfied with MTM services.     

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.     

The impact of residential medication management reviews (RMMRs) on medication regimen complexity

Objectives: The primary objective of this study was to investigate the impact of RMMRs on medication regimen complexity, as assessed by a validated measure.

Methods: Retrospective analysis of RMMRs pertaining to 285 aged care residents aged ≥ 65 years in Sydney, Australia. Medication regimen complexity was measured using the Medication Regimen Complexity Index (MRCI) at baseline, after pharmacists’ recommendations (assuming that all of the pharmacists’ recommendations were accepted by the General Practitioner (GP)), and after the actual uptake of pharmacists’ recommendations by the GP. Differences in the regimen complexity was measured using the Wilcoxon sign rank test.

Results: Pharmacists made 764 recommendations (average 2.7 recommendations per RMMR), of which 569 (74.5%) were accepted by GPs. The median MRCI at baseline in the sample was 25.5 (IQR = 19.0–32.5). No statistically significant differences were demonstrated in the MRCI scores after pharmacists’ recommendations (p = 0.53) or after GPs’ acceptance of these recommendations (p = 0.07) compared to the baseline.

Conclusion: Our study revealed high acceptance of pharmacists’ recommendations by GPs. This suggests that RMMRs are useful for identifying and resolving drug-related issues among residents of ACFs. However, our study failed to show a significant effect of RMMRs in reducing the medication regimen complexity, as measured by the MRCI. Further studies are needed to establish the association of medication regimen complexity and clinical outcomes in residents of ACFs.     

Comprehensive medication therapy management: identifying and resolving drug-related issues in a community pharmacy

OBJECTIVE: The aim of this study was to characterize comprehensive medication therapy management (MTM) involving a community pharmacy and local physicians by describing the drug-related issues encountered, identifying which medication types were associated with these issues, and listing the actions taken by physicians and pharmacists to address them. METHODS: In the MTM program studied, community pharmacists and physicians worked together to manage the drug therapy of ambulatory Iowa Medicaid recipients dispensed > or =4 medications for chronic conditions by a community pharmacy. After initial assessment, pharmacists made written recommendations to the patient's physician, and the physicians subsequently responded. Data were extracted from pharmacy records for patients who made > or =1 visit during the first 2 years of the program. Collected data included patient demographics, number of chronic conditions and medications at enrollment, type and number of drug-related issues, medication category, pharmacist recommendations, and physician acceptance of recommendations. RESULTS: Data were gathered for 150 patients. The mean (SD) age was 54.4 (19.4) years and 74.0% were female. They were taking a mean (SD) of 9.3 (4.6) medications and had a mean (SD) of 6.1 (3.1) medical conditions at enrollment. A total of 886 drug-related issues were classified into 7 categories: inappropriate adherence (25.9%), needs additional therapy (22.0%), wrong drug (13.2%), unnecessary drug therapy (12.9%), adverse drug reaction (11.1%), dose too low (9.7%), and dose too high (5.3%). Overall, physicians accepted 313 (47.4%) of the 659 recommendations to alter drug therapy made by pharmacists, with the highest rates of agreement to stop or change a medication (50.3% and 50.0%, respectively) and the lowest rate of agreement to start a new medication (41.7%). CONCLUSION: The MTM program showed that drug therapy for ambulatory patients taking multiple medications to treat chronic conditions can be improved through collaboration between physicians and community pharmacists.     

Diffusion of pharmacist interventions within the framework of clinical pharmacy activity in the clinical ward

BACKGROUND: Computerised physician order entry (CPOE) and the integration of a pharmacist in clinical wards have been shown to prevent medication errors. OBJECTIVES: The objectives were to describe interventions performed by a clinical pharmacist integrated into clinical wards with CPOE, to assess the acceptance of interventions by prescribers, and to describe factors associated with acceptance. METHODS: A 3-week prospective study was conducted in five wards of a 2000-bed French teaching hospital. RESULTS: During pharmacist review of medication orders and participation on physician rounds, six resident pharmacists provided interventions either conveyed orally to prescribers, using the computer system, or combining both methods. There were 221 pharmacist interventions concerning drug-drug interactions (27%), drug monitoring (17%) and computer-related problems (16%). Pharmacist interventions consisted of change of drug choice or dose adjustment (49%), drug monitoring (17%) and administration modality optimisation (14%). Interventions were provided solely via computer systems in 67% of cases. The rate of intervention acceptance was 47.1%. In multivariate analysis, acceptance was significantly associated with oral transmission (odds ratio [OR] = 6.46; 95% confidence interval [95% CI] [1.65-25.24]; p < 0.01), change of drug choice or dose adjustment recommendations (OR = 3.81; 95% CI [1.63-8.86]; p < 0.01) and administration modality optimisation recommendations (OR = 9.51; 95% CI [3.02-29.93]; p < 0.01). CONCLUSION: Communication method and nature of recommendation are factors associated with pharmacist intervention acceptance. CPOE is necessary to develop clinical pharmacy practice. However, only the integration of the pharmacist on the ward can guarantee a high level of acceptance of pharmacist interventions by prescribers.     

Validating reasons for medication discontinuation in electronic patient records at hospital discharge

Rationale, aims and objectives The accuracy of health care professionals in reporting safety events determines their usefulness for both system improvement and research. The study objectives were to: (1) validate (assess the accuracy of) the reasons recorded by doctors and pharmacists for discontinuing medication orders at discharge in a hospital's electronic patient records (EPR); (2) investigate the causes of any detected recording inaccuracy; and (3) collect preliminary data on the frequency and types of medication discontinuation. Methods This was a validation study in one English hospital. The study comprised two steps: extraction of discontinued medication orders from the EPR followed by short structured interviews with doctors and pharmacists who made the discontinuation. A total of 104 discontinued orders were discussed during 15 face‐to‐face and six telephone interviews. The software package spss was used for data analysis. Results Duplication of therapy (27, 25.2%), omission of drug (23, 21.5%) and dosage regimen change (19, 17.8%) were the three most frequent reasons given for discontinuing medications. The majority of recorded discontinuation reasons were correct (100, 96.2%) and complete (101, 97.1%), and hence were judged accurate (97, 93.3%). The difference in accurate recording between doctors (15, 88.2%) and pharmacists (82, 94.3%) was not statistically significant. Potential causes of recording inaccuracy included: slip or lapse, lack of training, carelessness and electronic system rigidity. Conclusion This study showed that doctors and pharmacists recorded accurate reasons for the majority of the discontinued medication orders. It also showed that utilizing pharmacists' recorded reasons during clinical interventions using EPR was beneficial in understanding and characterizing prescribing errors. Although they require further research, the reasons identified present preliminary data about the most prevalent types of pharmacists' interventions during hospital discharge.     

Prevalence and socio-demographic correlates of substance use in a rural community in Sikkim,North East India: Results from a pilot population survey

Over 80% of Glasgow's community pharmacies provide a supervised methadone service to opiate users, but fewer than this provide a needle exchange service. Postal questionnaires were sent in 1997 and annually from 2000 to 2003 to every pharmacy in Greater Glasgow. The original aim of the questionnaire was to determine the number of pharmacists in Glasgow that dispensed methadone and supervised its consumption, and to determine the pharmacists' attitudes to the provision of this service. As Glasgow has a high number of injecting drug users, two further sections were added to the questionnaire in 2001. These related to pharmacists' willingness to provide needle exchange. Over these years, the community provision of substitute medication and needle exchange service to drug users has grown considerably. In addition, there have been changes in the views and opinions of participating pharmacists in relation to the provision of such services. Reasons for non‐participation include the opinion that other customers would object; business reasons, for example, risks to staff, property, or theft; and premises being unsuitable. By contrast, the pharmacists' decision to offer a supervised consumption of methadone or needle exchange service appears to be based on the recognition of clinical need, rather than potential financial gain.     

Shifts in expectations: Evaluating physicians' perceptions as pharmacists become integrated into family practice

The objective of this study was to measure how primary care family physicians perceived their own and pharmacists' contributions to medication processes as pharmacists become integrated into primary care group family practices. The 22- item Family Medicine Medication Use Processes Matrix was mailed to physicians in seven sites at the 3rd, 12th and 19th month of pharmacist integration. Paired sample t-tests for the third month results were conducted to compare perceptions between pharmacist and physician contributions. One way repeated measure ANOVA test was conducted to determine significant changes over time. Physicians initially perceived their own contributions to be significantly higher than pharmacists in three subscales: Diagnosis & Prescribing, Monitoring and Administration/Documentation and their own contributions to be significantly lower than the pharmacists in the Education subscale. Over time, physicians perceived increases in the pharmacists' contribution to the Diagnosis & Prescribing, Monitoring and Medication Review subscales and decreases in their own contribution to the Diagnosis & Prescribing and Education subscales. Changes in family physicians' perceptions of pharmacists' contribution demonstrate an initial underestimate of pharmacists' role in primary care family practice and a gradual recognition of expertise and competence. This may have led to increased comfort in sharing aspects of contribution to medication use processes.     

Retrospective evaluation of medication appropriateness and clinical pharmacist drug therapy recommendations for home-based primary care veterans

Background:The Medication Appropriateness Index (MAI) has demonstrated reliability in several outpatient settings. Clinical pharmacists play key roles as members of an interdisciplinary team in determining medication appropriateness.Objective:The goal of this study was to examine medication appropriateness using the MAI and the degree of recommendation acceptance associated with clinical pharmacist medication reviews for veterans enrolled in the Home-Based Primary Care (HBPC) program.Methods:A retrospective analysis of clinical pharmacist medication reviews was performed by accessing the computerized patient medical record. Patients included in the study were enrolled in the HBPC program between March 2002 and January 2004. The data were examined to determine a total MAI score associated with medication recommendations after each review. The number and types of pharmacist recommendations, their acceptance rate, and the total number of medications discontinued were also evaluated.Results:Seventy-nine patients (mean [SD] age, 75.3 [10.3] years) identified through the pharmacy database met the inclusion criteria and were included in the study. No patients identified were excluded from the analysis. A statistically significant decrease in the overall MAI score was observed from the initial review to the end of the study (P < 0.001). Recommendations to patients' primary care providers included medication initiation/discontinuation, laboratory monitoring, dosage adjustment, and other issues associated with appropriate prescribing that could be categorized using the MAI. Recommendations to home health nurses included monitoring for medication adherence, efficacy, and adverse events. Pharmacist recommendation acceptance rates for primary care providers and home health nurses were 69% and 56%, respectively. Overall, 121 medications were discontinued during the study period.Conclusions:By using the MAI for evaluation, pharmacist recommendations significantly improved the appropriateness of medication use among veterans receiving home health care. A majority of pharmacist recommendations were accepted.