Social stratification in the dissemination of statins after stroke in Sweden

Purpose

Since 2005, statins have been recommended to patients with ischaemic stroke. The objective of this study was to analyse how statin treatment has been disseminated in different patient groups (age, sex, socioeconomic status and country of birth) in Sweden between 2004 and 2009.

Methods

The Swedish Stroke Register (Riks-Stroke) has been linked to the Longitudinal Integration Database for Health Insurance and Labour Market Studies. Approximately 85 % of stroke patients in Sweden are included in Riks-Stroke. Odds ratios for statin prescribing were calculated using a multivariable logistic regression model including age, sex, socioeconomic status and risk factors.

Results

During the study period, 108,950 ischaemic stroke patients were discharged alive from hospital. The proportion with statins at discharge increased from 32.9 % in 2004 to 60.1 % in 2009. Patients with secondary school or university education had slightly higher odds [odds ratio (OR) 1.07, 95 % confidence interval (CI) 1.04–1.11 and OR 1.05, 95 % CI 1.01–1.10 respectively] than patients with primary school education. Patients on a high income were prescribed more statins than those on a low income (OR 1.24, 95 % CI 1.19–1.28). Compared with patients born in Sweden, patients born in other countries were prescribed more statins (Nordic countries excepting Sweden: OR 1.07, 95 % CI 1.01–1.14; Europe: OR 1.31, 95 % CI 1.22–1.40; Outside Europe: OR 1.20, 95 % CI 1.08–1.34).

Conclusions

Statin prescribing after ischaemic stroke has increased from 2004 to 2009. Our results also show a social stratification in the dissemination of statins, with patients having a higher income and patients with higher education receiving statins more often than those with a lower income and education, and patients born in Sweden receiving statins less often than those born outside of Sweden.     

Medication reconciliation to solve discrepancies in discharge documents after discharge from the hospital

Background When patients are admitted to, and discharged from hospital there is a high chance of discrepancies and errors occurring during the transfer of patients’ medication information. This often causes drug related problems. Correct and fast communication of patients’ medication information between community pharmacy and hospital is necessary. Objective To investigate the number, type, and origin of discrepancies within discharge documents and between discharge documents and information in the pharmacy computer system, concerning the medication of patients living independently when they are discharged from hospital. Second, to test which variables have an impact on the number of discrepancies found and to study the time spent on the medication reconciliation process. Setting One quality-certified community pharmacy in the Netherlands. Methods Pharmacists reviewed discharge documents of patients discharged over one year. This information was compared to information available in the pharmacy computer system. Discrepancies were discussed with medical specialists and/or general practitioners. Type and origin of discrepancies were classified. Differences in variables between hospitals were tested using Independent-Samples Mann–Whitney U Test and Pearson Chi Square test. Poisson regression analysis was performed to test the impact of variables on the number of discrepancies found. Main outcome measure Number, type and origin of discrepancies for all independently living patients discharged from the hospital. Results During the study period, 100 discharges took place and were analyzed. No differences were found between the two main hospitals, a university hospital and a teaching hospital. In total, 223 discrepancies were documented. Sixty-nine discharges (69.0 %) required consultation with a patients’ medical specialist. A majority of the discrepancies (73.1 %) have their origin in hospital information. The number of discrepancies found increased with the number of medicines prescribed at discharge. The community pharmacist spent, on average, 45 min on the medication review after discharge. This included 11 min for counseling the patient. Conclusion Many discrepancies were found between different information sources at patient discharge from hospital. A majority of the discrepancies had their origin in hospital information. The number of medicines after discharge was related to the number of discrepancies found. The medication reconciliation process took an average of 45 minutes per patient.     

Potential drug–drug interactions in internal medicine wards in hospital setting in Pakistan

Background Multiple drugs therapies may be the potential source of drug–drug interactions that can result in alteration of therapeutic response and/or increase untoward effects of many drugs. Objective To identify the frequency and levels of potential drug–drug interactions (pDDIs) in internal medicine wards and their association with patients’ age, gender, length of hospital stay and number of prescribed medications; and to describe management of frequently identified major or moderate pDDIs. Setting Internal medicine wards of two major tertiary care hospitals of Khyber Pakhtunkhwa, Pakistan. Method Micromedex Drug-Reax system was used to screen patient’s profiles for pDDIs. Logistic regression was applied to determine the odds ratio for specific risk factors of pDDIs i.e., age, gender, hospital-stay and number of medications. Main outcome measure Overall prevalence and prevalence of contraindicated, major, moderate and minor pDDIs; levels of pDDIs; frequently identified major or moderate interactions; and odds ratios for risk factors. Results Total, 188 interacting drug-combinations were identified that contributed to 675 pDDIs. Of 400 patients, 52.8 % patients were presented with at least one pDDI (overall prevalence), 21.3 % with at least one major-pDDI, and 44.3 % with at least one moderate-pDDI. Of 675 pDDIs, most were of moderate (63.6 %) or major severity (23 %); good (61.2 %) or fair (25.5 %) type of scientific evidence; and delayed onset (50.2 %). Most frequently identified major or moderate interactions resulted in 45.3 % of all pDDIs. Their potential adverse outcomes included hepatotoxicity, bleeding, ototoxicity, nephrotoxicity, hypoglycemia, hyperglycemia, risk of thrombosis, hypotension, cardiac arrhythmias and reduction in therapeutic-effectiveness. There was significant association of the occurrence of pDDIs with patients’ age of 60 years or more (OR = 2.1; 95 % CI = 1.3–3.3; p = 0.003), hospital stay of 6 days or longer (OR = 2.6; 95 % CI = 1.5–4.5; p = 0.001), and seven or more number of prescribed medications (OR = 5.9; 95 % CI = 3.6–9.6; p < 0.001). Conclusion The present study has recorded a high prevalence of pDDIs in internal medicine wards. Patients with old age, longer hospital stay and increased number of prescribed medications were at higher risk.     

The pattern of pharmacological treatment of bipolar patients discharged from psychiatric units in Poland

Background

The concomitant use of two or more mood stabilisers (MS), second-generation antipsychotics (SGA), lamotrigine as well as antidepressants, is frequently reported in the treatment of bipolar patients The aim of this study was to investigate the pattern of pharmacological treatment with special regard to polypharmacy defined as two or more psychiatric drugs taken at the same time in the same patients with bipolar disorder discharged from psychiatric units in Poland.

Comprehensive coronary artery disease care in a safety-net hospital: results of Get With The Guidelines quality improvement initiative

BACKGROUND: Adherence to published coronary artery disease (CAD) guidelines is suboptimal, particularly among minorities and the poor. While hospital-based quality-improvement programs may increase the use of evidence-based therapies, little data exist regarding the impact of such programs in sociodemographically disadvantaged (vulnerable) populations. Vulnerable patients in the United States are cared for primarily within the safety-net health system, which comprises urban public hospitals and outpatient community health centers. Denver Health is an example of an integrated system that encompasses both types of facilities. OBJECTIVE: To assess evidence-based medication use in CAD patients after initiation of an inpatient quality-improvement program at Denver Health. METHODS: We reviewed the medical records of 499 patients with angiographically proven CAD who were hospitalized between July 1998 and December 2002. Patients were prospectively identified through a multidisciplinary intervention led by a nurse manager, and their records were input retrospectively into the American Heart Association's Get With The Guidelines patient management tool. The association's program, which recommends initiating 4 cardioprotective drug classes while patients are hospitalized, was started 2 years into the observation period (August 2000). Treatment rates were compared over the ensuing years. We evaluated temporal trends in discharge use of 4 drugs: (1) betablockers, (2) angiotensin-converting enzyme inhibitors (ACEIs), (3) hydroxymethylglutaryl coenzyme A reductase inhibitors (statins), and (4) aspirin. We calculated the proportion of eligible patients (no documented contraindication) who were prescribed each drug category as well as the proportion who received all 4 drug categories, our principal composite outcome. If any one drug was absent, the composite criterion was considered unmet. RESULTS: We observed progressive improvement in discharge use of the 4- drug composite: 18% in 1998-1999 (95% confidence interval [CI], 12%-25%), 50% in 2000 (95% CI, 37%-63%), 62% (95% CI, 54%-70%) in 2001, and 72% (65%-79%) in 2002 (P <0.001 for between-year differences). Among eligible patients discharged in 2002, 90% received beta-blockers, 91% received ACEIs, 86% received statins, and 93% received aspirin. CONCLUSIONS: Implementation of a multidisciplinary program led by a nurse manager was associated with increased CAD guideline compliance among sociodemographically disadvantaged patients. This compliance exceeded national averages. Achievement of the composite measure of use of all 4 recommended drug categories at discharge improved from 18% in 1998-1999 to 72% in 2002.     

A cross-sectional survey of the profile and activities of Antimicrobial Management Teams in Irish Hospitals

Background Surveillance of antimicrobial prescribing, in order to control the increase in antimicrobial resistance, is recommended by the Guidelines for Antimicrobial Stewardship in Hospitals in Ireland. Objective The objective of the study is to determine the profile and activities of Antimicrobial Management Teams (AMTs) in Irish Hospitals by surveying hospital pharmacists. Setting: Hospitals in Ireland. Method A self-completion postal questionnaire was developed from a recent study conducted by members of the authoring team in the United Kingdom, adapted for the Irish context. It was issued to all hospitals in Ireland (n = 70). Differences in responses, using Pearson’s Chi squared tests, were evaluated between public and private hospitals to determine whether the funding category had an effect on activities. Main outcome measures: (1) A profile of AMTs in Ireland. (2) The presence and content of antimicrobial prescribing policies and how adherence to the policies is measured. Results The response rate was 73 % (n = 51, 71 % public). 57 % (29/51) of hospitals have an antimicrobial management team in place with 93 % (27/29) having a Consultant Medical Microbiologist, 24 % (7/29) having a Consultant in Infectious Diseases and 69 % (20/29) having an Antimicrobial Pharmacist. There is an antimicrobial prescribing policy in place in 88 % (45/51) of hospitals responding. 80 % (36/51) of replies report that the volume of antibiotics prescribed is monitored, 47 % (24/51) conduct audits to measure appropriateness of all antibiotics prescribed and 43 % (22/51) conduct audits of appropriate prescribing of restricted antibiotics. Public hospitals were significantly more likely than private hospitals to review the volume of antibiotics prescribed (p = 0.021) and to audit the appropriateness of restricted antibiotics use (p = 0.003). A lack of resources was reported as the main barrier to antimicrobial surveillance by hospital pharmacists. Conclusion Around half of Irish hospitals do not have an antimicrobial management team in place but most hospitals have an antimicrobial prescribing policy. Most AMTs have representation by Consultants and Pharmacists, but audit and feedback of antibiotic prescribing activities is limited. Significant differences in audit activities were found between public and private hospitals, with private hospitals performing less well.     

Drug utilization pattern and cost for the treatment of severe sepsis and septic shock in critically ill cancer patients

Background Cancer patients are at high risk for developing sepsis. To our knowledge, there are no studies that evaluated the type of medications utilized and the associated cost in cancer patients with severe sepsis and septic shock. Objective To describe the drug utilization pattern and drug cost in the treatment of cancer patients with severe sepsis and septic shock. Setting 12-bed medical/surgical intensive care unit (ICU) of a comprehensive teaching cancer center. Methods A retrospective cohort study of cancer patients with severe sepsis or septic shock who were treated in the ICU between January and December, 2010. The ICU sepsis database was used to identify patients. The patient demographics and characteristics were recorded. In addition, the number and type of prescribed medications, total cost for each medication, type of infection, and culture results were determined. Main outcome measure The main outcomes were the type of medication classes utilized and the cost of the medications. Results During the study period, 116 cases were identified. Upon presentation, the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 21.8 (SD ±7.8), 30 (25.9 %) patients had neutropenia, and 94 (81 %) had positive cultures. The total cost of the medications prescribed for this cohort of patients was 291,030 Euro. The mean number of medications prescribed per patient and the mean total cost per patient were 11.7 (SD ±4.7) and 2,509 Euro (SD ±2,844), respectively. The most commonly prescribed medication classes were acid suppressive therapy, glycopeptides, penicillins/cephalosporins and vasopressors prescribed in 113 (97 %), 104 (89.7 %), 103 (88.9 %), and 102 (88 %) patients, respectively. The highest medication costs were associated with antifungals (mean 1,288 Euro/patient) and colony stimulating factors (mean 829 Euro/patient), prescribed in 55 (47.4 %) and 37 (31.9 %) patients, respectively. Medication costs were higher in non-survivors, compared to survivors (3,664 Euro vs. 1,430 Euro, p = 0.0001), and in patients with positive cultures, compared to patients with negative cultures (3,198 Euro vs. 1,865 Euro, p = 0.0004). Conclusion In cancer patients with severe sepsis and septic shock, multiple medications are prescribed which are associated with high cost.     

Medication at discharge in an orthopaedic surgical ward: quality of information transmission and implementation of a medication reconciliation form

Background Medication reconciliation (MedRec) at discharge is a cumbersome but necessary process to reduce the risk of medication errors at transitions of care. The main barriers to implementing such a process are the large number of professionals involved and a lack of collaboration among caregivers. Objective This study was designed to assess the need for a medication reconciliation form at discharge in an orthopaedic surgical ward. Setting The study was conducted in the orthopaedic surgery ward among inpatients at a 407-bed French teaching hospital. Method We first performed a retrospective audit to evaluate the quality of discharge medication information in the medical record, after which a 5-week prospective study was conducted in 2013. All patients admitted to the orthopaedic surgery unit who had at least two chronic diseases and three medications underwent MedRec at discharge. We designed a Best Possible Medication at Discharge List (BPMDL) to be completed by hospital staff and transmitted to community caregivers. Mean outcome measures We assessed the completeness of medication information in the medical records, discrepancies between medications noted on the BPMDL and those prescribed on the discharge order, and the value of the BPMDL for stakeholders. Results Thirty patients were included in the study. Only 4 % of medical records contained a discharge summary with complete medication information. In 67 % of cases, treatment discontinuations at admission were justified, and medications were reintroduced before discharge, while 107 treatments (45 %) were added but not prescribed on discharge orders. Discontinuations prior to discharge were justified in 60 % of cases (treatments were ended or supportive treatment was required during hospitalization). An average of 2.1 treatments were prescribed on discharge orders (vs. 9.4 prescribed on the BPMDL). Patients, general practitioners (GP), and physicians in long-term care settings (PLTCS) rated the format, content, and readability of the BPMDL as satisfactory, and it was found to be of value for patients and PLTCS to support medication information. Because of the very low response rate among GP (10 %), we were unable to determine their satisfaction with the MedRec discharge process. Conclusion The transmission of patient medication information at discharge is often lacking. As such, the BPMDL appears to have value to both patients and community health providers. Because this study was conducted within a single surgical unit, further study in other surgical wards is needed to assess generalizability.     

Pilot study to assess the influence of an enhanced medication plan on patient knowledge at hospital discharge

Purpose

This study assessed the effect of providing an enhanced medication plan (EMP) to patients during patient-physician conversation at hospital discharge and evaluated its immediate impact on patient knowledge on pharmacotherapy.

Methods

We observed patient-physician conversations at hospital discharge in three internal medicine wards of the University Hospital Heidelberg before and after the EMP was integrated into the discharge process, and documented how and to what extent physicians provided the patients with drug information. After the conversation, the patients’ knowledge was evaluated by three standardized questions about their pharmacotherapy.

Results

We observed 90 conversations (50 before EMP-implementation, 40 after). In both phases, the conversation duration was 5.6–6 min (p?=?0.56). However, the time spent on drug information increased significantly by 61.7 % after EMP-implementation (+63 s, p?=?0.02). Before implementation, physicians gave at least one drug administration recommendation for 75.1 % of all drugs, compared to 84.6 % after implementation (p?=?0.02). The EMP provided information for almost all drugs (98.9 %; p?p?Conclusion The provision of an EMP improves information transfer and therefore increases the patients’ knowledge of their individual drug treatment without prolonging the overall discharge process.     

The pharmacists’ potential to provide targets for interventions to optimize pharmacotherapy in patients with asthma

Background Despite of pharmacists’ specialized knowledge of medication and his/her regular contact with patients, the expertise of the pharmacist may not be used enough yet. Furthermore, the potential of pharmacy dispensing data is underestimated. Objective To provide targets for tailored interventions in asthma patients and to illustrate the potential value of pharmacists in the identification of these targets using individual pharmacy dispensing data. Setting We performed a cross sectional retrospective analysis assessing the quality of asthma patients’ pharmacotherapeutic treatment. Method Drug dispensing data from 2008 to 2009 were retrieved from a Dutch pharmacy database. All asthma patients were screened for potential suboptimal pharmacotherapy in 2009. Results were projected to a single community pharmacy to provide an estimate of the number of patients eligible for potential interventions. Main outcome measures (1) frequent use of short-acting β-agonists without preventive medication, (2) concomitant use of β-blockers, (3) multiple short courses of oral corticosteroids without using inhaled corticosteroids and 4) use of long-acting β-agonist without inhaled corticosteroids. Results A total of 8,504 patients were eligible for analysis of the quality of their asthma treatment. 20.9 % of all asthma patients used >100 DDD short-acting β-agonists per year, whereas between 21.2 % (≥400 DDD) and 31.4 % (100–199 DDD) of these patients did not receive preventive medication. Approximately 5.2 % of the asthma patients are using β-blockers concomitantly and 21.8 % of them received non-cardioselective β-blockers. 6.3 % of the asthma patients received two or more oral courses of corticosteroids in 2008 and 17.4 % of these patients did not receive inhaled corticosteroids in 2009. 2.9 % of the patients used a long-acting β-agonists without inhaled corticosteroids. 8.4 % of the asthma patients using both long-acting β-agonists and inhaled corticosteroids received these drugs in two separate inhalers. We estimated that about 400 asthma patients could be identified in an average pharmacy population (8,000 patients) and 33 (95 % CI 22–44) of these patients would be eligible for interventions. Conclusion This study shows the potential for pharmacists to use their own pharmacy records to identify suboptimal therapy of asthma patients, who may be targets for tailored interventions.