Clinical pharmacist consultant in primary care settings in Slovenia focused on elderly patients on polypharmacy: successful national program from development to reimbursement

Analysis of medication management system data to determine potentially inappropriate medication use and hospitalization among older adults living in residential care homes for the elderly population

OBJECTIVES

Many older adults living in Resident Care Homes for the Elderly (RCHEs) are at risk of polypharmacy and the use of potentially inappropriate medication (PIM). Few studies have evaluated the prevalence and consequences of PIM use among older adults living in RCHEs. The objectives of this study are (1) to evaluate the prevalence of PIM use in 29 RCHEs in Hong Kong, and (2) to investigate the association between PIM use and hospitalization in this population.

METHODS

This is a prospective, observational, cohort study which utilized final-administered medication data from RCHEs that participated in a medication management program. Data on the medications administered to all residents living in the participating RCHEs were extracted from the SafeMed Medication Management System (SMMS®), which is a purpose-built Information Technology supporting the entire medication management process at RCHEs. The outcome of interest is the 12-month period prevalence of PIM use (January 1 to December 31, 2023), which was obtained by comparing the medication data with the 2023 Beers criteria. Hospital admissions during the study period were extracted from the SMMS®.Multivariable logistic regression was conducted to investigate the association between PIM use and hospital admissions.

RESULTS

We included 6,346 residents (age 82.9 ± 8.6 years; female 61.9%). The average number of current medications was 6.8 ± 7.4. Over half (51.5%) of residents had polypharmacy (≥ 5 medications). The 12-month period prevalence of PIM use was 34.5%. Among the residents with PIMs, 65.1%, 25.5% and 9.4% used 1, 2 and > 2 PIMs, respectively. Residents with PIMs were associated with higher rates of hospitalization (Odds Ratio [OR] 1.73, 95% confidence interval [CI] 1.54 to 1.69), after adjusting for age, sex and comorbidities. The number of PIMs was significantly associated with higher risk of hospitalization (OR: 2.17, 95% CI: 1.82 to 2.59 for > 1 PIMs vs. 0).

CONCLUSIONS

The use of PIM was observed in one-third of older adults living in RCHEs, and was associated with an increased risk of hospitalization. Our findings highlighted the urgent need for strategies to improve clinicians' awareness of PIMs and their adverse impact, and to implement pharmacist-led medication reviews in RCHEs.

[Medical-pharmaceutical intervention on patients exposed to azathioprine-allopurinol interaction in the Community of Madrid]

OBJECTIVE

To evaluate the impact of a medical-pharmaceutical intervention strategy on patients exposed to azathioprine-allopurinol (AZA-ALO) interaction in the Community of Madrid (CM).

MATERIAL/METHODS

Multicentre retrospective observational study. We reviewed the database generated after an intervention carried out in the healthcare context in which Primary Care Pharmacists (PCP) review the treatment of patients with safety risks and, when there are incidents, they contact (by telephone and/or e-mail) their Family Physicians (FP) for possible resolution.

STUDY POPULATION

CM patients with an active clinical history in Primary Care who have been dispensed both medications (AZA-ALO) in the period April-June 2022 according to prescription billing data from the National Health System (NHS). Main variable: suppression or dose adjustment of either of the two drugs.

RESULTS

Forty-nine patients were analysed. Mean age: 65.65±11.67 years. Males; 77.6%. 8,834 patients withdrew azathioprine (28,724 packs) and 89,297 withdrew allopurinol (141,188 packs) from pharmacies, with a very low prevalence of patients at risk (<1%). The prescription was modified in 32 patients (65.31%-IC95%: 51.98%-78.63%), with allopurinol being discontinued in 65.62% and, with regard to azathioprine, the dose was reduced by 18.75% and discontinued in 9.37%. Analytical alterations compatible with adverse effects due to the interaction were recorded in 28 patients (57.1%-IC95%: 43.29%-71%), including anaemia (39.3%) and leukopenia/neutropenia (25%).

CONCLUSIONS

Coordinated intervention between pharmacists and physicians was effective, resulting in prescription modification in a significant percentage of patients, which reduced the risk of toxicity.

Medication reconciliation and seamless care led by clinical pharmacists in Slovenia: a national reimbursed program ensuring safe and effective transition of care

BACKGROUND

Medication errors frequently happen during patients' transitions between different healthcare settings. Medication reconciliation, provided by various healthcare specialists, could help reduce these errors. However, clinical pharmacists do not lead this service nationally in most countries.

AIM

This paper describes the development, implementation, and national evaluation of medication reconciliation in Slovenia as part of seamless care.

SETTING

All hospitals and community pharmacies in Slovenia.

DEVELOPMENT

The initial step involved the successful development of legislation in Slovenia. This process, termed 'seamless care,' was defined as a pharmaceutical service and five different steps of this process were developed: medication reconciliation upon admission (including the best possible medication history), during discharge, personal medication cards, and medication dispensing. A standard operational procedure was established in 2023 to guide these practices.

IMPLEMENTATION

A critical milestone in the implementation process was establishing a successful reimbursement scheme in 2023. Hospitals and community pharmacies implemented this service following successful reimbursement. Pharmacy managers and heads of hospital pharmacy departments were responsible for overseeing its implementation in hospitals and community pharmacies. The Health Insurance Institute of Slovenia is measuring the implementation.

EVALUATION

Trials were conducted in various Slovenian hospitals to evaluate this service's effectiveness, appropriateness, and adoption before its full implementation (reduced medication-related problems were observed). The Health Insurance Institute of Slovenia is currently evaluating the sustainability of the service and providing feedback to the providers.

CONCLUSION

Slovenia is the first country in this part of Europe to fully reimburse and implement medication reconciliation as a pharmaceutical service. This practice holds promise for exporting to other countries.

Evaluation of prescribing patterns of sodium valproate in neurological disease patients: a quasi-experimental pretest-posttest design study

BACKGROUND

The well-known anti-seizure medication, sodium valproate, is used to treat epilepsy, bipolar disorder, and other mental health conditions.

OBJECTIVE

This study aimed to determine how pharmacist counseling intervention affected the prescribing patterns and usage of sodium valproate in patients with neurological diseases.

METHODS

Patient prescriptions were analyzed in a quasi-experimental pretest-posttest design research, at baseline and after three months of pharmacy educational intervention. Medical history, drug-drug interactions, antipsychotic combinations, medication errors, and dosages were among the information gathered.

RESULTS

The reviewed prescriptions observed trend towards antipsychotic combination, 15 (2.5%) prescriptions had five medications, while 18 (3%) contained four, 169 (28.2%) containing three, 329 (54.8%) containing two, and 69 (11.5%) containing one, antipsychotic. Of the reviewed prescriptions, 6% had possible drug-drug interactions. However, following a 3-month pharmacy educational intervention, the tendency toward antipsychotic combination decreased significantly to 262 (52%) with prescriptions for 2 antipsychotics and 163 (32.3%) with 3 antipsychotics. Likewise, the decreases in medication errors related to frequency and dosage were 8 (1.6%) vs. 29 (4.8%) and 6 (1.2%) vs. 35 (5.8%), compared to baseline respectively. Additionally, medication adherence was raised significantly (p < 0.000) from 50 (8.3%) to 338 (67.1%) after the intervention.

CONCLUSION

More precise regulations should be placed on sodium valproate prescription patterns and usage, throughout implemented pharmacist initiative in patients counselling, provision of health education and therapeutic monitoring to improve health-related quality of life.

TRIAL REGISTRATION

This study was registered on clinicaltrial.gov with an identification code NCT05830981. https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05830981 (First Posted: April 26, 2023).

Improving the provision of clinical pharmacy services in low- and middle-income countries: a qualitative study in tertiary health facilities in Tanzania

Background

The provision of clinical pharmacy services (CPS) in low- and middle-income countries is still low. The reported challenges in providing CPS include healthcare structures, public policies, resources, workforce, culture and education inequalities. This study aimed to explore the strategies to improve the provision of CPS in tertiary health facilities in Tanzania.

Methods

This study was conducted between August and September 2021. We adopted an exploratory qualitative study to conduct 14 in-depth interviews with hospital administrators and 10 focus group discussions (FGDs) with healthcare providers. A purposeful sampling technique was used to recruit 97 participants, including 45 pharmacists, 31 medical doctors and 21 nurses across five tertiary healthcare institutions. Of those, 14 hospital administrators participated in 14 IDIs and 83 healthcare workers divided into 10 FGDs. Analysis was done using a qualitative thematic approach.

Results

The study identified several strategies that fall under four major themes: (i) strengthen preservice training by reviewing the Bachelor of Pharmacy training curriculum to include clinical pharmacy components; (ii) improve continuing professional training through regular provision of on-job training to pharmacists; (iii) revise the scope of work for pharmacists to include CPS provision in the job description; and (iv) improve operational environment by ensuring availability of guidelines, policies, and adequate number of pharmacists and good inter-professional communication skills.

Conclusions

This study's findings highlight that improving CPS provision requires strengthening pharmacists' training, scope of work and operational environment. The latter calls for multifaceted engagement from pharmacists, training institutions, policymakers, regulatory bodies and health systems for sustainable progress.

Medication Management in Portuguese Long-Term Care Facilities: A Preliminary Cross-Sectional Study

BACKGROUND/OBJECTIVES

Population ageing has been a pressing global issue for decades. Older adults, especially those residing in long-term care facilities (LTCFs), often experience frailty and polypharmacy, which can lead to negative clinical outcomes. In Portugal, LTCFs provide essential care for individuals aged 65 or older, offering temporary or permanent accommodation. These facilities are not considered healthcare providers, and as a result, pharmaceutical services are not mandatory. This study aimed to evaluate medication management practices in Portuguese LTCFs, identify which professionals are responsible for managing medications, and identify potential gaps in safety and efficacy.

METHODS

A cross-sectional electronic questionnaire was sent by email to 2552 Portuguese LTCFs from the Portuguese "Carta Social" database. Data collection took place between 20 July and 2 August 2023, yielding a response rate of 15.4% (392 institutions).

RESULTS

Most LTCFs (94.39%) oversee their resident's medication, with 75.95% using the same pharmacy. Individualised medication packaging is used by 57.84% of facilities, and 97.84% provide medication reconciliation and review, mainly conducted by physicians and nurses. Medication is often stored in nursing offices (81.12%) but also in kitchens or dining rooms. Nurses are responsible for medication storage (87.50%) and preparation (81.89%), although non-nursing staff are also involved. In 63.27% of LTCFs, the same individual is responsible for both the preparation and verification of medication. Assistants are involved in both the checking (30.56%) and administering (45.66%) of medication.

CONCLUSIONS

The results presented illustrate the current status of LTCFs in Portugal. Medication management presents a significant challenge, and it is notable that the role of the pharmacist in this process is not as prominent as it is in other countries.

Association between benzodiazepine anxiolytic polypharmacy and concomitant psychotropic medications in Japan: a retrospective cross-sectional study

Introduction

Guidelines for various psychiatric disorders recommend short-term use of benzodiazepine anxiolytic monotherapy in few cases. Contrarily, benzodiazepine anxiolytic polypharmacy (BAP) is not recommended in any case. However, BAP is often used in real world. Therefore, this study aimed to determine the association between BAP and concomitant use of psychotropic medications.

Method

This retrospective cross-sectional study used claims data from the Japan Medical Data Center. Medical information of health insurance subscribers treated with benzodiazepine anxiolytics in June 2019 was extracted. Prescription of two or more benzodiazepine anxiolytics was defined as BAP. Binary logistic regression analysis was performed to investigate the factors associated with BAP, using age group, sex, type of subscriber, and number of concomitant hypnotics, antidepressants, and antipsychotics (none, one, and two or more) as covariates.

Result

The eligible participants were 104,796 adults who were prescribed benzodiazepine anxiolytics. Among them, 12.6% were prescribed two or more drugs. Logistic regression analysis revealed that BAP was significantly associated with those who received hypnotic monotherapy (adjusted odds ratio [aOR]: 1.04, 95% confidence interval [CI]: 1.001-1.09, p=0.04), antidepressant monotherapy and polypharmacy (aOR: 1.57, 95% CI: 1.51-1.63, p<0.001 and aOR: 1.98, 95% CI: 1.88-2.09, p<0.001, respectively), and antipsychotic monotherapy and polypharmacy (aOR: 1.12, 95% CI: 1.07-1.19, p<0.001 and aOR: 1.41, 95% CI: 1.30-1.54, p<0.001, respectively). Conversely, lower BAP was associated with those who received hypnotic polypharmacy (aOR: 0.86, 95% CI: 0.81-0.91, p<0.001).

Discussion

This study showed that the greater the number of concomitant antidepressants and antipsychotics, the greater the association with BAP. Since combination therapy with antidepressants or antipsychotics is generally not recommended, patients receiving combination therapy with these medications may be resistant to pharmacotherapy. Therefore, implementing the recommended non-pharmacological treatments may reduce BAP.

Prevalence and predictors of inappropriate prescribing in outpatients with severe mental illness

Background

Potentially inappropriate prescribing (PIP) is frequent in geriatrics and results in an increased risk for adverse effects, morbidity, mortality and reduced quality of life. Research on PIP in psychiatry has mainly focused on elderly patients and inpatients.

Objectives

To determine the prevalence and the predictors of PIP of psychotropic medication in outpatients with severe mental illness.

Design

This study is part of the Muva study, a pragmatic open Stepped Wedge Cluster Randomized Trial of a physical activity intervention for patients (age ⩾ 16 years) with severe mental illness.

Methods

A structured medication interview, questionnaires on social functioning, quality of life and psychiatric symptoms, and BMI and waist circumference measurements were performed followed by a structured medication review. Patients were divided into groups: PIP versus no PIP. Between-group differences were calculated and a multivariate binary logistic regression was performed to examine predictors for PIP. A receiver operating characteristics analysis was performed to determine the area under the curve (AUC).

Results

In 75 patients, an average of 5.2 medications of which 2.5 psychotropic medication was used. 35 (46.7%) patients were identified with PIP. Unindicated long-term benzodiazepine use was the most frequently occurring PIP (34.1%). Predictors of PIP were female gender [odds ratio (OR) = 4.88, confidence interval (CI) = 1.16-20.58, p = 0.03], number of medications (OR = 1.41, CI = 1.07-1.86, p = 0.02) and lower social functioning (OR = 1.42, CI = 1.01-2.00, p = 0.05). The AUC was 0.88 for the combined prediction model.

Conclusion

The prevalence of PIP of psychotropic medication in outpatients with severe mental illness is high. It is therefore important to identify, and where possible, resolve PIP by frequently performing a medication review with specific attention to females, patients with a higher number of medications and patients with lower social functioning.

Trial registration

This trial was registered in The Netherlands Trial Register (NTR) as NTR NL9163 on 20 December 2020 (https://trialsearch.who.int/Trial2.aspx?TrialID=NL9163).

Clinical pharmacy services in mental health in Europe: a commentary paper of the European Society of Clinical Pharmacy Special Interest Group on Mental Health

A large proportion of the world's disease burden is attributable to mental illnesses. Although effective interventions are available, many patients still have limited access to evidence-based treatments. Aside from access, treatment gaps, including inappropriate medication selection and monitoring, are also routinely recognised. Mental health clinical pharmacists can help address these gaps and enable patients to receive optimised pharmaceutical care, particularly appropriate medication selection and monitoring. The European Society of Clinical Pharmacy (ESCP) Special Interest Group on Mental Health was established to improve standardised service provision in mental health settings across Europe. The Special Interest Group identified significant barriers (predominantly associated with reimbursement and position within the multidisciplinary team) to effective pharmaceutical care amongst those with mental illnesses. This commentary presents recommendations to address these gaps through improved mental health clinical pharmacy service provision.

Building a novel self-iterative clinical pharmacist intervention model in psychiatric hospital: Application and evaluation

Clinical pharmacist intervention (CPI) in psychiatric hospital has not been widely developed in China. This study aimed to establish a real-time dynamic self-iterative CPI model in The Affiliated Mental Health Center of Jiangnan University and evaluated its effect. We focused on the running data in 2021 and 2022. The number of interventions, intervention types and intervention strategies were evaluated. In 2021 and 2022, a total of 443 interventions were reported. Among them, 271 (61.17 %) were identified during ward rounds by physicians, pharmacists and nurses. The proportion of CPI through ward rounds and information system gradually decreased while intervention through other ways increased. Meanwhile, there are various of CPI types including adverse drug reactions (26.86 %), therapeutic drug monitoring recommendations (13.32 %), drug usage and dose adjustment (10.61 %) and among them, adverse reactions are the focus of pharmacists' attention. Besides, the intervention strategies of pharmacists mainly concentrated in medication change (18.74 %), medication discontinuation (15.58 %) and dose reduction (12.19 %). In addition, the self-iterative function can continuously optimize the intervention level of clinical pharmacists. Overall, the CPI model established in this study effectively promote pharmacist intervention and accelerate pharmaceutical transformation.

Risk Factors Associated With Polypharmacy and Potentially Inappropriate Medication Use in Ambulatory Care Among the Elderly in the United States: A Cross-Sectional Study

INTRODUCTION

Polypharmacy, defined as the concurrent use of multiple (commonly five or more) prescription drugs, is widely prevalent among the elderly. It is a preventable and significant contributor to morbidity and mortality among older people. It is linked to prescribing potentially inappropriate medications (PIMs), which have been shown to be associated with an increased risk of adverse drug interactions and reduced compliance, and in some cases result in prescribing cascades where more drugs are prescribed to manage adverse outcomes. This study aimed to examine risk factors associated with polypharmacy and PIMs among elderly patients in outpatient settings in the US.

METHODS

We conducted a cross-sectional analysis using the nationally representative National Ambulatory Medical Care Survey, between 2010 and 2016. We extracted data from all people aged 65 years or older and evaluated factors associated with polypharmacy and PIMs using multivariable logistic regression. Weights were applied to obtain national estimates.

RESULTS

During the study period, there were a total of 81,295 ambulatory visits among adults 65 years and older. Being a woman (compared with a man) was more likely to be associated with greater prevalence of PIMs (OR: 1.31, 95% CI 1.23-1.40), and living in rural areas were more likely to be associated with both polypharmacy (OR: 1.15, 95% CI 1.07-1.23) and PIMs (OR: 1.19, 95% CI 1.09-1.29), compared with living in urban areas. Older age was positively associated with polypharmacy (OR: 1.08, 95% CI 1.06-1.10), but negatively associated with PIMs (OR: 0.97, 95% CI 0.95-0.99).

CONCLUSIONS

Our study suggests age, being a woman, and living in rural areas are risk factors for both polypharmacy and PIMs usage. Aside from primary care providers' roles in managing polypharmacy, collaborative care with other specialty providers, such as clinical pharmacists, should also be considered as an approach to improving the quality of prescribing in geriatric patients. Future research should further explore reasons for polypharmacy and focus on deprescribing and quality improvement initiatives in primary care to lower polypharmacy among the elderly.

Theoretical Underpinnings of a Model to Reduce Polypharmacy and Its Negative Health Effects: Introducing the Team Approach to Polypharmacy Evaluation and Reduction (TAPER)

BACKGROUND

Polypharmacy, particularly among older adults, is gaining recognition as an important risk to health. The harmful effects on health arise from disease-drug and drug-drug interactions, the cumulative burden of side effects from multiple medications and the burden to the patient. Single-disease clinical guidelines fail to consider the complex reality of optimising treatments for patients with multiple morbidities and medications. Efforts have been made to develop and implement interventions to reduce the risk of harmful effects, with some promising results. However, the theoretical basis (or pre-clinical work) that informed the development of these efforts, although likely undertaken, is unclear, difficult to find or inadequately described in publications. It is critical in interpreting effects and achieving effectiveness to understand the theoretical basis for such interventions.

OBJECTIVE

Our objective is to outline the theoretical underpinnings of the development of a new polypharmacy intervention: the Team Approach to Polypharmacy Evaluation and Reduction (TAPER).

METHODS

We examined deprescribing barriers at patient, provider, and system levels and mapped them to the chronic care model to understand the behavioural change requirements for a model to address polypharmacy.

RESULTS

Using the chronic care model framework for understanding the barriers, we developed a model for addressing polypharmacy.

CONCLUSIONS

We discuss how TAPER maps to address the specific patient-level, provider-level, and system-level barriers to deprescribing and aligns with three commonly used models and frameworks in medicine (the chronic care model, minimally disruptive medicine, the cumulative complexity model). We also describe how TAPER maps onto primary care principles, ultimately providing a description of the development of TAPER and a conceptualisation of the potential mechanisms by which TAPER reduces polypharmacy and its associated harms.

Recommendations for wider adoption of clinical pharmacy in Central and Eastern Europe in order to optimise pharmacotherapy and improve patient outcomes

Clinical pharmacy as an area of practice, education and research started developing around the 1960s when pharmacists across the globe gradually identified the need to focus more on ensuring the appropriate use of medicines to improve patient outcomes rather than being engaged in manufacturing and supply. Since that time numerous studies have shown the positive impact of clinical pharmacy services (CPS). The need for wider adoption of CPS worldwide becomes urgent, as the global population ages, and the prevalence of polypharmacy as well as shortage of healthcare professionals is rising. At the same time, there is great pressure to provide both high-quality and cost-effective health services. All these challenges urgently require the adoption of a new paradigm of healthcare system architecture. One of the most appropriate answers to these challenges is to increase the utilization of the potential of highly educated and skilled professionals widely available in these countries, i.e., pharmacists, who are well positioned to prevent and manage drug-related problems together with ensuring safe and effective use of medications with further care relating to medication adherence. Unfortunately, CPS are still underdeveloped and underutilized in some parts of Europe, namely, in most of the Central and Eastern European (CEE) countries. This paper reviews current situation of CPS development in CEE countries and the prospects for the future of CPS in that region.

Polypharmacy in chronic liver disease patients: Implications for disease severity, drug-drug interaction, and quality of life

Multiple prescriptions for different medications may be needed for chronic conditions, increasing the risk of polypharmacy. The WHO defined polypharmacy as "the administration of many drugs at the same time or the administration of an excessive number of drugs". The primary goal of this study was to evaluate polypharmacy in patients with chronic liver disease and to identify potential drug-drug interactions associated with it. A cross-sectional study was conducted at a tertiary care hospital in Mangalore, Karnataka, for six months, from November 2020 to April 2021. The study involved 118 patients with chronic liver disease from various age groups. Data was gathered by analyzing patients' medical records kept on the ward and interviewing them individually. In admission and discharge prescriptions, polypharmacy was examined. Online interaction checkers from Drugs.com and Medscape were used to interpret potential drug-drug interactions. The SF-36 and Chronic Liver Disease Questionnaire were used to measure the quality of life. The data obtained were analyzed statistically to determine the significant correlation. The number of prescribed drugs was significantly correlated (P = 0.018) with the severity of liver disease in Child-Pugh categories B and C. Additionally, moderate polypharmacy reduced quality of life (P < 0.05), and the physical health category was significantly associated with disease severity (P < 0.05). Drug-drug interactions were found in 108 out of the 118 examined prescriptions, totaling 586 interactions in the admission list and 405 interactions in the discharge list. If the potentially serious main drug interaction identified in this study is not well monitored, it could lead to a serious, potentially fatal health condition. Despite being advised, safety is not always guaranteed by liver enzyme monitoring. Therefore, healthcare providers must take additional precautions to avoid inappropriate prescribing, minimize side effects, and ensure drug safety.

Development and validation of a nomogram to predict the risk of potentially inappropriate medication use in older lung cancer outpatients with multimorbidity

BACKGROUND

At present, there is no predictive model that can predict the prevalence of potentially inappropriate medication (PIM) use in older lung cancer outpatients.

RESEARCH DESIGN AND METHODS

We measured PIM by the 2019 Beers criteria. Significant factors were identified to develop the nomogram using logistic regression. We validated the nomogram internally and externally in two cohorts. The discrimination, calibration, and clinical practicability of the nomogram were verified using receiver operating characteristic (ROC) curve analysis, Hosmer-Lemeshow test, and decision curve analysis (DCA), respectively.

RESULTS

A total of 3300 older lung cancer outpatients were divided into a training cohort (n = 1718) and two validation cohorts, including an internal validation cohort (n = 739) and an external validation cohort (n = 843). A nomogram for predicting PIM use patients was developed using six significant factors. ROC curve analysis showed that the area under the curve was 0.835 in the training cohort and 0.810 and 0.826 in the internal validation and external validation cohorts, respectively. The Hosmer‒Lemeshow test yielded P = 0.180, 0.779 and 0.069, respectively. The nomogram demonstrated a high net benefit in DCA.

CONCLUSIONS

The nomogram could be a convenient, intuitive, and personalized clinical tool for assessing the risk of PIM in older lung cancer outpatients.

Clinical pharmacy services are reimbursed in Germany: challenges of real world implementation remain

Over the last two decades, community pharmacy has experienced major changes as the role of pharmacists is evolving from a product to a service and a patient focus. As part of this change, new and innovative clinical pharmacy services aimed at improving medicines use and patient outcomes have been designed, both nationally and internationally. Since June 2022, five services are reimbursed by all statutory health insurance funds and private insurance companies in Germany: medication review for patients with polymedication; blood pressure control in hypertension; assuring proper inhalation techniques for patients receiving a new device or a device change; medication review including a follow-up for patients taking oral anticancer drugs or immunosuppressants post-transplantation. Beyond reimbursement, the upscaling and sustainable provision of these professional services are now the main challenges. Implementation research will provide important information for the further development of pharmaceutical care programs.

Potentially inappropriate medications in older Chinese outpatients based on the Beers criteria and Chinese criteria

Objective: Polypharmacy increases the prevalence of potentially inappropriate drugs potentially inappropriate medications among older persons, lowering their quality of life. PIMs use can lead to higher mortality in older patients. This study aimed to compare the prevalence of PIMs in older Chinese outpatients according to the Beers criteria and the Chinese criteria and to analyze the risk factors. Second, we describe the differences between the two criteria, focusing on the inappropriate prescription of drugs in older outpatients.

Methods: In Chengdu, Southwest China, a cross-sectional study was undertaken using electronic medical data from 9 general hospitals s. Outpatients above the age of 60 who were treated in the Geriatrics Center of these medical institutions were included. The 2019 Beers criteria and the 2017 Chinese criteria were used to evaluate the PIM status of older outpatients, and binary logistic regression was used to identify potential risk factors for PIMs.

Results: There were 44,458 prescriptions from 2016 to 2018. The prevalence of PIMs among older outpatients was 30.05% (according to the Beers criteria) and 35.38% (according to the Chinese criteria), with statistical difference. Estazolam, hydrochlorothiazide and alprazolam were the top three PIMs in the Beers criteria, while the top three PIMs in the Chinese criteria were clopidogrel, estazolam and insulin. The prevalence of PIMs was associated with age, the number of diseases and the number of drugs. PIMs were shown to be more common in patients aged 70 and above, with more than 2 kinds of diseases and more than 4 kinds of drugs.

Conclusion: PIMs were shown to be common among older outpatients in China, according to this study. The detection rate of the Chinese criteria was higher than that of the Beers criteria.

Pharmacist Intervention in Portuguese Older Adult Care

Healthy ageing has become one of the most significant challenges in a society with an increasing life expectancy. Older adults have a greater prevalence of chronic disease, with the need for multiple medications to appropriately control these issues. In addition to their health concerns, ageing individuals are prone to loneliness, dependence, and economic issues, which may affect their quality of life. Governments and health professionals worldwide have developed various strategies to promote active and healthy ageing to improve the quality of life of older adults. Pharmacists are highly qualified health professionals, easily accessible to the population, thus playing a pivotal role in medication management. Their proximity to the patient puts them in a unique position to provide education and training to improve therapeutic adherence and identify medication-related problems. This paper aims to address the importance of Portuguese community pharmacists in the medication management of older adults, emphasising their intervention in health promotion, patient education, medication-related problems, deprescription, dose administration aids, and medication review and reconciliation. We also discuss home delivery services and medication management in long-term care facilities.

Priority setting and cross-country learning: the relevance of TO-REACH for primary care

Aim:

To inform the primary care community about priorities for research in primary care as came up from the European project TO-REACH and to discuss transferability of service and policy innovations between countries.

Background:

TO-REACH stands for Transfer of Organizational innovations for Resilient, Effective, equitable, Accessible, sustainable and Comprehensive Health services and systems. This EU-funded project has put health systems and services research higher on the European agenda and has led to the current development of a European ‘Partnership Transforming Health and Care Systems’.

Methods:

To identify research priorities, both qualitative and quantitative approaches were used. Policy documents and strategic roadmaps were searched, and priorities were mapped. Stakeholders were involved through national roundtable consultations and online consultations. Regarding transferability, we carried out a review of the literature, guided by a conceptual framework, and using a snowballing approach.

Findings:

Primary care emerged as an important priority from the inventory, as are areas that are conducive to strengthening primary care, such as workforce policies. The large variation in service organisation and policy around primary care in Europe is a huge potential for cross-country learning. However, the simple transfer of primary care service and policy arrangements from one health system to another has a big chance to fail, unless known conditions for successful transfer are taken into account and gaps in our knowledge about transfer are resolved.

Prevalence of Polypharmacy and Potentially Inappropriate Medications Use in Elderly Chinese Patients: A Systematic Review and Meta-Analysis

Objectives: Polypharmacy and potentially inappropriate medication (PIM) use among elderly Chinese patients have not yet been investigated by systematic review and meta-analysis. The purposes of this study were to investigate the prevalence of polypharmacy and PIM use and the risk factors associated with PIM use in elderly Chinese patients.

Methods: Databases including PubMed, EMBase, and Web of Science were searched to collect studies which used Chinese criteria, Beers criteria, or STOPP criteria to evaluate the PIM status of elderly Chinese patients from inception to August 2021 (PROSPERO Code No: CRD42021262821). Observational studies reporting the prevalence of polypharmacy and PIM use in elderly Chinese patients were meta-analyzed. The pooled prevalence and risk ratio (RR) were calculated with a 95% confidence interval (CI).

Results: A total of 8 articles involving 4,558,786 patients were included. The overall prevalence of polypharmacy (concomitant use of more than 5 medicines) and PIM use pooled by meta-analysis in Chinese older patients was 48% (95% CI: 0.17, 0.79, p = 0.003) (inpatients 73%, outpatients 23%) and 39% (95% CI: 0.25, 0.54, p < 0.001) (inpatients 50%, outpatients 29%), respectively. Polypharmacy (RR: 2.03, 95% CI: 1.13, 3.64) was significantly associated with PIM use.

Conclusion: This meta-analysis demonstrated a high prevalence of polypharmacy and PIM use among elderly patients in China. Affected by the quantity and quality of the included studies, the aforementioned conclusions need to be confirmed by large samples and high-quality studies.

Mitigating the Risk of Adverse Effects Related to Augmentation Therapy for Resistant Major Depressive Disorder: A Case Report

Polypharmacy of psychotropic medications predisposes older adults to adverse drug events (ADEs). One contributing factor is inhibition of metabolic pathways between substrates (competitive inhibition) or between substrates and inhibitors of the same cytochrome P450 (CYP450) isoforms. The purpose of this case report is to demonstrate observed sedation and difficulty concentrating from augmentation therapy for resistant major depressive disorder (MDD) and to highlight the value of clinical tools to identify opportunities for treatment optimization to reduce ADEs. The pharmacist identified significant medication burden and competitive inhibition of drug metabolism in the CYP450 system during a telehealth medication therapy management consultation with a 69-year-old male. The pharmacist recommended clinical monitoring and communicated concerns about medication-induced sedation, difficulty concentrating, and other medication-related problems (MRP) to providers. Several recommendations were implemented which helped improved patient’s outcomes. Individualizing MDD pharmacotherapy based on pharmacokinetic and pharmacodynamic drug interactions and geriatric dosage considerations may lead to better outcomes and tolerability among older adults.

Lithium surveillance by community pharmacists and physicians in ambulatory patients: a retrospective cohort study

BACKGROUND

Shared care agreements between clinical pharmacists and physicians can improve suboptimal lithium monitoring in in- and outpatient settings. However, it is unknown whether incorporating community pharmacists in such agreements can also improve lithium monitoring in an outpatient setting.

AIM

To assess the necessity for a shared care agreement for lithium monitoring in our region by investigating: intervention rates by community pharmacists and whether those are sufficient; lithium monitoring by physicians in ambulatory patients; the extent of laboratory parameter exchange to community pharmacists.

METHOD

Patient files of lithium users were surveyed in a retrospective cohort study among 21 community pharmacies in the Northern Netherlands. Outcome was the intervention rate by community pharmacists and whether those were deemed sufficient by an expert panel. Additionally, we investigated both the percentages of patients monitored according to current guidelines and of laboratory parameters exchanged to community pharmacists.

RESULTS

129 patients were included. Interventions were performed in 64.4% (n = 29), 20.8% (n = 5), and 25.0% (n = 1) of initiations, discontinuations, and dosage alterations of drugs interacting with lithium, respectively. The expert panel deemed 40.0% (n = 14) of these interventions as "insufficient". Physicians monitored 40.3% (n = 52) of the patients according to current guidelines for lithium serum levels and kidney functions combined. Approximately half of the requested laboratory parameters were available to the community pharmacist.

CONCLUSION

Intervention rates by community pharmacists and lithium monitoring by physicians can be improved. Therefore, a shared care agreement between community pharmacists, clinical pharmacists, and physicians is needed to improve lithium monitoring in ambulatory patients.

A pharmacist-led intervention to improve the management of opioids in a general practice: a qualitative evaluation of participant interviews

Background Opioid prescribing has escalated, particularly long-term in chronic noncancer pain. Innovative models of care have been recommended to augment regulatory and harm-minimisation strategies and to review the safety and benefits of opioids for the individual patient. Medication stewardship and pharmacist integration are evolving approaches for general practice. Aim To explore enablers, barriers, and outcomes of a pharmacist-led intervention to improve opioid management in general practice, from the perspectives of general practitioners (GPs) and practice personnel. Method The study was part of a mixed-methods investigation into a general practice pharmacist pilot. Qualitative data relevant to opioids were analysed. Data from 13 semi-structured interviews were coded, analysed iteratively and thematically, and interpreted conceptually through the framework of Opioid Stewardship fundamentals proposed by the National Quality Forum. Results Seven themes and 14 subthemes aligned with stewardship fundamentals. Participants considered organisational policy, supported by leadership and education, fostered collaboration and consistency and improved practice safety. Patient engagement with individualised resources, 'agreements' and 'having the conversation' with the pharmacist enabled person-centred opioid review and weaning. GPs reported greater accountability and reflection in their practices, in the broader context of opioid prescribing and dilemmas in managing patients transitioning through care. Receiving feedback on practice deprescribing outcomes encouraged participants' ongoing commitment. Patient communication was deemed an early barrier; however, learnings were applied when transferring the model to other high-risk medicines. Conclusion Improved opioid management was enabled through implementing pharmacist-led coordinated stewardship. The findings offer a practical application of guideline advice to individualise opioid deprescribing.