Starting an automated dose dispensing service provided by community pharmacies in Finland

Managing medication in very old age: A qualitative study among Faroese nonagenarians

BACKGROUND

Currently, people generally live longer, and consequently, the number of older people experiencing periods of multimorbidity and the need for medication will increase. Managing multiple medications can be a complex and challenging task, especially for older people who may experience a decline in their cognitive and physical abilities. The aim of this study was to gather knowledge on how home-dwelling people who are 90 years or older manage their daily medication, what strategies they use, and what challenges they experience regarding medication. This knowledge is necessary for providing support and care for the oldest old regarding their medication management in daily living.

METHOD

Semi-structured interviews were conducted with 10 men and women aged 91-97 years who were part of the Faroese Nonagenarian Study conducted in 2021. The analysis was conducted by using thematic analysis as suggested by Braun and Clarke.

RESULTS

We identified three important themes for understanding how the oldest-old citizens manage medication and the challenges and worries that they sometimes experience. These themes were managing medication in daily living, challenges regarding medication management, and worries among the participating older people and their relatives. The majority of the participants received automated dose dispensing (ADD) services, which they considered a great help. In addition, they developed personal strategies to manage their medication. However, the changing colour and shape of tablets caused concern among the participants, and concern about side effects were not always taken seriously by their general practitioners.

CONCLUSION

In addition to personal strategies, ADD services helped the participants manage medications in daily living. However, user involvement and regular counselling with their doctors appeared to be insufficient and, in some cases, absent. This study points to the necessity of strengthening user involvement by providing sufficient and regular counselling about medication between healthcare providers and people of very old age.

Cost savings from medication reviews in community pharmacies for nursing home residents in Estonia: a case study

BACKGROUND

The aim of this study is to assess the cost savings from medication reviews conducted for individuals living in nursing homes in Estonia. Medication reviews performed as part of the automated dose dispensing (ADD) service by community pharmacies might help identify suboptimal medicine regimens.

METHODS

We use a case study approach to identify suboptimal use of medication in treatment plans and estimate the potential cost saving from medication reviews. To achieve this, we assess 101 treatment plans submitted for medication review by nursing homes in Estonia between 2021 and 2023. Additionally, we run OLS regressions to identify the most important determinants of medication cost savings.

RESULTS

We estimate an average direct cost saving of €43.62 per patient per year, which corresponds to 8.27% of the average annual medication costs. If medication reviews were conducted for all elderly individuals over 75 years old who use six or more prescription medicines, nearly 2% of Estonia's pharmaceutical budget could be saved. Regression analysis indicates that the most significant contributors to these cost savings are suboptimal use of generics, incorrect dosages (too high), and the elimination of incorrect medications.

CONCLUSIONS

Our study suggests that annual medication reviews conducted as part of the ADD service might help reduce medication expenditure when offered to a wider public.

Multidose Drug Dispensing in Community Healthcare Settings for Patients With Multimorbidity and Polypharmacy

Multidose drug dispensing (MDD) is the dispensing of different drugs in dose bags containing one, some, or all units of medicine that a patient needs to take at specific times. The aim of this narrative review is to provide an overview of the literature describing the use of MDD systems in community healthcare settings in patients with multimorbidity and polypharmacy. A literature search identified 14 studies examining adherence, medication knowledge, quality of drug prescription (including inappropriate drug use, drug-drug interactions), medication incidents, and drug changes after MDD initiation, as well as healthcare professional (HCP) and patient perspectives. There are limited data on MDD in community healthcare settings, particularly on outcomes such as adherence. Studies are mostly from Northern Europe. Patients selected for MDD are more likely to be older, female, cognitively impaired, and have a higher number of disease diagnoses and drugs than those who do not receive drugs through MDD. MDD is generally initiated for patients who have decreased capacity for medication management. Several advantages of MDD have been reported by patients and HCPs, and studies indicate that MDD can be improved by medication review, defining clear roles and responsibilities of HCPs in the medication management chain, and comprehensive follow-up of patients. Future development, implementation, and assessment of MDD systems in community healthcare should be designed in collaboration with HCPs and patients, to identify ways to optimize the systems and improve patient outcomes.

Automated multi-dose dispensing in persons with and without Alzheimer's disease-impacts on pharmacotherapy

Purpose

We investigated the drug use before and after transition to automated multi-dose dispensing (MDD) service among persons with Alzheimer’s disease (AD) and compared whether the changes were similar in persons without AD.

Methods

The register-based Finnish nationwide MEDALZ cohort includes 70,718 community-dwelling persons diagnosed with AD during 2005–2011. Each person who initiated MDD was matched in both groups with a comparison person without MDD by age, gender and for persons with AD, also time since AD diagnosis at the start of MDD. The study cohort included 15,604 persons with AD in MDD and 15,604 no-MDD, and 5224 persons without AD in MDD and 5224 no-MDD. Point prevalence of drug use was assessed every 3 months, from 1 year before to 2 years after the start of MDD and compared between persons in MDD to those who did not have MDD.

Results

MDD was started on average 2.9 (SD 2.1) years after AD diagnosis. At the start of MDD, the prevalence of drug use increased especially for antipsychotics, antidepressants, opioids, paracetamol and use of ≥ 10 drugs among persons with and without AD. Prevalence of benzodiazepine use (from 12% 12 months before to 17% at start of MDD), memantine (from 29 to 46%) and ≥ 3 psychotropics (from 3.2 to 6.0%) increased among persons with AD. Decreasing trend was observed for benzodiazepine-related drugs, urinary antispasmodics and non-steroidal anti-inflammatory drugs.

Conclusion

MDD seems to be initiated when use of psychotropics is initiated and the number of drugs increases.

Supplementary information

The online version contains supplementary material available at 10.1007/s00228-021-03258-y.

Integrating medication risk management interventions into regular automated dose dispensing service of older home care clients - a systems approach

BACKGROUND

Automated dose dispensing (ADD) services have been implemented in many health care systems internationally. However, the ADD service itself is a logistic process that requires integration with medication risk management interventions to ensure safe and appropriate medication use. National policies and regulations guiding ADD in Finland have recommended medication reconciliation, review, and follow-up for suitable risk management interventions. This implementation study aimed to develop a medication management process integrating these recommended risk management interventions into a regular ADD service for older home care clients.

METHODS

This study applied an action research method and was carried out in a home care setting, part of primary care in the City of Lahti, Finland. The systems-approach to risk management was applied as a theoretical framework.

RESULTS

The outcome of the systems-based development process was a comprehensive medication management procedure. The medication risk management interventions of medication reconciliation, review and follow-up were integrated into the medication management process while implementing the ADD service. The tasks and responsibilities of each health care professional involved in the care team became more explicitly defined, and available resources were utilized more effectively. In particular, the hospital pharmacists became members of the care team where collaboration between physicians, pharmacists, and nurses shifted from parallel working towards close collaboration. More efforts are needed to integrate community pharmacists into the care team.

CONCLUSION

The transition to the ADD service allows implementation of the effective medication risk management interventions within regular home care practice. These systemic defenses should be considered when national ADD guidelines are implemented locally. The same applies to situations in which public home care organizations responsible for services e.g., municipalities, purchase ADD services from private service providers.

Enhanced coordination of care to reduce medication risks in older home care clients in primary care: a randomized controlled trial

BACKGROUND

As populations are aging, a growing number of home care clients are frail and use multiple, complex medications. Combined with the lack of coordination of care this may pose uncontrolled polypharmacy and potential patient safety risks. The aim of this study was to assess the impact of a care coordination intervention on medication risks identified in drug regimens of older home care clients over a one-year period.

METHODS

Two-arm, parallel, cluster randomized controlled trial with baseline and follow-up assessment at 12 months. The study was conducted in Primary Care in Lohja, Finland: all 5 home care units, the public healthcare center, and a private community pharmacy.

PARTICIPANTS

All consented home care clients aged > 65 years, using at least one prescription medicine who were assessed at baseline and at 12 months.

INTERVENTION

Practical nurses were trained to make the preliminary medication risk assessment during home visits and report findings to the coordinating pharmacist. The coordinating pharmacist prepared the cases for the triage meeting with the physician and home care nurse to decide on further actions. Each patient's physician made the final decisions on medication changes needed. Outcomes were measured as changes in medication risks: use of potentially inappropriate medications and psychotropics; anticholinergic and serotonergic load; drug-drug interactions.

RESULTS

Participants (n = 129) characteristics: mean age 82.8 years, female 69.8%, mean number of prescription medicines in use 13.1. The intervention did not show an impact on the medication risks between the original intervention group and the control group in the intention to treat analysis, but the per protocol analysis indicated tendency for effectiveness, particularly in optimizing central nervous system medication use. Half (50.0%) of the participants with a potential need for medication changes, agreed on in the triage meeting, had none of the medication changes actually implemented.

CONCLUSION

The care coordination intervention used in this study indicated tendency for effectiveness when implemented as planned. Even though the outcome of the intervention was not optimal, the value of this paper is in discussing the real world experiences and challenges of implementing new practices in home care.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02545257). Registered September 9 2015.

An inventory of collaborative medication reviews for older adults - evolution of practices

Background

Collaborative medication review (CMR) practices for older adults are evolving in many countries. Development has been under way in Finland for over a decade, but no inventory of evolved practices has been conducted. The aim of this study was to identify and describe CMR practices in Finland after 10 years of developement.

Methods

An inventory of CMR practices was conducted using a snowballing approach and an open call in the Finnish Medicines Agency’s website in 2015. Data were quantitatively analysed using descriptive statistics and qualitatively by inductive thematic content analysis. Clyne et al’s medication review typology was applied for evaluating comprehensiveness of the practices.

Results

In total, 43 practices were identified, of which 22 (51%) were designed for older adults in primary care. The majority (n = 30, 70%) of the practices were clinical CMRs, with 18 (42%) of them being in routine use. A checklist with criteria was used in 19 (44%) of the practices to identify patients with polypharmacy (n = 6), falls (n = 5), and renal dysfunction (n = 5) as the most common criteria for CMR. Patients were involved in 32 (74%) of the practices, mostly as a source of information via interview (n = 27, 63%). A medication care plan was discussed with the patient in 17 practices (40%), and it was established systematically as usual care to all or selected patient groups in 11 (26%) of the practices. All or selected patients’ medication lists were reconciled in 15 practices (35%). Nearly half of the practices (n = 19, 44%) lacked explicit methods for following up effects of medication changes. When reported, the effects were followed up as a routine control (n = 9, 21%) or in a follow-up appointment (n = 6, 14%).

Conclusions

Different MRs in varying settings were available and in routine use, the majority being comprehensive CMRs designed for primary outpatient care and for older adults. Even though practices might benefit from national standardization, flexibility in their customization according to context, medical and patient needs, and available resources is important.

Older adults using multi-dose dispensing exposed to risks of potentially inappropriate medications

BACKGROUND

Multi-dose dispensing (MDD) of medications is a health technology designed to promote medication adherence and patient safety. MDD has been used as an alternative to ordinary prescription dispensing for patients, mostly elderly with high medication use.

OBJECTIVE

To evaluate the initiation phase of the MDD service to older adults ≥65 years and assess wheter the medication use of the new MDD patients is appropriate in terms of drug related problems.

METHODS

The European Union EU(7)-PIM list and the Inxbase databases were used for identifying potentially inappropriate medications (PIMs) and drug-drug interactions (DDIs). The study sample consisted of a total of 208 patients aged 65-108 years who were involved in the MDD service (PharmaService Ltd.) in Finland in 2015-2016. Clinically significant differences of PIM and DDI occurrences were identified using a Pearson's chi-square test throughout the demographic groups under study.

RESULTS

Results demonstrate that for 81% of the study participants, at least one medication from the EU (7)-PIM list was prescribed, and up to 64% of PIMs were clinically significant. According to the Inxbase database, five patients (2.4%) were prescribed category D clinically significant DDIs. Additionally, 61% of the patients saw an increase in the number of medications prescribed within six months after the initial MDD order.

CONCLUSIONS

The results suggest that the MDD service should be accompanied by a regular medication review tailored to specific patient groups (i.e., older patients) to avoid potential DRPs.

Community pharmacists' knowledge of COPD, and practices and perceptions of medication counseling of COPD patients

Background and purpose

COPD is one of the leading causes of morbidity and mortality worldwide. Although medication counseling interventions by pharmacists have been found to support the management of COPD, little is known about pharmacists’ knowledge concerning COPD and regular practices and perceptions concerning medication counseling of COPD patients. The purpose of this study was to research these topics among Finnish community pharmacists.

Materials and methods

In January 2017, an electronic survey was e-mailed to Finnish community pharmacies (n=741) via the Association of the Finnish Pharmacies. One pharmacist from each pharmacy, preferably a specialist in asthma, was invited to answer the survey.

Results

Completed responses were received from 263 pharmacists (response rate =35%), of whom 196 pharmacists were specialists in asthma. Response rate among asthma pharmacists was 42%. Pharmacists were positive about their role in medication counseling and in support of the self-management of COPD patients. COPD-related knowledge was self-assessed as being good and was on a good level in respect of basic facts. However, almost half (46%) of the pharmacists did not know that COPD is considered a national public health issue, and ~50% of the pharmacists were not familiar with the current care guideline on COPD. Medication counseling was found to be more medicinal product-driven and less advisory concerning lifestyle changes such as smoking cessation and physical exercise.

Conclusion

Although the pharmacists’ knowledge of COPD was good on general topics, there were some gaps in their knowledge on the current care guideline and status of the disease. Pharmacists should more systematically individually target medication counseling according to patients’ needs. In addition, lifestyle treatments, including smoking cessation and physical exercise, should be part of the medication counseling.

Impact of the automated dose dispensing with medication review on geriatric primary care patients drug use in Finland: a nationwide cohort study with matched controls

OBJECTIVE

In an automated dose dispensing (ADD) service, medicines are dispensed in unit-dose bags according to administration times. When the service is initiated, the patient's medication list is reconciled and a prescription review is conducted. The service is expected to reduce drug use. The aim of this national controlled study was to investigate whether the ADD service with medication review reduces drug use among geriatric primary care patients.

DESIGN, SETTING AND PATIENTS

This is a nationwide cohort study with matched controls. The study group consisted of all primary care patients ≥65 years enrolled in the ADD service in Finland during 2007 (n = 2073). Control patients (n = 2073) were matched by gender, age, area of patient's residence and number of the prescription drugs reimbursed. The data on all prescription drugs reimbursed during the 1 year periods before and after the ADD service enrollment were extracted from the Finnish National Prescription Register. Drug use was calculated as defined daily doses (DDD) per day.

RESULTS

The studied 20 most used drugs covered 86% of all reimbursed drug use (in DDD) of the study group. The use of 11 out of these 20 active substances studied was reduced significantly (p < .001-.041) when the drug use was adjusted by the number of chronic diseases. Two of these drugs were hypnotics and six were cardiovascular system drugs.

CONCLUSIONS

Drug use was decreased after initiation of the ADD service in primary care patients ≥65 years compared to matched controls in this 1 year cohort study. Further studies should be conducted in order to explore the causality, assess the ADD service's impact on drug use quality and costs, as well as impact of accompanied prescription review on positive outcomes.

An In-home Advanced Robotic System to Manage Elderly Home-care Patients' Medications: A Pilot Safety and Usability Study

PURPOSE

We examined the safety profile and usability of an integrated advanced robotic device and telecare system to promote medication adherence for elderly home-care patients.

METHODS

There were two phases. Phase I aimed to verify under controlled conditions in a single nursing home (n = 17 patients) that no robotic malfunctions would hinder the device's safe use. Phase II involved home-care patients from 3 sites (n = 27) who were on long-term medication. On-time dispensing and missed doses were recorded by the robotic system. Patients' and nurses' experiences were assessed with structured interviews.

FINDINGS

The 17 nursing home patients had 457 total days using the device (Phase I; mean, 26.9 per patient). On-time sachet retrieval occurred with 97.7% of the alerts, and no medication doses were missed. At baseline, Phase II home-dwelling patients reported difficulty remembering to take their medicines (23%), and 18% missed at least 2 doses per week. Most Phase II patients (78%) lived alone. The device delivered and patients retrieved medicine sachets for 99% of the alerts. All patients and 96% of nurses reported the device was easy to use.

IMPLICATIONS

This trial demonstrated the safety profile and usability of an in-home advanced robotic device and telecare system and its acceptability to patients and nurses. It supports individualized patient dosing schedules, patient-provider communications, and on-time, in-home medication delivery to promote adherence. Real time dose-by-dose monitoring and communication with providers if a dose is missed provide oversight generally not seen in home care.

Feasibility of a practical nurse administered risk assessment tool for drug-related problems in home care

AIM

To evaluate feasibility of a practical nurse-administered Drug-related Problem Risk Assessment Tool among home care clients ⩾65 years.

METHODS

Altogether, 36 practical nurses participated in the study. They were trained about the purpose and use of the tool. The training consisted of a day long interactive workshop and involved reviewing four self-selected clients' medications using the tool (one as a pre-assignment before and three as post-assignments after the workshop). The data of this study were collected during the training. Triangulation, i.e. combination of methods and data, was used to evaluate the feasibility of the tool. Quantitative data were gathered from returned post-assignment tools and qualitative data from face-to-face discussions and open questions in feedback forms the practical nurses returned after the training.

RESULTS

Practical nurses spent 10-45 minutes reviewing one client's medication using the tool (mean 20±8). They identified reliably 88% of the risk medicines used by the clients listed in the tool. Of the respondents (n=23) of the feedback forms, 43% reported that they felt it easy or quite easy to answer the questions of the tool. Generic names of medicines, time constraints, home-care workers'/client's lack of interest to client's pharmacotherapy and short client contacts were the most common barriers to use the tool.

CONCLUSIONS

The Drug-Related Problem Risk Assessment Tool turned out to be feasible among practical nurses. The brief training on the content and use of the tool seems to be sufficient for ensuring reliable use of the tool.

Content validation of a tool for assessing risks for drug-related problems to be used by practical nurses caring for home-dwelling clients aged ≥65 years: a Delphi survey

PURPOSE

Home care services are becoming a critically important part of health care delivery as populations are aging. Those using home care services are increasingly older, more frail than previously, and use multiple medications, making them vulnerable to drug-related problems (DRPs). Practical nurses (PN) visit home-dwelling aged clients frequently and, thus, are ideally situated to identify potential DRPs and, if needed, to communicate them to physicians for resolution. This study developed and validated the content of a tool to be used by PNs for assessing DRP risks for their home-dwelling clients aged ≥65 years.

METHODS

The first draft of the tool was based on two systematic literature reviews and clinical experience of our research group. Content validity of the tool was determined by a three-round Delphi survey with a panel of 18 experts in geriatric care and pharmacotherapy. An agreement by ≥80% of the panel on an item was required.

RESULTS

The final tool consists of 18 items that assess risks for DRPs in home-dwelling aged clients. It is divided into four sections: (1) Basic Client Data, (2) Potential Risks for DRPs in Medication Use, (3) Characteristics of the Client's Care and Adherence, and (4) Recommendations for Actions to Resolve DRPs.

CONCLUSIONS

The Delphi process resulted in a structured DRP Risk Assessment Tool that is focused on the highest priority DRPs that should be identified and resolved. The tool also assists the PNs to identify solutions to these problems, which is a unique feature compared to similarly purposed prior tools.

Prevalence of suboptimal drug treatment in patients with and without multidose drug dispensing--a cross-sectional study

PURPOSE

The aim of this study was to compare the prevalence of suboptimal drug treatment in older patients with and without multidose drug dispensing (MDD).

METHODS

In 200 hip fracture patients (≥65 years of age), originally recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was compared between patients with and without MDD. Two specialist physicians independently assessed and then agreed on the quality of the drug treatment of each patient. Suboptimal drug treatment was defined as ≥1 STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) or ≥1 START (Screening Tool to Alert to Right Treatment) outcome assessed as clinically relevant after individual considerations had been made, i.e. over- or undertreatment (≥1 inappropriate and ≥1 missing drug, respectively).

RESULTS

Patients with MDD (n=100) differed from patients without MDD (n=100) in several ways, for example by being older (87.6 vs. 81.5 years) and using more drugs (8.4 vs. 5.9 drugs). The total number (±standard deviation) of inappropriate and/or missing drugs per person was greater in MDD patients compared with patients without MDD (1.92±1.52 vs. 1.06±1.29, P<0.0001); MDD patients had an additional 0.77 inappropriate drugs and an additional 0.09 missing drugs per person. The prevalence of suboptimal drug treatment was greater in patients with MDD than in those without MDD (86 vs. 55%, P<0.0001). Logistic regression revealed that suboptimal drug treatment was 8.0 times as common in MDD patients, after adjustments for age, sex, number of drugs, cognition, and residence (95% confidence interval 2.4; 26.9). Corresponding figures for over- and undertreatment were 2.9 (1.1; 7.4) and 1.8 (0.8; 4.3), respectively.

CONCLUSIONS

Suboptimal drug treatment, including over- and undertreatment, is more common in MDD patients than in patients who receive their drugs via ordinary prescriptions. The findings confirm safety concerns regarding quality of drug treatment in MDD patients.