Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis

We set out to determine the effects of pharmacist-led medication review in older people by means of a systematic review and meta-analysis covering 11 electronic databases. Randomized controlled trials in any setting, concerning older people (mean age > 60 years), were considered, aimed at optimizing drug regimens and improving patient outcomes. Our primary outcome was emergency hospital admission (all cause). Secondary outcomes were mortality and numbers of drugs prescribed. We also recorded data on drug knowledge, adherence and adverse drug reactions. We retrieved 32 studies which fitted the inclusion criteria. Meta-analysis of 17 trials revealed no significant effect on all-cause admission, relative risk (RR) of 0.99 [95% confidence interval (CI) 0.87, 1.14, P  = 0.92], with moderate heterogeneity (I² = 49.5, P  = 0.01). Meta-analysis of mortality data from 22 trials found no significant benefit, with a RR of mortality of 0.96 (95% CI 0.82, 1.13, P  = 0.62), with no heterogeneity (I² = 0%). Pharmacist-led medication review may slightly decrease numbers of drugs prescribed (weighted mean difference = −0.48, 95% CI −0.89, −0.07), but significant heterogeneity was found (I² = 85.9%, P  < 0.001). Results for additional outcomes could not be pooled, but suggested that interventions could improve knowledge and adherence. Pharmacist-led medication review interventions do not have any effect on reducing mortality or hospital admission in older people, and can not be assumed to provide substantial clinical benefit. Such interventions may improve drug knowledge and adherence, but there are insufficient data to know whether quality of life is improved.     

Impact of a Pharmaceutical Care Program at Discharge on Patients at High Risk of Readmission According to the Hospital Score

Background: A significant percentage of hospital readmissions within 30 days of discharge are a result of avoidable drug-related problems. Stratifying patients according to readmission risk is key to pharmaceutical intervention (PI) design strategies to improve treatment outcomes. Objective: To assess whether a pharmaceutical care (PC) program at discharge in polymedicated patients at high potentially avoidable readmission (PAR) risk, according to the HOSPITAL score, improves 30-day readmission rate (30-dRR). Methods: This prospective controlled, quasi-experimental, 11-month study included 163 chronic polymedicated patients (>5 medications) at high PAR risk according to the HOSPITAL score. We calculated the 30-dRR and number of medication variations and Medication Regimen Complexity Index-E (MRCI-E) after PI. Results were compared with a retrospective cohort of chronic patients at high PAR risk. Results: The 30-dRR was 18.4% in the intervention group and 25.6% in the control group (odds ratio [OR] = 0.66; 95% CI = 0.38 to 1.14). Total medication reduction (−1.28; 95% CI = −1.88 to −0.68), number of high-risk medications in chronic patients (−0.58; 95% CI = −0.9 to −0.26), and MRCI-E (−6.42; 95% CI = −8.07 to −4.76) were statistically significant (P < .001). The number of medications at discharge was associated with an increased readmission risk (OR = 1.07; 95% CI = 1.01 to 1.14). Conclusions: The degree of polypharmacy and patients’ treatment complexity after hospital discharge significantly reduced as a result of the PC program compared with the control group. This highlights the need for patient selection and prioritization strategies for implementing PIs focused on reducing polypharmacy and preventing drug-related problems that may cause PAR.     

Impact of pharmacist and physician collaborations in primary care on reducing readmission to hospital: A systematic review and meta-analysis

BackgroundReadmissions to hospital due to medication-related problems are common and may be preventable. Pharmacists act to optimise use of medicines during care transitions from hospital to community.ObjectiveTo assess the impact of pharmacist-led interventions, which include communication with a primary care physician (PCP) on reducing hospital readmissions.MethodsPubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL and Web of Science were searched for articles published from inception to March 2021 that described interventions involving a pharmacist interacting with a PCP in regards to medication management of patients recently discharged from hospital. The primary outcome was effect on all-cause readmission expressed as Mantel-Haenszel risk ratio (RR) derived from applying a random effects model to pooled data. Sensitivity analysis was also conducted to investigate differences between randomised controlled trials (RCTs) and non-RCTs. The GRADE system was applied in rating the quality of evidence and certainty in the estimates of effect.ResultsIn total, 37 studies were included (16 RCTs and 29 non-RCTs). Compared to control patients, the proportion of intervention patients readmitted at least once was significantly reduced by 13% (RR = 0.87, CI:0.79–0.97, p = 0.01; low to very low certainty of evidence) over follow-up periods of variable duration in all studies combined, and by 22% (RR = 0.78, CI:0.67–0.92; low certainty of evidence) at 30 day follow-up across studies reporting this time point. Analysis of data from RCTs only showed no significant reduction in readmissions (RR = 0.92, CI:0.80–1.06; low certainty of evidence).ConclusionsThe totality of evidence suggests pharmacist-led interventions with PCP communication are effective in reducing readmissions, especially at 30 days follow-up. Future studies need to adopt more rigorous study designs and apply well-defined patient eligibility criteria.     

Pharmacy-led interventions to improve medication adherence among adults with diabetes: A systematic review and meta-analysis

BackgroundControl of blood glucose and a reduced risk of complications are important treatment goals in diabetes. Medication non-adherence can influence the outcome of diabetes. Involvement of a pharmacist in diabetes care might help patients to achieve better treatment outcomes. Existing literature reviews have focused on a limited number of interventions and outcome measures, and have involved different healthcare professionals. None of the previous reviews have used a standardized effect size to compare the effects of different pharmacist-led interventions and different outcome measures.ObjectiveTo review pharmacist-led interventions to improve medication adherence in patients with diabetes and to assess the effectiveness of these interventions on medication adherence.MethodsSix databases were systematically searched between March and September 2017 for randomized controlled trials: PubMed, Cochrane library, EMBASE, CINAHL, JSTOR, and Web of Science. The outcome measures used were: medication adherence, HbA1c, fasting plasma glucose (FPG), post-prandial blood glucose (PPG), or random blood glucose (RBG). Cohen's d, a standardized effect size, enabled a comparison of studies with different outcome measures. The Cochrane risk of bias tool was used to assess the quality of the studies.ResultsFifty-nine studies were included in this review. Pharmacist-led interventions enhanced outcomes in patients with diabetes (standardized mean difference (SMD) ?0.68; 95% CI -0.79, ?0.58; p < 0.001). Sub-group analysis by intervention strategy, the type of intervention and outcome measures produced similar results. Further analysis showed that education, printed/digital material, training/group discussion, were more effective than other interventions.ConclusionThis finding supports the role of the pharmacist in diabetes care to enhance medication adherence.     

Association of pharmacist counseling with adherence, 30-day readmission,and mortality: A systematic review and meta-analysis of randomized trials

Objective(s)To determine the association of pharmacist medication counseling with medication adherence, 30-day hospital readmission, and mortality.MethodsThe initial search identified 21,590 citations. After applying the inclusion and exclusion criteria, 62 randomized controlled trials (RCTs) (49 for the meta-analysis) were included in the final analysis. Data were pooled using a random-effects model.ResultsThe participants in most of the studies were older patients with chronic diseases who, therefore, were taking many drugs. The overall methodologic quality of evidence ranged from low to very low. Pharmacist medication counseling versus no such counseling was associated with a statistically significant 30% increase in relative risk (RR) for medication adherence, a 24% RR reduction in 30-day hospital readmission (number needed to treat = 4.2), and a 30% RR reduction in emergency department visits. RR reductions for primary care visits and mortality were not statistically significant.ConclusionThe evidence supports pharmacist medication counseling to increase medication adherence and to reduce 30-day hospital readmissions and emergency department visits. However, higher-quality RCT studies are needed to confirm or refute these findings.     

A systematic review with meta-analysis of parental interventions for human papillomavirus vaccine uptake

ObjectivesWith the growing ability of pharmacists to vaccinate against HPV, this systematic review with meta-analysis examined the efficacy of interventions targeting parents of children and adolescents in the US to increase HPV vaccine uptake.Data sourcesA systematic search of PubMed, Web of Science, SCOPUS, CINAHL, and Medline was conducted from January 2006 to January 2022.Study selectionWe included parent-based randomized controlled trials (RCTs) in the US that measured actual HPV vaccine initiation and completion from patients’ medical records.Data extractionThe revised Cochrane risk-of-bias tool for randomized trials (RoB2) was used to assess studies for risk of bias, and the Michie and Prestwich Theory Coding Scheme will be used to assess the extent of theory use. Results were pooled using the inverse-variance heterogeneity model (IVhet).ResultsOf 770 studies, 13 were included for data extraction, and 12 were included in the meta-analysis. Parent-based interventions, when compared to controls, did not demonstrate a statistically significant increase in HPV vaccine initiation (OR = 1.24, 95% CI [0.86, 1.77]) or completion (OR = 1.23, 95% CI [0.78, 1.96]). However, sensitivity analysis suggested parent-based RCTs could improve HPV vaccine initiation (OR = 1.19, 95% CI [0.16, 1.22]) but not completion (OR = 1.25, 95% CI [0.86, 1.81]), after removing cluster RCTs. Reminders/recall interventions showed a significant increase in HPV vaccine initiation (OR = 1.19, 95% CI [0.16, 1.22]) and completion (OR = 1.52, 95% CI [1.04, 2.21]). Eight studies reported theory use in intervention development. No statistically significant differences were observed between atheoretical versus non-theory-based trials.ConclusionOverall, parent-based interventions do not increase HPV vaccine uptake. Reminder and recall systems have the potential to improve HPV vaccine initiation and completion, and pharmacies can leverage these tools to improve vaccination. Behavioral theories and pharmacy-based HPV vaccination appear to be under-utilized.     

Pharmacist-led collaborative medication management programs for oral antineoplastic therapies: A systematic literature review

ObjectivesThe aim of this systematic review is to summarize the structure, process, and outcomes of pharmacist-led collaborative medication management programs for oral antineoplastic therapies (OATs).MethodsIncluded studies were peer-reviewed journal articles published in English, between January 2000 to May 2020, and reporting on pharmacist-led collaborative medication management programs for patients on OATs. To be included, studies had to report on the pharmacy practice model, pharmacist interventions, and outcomes of the medication management program. The Donabedian model informed the data extraction and summary. Two independent researchers assessed the risk of bias (confounding) for all included studies (n = 12) using the NIH tool and Cochrane ROBINS-I for observational research.ResultsThere were 12 studies that met inclusion criteria. The structure of the programs included hiring oncology pharmacists to deliver interventions, standardized templates for electronic medical record documentation, and administrative workflow changes (e.g., automatic referrals). The most common pharmacist interventions (processes) were patient education and counseling, adverse event monitoring, and dose modifications. All studies reported one or more positive outcomes, including improved patient adherence, safety, cost savings, cost avoidance, and patient satisfaction. All included studies used an observational study designs, and the majority of studies had moderate to high risk of bias.ConclusionThe evidence suggests that pharmacist-led collaborative medication management programs may have beneficial clinical and economic outcomes. The implementation of these programs could be strengthened by using a conceptual framework to guide program development, implementation, and evaluation and effectiveness-hybrid study designs to assess clinical and implementation outcomes. The risk of bias should be addressed by using more robust study designs and rigorous data collection and analysis methods.     

Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) During Pregnancy and the Risk for Autism spectrum disorder (ASD) and Attention deficit hyperactivity disorder (ADHD) in the Offspring: A True Effect or a Bias? A Systematic Review & Meta-Analysis

Background and ObjectiveAn inconsistent association between exposure to SSRIs and SNRIs and the risk for ASD and ADHD in the Offspring was observed in observational studies. Some suggest that the reported association might be due to unmeasured confounding. We aimed to study this association and to look for sources of bias by performing a systematic review and meta-analysis.MethodsMedline, Embase, and the Cochrane Library were searched up to June 2019 for studies reporting on ASD and ADHD in the Offspring following exposure during pregnancy. We followed the PRISMA 2009 guidelines for data selection and extraction. Outcomes were pooled using random-effects models and odds ratios (OR), and 95% confidence intervals (CI) were calculated for each outcome using the adjusted point estimate of each study.ResultsEighteen studies were included in the meta-analysis. We found an association between SSRIs/SNRIs prenatal use and the risk for ASD and ADHD (OR=1.42, 95% CI: 1.23–1.65, I²=58%; OR=1.26, 95% CI: 1.07-1.49, I²=48%, respectively). Similar findings were obtained in women who were exposed to SSRIs/SNRIs before pregnancy, representing statistically significant association with ASD (OR=1.39, 95% CI: 1.24-1.56, I²=33%) and ADHD (OR=1.63, 95% CI: 1.50-1.78, I²=0%) in the Offspring, although they were not exposed to those medications in utero.ConclusionsAlthough we found an association between exposure to SSRIs/SNRIs during pregnancy and the risk for ASD and ADHD, an association with those disorders was also present for exposure pre-pregnancy, suggesting that the association might be due to unmeasured confounding. We are aiming to further assess the role of potential unmeasured confounding in the estimation of the association and perform a network meta-analysis.     

The impact of community pharmacist involvement on transitions of care: A systematic review and meta-analysis

ObjectivesTo evaluate the impact of community pharmacist involvement on transitions of care, specifically on 30-day hospital readmissions.Data SourcesWe searched the following databases from inception to August 2018: MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, International Pharmaceutical Abstracts, ProQuest Health and Medical Collection, ProQuest Nursing and Allied Health Database, and Web of Science. We also searched clinical trials registries and personal files to identify additional studies.Study SelectionStudies were eligible if the intervention included community pharmacists and patients were being discharged from the hospital to home. We included reports of randomized controlled trials, nonrandomized controlled trials, controlled before-and-after studies, and interrupted time series published in English.Data ExtractionWe extracted intervention characteristics from each study and 30-day readmissions when present.ResultsFrom 744 abstracts that met our inclusion criteria, we included 39 articles describing 36 unique studies, 10 which contributed to the primary outcome of 30-day readmissions. Overall, community pharmacist involvement in transitions of care was associated with a non–statistically significant 28% reduction in 30-day readmissions (relative risk [RR], 0.72; 95% CI 0.50-1.02; I² = 82%). When using per protocol data, community pharmacist involvement in transitions of care was associated with a statistically significant 40% reduction in 30-day readmissions (RR, 0.60; 95% CI 0.41-0.88; I² = 77%). Studies with more active involvement of community pharmacists had a greater effect on 30-day readmissions (RR, 0.55; 95% CI 0.32-0.95; I² = 88%) than those with less active involvement did (RR, 1.02; 95% CI 0.80-1.31; I² = 0%).ConclusionOur review shows that community pharmacists can have a beneficial effect on patients’ transitions of care; however, the body of evidence is limited by the heterogeneity and imprecision. Future studies should test interventions in which community pharmacists play an integral part and ensure that interventions are completed with fidelity.     

Effect of pharmacist care on clinical outcomes among people living with HIV/AIDS: A systematic review and meta-analysis

BackgroundPharmacists play a significant role in the multidisciplinary care of people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (PLWHA). However, there is less evidence to clarify the impact of pharmacist as an individual team member on HIV care.ObjectiveThis study aims to determine the effects of pharmacist intervention on improving adherence to antiretroviral therapy (ART), viral load (VL) suppression, and change in CD4-T lymphocytes in PLWHA.MethodsWe identified relevant records from six databases (Pubmed, EMBASE, ProQuest, Scopus, Cochrane, and EBSCOhost) from inception till June 2020. We included studies that evaluated the impact of pharmacist care activities on clinical outcomes in PLWHA. A random-effect model was used to estimate the overall effect [odds ratio (OR) for dichotomous and mean difference (MD) for continuous data] with 95% confidence intervals (CIs). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to evaluate the quality of evidence.The review protocol was published on PROSPERO (CRD42020167994).ResultsTwenty-five studies involving 3206 PLWHA in which pharmacist-provided intervention either in the form of education with or without pharmaceutical-care either alone or as an interdisciplinary team member were included. Eight studies were randomized controlled trials (RCTs), while 17 studies were non-RCTs. Pooled-analyses showed a significant impact of pharmacist care compared to usual care group on adherence outcome (OR: 2.70 [95%, CI 1.80, 4.05]), VL suppression (OR: 4.13 [95% CI 2.27, 7.50]), and rise of CD4-T lymphocytes count (MD: 66.83 cells/mm³ [95% CI 44.08, 89.57]). The strength of evidence ranged from moderate, low to very low.ConclusionThe findings suggest that pharmacist care improves adherence, VL suppression, and CD4-T lymphocyte improvement in PLWHA; however, it should be noted that the majority of the studies have a high risk of bias. More research with more rigorous designs is required to reaffirm the impact of pharmacist interventions on clinical and economic outcomes in PLWHA.     

Impact of community-pharmacist-led medication review programmes on patient outcomes: A systematic review and meta-analysis of randomised controlled trials

Background: The role of pharmacists has evolved over the past few decades from being product-oriented to being service-oriented. Community-pharmacist-led medication review programmes have been commissioned in different countries under different names. The services provided by general pharmacists can have a positive impact on patient health, but the impact of the services offered by community pharmacists is relatively unknown. Objective: To evaluate the effectiveness of community-pharmacist-based medication review programmes among patients with long-term conditions. Methods: The electronic databases Cochrane Library, MEDLINE and Embase were searched from their inception until January 2020 for randomised controlled trials (RCTs) published in the English language assessing the effectiveness of community-pharmacist-led medication review programmes on patients’ clinical and healthcare utilisation outcomes. Random-effects meta-analysis was used to pool data statistically, where applicable. The study protocol was published in PROSPERO (ID: CRD42020165693). Results: Forty-two reports of 40 RCTs were included in the systematic review, and 12 RCTs were included in the meta-analysis. Compared to the control, a significant improvement was noted in the community-pharmacist-based medication review group for the following outcomes: blood pressure (BP) in patients with diabetes (mean difference [MD] in systolic blood pressure [SBP]: 6.82 [95% CI -11.33, ?2.32]; MD in diastolic blood pressure [DBP]: 2.13 [95% CI -3.35, ?0.92]) and in the hypertension patients (MD in SBP: 6.21 [95% CI -13.26, 0.85]; MD in DBP: 2.11 [95% CI -6.47, 2.26]), HbA1c in patients with diabetes (MD -0.61; 95% CI -0.96, ?0.25), and total cholesterol (TC) in patients with hyperlipidaemia (MD -0.18; 95% CI -0.32, ?0.05). Conclusion: Community-pharmacist-led medication review can improve certain clinical and healthcare utilisation outcomes in patients with long-term conditions.     

Polypharmacy among COVID-19 patients: A systematic review

BackgroundPolypharmacy, the concomitant use of 5 or more medications, is highly prevalent among older adults and individuals with multimorbid conditions and has been linked to suboptimal clinical outcomes in various diseases. However, little is known about the impact of polypharmacy on clinical outcomes among coronavirus disease 2019 (COVID-19) patients.ObjectiveThis systematic review summarizes the available literature on the association between polypharmacy and specific drug classes, and clinical outcomes among COVID-19 patients.MethodsWe conducted an electronic database search on Embase, Medline, Cochrane, Scopus, Google Scholar, clinicaltrials.gov, LITCOVID, PubMed, PubMed Central (PMC), and China national knowledge infrastructure for studies on Polypharmacy among COVID-19 patients using relevant combinations of the keywords. Only studies published between November 2019 to September 2020 were included. Seven articles out of 1502 unique articles met the inclusion criteria and were used for the current study. We adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline in conducting and reporting this systematic review.ResultsThe total sample size of all studies was 474,342, out of which 10,519 patients were COVID-19 positive, and 4818 COVID-19 positive patients experienced polypharmacy. Five out of the 7 included studies found associations between polypharmacy and negative clinical outcomes among COVID-19 patients. Polypharmacy was associated with increase in the relative risk of a positive COVID-19 test result (P < 0.01), death among male COVID-19 patients (P < 0.001), increase in the rate of acute kidney injury (P = 0.003), and adverse drug reactions (P < 0.001). Antipsychotic drugs were associated with severe COVID-19 morbidity (OR = 2.79; 95% CI 2.23–3.49) and increased risk of death among COVID-19 infected men (OR = 1.71; 95% CI 1.18–2.48) and women (OR = 1.96; 95% CI 1.41–2.73).ConclusionPolypharmacy and selected drug classes are associated with increased risk of adverse clinical outcomes among COVID-19 patients. Understanding these relationships can enhance risk stratification and evidence-based decision-making that may improve care and clinical outcomes of COVID-19 patients.     

Methodological standards for conducting and reporting meta-analyses: Ensuring the replicability of meta-analyses of pharmacist-led medication review

BackgroundMeta-analyses of clinical pharmacy services are frequently criticized for restricted data transparency and reproducibility.ObjectivesTo describe the methodological characteristics of meta-analyses of pharmacist-led medication reviews, to identify the elements that limit their replicability and robustness, and to propose recommendations for an appropriate conduction and reporting.MethodsA meta-research study was conducted. Systematic searches of the PubMed, Scopus, and Web of Science databases were performed to identify meta-analyses of pharmacist services. Meta-analyses assessing the effect of pharmacist-led medication reviews were selected for data extraction, analysis and replication. Two replication exercises were performed for the two most common outcomes: (i) considering the data provided by authors to construct the meta-analysis and (ii) considering the raw data available in the primary studies included. Prediction intervals (PI), fragility index (FI), and number needed to treat (NNT) were also calculated for each replicated meta-analysis.ResultsNine studies reporting meta-analyses about pharmacist-led medication review were found comprising 30 different outcomes. Eleven meta-analyses, including six for hospital admission and five for mortality, were replicated. In five meta-analyses, the pooled effect sizes of the replicated meta-analyses differed from the original ones. Only four meta-analyses mentioned the statistical method used. Other meta-analytic parameters (e.g., q-value, tau2) were omitted in all studies. In nine meta-analyses, the data from primary studies had been incorrectly extracted for at least one variable. The PI demonstrated that the uncertainty intervals of the effect sizes were always underestimated by the authors. NNTs showed wide intervals, ranging from benefit to harm, in almost all meta-analyses. Nine recommendations to facilitate the replication of a meta-analysis were proposed: providing all original data needed to build the analysis; informing about the imputed data or data obtained from different sources; performing sensitivity analyses for imputed or unpublished data; inform about all the statistical methods used; providing all statistical results; and reporting the PI, FI and NNT.ConclusionErrors in data extraction and poor reporting of meta-analytic parameters are common in the pharmacy literature. We proposed nine recommendations to enhance data reproducibility and interpretability. Journal editors and peer reviewers should ensure that authors strictly comply with minimum standards for conduction and reporting of meta-analyses.     

Assessment of the Impact of Pharmacist-led Transitions of Care Services in a Primary Health Center

Background: The impact of pharmacist-led transition of care services with collaborative drug therapy management has shown to improve patients’ outcomes and decrease health costs. Compelling statistics show higher readmission rates for under-insured patients compared with insured patients at primary health care clinics. Methods: This is a single center, prospective, cohort study designed to examine team-based collaborative drug therapy management and its effect on therapeutic outcomes of under-insured patients with target chronic diseases managed in a primary health center. Targeted chronic diseases included dyslipidemia, diabetes, hypertension, anticoagulation disorders, chronic obstructive pulmonary disease, and heart failure. The primary outcome measures included percentage of time in therapeutic international normalized ratio (INR) and percentage of patients at targeted goals of blood pressure, lipids, and hemoglobin A1c (HbA1c). Secondary outcomes included reduced emergency department visits, number of patient encounters, hospital readmissions within 30 days of discharge, and disease exacerbation rates. Results: Patients were at INR goal 58% of the time compared with 52% at baseline (P = .66). There was a 9% improvement in mean HbA1c in the intervention group when compared with baseline (9.6% vs 10.9%, P = .03). With pharmacist intervention, 73.8% of the patients had their blood pressure at goal compared with 50% at baseline (P = .14). A limited number of patients were readmitted for different reasons, including uncontrolled disease states. Conclusions: The pharmacist-physician collaborative drug therapy management led to improved blood pressure control, average HbA1c, and time in therapeutic INR range. A decrease in health care utilization was also identified.     

A systematic review and meta-analysis of treatment outcomes following antibiotic therapy among patients with carbapenem-resistant Klebsiella pneumoniae infections

IntroductionCarbapenem-resistant Klebsiella pneumoniae (CRKP) infections are a major global public health challenge. This study aimed to systematically review the evidence on treatment outcomes (mortality, clinical and microbiological response) following antibiotic therapy administered for CRKP infections.MethodsMedline, EMBASE, the Cochrane Central Register of Controlled Trials, and the International Pharmaceutical Abstracts databases were searched from inception to 26 December 2018. Data were analysed via meta-analysis techniques using random-effects (DerSimonian and Laird) modelling.ResultsFifty-four observational studies involving 3195 CRKP-infected patients who received antibiotic treatment were included. The pooled mortality, clinical and microbiological response rates were 37.2% (95% confidence interval [CI] 33.1–41.4%), 69.0% (95% CI 60.1–78.2%) and 63.7% (95% CI 53.7–74.1%), respectively. Compared with combination therapy, monotherapy was associated with a higher likelihood of mortality (odds ratio [OR] 1.45, 95% CI 1.18–1.78%), but there were no statistically significant differences in the likelihood of achieving clinical and microbiological responses. There were no statistically significant differences in the pooled likelihood of mortality, clinical or microbiological responses between two-drug and three-or-more-drug combination therapies or combination-containing and combination-sparing regimens of polymyxins, tigecycline, aminoglycosides and carbapenems. Moreover, clinical outcomes did not significantly differ among the various monotherapies.ConclusionsThese data highlight the need for systematic studies and well-designed randomised clinical trials to identify and evaluate the most appropriate antibiotic therapies for CRKP infections towards informing clinical decision-making. Furthermore, continuous surveillance of antimicrobial susceptibility patterns at local, regional, and national/international levels are important to support empirically-based therapy until susceptibility results for the isolate from the patient are available.     

Implementation of a pharmacist-led transitions of care program in an indigent care clinic: A randomized controlled trial

ObjectivesPharmacists’ involvement in the transitions of care has shown the potential to decrease readmissions and increase access to care in many populations; however, the uninsured patient populations have not been studied. The evidence for the feasibility of implementing transitions of care services in indigent care clinics with limited resources also remains limited. The objectives were to implement a pharmacist-led transitions of care program in an indigent care clinic, to demonstrate the feasibility of its implementation, and to evaluate its impact on readmissions and emergency department (ED) visit rates among an uninsured population.MethodsThe study was a single-blind, parallel, randomized controlled trial implemented in an indigent care clinic in the Southeast region of the United States from October 2018 to July 2019. Eligible patients were those older than 18 years, uninsured, English-speaking, diagnosed with any condition, and recently discharged from a local community hospital within the past 16 days. The primary outcome was the hospital readmission rate at 30 days after discharge. The secondary outcomes included 60- and 90-day readmission rates in addition to 30-, 60-, and 90-day ED visit rates.ResultsA total of 88 participants were recruited. The intervention was successfully implemented in the clinic, but patient-level barriers to follow-ups included transportation, accessibility, financial burdens, inconsistent telephone communication, and a lack of knowledge about the importance of follow-ups. At 30 days postdischarge, 13.64% of the patients in the usual care group experienced readmissions compared with 9.30% of the patients in the intervention group. The relative change in the 30-day readmission rates between the usual care and the intervention groups was 1.7 (rate ratio [RR] 1.69 [95% CI 0.47–6.08]). The RRs were insignificant for the 30-, 60-, and 90-day readmission and ED visit rates.ConclusionThis study demonstrated the feasibility of implementing transitions of care services in a clinic with limited resources by pharmacists. The intervention showed promising results by reducing readmission rates.     

Factors Associated With Medication Errors at a Teaching Hospital in Malaysia

Background: Medication errors (MEs) continue to pose a significant problem to health care systems across the world, not only causing harm and death in patients but also consuming approximately $42 billion annually in health care expenditure. The emergency department (ED) is considered a high-risk area of having MEs to occur. Little is known about the associated factors of ME in the ED of hospitals in Malaysia. Objective: The objective of this study was to determine the factors associated with ME in an ED of a teaching hospital. Methods: A cross-sectional study was conducted on patients who visited the ED of Hospital Universiti Sains Malaysia over 9 weeks during normal working hours (ie, 8:00 am-5:00 pm). A total of 547 patients who satisfied the inclusion criteria were enrolled for the study. Patient demographic information, clinical characteristics, and medication orders and procedures were observed and recorded. The required number of patient data (n = 311) were selected randomly for analysis. Multiple logistic regression method was employed to determine factors associated with ME. Results: Of the 311 patient data, 95 (30.5%) patients had at least 1 ME. The factors found to be associated with ME were number of medications (adjusted odds ratio [OR], 1.91; 95% confidence interval [CI], 1.51-2.41), triage (adjusted OR, 0.11; 95% CI, 0.04-0.27), gender (adjusted OR, 0.50; 95% CI, 0.26-0.93), and time of patient visit (adjusted OR, 0.34; 95% CI, 0.52-0.75). Conclusion: Medication error was not uncommon in our ED setting. Patients with a higher number of medications prescribed during visit to the ED were found to be particularly at risk. Identification of such factors may guide intervention measures to prevent MEs in this setting.