Handling drug-related problems in rehabilitation patients: a randomized study

Background Drug-related problems (DRPs) have been found to be associated with increased morbidity, mortality, and health costs. Objective To investigate whether the inclusion of pharmacists in a rehabilitation team influences the handling of DRPs in the ward and whether an intervention in hospital affects drug use after discharge. Setting The rehabilitation ward of a general hospital in Oslo, Norway. Methods Patients were randomized into an intervention group (IG) or a usual care group (CG). The IG patients were followed prospectively by a pharmacist, who reviewed the patients?? drug therapies using information from their medical records and patient interviews. The pharmacist identified DRPs and suggested solutions during multidisciplinary team meetings. The IG patients received targeted drug counselling from the pharmacist before discharge. The drug therapy in the CG, for the period from study randomization to discharge, was assessed retrospectively by the pharmacist, who identified DRPs and recorded how they were acted upon. Three months after discharge, pharmacists who were blinded to the patient randomization, visited the patients at home and interviewed them about their medication. Main outcome measures: Types and frequencies of DRPs in the IG and CG were compared at hospital admission, at discharge, and 3?months after discharge. Results Of the 77 patients included, 40 belonged to the IG and 37 to the CG. Patient characteristics (IG vs CG) were as follows: age 73.5 versus 76.8?years; female 58 versus 68%; mean number of drugs at admission 8.3 versus 7.8; and mean number of drugs at discharge 8.5 versus 7.7. At admission, 4.4 DRPs per patient were recorded in the IG and 4.2 in the CG. Significantly more DRPs were acted upon and resolved in the IG; at discharge, the IG had 1.2 DRPs per patient and the CG had 4.0 (P?<?0.01). At the home visit, a significant difference between the groups was found: 1.63 versus 2.62 DRPs (P?=?0.02) for the IG and the CG, respectively. Conclusion Involvement of a pharmacist in drug-therapy management, including participation in multidisciplinary team discussions, markedly improved the identification and resolution of DRPs during a hospital stay. The benefit persisted after discharge.     

Cost benefit analysis of clinical pharmacist interventions in medical intensive care unit in Palestine medical complex: Prospective interventional study

BackgroundClinical pharmacy services in the critical health care settings have expanded dramatically.Study problem.Clinical pharmacy services have limited implementation in Palestine. Many intensive care units (ICUs) patients do not get the intended beneficial effects of their treatment due to treatment related problems and their consequent cost burden.AimTo evaluate the impact of the clinical pharmacist interventions on costs of care and safety of patient by assessing treatment related problems among medical ICUs patients in Palestine.MethodologyA prospective interventional study was conducted at medical ICU of the major public hospital in Ramallah city over a 4-month period (between September and December 2020). Patients were randomly assigned to either an intervention or a control group (With / without clinical pharmacist involvement). Treatment related problems were identified in both study groups by the clinical pharmacist, but interventions were only provided to the intervention group. The total economic benefit included both cost savings from intervention and cost avoidance from preventable adverse drug events (ADEs) resulted from CP interventions. The primary outcomes with the clinical pharmacist interventions were net benefit and benefit to cost ratio, which were calculated using previously published methodologies and adjusted to the Palestinian settings. The analysis of CP interventions acceptance by physicians was performed.ResultsDuring the 4-month study period, the 117 patients admitted to the ICU were included into the analysis; 66 patients in the intervention group and 51 in the control group. The interventions made by a clinical pharmacist resulted in direct cost saving of NIS8,990.05 ($2799.63) and cost avoidance of NIS22,087.5 ($ 6878.37). Translated into a net savings of NIS188.35 ($58.65) per intervention and NIS470 ($146.36) per patient. Comparison of benefits (NIS31,077.55) ($9678.00) and costs (NIS19,043.928) ($5930.55) indicate a net economic benefit to the institution of (NIS 12,033.623) ($3747.44) and a benefit cost ratio of 1.63.ConclusionIntegrating a clinical pharmacist in the ICU team was investment that resulted in benefits in term of cost saving and cost avoidance.     

临床药师参与成功救治甲型H1N1流感危重症患儿的实践与思考

目的:探讨临床药师在参与成功救治甲型H1N1流感危重症患儿临床药物治疗中的作用。方法:从本专业的角度并结合患儿的实际情况,临床药师从药动学、药效学、药物相互作用和药品不良反应等方面着手,参与临床药物治疗工作。结果:我院集"三甲"综合医院优势,多学科紧密配合救治,使患儿临床症状完全消失,所有检查指标均正常,已达到临床治愈。结论:临床药师是医疗团队的重要组成,临床药师参与临床药物治疗工作,能提高临床治疗的效果和安全性。     

临床药师干预对癌痛控制效果的随机对照研究

目的：评价临床药师干预对癌痛控制的效果。方法：以2015年9月-2016年1月在某院肿瘤内科收治入院的成人癌痛患者为研究对象。将符合纳入、排除标准的100名患者随机分为干预组和对照组。对照组50名患者接受医生和护士的常规诊疗,干预组50名患者在对照组基础上增加了临床药师干预。干预措施包括镇痛药物剂量调整、患者教育、镇痛药物疗效评估、向医生提出个体化用药建议、及时报告阿片类药物相关不良反应等。比较2组患者在1,2,3,7,14 d时的疼痛评分,干预前后用药依从性、便秘改善情况,对干预过程中药师提出的用药建议进行汇总。采用SPSS13.0进行统计分析,以P<0.05为有统计学差异。结果：和对照组相比,干预组在24 h（4.12 vs 4.84,P=0.048）、48 h（3.10 vs 4.60,P<0.001）、72 h（2.68 vs 3.92,P<0.001）、7 d（2.71 vs 3.74,P<0.001）、14 d（2.28 vs 3.42,P<0.001）。干预组患者在经药师宣教后,用药依从性好的患者人数增加了近1倍,差异有统计学意义（P<0.05）,而对照组在诊疗前后用药依从性无变化（P=0.499）。干预组50例患者中,有34例发生便秘,23例便秘得到有效改善,有效率为67.65%;对照组有33例患者发生便秘,14例得到有效改善,有效率为42.42%。2组便秘改善有效率具有明显的组间差异（P=0.038）。临床药师针对干预组患者的药学监护共提出了122条建议,医生共采纳74条,采纳率为60.65%。结论：临床药师干预可降低患者疼痛强度和镇痛药物相关不良反应发生率、提高疼痛缓解率与用药依从性,作为多学科癌痛治疗团队中的一员,临床药师在癌痛管理中发挥着重要作用。     

临床药师提供的药学服务对他汀类药物治疗服务系统建设的影响研究

目的探讨临床药师主导的药学服务对他汀类药物治疗服务系统构建及评价的影响。方法200例服用他汀类药物治疗的老年(62~88岁)患者,按随机原则分为药师干预组和对照组,每组100例。对照组通过传统用药护理、发放宣教手册、电话回访实施干预;药师干预组在对照组基础上结合药师小组在临床前行讨论模式,经由本社区居委会领导精选交流及协调,每周按时由合格教师或临床药师构建成服务小组,为社区提供免费药学服务和充分培训,进而可更好完成药品使用审评数据分析及收集。对比两组干预前后用药相关问题(DRP)发生情况及药物治疗收益(安全性、有效性、经济性、适当性)。结果干预后,药师干预组DRP发生率30.0%低于对照组的70.0%,差异有统计学意义(P<0.05)。干预后,两组的DRP出现条目数、DRP总药物数量、DRP处方药数量均较干预前减少,且药师干预组减少量更多。干预后,药师干预组药品不良反应(ADR)、重复用药、相互作用、潜在不适当用药(PIM)、其他用药问题发生率分别为13.0%、1.0%、1.0%、2.0%、25.0%,均低于对照组的26.0%、7.0%、7.0%、10.0%、40.0%,差异有统计学意义(P<0.05);药师干预组用药信念好、用药认知好的占比和近3个月就诊率均高于对照组,欧洲视觉模拟标尺法(QOL EQ-VAS)评分低于对照组,医保用药数量、用药数量、月药费均少于对照组,剂量不当、治疗不足的占比均低于对照组,差异有统计学意义(P<0.05)。两组干预后用药依从性好、超适应证、无适应证的占比和欧洲五维健康量表(QOL EQ-5D)评分比较差异均无统计学意义(P>0.05)。结论以临床药师为主导的药学服务,能显著提高老年患者用药安全性、有效性、经济性和适当性,临床药师地位得到提高以及公众的认同。     

中国临床药师工作模式的系统性评价

目的:评价中国临床药师干预效果的研究,考察临床药师的干预模式,评价临床药师的干预结果。方法:检索PUBMED、COCHRANE、CNKI、万方、维普数据库,纳入中国临床药师干预的随机对照试验,两名评价员按照固定的纳入排除标准,独立对文献资料进行提取。结果:共纳入临床药师参与的随机对照试验25篇,干预领域从高到低依次为内分泌科、呼吸科、心血管科、抗感染科、肿瘤科。干预方式为医院药学信息服务、药物认知或生活方式干预、患者教育与用药咨询、出院用药与随访、建立医疗团队等项目。药师干预的一级、二级、三级、四级有效率分别为50%、75%、76%、86%。结论:临床药师的干预可以提高依从性、认知度,降低患者不良反应发生率的药费。临床药师工作模式已经初见成效,但我国药学服务的模式与评价模式仍有待改善。     

Study on Impact of Clinical Pharmacist’s Interventions in the Optimal Use of Oral Anticoagulants in Stroke Patients

Anticoagulants are very useful medications but can also lead to haemorrhagic as well as thromboembolic complications when not used correctly or without proper medical attention. Anticoagulant’s complex pharmacology and pharmacokinetics contribute to its narrow margin of safety. Pharmacist’s unique knowledge of pharmacology, pharmacokinetics and interactions makes them well-suited to assist patients in maintaining safe and effective anticoagulation. Successful anticoagulation therapy implies fewer incidences of therapeutic failures and bleeding complications. The anticoagulation management service staffed by clinical pharmacists is a service established to monitor and manage oral and parenteral anticoagulants. In this research work, 40 patients each were included in the intervention and the control groups. In the intervention group, patient’s knowledge score on anticoagulation increased from an average of 5.6±3.2 to 13.8±0.94 (P=0.000) after clinical pharmacist’s counselling, whereas in the control group there was no significant improvement in patient’s baseline knowledge over the knowledge score at the end of the study (8.0±1.59 vs. 8.3±2.6) (P=0.218). In the intervention group, 73.45% of the international normalised ratio test results were within the therapeutic range, 8.45% supratherapeutic and 18.5% subtherapeutic during the 6 months data collection period. The corresponding data for the control group were 53.2 (P=0.000), 18.4 (P=0.000) and 28.4% (P=0.002), respectively. Forty four adverse drug reactions (ADRs) related to anticoagulants were identified in the intervention group as compared to 56 in the control group. These results revealed that the clinical pharmacist’s involvement in the anticoagulation management improved the therapeutic outcome of patients and demonstrate the benefits of clinical pharmacist guided anticoagulation clinics in India.     

Clinical and economic effects of pharmacy services in geriatric ambulatory clinic

Pharmacy services were introduced in an established multidisciplinary geriatric ambulatory clinic. The pharmacist collaborated with primary care providers to optimize patients' drug regimens. Over 8 months there were 250 patient visits to the clinic. Traditional medical care was provided at 144 (57.6%) of these visits and traditional medical care plus pharmacist evaluation was provided at 106 (42.4%). The pharmacist identified 220 potential and actual drug-related problems. Acceptance of pharmacist-recommended changes in drug therapy was 98.6%. A mean reduction of 3.4 agents/patient was achieved in the intervention group (p<0.0001). Clinical outcomes of changes in drug therapy were neutral or positive in 99.5% of cases. Pharmacy services resulted in net savings of $7,788 annually.     

Effect of pharmacist participation on a medical team on costs, charges, and length of stay

The financial impact of pharmacist participation on a medical team in a tertiary-care teaching hospital was studied prospectively. Two medical teams, one with and one without a pharmacist, operated simultaneously for 11 months. Physicians and a pharmacist on the teams rotated monthly during the first five months of the study. Subsequently, the hospital administrator, who was unaware that the controlled study was under way, permanently assigned an attending physician to the team that did ot have a pharmacist. After patients' discharge, pharmacy costs, pharmacy charges, hospital charges, and length of stay (LOS) were compared for the two teams. Data analysis was separated into four phases: phase 1, during which attending physicians rotated monthly; phase 2, with a permanent attending physician; phase 3, which encompassed the entire 11 months; and phase 4, which encompassed the 11-month period but omitted patients whose LOS exceeded 30 days. Data were analyzed for a total of 619 patients on the two teams. In phase 1, the team with a pharmacist had significantly lower per-patient pharmacy costs, pharmacy charges, hospital charges, and LOS. In phase 2, no significant differences were found between the teams. In phase 3, the only significant difference was that the team with a pharmacist had lower pharmacy costs and pharmacy charges. In phase 4, the team that included a pharmacist had significantly lower pharmacy costs ($105 difference), pharmacy charges ($368 difference), hospital charges ($2065 difference), and LOS (1.3-day difference). Participation of pharmacists on the medical team can significantly reduce pharmacy costs and charges, hospital charges, and LOS.     

医疗机构药师干预促进合理用药管理的系统评价

目的:了解药师为规范临床药物治疗行为进行技术合作和技术干预的内容,以及我国开展合理用药工作的现状,为合理用药管理提供决策依据。方法:以干预、药学、药事和药师等检索词建立检索策略,通过文献计量学方法,统计、分析2005-2013年中国医院数字图书馆(CHKD)和万方医学网(Wanfang Med Online)发表的"药师参与合理用药工作管理"的相关文献;统计文献数量,分析汇总期刊分布。结果:检索2005-2013年发表的干预相关文献1 478篇,有效文献991篇,分布于196种杂志,相关论文在期刊中的分布并不均匀,具有明显的集中和离散规律;载文量前10位均为药学期刊,达404篇,载文量占40.77%,期刊占1.00%,显示较高的集中趋势。药师干预随年度逐步增长,干预内容随国家相关法规的颁布、政策的调整、管理工作的安排而变化。药事干预分层制策,因地制宜; 干预方法、形式及内容多样,干预对象涉及医、药、护及患者;根据工作内容,干预时机分事前、事中和事后干预;干预地点前移;干预适度;干预质量逐步提高。结论:我国医疗机构药师参与临床实践形式呈多样化,涵盖专科疾病治疗、抗凝门诊、处方管理、药物应用管理、治疗药物评价与分析、静脉输液配置、治疗药物监测、药物不良反应监测、药品临床应用数据分析、药物相关的健康教育及解决与药物有关的问题等专业性实践。临床实践证明,药师干预是规范药物相关医疗行为,促进药物合理使用的一种行之有效的手段之一;干预同时若叠加行政管理,建立规范的干预标准及干预质量评价体系,药师干预的效果会进一步提高。     

Evaluation of pharmacist interventions as part of a multidisciplinary cancer pain management team in a Chinese academic medical center

ObjectiveThe objective of this study was to evaluate pharmacist interventions in the cancer pain management of hospitalized patients, focusing on a clinically meaningful change in drug-related problems and pain score.MethodsA retrospective data analysis was performed at a single academic comprehensive cancer center. Hospitalized patients with moderate to severe pain who had already received analgesic medication for at least 3 consecutive days were included. For patients who met the criteria for admission, a pharmacist followed up daily during hospitalization and evaluated the patient during pre- (first) and postintervention (second, third, and fourth) visits. Medication problems, medication changes, and changes in pain scores were assessed.ResultsA total of 195 patients were included in the study. The pharmacist identified 12 types of pharmacotherapeutic drug–related problems. The top 3 problems were nonadherence or missed doses (27.69%), inappropriate opioid selection (22.56%), and inappropriate dosage (16.41%). After the intervention of pharmacists, these drug-related problems decreased by 74.54% on average. Across all visits, the changes in pain scores (mean ± SD: 2.80 ± 1.92 vs. 1.90 ± 1.58, P < 0.05) and the number of patients with mild (172 vs. 128, P < 0.05), moderate (58 vs. 21, P < 0.05), and severe pain (9 vs. 2, P < 0.05) indicated a marked decrease in patients’ pain levels after the inclusion of pharmacist in the cancer pain multidisciplinary management team (CPMMT).ConclusionParticipation by the pharmacist in the CPMMT led to a marked reduction in most of the drug-related problems and a statistically significant change in pain score during the 4 visits, indicating that pharmacists play an active role in CPMMT.     

An evaluation of a collaborative pharmacist prescribing model compared to the usual medical prescribing model in the emergency department

BackgroundWorkforce reform has placed a significant focus on the role of non-medical prescribers in the healthcare system. Pharmacists are trained in pharmacology and therapeutics, and therefore well placed to act as non-medical prescribers.ObjectivesTo assess the safety and accuracy of inpatient medication charts within a pharmacist collaborative prescribing model (intervention), compared to the usual medical model (control) in the emergency department (ED). Another objective compared venous thromboembolism (VTE) risk assessment and prescribing, between intervention and control groups.MethodsAdult patients in ED referred for hospital admission were randomised into control or intervention by a block randomisation method, until the required sample size was reached. Medication charts were audited retrospectively by an independent auditor, using validated audit forms.ResultsIntervention group medication charts contained significantly fewer prescribing errors, omissions and discrepancies compared to the control group, and improved documentation of adverse drug reactions. VTE risk assessment and prescribing had higher guideline concordance in the intervention group compared to the control group.ConclusionsThis collaborative prescribing trial showed excellent results in safety and accuracy of pharmacist prescribing when compared to the usual medical model of prescribing. The admitting medical practitioner and extended scope pharmacist prescriber worked as a collaborative team in emergency, which improved Australian national prescribing safety indicators.     

Introduction of pharmaceutical expertise in a palliative care team in Sweden

Objective This paper presents for the first time the inclusion of dispensing pharmacists, a special group of pharmacy professionals, in a Swedish palliative care team. It also presents the drug stock management in the medication room of the clinical area and the improvement of drug logistics. In addition to a dispensing pharmacist, a pharmacist was included in this part of the project as well. Setting The palliative care team at ASIH L?ngbro Park, Sweden. Method The intervention with the dispensing pharmacists as new members of the interdisciplinary palliative team was evaluated by a questionnaire to the staff. An inventory of the different drugs in stock was performed in March 2006 and in April 2007, respectively. The inventory turnover rate was determined and the drug consumption for the last 6 months of 2005 and 2006, respectively, was also analysed. Main outcome measures The questionnaire used rating scales allowing participants to rate the questions/statements. The number of different drugs and drug packages in stock were recorded during the inventories. Drug costs were calculated and the inventory turnover rate was determined by dividing the annual cost of drugs by the value of the inventory. Drug consumption was analysed using the Xplain statistical programme, a statistical tool from Apoteket AB. Results The overall impression of the dispensing pharmacists was positive. The staff reported advantages in having a dispensing pharmacist present at ASIH not only for the drug logistics, but also for drug-related queries. The inventory of the drug stock and the drug-handling process resulted in a 14% reduction of product numbers and a 36% reduction in the tied-up capital for drugs in stock. The inventory turnover rate increased from 6.7 to 9.5. A 7% reduction of medication costs was also observed when comparing the last 6 months of 2006 with the costs in 2005. Conclusion The principal result of this project is that inclusion of pharmaceutical expertise on a palliative care team can be a valuable asset for the team in pharmaceutical issues and of great benefit for stock management, including cost savings and improvement of drug logistics.     

Evaluation of a Dedicated Pharmacist Staffing Model in the Medical Intensive Care Unit

Purpose:

Published studies have shown that pharmacists on medical rounds reduce the incidence of preventable adverse drug events (ADEs). However, the impact of a dedicated pharmacist who provides consistent patient care in a critical care unit remains to be evaluated.

Objective:

To determine the impact of a pharmacist who is permanently assigned to the medical intensive care unit (MICU) on the incidence of preventable ADEs, drug charges, and length of stay (LOS) in the MICU.

Design:

A randomized, experimental versus historical control group design was used. Preventable ADEs were identified and validated by 2 pharmacists and a critical care physician. Information about MICU drug charges and LOS were obtained from the hospital administrative database.

Results:

The intervention group had fewer occurrences of ADEs (10 ADEs/1,000 patient days) when compared to the control group (28 ADEs/1,000 patient days) at a significance level of .03. No significant differences were found between the 2 groups in MICU drug charges and LOS. The vast majority of the 596 documented recommended interventions (99%) were accepted by the medical team. Nutrition monitoring, medication indicated but not prescribed, and dosage modification were the top 3 problems identified by the pharmacist.

Conclusion:

The addition of a dedicated critical care pharmacist to the MICU medical team improves the safe use of medication. The services of a dedicated critical care pharmacist should be expanded to include weekend hours to ensure the benefits of improved medication safety.     

Effect of a pharmacist's and a nurse's interventions on cost of drug therapy in a medical intensive-care unit

The effect of interventions by a pharmacist and a nurse on the cost of drug therapy in a medical intensive-care unit (ICU) was determined. A pharmacist taught cost-avoidance concepts related to medication use to a senior member of the nursing staff. The pharmacist and the nurse documented during a 91-day period all interventions that resulted in a discontinuation or change in drug therapy or involved nonformulary drug requests or serum drug concentration determinations. Costs that were avoided or added as a result of these interventions were determined using drug acquisition costs and (for interventions involving i.v. therapy) the cost of related supplies. Costs were calculated for both the initial 24-hour period after each intervention and the expected duration of therapy. The 345 interventions of the pharmacist and the nurse represented $6,383 in 24-hour cost avoidance and $23,993 in total cost avoidance. The majority of interventions resulted in discontinuation of medications or changes in drug dosage; most of those interventions involved antimicrobial agents. Other frequent interventions involved changes in route of administration and the interchange of therapeutic alternates. A pharmacist and a nurse had a positive impact on the cost of drug therapy in a medical ICU.     

药学干预对脑梗死患者的治疗效果分析

探讨药学干预对脑梗死患者治疗的作用。采用回顾性分析的方法,随机抽取本院2015年1~6月出院病例300例作为干预前组,抽取2016年1~6月出院病例300例作为干预后组。对药学干预前后的用药合理性、临床疗效、药物不良反应和治疗费用进行对比分析。经药师对临床治疗进行药学干预后,医嘱不适宜例数较干预前下降71.6%,不适宜医嘱条数下降82.7%;不良反应例数较干预前减少30.3%;患者住院费用也较干预前平均减少1852.23元（13.84%）;但药学干预后未对疗效造成影响。以上结果表明,临床药师的药学干预对促进脑梗死患者合理用药、减少不良反应、降低患者治疗费用均具有重要意义。     

干预前后清洁手术围术期抗感染药物使用状况分析

目的:评价临床药师干预清洁手术围术期预防性使用抗菌药物的效果。方法:某"三甲"医院临床药师依据该院围术期抗菌药物预防使用规范,对病区清洁手术预防用药过程进行干预。将2011年7-8月实施临床药师干预的509例患者作为干预组,2010年7-8月未实施临床药师干预的495例患者为未干预组,比较干预前后抗菌药物使用的合理性状况、用药频度(DDDs)、抗菌药物费用。结果:抗菌药物使用的合理率由未干预组的55.96%上升至干预组的67.58%(P<0.01);抗菌药物种类由未干预组的51种降至干预组的35种;干预组第1、2代头孢菌素使用增多,第3代及3代以上头孢菌素使用减少,与未干预组比较差异有统计学意义(P<0.05);干预组二、三线抗菌药物DDDs的降低也使得药品费用有了显著性下降(P<0.05)。结论:临床药师的干预提高了清洁手术围术期抗菌药物使用的合理性,改善了抗菌药物的使用状况。