Effect of pharmacists’ interventions on health outcomes of children with asthma: A systematic review

MethodsA literature search was performed in January 23, 2018 at the Embase, LILACS, OpenThesis, PubMed, Cochrane Library, and Web of Science databases through January 23, 2018, using keywords related to “asthma,” “pharmacist,” and “children.” This systematic review followed the methodologic standards recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included intervention studies on the effect of pharmacists’ interventions on pediatric patients with asthma, performed in hospital or ambulatory care settings, with presenting process and outcome indicators as a result of pharmacists’ interventions. The methodologic quality of the included studies was assessed independently by 2 researchers. The Cohen kappa index was used to measure the degree of agreement between the 2 investigators.ResultsThe search yielded 3671 records, of which 5 were included in this review. Most of these studies were conducted in the United States (n = 2) and in outpatient clinics (n = 4). All studies described components of pharmacists’ interventions. The most reported category concerning pharmacists’ work process was the initial assessment of patients’ conditions, with the assessment of outcomes (at baseline and follow-up) as the only category present in all studies. The most assessed outcomes at baseline were asthma control, emergency department visits, medication use and technique, and adherence to asthma therapy. At follow-up, emergency department visits were the most evaluated outcome (n = 2), and no study assessed economic outcomes. The average consultation time ranged from 20 to 45 minutes, and the number of encounters ranged from 2 to 3.ConclusionThis study highlighted the limited number of studies, most with low quality, on the impact of the pharmacist on pediatric asthma. The most assessed outcome was the number of emergency department visits, with positive results after interventions. Heterogeneity regarding assessed outcomes and work processes was noted, which limited comparison of the results and interventions.     

A review of published studies of patients’ illness perceptions and medication adherence: Lessons learned and future directions

BackgroundPatients who seek medical care and who are prescribed medication may choose to either accept or not accept the prescriber’s recommendations to use the prescribed medication. The Common Sense Model (CSM) is one behavioral model that can help researchers and practitioners to identify patients’ illness perceptions that drive their decisions.ObjectiveThis article reviews published research that evaluated the impact of illness representations (as defined in CSM) with medication adherence.MethodsA narrative review of published research in illness representation and medication adherence was conducted. Articles were searched using MEDLINE, PreMEDLINE, evidence-based medicine reviews, and the International Pharmaceutical Abstracts databases and using the search terms medication adherence, compliance, illness perception, self-regulation theory, and common-sense model.ResultsEleven published studies were identified that compared illness representation (or illness perception) and medication adherence. Each illness representation factor, with the exception of illness coherence, directly or indirectly impacted medication adherence. Illness identity, where symptoms are used to label a health condition, can impact medication adherence, even with asymptomatic conditions such as hypertension. Patient age, disease condition, and culture may impact patient response to illness perceptions. Recommendations for future research are to (1) use longitudinal studies to evaluate the cause-effect relationships between illness perceptions and medication adherence, (2) study patients’ early experiences with their illness, (3) recruit patients who are nonadherent, (4) use clinical outcome measures in addition to the self-report medication adherence measures, and (5) include patient age and culture in the model.ConclusionsAlthough the CSM is a well-known patient behavior model, its use to explain medication adherence has been limited to cross-sectional studies across various health conditions. Further research is needed to elucidate the relationships between illness perceptions and patient medication adherence, which can help practitioners to better engage and communicate with patients.     

Effect of β-blockers on platelet aggregation: a systematic review and meta-analysis

AimsPlatelets play an important role in cardiovascular disease, and β-blockers are often prescribed for cardiovascular disease prevention. β-Blockers may directly affect platelet aggregation, because β-adrenergic receptors are present on platelets. There is uncertainty about the existence and magnitude of an effect of β-blockers on platelet aggregation. The aim of this study was to perform a systematic review and meta-analysis of the effect of β-blockers on platelet aggregation.MethodsMEDLINE and EMBASE were searched until April 2014. Two reviewers independently performed data extraction and risk of bias assessment. Type of β-blocker, population, treatment duration and platelet aggregation were extracted. Standardized mean differences were calculated for each study and pooled in a random-effects meta-analysis.ResultsWe retrieved 31 studies (28 clinical trials and three observational studies). β-Blockers decreased platelet aggregation (standardized mean difference −0.54, 95% confidence interval −0.85 to −0.24, P < 0.0001). This corresponds to a reduction of 13% (95% confidence interval 8–17%). Nonselective lipophilic β-blockers decreased platelet aggregation more than selective nonlipophilic β-blockers.ConclusionsClinically used β-blockers significantly reduce platelet aggregation. Nonselective lipophilic β-blockers seem to reduce platelet aggregation more effectively than selective nonlipophilic β-blockers. These findings may help to explain why some β-blockers are more effective than others in preventing cardiovascular disease.     

A systematic review of the literature on ‘medication wastage’: an exploration of causative factors and effect of interventions

Introduction Reducing any wastage, including that of medications, is a paramount objective in promoting appropriate utilisation of finite resources. The objective was to systematically review the published literature, the possible causative factors associated with medication wastage and the effectiveness of any interventions to reduce wastage. Method A systematic review of studies published in English was identified from the following databases: Cumulative Index to Nursing and Allied Health Literature, Embase, Medline, PubMed, Science Citation Index and The Cochrane Library. Data extraction and critical appraisal was undertaken independently by two researchers. Results and discussion Title, abstract and full paper screening reduced the 14,157 studies to 42. A general definition of medication wastage was reported in one paper only. ‘Medication changed’, ‘patient death’, ‘resolution of patient’s condition’ and ‘expired medications’ were most commonly cited reasons for wastage. Only two studies were identified reporting wastage as a research outcome measure following intervention. Conclusion The systematic review has identified a limited literature on medication wastage with a lack of consistency of terms. There is a paucity of robust research focusing on the impact of healthcare interventions on outcomes around medication wastage.     

Quality of life among alcohol-dependent patients: How satisfactory are the available instruments? A systematic review

Aim

The purpose of this systematic review was to compare quality-of-life instruments used as outcome measures in randomized clinical trials for alcohol-dependence treatment.

Methods

Randomized controlled clinical trials, indexed in the EMBASE, PubMed and PsycINFO databases since 1981, which aimed at improving the quality of life in alcohol-dependent patients and used as instrument to measure the quality of life, as specifically designated by the authors, were included.

Results

Of the 331 articles screened, 18 studies were included in the review. Eight different quality-of-life instruments were used as outcome measures. Twenty-seven life domains were explored. Between-scale heterogeneity was high. The scale most frequently used was the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Only 1 clinical trial demonstrated a significant difference between intervention groups at all endpoints, using the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q).

Conclusion

Because many different instruments were used, it is difficult to compare quality-of-life improvement between trials. The most frequently used instrument was a generic health status measure that may not be well suited as a quality-of-life measure for subjects with alcohol dependence. The construction and validation of a specific patient-reported outcome based on alcohol-dependent patients’ concerns would effectively contribute to the assessment of treatment efficacy.     

Stakeholder perspectives on pharmacist involvement in a memory clinic to review patients’ medication management and assist with deprescribing

BackgroundMemory clinics usually involve a team of health professionals who assess and review people with memory impairment. Memory clinic patients are typically older, have multiple comorbidities and potentially inappropriate polypharmacy. Pharmacists are not typically part of memory clinic teams.ObjectiveTo explore stakeholder perspectives on pharmacist involvement in a memory clinic to conduct medication reviews and assist with deprescribing potentially inappropriate/unnecessary medications.MethodsQuantitative and qualitative evaluation of stakeholder perspectives within a deprescribing feasibility study. Patient/carer questionnaires were administered at 6-month follow-up. Fax-back surveys were sent to general practitioners (GPs) shortly after the pharmacist review. A focus group was conducted with memory clinic staff and semi-structured interviews with pharmacists at conclusion of the study. Focus group/interviews were transcribed and thematically analysed.ResultsMost patients/carers found the pharmacist medication review helpful (84%, 31/37) and believed it was important to have pharmacists in the memory clinic (92%, 36/39). Twenty-one (48%) GPs responded to the survey; most found the pharmacist reports useful for identifying inappropriate medication and providing deprescribing recommendations (86% and 81%, respectively), and 90% thought a pharmacist review should be part of the memory clinic service. Feedback from memory clinic staff and pharmacists was largely positive. Questions were raised by some staff about whether deprescribing fell within the clinic's scope of practice. Challenges associated with memory clinic-GP communication were highlighted.ConclusionPatients, GPs and memory clinic staff were receptive to increased pharmacist involvement in the memory clinic. Stakeholder feedback will inform the development and delivery of pharmacist medication reviews and deprescribing in memory clinics.     

The impact of a community pharmacy service on patients’ medication adherence and ambulatory sensitive hospitalizations

BackgroundIn July 2012 a nationwide community pharmacy-based service was launched in New Zealand. The Long Term Conditions (LTC) service was introduced to help patients with chronic medical conditions, who have difficulties adhering to their medication regimens, improve their adherence. As part of the service pharmacists provide a variety of interventions including: patient education, medication reconciliation, medication synchronization, as well as preparing adherence support aids such as blister packs, sending reminders, and providing tailored dispensing frequencies. Seven years after its introduction scant data are available measuring the impact of the service on patients’ health outcomes.ObjectiveTo examine the impact of LTC on patients’ medication adherence and ambulatory sensitive hospitalizations.MethodsThis was a retrospective matched-cohort study using routinely collected health data. The population studied were individuals enrolled in LTC between July 2013 and December 2014 and a control group of propensity score matched individuals who never received the service. Outcomes were assessed during and after completion of the intervention. Sensitivity analysis was also undertaken whereby only those who completed the intervention and their controls were used in the analysis.ResultsThe matched cohort consisted of 51,138 individuals in the intervention and 51,138 in the control. Enrolment in LTC was associated with greater medication adherence, with individuals in the intervention group having 2.99 (95% CI: 2.79–3.20) greater odds of being adherent 12 months after the start of the study period, compared to the control group. These patients also had 1.86 (95% CI: 1.78–1.96) greater odds of having an ambulatory sensitive hospitalization 12 months after the start of the study period, compared to the control group.ConclusionThis study found that enrolment in LTC achieved one of the service's primary aims of improved medication adherence. However, enrolment in the service also appears to be associated with greater ambulatory sensitive hospitalizations, which is an unexpected finding. Further research is needed to better understand this.     

The impact of cardiovascular medication use on patients’ daily lives: a cross-sectional study

Background The management of multiple long-term medicines of patients with chronic diseases creates a burden for patients. However, limited research is performed on its impact on patients’ daily lives. Objective The aim of this study was to explore the impact of cardiovascular medication on different daily life aspects and to examine differences of these aspects between adherent and non-adherent patients. Setting Two community pharmacies in the Netherlands. Method In this cross-sectional study patients (≥ 45 years) using cardiovascular medication participated. Two equally group sized samples of patients non-adherent as assessed with pharmacy refill data, and patients adherent were selected. Main outcome measure Data were collected by means of the Living with Medicines Questionnaire measuring the impact of medicines use on patients’ daily lives. Results In total, 196 patients participated, including 96 non-adherent patients. Substantial proportions of patients experienced medication-related burden on different daily life aspects. This burden was mainly related to the acceptance of long-term medicine use, medication-related concerns or dissatisfaction, the interference of medicines with social and daily lives, and the interaction and communication with health care providers. No statistically significant results were found when comparing the impact on patients’ daily lives between adherent and nonadherent patients. Conclusion Health care providers should acknowledge the impact of multiple long-term medicines on patient’s daily lives and should make an effort to diminish patients’ medication-related burden by improving patient–provider relationships and by providing adequate treatment information incorporating patients’ individual circumstances. This may facilitate the integration of long-term medicine use in patients’ daily lives.     

Patients' and healthcare providers’ perspectives on diabetes management: A systematic review of qualitative studies

BackgroundDespite the availability of evidence-based guidance to deliver effective diabetes care, many patients do not achieve goals as recommendations. This systematic review was to synthesize useful insight perspectives by patients and providers to identify factors related to diabetes management using Chronic Care Model.ObjectiveThis systematic review aimed to synthesize perspectives by patients and providers in order to identify factors related to diabetes management.MethodsDatabases were searched including CINAHL, PubMed, Science Direct, and Web of Science from January 2001 to September 2017. Combination of search terms were used like ‘qualitative,’ ‘diabetes management,’ ‘patients’ perspective,’ and ‘provider's perspective.’ All qualitative studies used were in English with available full text. Chronic Care Model framework was used to analyze the content and to organize the findings.ResultsOf 108 articles used, only 23 of this met the inclusion criteria. Nine factors were identified including community linkage, health service system for diabetic patients, continuity of care, self-management, providers' support, referral system, patient-provider interaction, increasing competency of healthcare providers and family support. Community linkage was revealed to be an important factor to encourage diabetic patients to look after their disease while health service system showed the limit of accessibility due to location, medical service availability, finance, information, and time. Continuity of care has shown lack of coordination in referral system within a health care team and self-management was dependent on the knowledge, beliefs, attitude, and behavior of the patient. More so, providers’ support through an effective plan and/or strategy has also indicated to help patients get their target goal. Poor interaction between patients and health providers was found to be largely attributed to language barrier and lack of communication skill. Improving competency for the health providers can be achieved through continuing professional education. Both perspectives supported a family involvement and community resources for diabetes patients.ConclusionFactors related to diabetes management from nine themes showed various gaps in both perspectives. Further research on new models for diabetes management is required.     

Applicability of pharmacist to technician ratio laws and regulations on non-resident pharmacies – A multistate legal review

A challenge presents itself when a pharmacy obtains multiple non-resident pharmacy licenses and is mandated to comply with the laws and regulations of those states, including pharmacist to technician ratios. Current laws and regulations regarding ratios vary greatly amongst the states. Additionally, non-resident licensees, are at times required to comply with several different state pharmacy laws and regulations simultaneously, which often are in conflict and create a significant barrier for the pharmacy to comply. This legal analysis reveals the following. 1) Those states that have a ratio in law or regulation, and 2) of those states, which states mandate compliance with their ratio on a non-resident pharmacy. States would benefit from amending their laws and regulations to both eliminate ratios and allow pharmacies to solely follow the laws and rules of their resident state to avoid confusion and to mitigate conflict of law issues.     

Appropriateness of vancomycin therapeutic drug monitoring and its outcomes among non-dialysis patients in a tertiary hospital in Singapore

Background Vancomycin therapeutic drug monitoring (TDM) is commonly performed to ensure safe and effective use of the antibiotic. Aim of Study To evaluate appropriateness of vancomycin TDM and its outcomes in Singapore General Hospital. Method A retrospective, cross-sectional study was conducted between 1 January 2014 and 28 February 2014 involving patients who received?≥?1 dose of intravenous vancomycin with TDM. Patient demographics and relevant vancomycin TDM data were collected from medical records. Results Of 746 vancomycin troughs measured among 234 patients, 459 troughs (61.5%) were taken inappropriately, with a median time of 2.6 h (interquartile range 1.1–4.3) before the next scheduled dose. Inappropriate interpretation of vancomycin troughs resulted in 41 unnecessary dose suspensions, 24 dose changes, and 102 unchanged vancomycin doses. The cost incurred due to inappropriate interpretation and measurement after discontinuation of treatment was US$7286. No differences in rates of vancomycin related nephrotoxicity, ototoxicity, recurrent infection, development of infection secondary to vancomycin resistant microorganism and mortality were observed (p?>?0.05). Conclusion This study highlighted a high incidence of inappropriate vancomycin TDM which has led to increased healthcare cost.     

A systematic review of existing data on long-term lithium therapy: neuroprotective or neurotoxic?

Lithium is an efficacious agent for the treatment of bipolar disorder, but it is unclear to what extent its long-term use may result in neuroprotective or toxic consequences. Medline was searched with the combination of the word 'Lithium' plus key words that referred to every possible effect on the central nervous system. The papers were further classified into those supporting a neuroprotective effect, those in favour of a neurotoxic effect and those that were neutral. The papers were classified into research in humans, animal and in-vitro research, case reports, and review/opinion articles. Finally, the Natural Standard evidence-based validated grading rationale was used to validate the data. The Medline search returned 970 papers up to February 2006. Inspection of the abstracts supplied 214 papers for further reviewing. Eighty-nine papers supported the neuroprotective effect (6 human research, 58 animal/in vitro, 0 case reports, 25 review/opinion articles). A total of 116 papers supported the neurotoxic effect (17 human research, 23 animal/in vitro, 60 case reports, 16 review/opinion articles). Nine papers supported no hypothesis (5 human research, 3 animal/in vitro, 0 case reports, 1 review/opinion articles). Overall, the grading suggests that the data concerning the effect of lithium therapy is that of level C, that is 'unclear or conflicting scientific evidence' since there is conflicting evidence from uncontrolled non-randomized studies accompanied by conflicting evidence from animal and basic science studies. Although more papers are in favour of the toxic effect, the great difference in the type of papers that support either hypothesis, along with publication bias and methodological issues make conclusions difficult. Lithium remains the 'gold standard' for the prophylaxis of bipolar illness, however, our review suggests that there is a rare possibility of a neurotoxic effect in real-life clinical practice even in closely monitored patients with 'therapeutic' lithium plasma levels. It is desirable to keep lithium blood levels as low as feasible with prophylaxis.     

Lazy Sunday afternoons: the negative impact of interruptions in patients’ daily routine on adherence to oral antidiabetic medication. A multilevel analysis of electronic monitoring data

Purpose

Considerable variability in adherence over time exists. The aim of this study was to investigate to what extent deviations from the prescribed regimen in type 2 diabetes patients can be explained by characteristics of the individual ‘medication intake moments’ and the patient.

Methods

Medication intake of 104 non-adherent type 2 diabetes patients from 37 community pharmacies was electronically monitored for 6 months. The primary outcome measures were: (1) whether or not the intake occurred and (2) whether or not the intake occurred within the agreed-upon time period (correct timing). Multilevel logistic regression analyses were performed to account for the nested structure of the data.

Results

Medication intakes in the evening and during weekends and holidays were more likely to be incorrectly timed and also more likely to be completely missed. Irrespective of timing, most intakes occurred in the mornings of Monday through Thursday (96 %), and least intakes occurred on Saturday evening (82 %). Correctly timed intakes most often occurred on Monday and Tuesday mornings (61 %) in contrast to Sunday evenings (33 %). A patient’s medication regimen was significantly associated with adherence.

Conclusion

Based on our results, among patients who already have difficulties in taking their oral antidiabetic medication, interruptions in the daily routine negatively influence the intake of their medication. Professionals need to be aware of this variation in adherence within patients. As regular medication intake is important to maintain glycaemic control, healthcare professionals and patients should work together to find strategies that prevent deviations from the prescribed regimen at these problematic dosing times.