Negative clinical outcomes associated with drug-related problems in heart failure (HF) outpatients: impact of a pharmacist in a multidisciplinary HF clinic

Definition of Polypharmacy in Heart Failure: A Scoping Review of the Literature

Patients with heart failure (HF) have a high prevalence of polypharmacy, which can lead to drug interactions, cognitive impairment, and medication non-compliance. However, the definition of polypharmacy in these patients is still inconsistent. The aim of this scoping review was to find the most common definition of polypharmacy in HF patients. We conducted a scoping review searching Medline, Embase, CINAHL, and Cochrane using terms including polypharmacy, HF and deprescribing, which resulted in 7,949 articles. Articles without a definition of polypharmacy in HF patients and articles which included patients < 18 years of age were excluded; only 59 articles were included. Of the 59 articles, 49% (n = 29) were retrospective, 20% (n = 12) were prospective, 10% (n = 6) were cross-sectional, and 27% (n = 16) were review articles. Twenty percent (n = 12) of the articles focused on HF with reduced ejection fraction, 10% (n = 6) focused on HF with preserved ejection fraction and 69% (n = 41) articles either focused on both diagnoses or did not clarify the specific type of HF. The most common cutoff for polypharmacy in HF was five medications (59%, n = 35). There was no consensus regarding the inclusion or exclusion of over-the-counter medications, supplements, or vitamins. Some newer studies used a cutoff of 10 medications (14%, n = 8), and this may be a more practical and meaningful definition for HF patients.

Medication Related-Problems and Associated Factors Among Patients with Hypertension at a Tertiary Care Hospital in Ethiopia: A Prospective Interventional Study

Background

Hypertension affects more than 1.4 billion people worldwide currently, with that number anticipated to climb to 1.6 billion by 2025 with high mortality and morbidity effects. Medication related problems in cardiovascular disease patients, especially among hypertension patients were found to be high and a critical problem which is associated with high mortality, complication, prolonged hospital stay, compromised quality of life and increase health care cost.

Objective

To determine medication related problems and its predictors among hypertension patients on chronic follow-up at Jimma Medical Center.

Methods

A prospective interventional study was conducted among hypertension patients from November 28, 2021 to June 30, 2022 at Jimma Medical Center. Medication related problems were classified and identified based on Pharmaceutical care network Europe drug classification tool version 9.0. Interventions were done through discussion with individual prescriber and patients. Consecutive sampling technique was used. Binary Logistic regression was used to identify independent predictors of medication related problems. Variables having P-values < 0.05 were considered statistically significant.

Results

Among 384 hypertension patients included in the study, 219 (57.1%) were male. The mean (SD) age was 49.06+17.79. Two thirds of study participants had at least one medication related problem. A total of 483 MRPs were identified among 231 (60.15%) patients. Treatment effectiveness related problem (55.48%) was the most common observed medication related problems. Alcoholism (AOR; 3.15, 95% CI [1.46-7.23]), stage II hypertension (AOR=2.77, 95% CI= [3.53-4.66]); comorbidity (AOR=2.88, 95% CI= [1.47-5.66]) and polypharmacy (AOR=3.07, 95% CI= [1.57-5.99]) were the independent predictors of medication related problems.

Conclusion

The prevalence of medication related problems was high among hypertensive patients. Alcoholism, stage II hypertension, comorbidity and poly-pharmacy were the predictors of medication related problems. Therefore, to overcome the problems, clinical pharmacists, physicians and other health care professionals have to work in collaboration.

Medication Complexity Among Older Adults with HF: How Can We Assess Better?

Medical management of heart failure (HF) has evolved and has achieved significant survival benefits, resulting in highly complex medication regimens. Complex medication regimens create challenges for older adults, including nonadherence and increased adverse drug events, especially associated with cognitive impairment, physical limitations, or lack of social support. However, the association between medication complexity and patients' health outcomes among older adults with HF is unclear. The purpose of this review is to address how the complexity of HF medications has been assessed in the literature and what clinical outcomes are associated with medication regimen complexity in HF. Further, we aimed to explore how older adults were represented in those studies. The Medication Regimen Complexity Index was the most commonly used tool for assessment of medication regimen complexity. Rehospitalization was most frequently assessed as the clinical outcome, and other studies used medication adherence, quality of life, healthcare utilization, healthcare cost, or side effect. However, the studies showed inconsistent results in the association between the medication regimen complexity and clinical outcomes. We also identified an extremely small number of studies that focused on older adults. Notably, current medication regimen complexity tools did not consider a complicated clinical condition of an older adult with multimorbidity, therapeutic competition, drug interactions, or altered tolerance to the usual dose strength of the medications. Furthermore, the outcomes that studies assessed were rarely comprehensive or patient centered. More studies are required to fill the knowledge gap identifying more comprehensive and accurate medication regimen complexity tools and more patient-centered outcome assessment.

Drug-related problems and its predictors among hospitalized heart failure patients at Jimma Medical Center, South West Ethiopia: prospective interventional study

Background

Drug-related problems are associated with high mortality, complications, prolonged hospital stay, compromised quality of life, and increased healthcare costs. This problem is high in patients hospitalized with chronic conditions such as heart failure. However, there are limited studies conducted on this area, particularly in Ethiopia.

Objective

To evaluate drug-related problems, their predictors, and clinical pharmacist intervention among hospitalized heart failure patients at Jimma Medical Center, Ethiopia.

Methods and participants

A prospective interventional study was conducted among hospitalized heart failure patients from September 30, 2020, to May 28, 2021, at Jimma Medical Center. Drug-related problems were sorted based on the Pharmaceutical Care Network Europe drug classification tool version 9.0. Patient's specific data were collected using a structured questionnaire. Data was analyzed using statistical software package version 23.0. Multivariate logistic regression analysis was used to identify independent predictors of drug-related problems occurrence and statistical significance was considered at a p value < 0.05.

Results

A total of 237 heart failure patients were included in this study. The mean (SD) age was 49.06 + 17.79. About two-thirds (66.2%) of study patients had at least one drug-related problem during their hospital stay. A total of 283 drug-related problems were identified among 157 patients. Treatment effectiveness-related problem (55.48%) was the most common observed drug-related problem. The independent predictors of drug-related problems were khat chewing [AOR = 3.25, 95% CI = (1.46–7.23)], hospital stay > 18 days [AOR = 3.77, 95% CI = (1.93–7.37)]; presence of comorbid condition [AOR = 2.59, 95% CI = (1.35–4.96)] and polypharmacy [AOR = 2.94, 95% CI = (1.54–5.61)].

Conclusion

The prevalence of drug-related problems was high among hospitalized heart failure patients in the study area. Chewing khat, prolonged hospital stay, comorbidity, and polypharmacy were the predictors of drug-related problems. Hence, to overcome these problems, clinical pharmacists, physicians, and other health professionals have to work in collaboration.

Impact of medication therapy management interventions on drug therapy problems, medication adherence and treatment satisfaction among ambulatory heart failure patients at Tikur Anbessa Specialised Hospital, Addis Ababa, Ethiopia: a one-group pre-post quasi-experimental study

OBJECTIVE

To determine the impact of medication therapy management interventions on drug therapy problems (DTPs), medication adherence and treatment satisfaction among ambulatory heart failure (HF) patients.

STUDY DESIGN, SETTING AND PARTICIPANTS

A one-group pre-post quasi-experimental study was conducted on 423 ambulatory HF patients at Tikur Anbessa Specialised Hospital (TASH), Addis Ababa, Ethiopia. All ambulatory HF patients ≥18 years old attending the adult cardiac clinic of TASH and having a complete medical record and fully met the inclusion criteria were taken as study participants.

INTERVENTIONS

Educational interventions along with a brochure with information on the nature of HF disease and its treatment were provided to study participants. DTPs encountered were resolved by a team of pharmacists and physicians.

RESULTS

In the preintervention phase, 288 DTPs were identified with a mean (SD) of 1.3±1.1. A significant reduction of DTPs (0.67±1.1, p<0.001) was observed in the postintervention phase compared with the preintervention phase. At the postintervention phase, 36.4%, 61.9% and 1.7% of HF patients were highly, medium and low adherent to their treatment regimens, respectively. The total composite score for treatment satisfaction of the study participants was 80.35%.

CONCLUSIONS

The findings of this study demonstrated that by teaming up clinical pharmacists with cardiologists and cardiology fellows, it was possible to reduce the occurrence of DTPs, improve medication adherence and increase treatment satisfaction of HF patients attending at the outpatient cardiac clinic.

Heart Failure in Older Adults: Medical Management and Advanced Therapies

As the population ages and the prevalence of heart failure increases, cardiologists and geriatricians can expect to see more elderly patients with heart failure in their everyday practice. With the advancement of medical care and technology, the options for heart failure management have expanded, though current guidelines are based on studies of younger populations, and the evidence in older populations is not as robust. Pharmacologic therapy remains the cornerstone of heart failure management and has improved long-term mortality. Prevention of sudden cardiac death with implantable devices is being more readily utilized in older patients. Advanced therapies have provided more options for end-stage heart failure, though its use is still limited in older patients. In this review, we discuss the current guidelines for medical management of heart failure in older adults, as well as the expanding literature on advanced therapies, such as heart transplantation in older patients with end-stage heart failure. We also discuss the importance of a multidisciplinary care approach including consideration of non-medical co-morbidities such as frailty and cognitive decline.

Effects of Pharmacist Interventions on Cardiovascular Risk Factors and Outcomes: An Umbrella Review of Meta-analysis of Randomized Controlled Trials

AIM

To grade the evidence from published meta-analyses of randomized controlled trials (RCTs) that assessed effects of pharmacist intervention on cardiovascular risk factors and cardiovascular outcomes.

METHODS

MEDLINE, Embase, and the Cochrane Library were searched from database inception to July 2021. Meta-analyses of RCTs were eligible. Quality of evidence were assessed by GRADE approach.

RESULTS

From 9,308 publications, 149 full-text articles were evaluated for eligibility, and 24 studies with 85 unique meta-analyses that assessed effects of pharmacist intervention on cardiovascular risk factors and cardiovascular outcomes. Overall, 71.7% (61/85) of unique meta-analyses showed significant impacts of pharmacist intervention. For the quality of evidence, 63.4% of meta-analyses had large heterogeneity (I² > 50%) while 1.2%, 16.5%, 32.9% and 49.4% of meta-analyses were graded as high, moderate, low and very low quality based on GRADE approach, respectively. Among meta-analyses with moderate quality, pharmacist interventions significantly mitigated risk factors (including 6/3 mmHg reduction of blood pressure, increased the rate of lipid control, glucose control and smoking cessation (pooled OR 1.91 (1.55, 2.35), 3.11 (2.3, 4.3), and 2.3 (1.33, 3.97), respectively)) and improved medication adherence (pooled OR 1.67 (1.38, 2.02)). Furthermore, pharmacist interventions significantly reduced all-cause mortality (pooled OR 0.72 (0.58, 0.89)) and improved quality of life in patients suffering from chronic heart failure.

CONCLUSION

This umbrella review found convincing evidence that pharmacist intervention can provide a wide range of benefits in cardiovascular disease management, ranging from risk factor control, improvement in medication adherence and in some setting, reduction in morbidity and mortality.

Drug-Related Problems Among Ambulatory Heart Failure Patients on Follow-Up at Debre Berhan Comprehensive Specialized Hospital, Ethiopia

Purpose

The purpose of this study was to assess drug-related problems (DRPs) among ambulatory heart failure (HF) patients attending at medical referral clinic of Debre Berhan Comprehensive Specialized Hospital, Ethiopia.

Materials and Methods

A hospital-based cross-sectional study was conducted among 344 HF patients. Drug-related problems were classified using modified Cipolle’s DRP classification schemes and drug–drug interactions were assessed using Micromedex, up-to-date, and drug.com drug–drug interaction checkers. The data was entered into Epidata version 4.2.0 and analyzed using SPSS version 25.0 statistical software. Descriptive statistics were used to summarize patients’ characteristics. Univariable and multivariable binary logistic regression analysis was performed to identify associated factors with dependent variables. P < 0.05 was considered statistically significant.

Results

The mean age of the study participants was 53.38 ± 18.84 years and nearly half (45%) were in the age group of 31–60 years. Drug-related problems were found in 80.8% of HF patients. A total of 416 DRPs were identified. Adverse drug reaction (35.58%) was the top DRPs identified followed by the need for additional drug therapy (30.53%) and ineffective drug therapy (26.9%), respectively. Diuretics (45%), beta-blockers (BBs) (12.42%), and angiotensin-converting enzyme inhibitors (ACEIs) (10%) were the commonly used drug classes by study participants. The presence of comorbidity (p ˂ 0.001) and level of education of study participants (p = 0.03) had a significant association with the occurrence of DRPs.

Conclusion

The prevalence of DRPs among ambulatory HF patients was high. The presence of comorbidity and the educational level of study participants had a significant association with the occurrence of DRPs. Checking potential drug–drug interactions before starting a new therapy, monitoring adverse drug reactions, ensuring sustainable availability of medications, and regular education programs are recommended to minimize DRPs.

Development and validation of explicit criteria to identify potentially inappropriate prescribing for adults with type 2 diabetes mellitus

BACKGROUND

Early detection and timely resolution of potentially inappropriate prescribing (PIP) prevents adverse outcomes and improves patient care. An explicit tool specifically designed to detect PIP among people with Type 2 Diabetes Mellitus (T2DM) has not been published.

OBJECTIVES

This study aims to develop and validate the Inappropriate Medication Prescribing Assessment Criteria for Type 2 Diabetes Mellitus (IMPACT2DM); an explicit tool that can be used to identify PIP for adults with T2DM.

METHODS

Current national and international guidelines for the management of T2DM and drug information software programs were used to generate potential items. The content of the IMPACT2DM was validated by 2 consecutive rounds of Delphi method. Physicians and clinical pharmacists experienced in providing care for people with diabetes and authors of selected diabetes guidelines were invited to participate in the Delphi panel. Consensus was assumed if 90% (first round) and 85% (second round) of expert panelists showed agreement to include or exclude an item.

RESULTS

A total of 95 potential items were generated from selected diabetes guidelines and drug information software programs. After the first Delphi round 27 items had ≥90% agreement and were included in the tool; 19 items were considered not PIP and were excluded from the tool. The second round contained 49 items; of these 43 were included and 6 were excluded from the tool. The final IMPACT2DM contains 70 items categorized by type of PIP and arranged in terms of medical conditions and medication classes. IMPACT2DM can be applied using information on medical charts and requires minimal or no clinical knowledge to assess quality of diabetes care and improve medication selection.

CONCLUSIONS

IMPACT2DM has been developed from current quality evidence and undergone content validation. It is the first explicit tool specifically designed to identify PIP for adults with T2DM.

Drug-related problems and its determinant among hospitalized neonates with sepsis at Jimma University Medical Center, Ethiopia: a prospective observational study

BACKGROUND

Neonatal populations are quite susceptible to drug-related problems (DRPs) because of clinical heterogeneity and clinical practice trends. However, studies reporting DRPs in the neonatal population are quite limited.

OBJECTIVE

This study aimed to assess the magnitude and types of DRPs and determinant factors among neonates admitted with neonatal sepsis at the Neonatal Intensive Care Unit (NICU) of the Jimma University Medical Center (JUMC), Ethiopia.

METHODS

A hospital-based prospective observational study was conducted involving 201 neonates with sepsis admitted to the NICU from May to August 30, 2018. DRPs were classified using Cipolle's classification method. Statistical Package for Social Science Version 22 was employed for data analysis. Logistical regression was carried out to determine the determinants of DRPs. A p-value < 0.05 was considered to be statistically significant.

RESULTS

Of 201 neonates with sepsis included in this study, 125 (62.2%) were males and the median age of the neonate was 5 days. The mean (±standard deviation) number of medications taking during their hospital stay was 2.6 ± 0.7. DRPs were identified in 98 neonates, at a rate of 48.8% (95% CI, 41.7-55.9). Dose too high (42, 35.8%) and need additional drug therapy (40, 34.1%) were the commonly identified DRPs. Taking antibiotics plus other medications (Adjusted Odds Ratio (AOR) =5.2, 95%CI [1.2-22.0], p = 0.02) was a determinant factor for the occurrence of DRPs.

CONCLUSION

The burdens of DRPs occurrence were high in hospitalized neonates with sepsis. The most common DRPs identified were dose too high and need additional drug therapy. Combined use of other medicines with antibiotics was a predictor of DRP occurrence. The innovative way to tackle the occurrence of DRPs, such as the incorporation of clinical pharmacy service provider into the neonatal care team, which will prevent, detect and/or minimize the occurrence of DRPs, is highly recommended.

Complex and Potentially Harmful Medication Patterns in Heart Failure with Preserved Ejection Fraction

BACKGROUND

Complex medication regimens, often present in heart failure with preserved ejection fraction, may increase the risk of adverse drug effects and harm. We sought to characterize this complexity by determining the prevalence of polypharmacy, potentially inappropriate medications, and therapeutic competition (where a medication for 1 condition may worsen another condition) in 1 of the few dedicated heart failure with preserved ejection fraction programs in the United States.

METHODS

We conducted chart review on 231 patients with heart failure with preserved ejection fraction seen in the University of Michigan's Heart Failure with Preserved Ejection Fraction Clinic between July 2016 and September 2019. We recorded: 1) standing medications to determine the presence of polypharmacy, defined as ≥10 medications; 2) potentially inappropriate medications based on the 2016 American Heart Association Scientific Statement on drugs that pose a major risk of causing or exacerbating heart failure, the 2019 Beers Criteria update, or a previously described list of medications associated with geriatric syndromes; and 3) competing conditions and subsequent medications that could create therapeutic competition.

RESULTS

The prevalence of polypharmacy was 74%, and the prevalence of potentially inappropriate medications was 100%. Competing conditions were present in 81% of patients, of whom 49% took a medication that created therapeutic competition.

CONCLUSION

In addition to confirming that polypharmacy was highly prevalent, we found that potentially inappropriate medications and therapeutic competition were also frequently present. This supports the urgent need to develop patient-centered approaches to mitigate the negative effects of complex medication regimens endemic to adults with heart failure with preserved ejection fraction.

Drug-Therapy Problems and Predictors among Hospitalized Heart-Failure Patients: A Prospective Observational Study

BACKGROUND

Heart-failure patients are at high risk of experiencing drug-therapy problems, owing to polypharmacy, comorbidities, and usually advanced age. Drug-therapy problems can lead to poor clinical outcomes, increased health-care costs and decreased quality of life, and thus strategies for identifying, resolving, and preventing them are urgently needed. Therefore, this study aimed at investigating the incidence and predictors of drug-therapy problems among hospitalized heart-failure patients.

METHODS

This hospital-based prospective observational study was conducted from February 1 to May 31, 2014 at Jimma University Specialized Hospital. Patients of either sex aged 18 years and above with chronic heart failure and complete medical records were enrolled. Patients with high-output heart failure, <1 day of hospital stay, unwilling to give written informed consent, and unconscious without caregivers were excluded. Data were collected from medication charts, laboratory reports, patients/caregivers, morning multidisciplinary meetings, and ward rounds. Multivariate binary logistic regression analysis was done to identify independent predictors of drug-therapy problems.

RESULTS

A total of 104 heart-failure patients (mean age 51.20±15.66 years, females 51.9%) were consecutively enrolled, and 95 (91.3%) had experienced at least one drug-therapy problem (total 268, mean 2.82±1.39 encounters per patient). Of these problems, 45.5% were the need for additional drugs, followed by noncompliance (22.0%), inappropriate dosing (9.3%), unnecessary drugs (9.0%), ineffective drugs (8.2%), and adverse drug reactions (6.0%). None of the independent variables was found to be an independent predictor of having at least one drug-therapy problem. However, the number of clinical/pharmacological risk factors (AOR 7.93), female sex (AOR 3.24), and length of hospital stay (AOR 12.98) were predictors of noncompliance.

CONCLUSION

Patients suffered from a large number of drug-therapy problems. Drugs with survival benefit were underused. Noncompliance and the need for additional drug therapy were the most frequently identified drug-therapy problems. Numbers of clinical/pharmacological risk factors, length of hospital stay, and female sex were identified as predictors for noncompliance.

Magnitude and determinants of drug therapy problems among type 2 diabetes mellitus patients with hypertension in Ethiopia

Introduction

Type 2 diabetes mellitus patients with hypertension are at high risk of drug therapy problems since they are subject to receive multiple drug therapies due to comorbidities.

Objectives

To determine the magnitude of drug therapy problems and its determinants among Type 2 diabetes mellitus patients with hypertension.

Methods

A cross-sectional study was employed among 423 randomly selected participants based on the inclusion criteria. A structured questionnaire and review of patients' medical record were employed in the data collection. The classification system used by Cipolle was used to classify and evaluate drug therapy problems. Data were analyzed using Statistical Package for the social sciences version 25.0 software. Multivariate logistic regression analysis was used to identify determinants of drug therapy problems with a statistical significance of p ⩽ 0.05.

Results

A total of 491 drug therapy problems with a mean of 1.86 ± 0.53 drug therapy problems per patient were identified, and 62.4% (264) of them experienced at least one drug therapy problem. Non-compliance (197, 40.1%), needs of additional drug therapy (119, 24.2%), and dosage too low (91, 18.5%) were the most frequently observed drug therapy problems in the study setting. Anti-diabetic medications (88.4%), statins (44.5%), and aspirin (33.5%) were the most commonly involved drugs in drug therapy problems. The determinants of drug therapy problems were very low family income (adjusted odds ratio = 4.64, p = 0.010), age (45-65 years old) (adjusted odds ratio = 2.55, p = 0.008), presence of comorbidity (adjusted odds ratio = 9.19, p < 0.001), and taking ⩾5 medications (adjusted odds ratio = 2.84, p = 0.001).

Conclusion

Approximately three out of five patients had one or more drug therapy problems encountered. In this study, the most common types of drug therapy problems were non-compliance, needs additional drug therapy, and dosage too low. Family monthly income, age, comorbidities, and number of medications were the significant determinants of drug therapy problems. Therefore, patient education regarding medication adherence, routine medication review, and strengthening clinical pharmacy services should be promoted.

[Cross-cultural adaptation of the PAIR instrument: Pharmacotherapy Assessment in Chronic Renal Disease for application in Brazil]

Individuals suffering from chronic kidney disease (CKD) are often on multiple medications, which exposes them to drug-related problems (DRP). There are no available tools in Brazil to assess the pharmacotherapy and management of DRPs systematically in this population. The scope of this study was to perform a cross-cultural adaptation of PAIR criteria (Pharmacotherapy Assessment in Chronic Renal Disease) to Brazilian Portuguese. PAIR criteria consist of 50 DRP clinically significant items for CKD. The process of cross-cultural adaptation involved translation, synthesis, back-translation, and an analysis by an expert committee as well as a pre-test of the first draft document. A review committee consisting of 2 pharmacists and 2 nephrologists analyzed the semantic, linguistic, experiential, and conceptual equivalence between the original and translated versions. All items that obtained a score below 80% were reviewed. Word adjustments were made, as well as the exclusion of 6 DRP due to non-applicability to the Brazilian context. Thus, the final version of PAIR defined as "Avaliação da farmacoterapia na doença renal crônica" was translated and adapted into the Brazilian Portuguese language.

Pharmacotherapy assessment in chronic kidney disease: validation of the PAIR instrument for use in Brazil

Individuals with chronic kidney disease (CKD) use polypharmacy, which, in combination with renal impairment, exposes them to the risk of drug-related problems (DRPs). There are no available tools in Brazil to systematically assess the pharmacotherapy and management of DRPs in this population. Therefore, the objective of this work was to validate the PAIR instrument (Pharmacotherapy Assessment in Chronic Renal Disease) for use in Brazilian Portuguese. This is a retrospective longitudinal observational study. Medical records from 100 CKD patients under conservative treatment, between 2016 and 2017, in a nephrology clinic, were analyzed. PAIR was applied by pharmacists in two consultations of the same patient, with an interval of 6 months. Reliability, conceptual validity, responsiveness of the instrument and prevalence of DRPs in the studied sample were assessed. A mean of 1.26 ± 0.96 DRPs/patient was identified. Inter-rater reliability coefficients (k) ranged from 0.58 to 0.94 and from 0.79 to 1.00 for test-retest, revealing moderate to perfect level of agreement. In conceptual validity, a mean of 1.60 ± 1.24 DRPs/patient was identified by the nephrologist through clinical judgment, compared to 1.33±0.76 DRPs/patient identified by the pharmacist using PAIR (p = 0.07). Therefore PAIR allowed the identification of clinically significant DRPs. In responsiveness, a mean of 1.26 ± 0.96 DRPs/patient was identified at the first consultation and 1.11 ± 1.02 DRPs/patient at the subsequent consultation (p = 0.17) by the pharmacist using PAIR. The number of DRPs between the periods did not change. As a conclusion, the PAIR allowed the identification of clinically significant DRPs in CKD, constituting a new validated instrument to be used in Brazil.

Evaluating an implementation programme for medication review with follow-up in community pharmacy using a hybrid effectiveness study design: translating evidence into practice

OBJECTIVES

To evaluate an implementation programme of a community pharmacy medication review with follow-up (MRF) service using a hybrid effectiveness-implementation study design, and to compare the clinical and humanistic outcomes with those in a previously conducted cluster randomised controlled trial (cRCT).

SETTING

Community pharmacies in Spain.

PARTICIPANTS

135 community pharmacies and 222 pharmacists providing MRF to polymedicated patients aged 65 or over.

INTERVENTION

The intervention was an implementation programme for the MRF service. A national level group was established, mirrored with a provincial level group. A series of interventions were defined (1) to engage pharmacy owners with the implementation model and (2) to provide training to pharmacists consisting of clinical case studies, process of MRF, communication skills and data collection methods and (3) practice change facilitators.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes for the implementation programme were progress, reach, fidelity and integration. The secondary outcomes were number of medications, non-controlled health problems, emergency visits, hospitalisations and health-related quality of life, which were compared with a previous 6-month cluster RCT.

RESULTS

55% of pharmacies reached the implementation phase and 35.6% remained in the testing phase at 12 months. A reach of 89.3% (n=844) was achieved. Fidelity average score was 8.45 (min: 6.2, max: 9.3) out of 10. The integration mean score was 3.39 (SD: 0.72) out of 5. MRF service outcomes were similar to the cluster RCT study; however, the magnitude of the outcomes was delayed.

CONCLUSIONS

The implementation of pharmacy services is a complex multifactorial process, conditioned by numerous implementation factors. In the absence of remuneration, the implementation of the MRF service is a slow process, taking at least 12 months to complete.

TRIAL REGISTRATION NUMBER

CGFTRA-2017-01.

Potentially Inappropriate Prescriptions in Heart Failure with Reduced Ejection Fraction (PIP-HFrEF)

Heart failure (HF) is a chronic debilitating and potentially life-threatening condition. Heart Failure patients are usually at high risk of polypharmacy and consequently, potentially inappropriate prescribing leading to poor clinical outcomes. Based on the published literature, a comprehensive HF-specific prescribing review tool is compiled to avoid medications that may cause HF or harm HF patients and to optimize the prescribing practice of HF guideline-directed medical therapies. Recommendations are made in line with the last versions of ESC guidelines, ESC position papers, scientific evidence, and experts' opinions.

Evaluation of drug therapy problems, medication adherence and treatment satisfaction among heart failure patients on follow-up at a tertiary care hospital in Ethiopia

BACKGROUND

Drug therapy problems (DTPs) are major concerns of healthcare and have been identified to contribute to negative clinical outcomes. The occurrence of DTPs in heart failure patients is associated with worsening of outcomes. The aim of this study was to assess DTPs, associated factors and patient satisfaction among ambulatory heart failure patients at Tikur Anbessa Specialized Hospital (TASH).

METHODS

A hospital based prospective cross-sectional study was conducted on 423 heart failure patients on follow up at TASH. Data was collected through patient interview and chart review. Descriptive statistics, binary and multiple logistic regressions were used for analyses and P < 0.05 was used to declare association.

RESULTS

Majority of the patients were in NYHA class III (55.6%) and 66% of them had preserved systolic function. DTPs were identified in 291(68.8%) patients, with an average number of 2.51±1.07.per patient. The most common DTPs were drug interaction (27.3%) followed by noncompliance (26.2%), and ineffective drug use (13.7%). β blockers were the most frequent drug class involved in DTPs followed by angiotensin converting enzyme inhibitors. The global satisfaction was 78% and the overall mean score of treatment satisfaction was 60.5% (SD, 10.5).

CONCLUSION

Prevalence of DTPs as well as non-adherence among heart failure patients on follow up is relatively high. Detection and prevention of DTPs along with identifying patients at risk can save lives, help to adopt efficient strategies to closely monitor patients at risk, enhance patient's quality of life and optimize healthcare costs.

Risk factors for drug-related problems in a general hospital: A large prospective cohort

OBJECTIVE

To identify risk factors for potential Drug-Related Problems (DRP) at admission in hospitalized patients.

METHODOLOGY

Prospective cohort study conducted in adults patients hospitalized (May 2016 to May 2018) in a general tertiary care hospital in Brazil. Potential DRP were detected by daily review of 100% of electronic medication orders by hospital pharmacists and classified by the Pharmaceutical Care Network Europe classification system (PCNE version 6.2). For the identification of risk factors of potential DRP, backward stepwise logistic regression was used to identify the set of independent predictors among over 120 variables collected in the initial 48 hours after admission in a training set consisting of 2/3 of the study population. The model was validated in the remaining sample.

RESULTS

The study population consisted of 1686 patients aged 52.0+/- 18.3 years-old, 51.4% females, with a median length of stay of 3.24 days, and 4.5% in-hospital mortality. The cumulative incidence of potential DRP was 14.5%. Admission for elective surgery and main diagnosis of disease of the circulatory system were associated with reduced risk of DRP (OR 0.41 and 0.57, respectively, p<0.05). The independent risk factors of DRP are heart rate ≥ 80 bpm (OR 1.41, p = 0.05), prescription of more than seven drugs in day 2 (OR 1.63, p = 0.05), prescription in day 1 of drugs of the Anatomical Therapeutic Chemical Code (ATC) class A (alimentary tract and metabolism, OR 2.24, p = 0.003), prescription in day 2 of two or more ATC class A drugs (OR = 3.52, p<0.001), and in day 1 of ATC class J drugs (antiinfectives for systemic use, OR 1.97, p = 0.001). In the validation set, the c-statistic of the predictive model was 0.65, the sensitivity was 56.1% and the specificity was 65.2%.

CONCLUSION

This study identified seven independent risk factors of potential DRP in patients hospitalized in a general hospital that have fair predictive performance for utilization in clinical practice.

Polypharmacy and health outcomes in atrial fibrillation: a systematic review and meta-analysis

Objective

To undertake a systematic review and meta-analysis examining the impact of polypharmacy on health outcomes in atrial fibrillation (AF).

Data sources

PubMed and Embase databases were searched from inception until 31 July 2019. Studies including post hoc analyses of prospective randomised controlled trials or observational design that examined the impact of polypharmacy on clinically significant outcomes in AF including mortality, hospitalisations, stroke, bleeding, falls and quality of life were eligible for inclusion.

Results

A total of six studies were identified from the systematic review, with three studies reporting on common outcomes and used for a meta-analysis. The total study population from the three studies was 33 602 and 37.2% were female. Moderate and severe polypharmacy, defined as 5–9 medicines and >9 medicines, was observed in 42.7% and 20.7% of patients respectively, and was associated with a significant increase in all-cause mortality (Hazard ratio [HR] 1.36, 95% CI 1.20 to 1.54, p<0.001; HR 1.84, 95% CI 1.40 to 2.41, p<0.001, respectively), major bleeding (HR 1.32, 95% CI 1.14 to 1.52, p<0.001; HR 1.68, 95% CI 1.35 to 2.09, p<0.001, respectively) and clinically relevant non-major bleeding (HR 1.12, 95% CI 1.03 to 1.22, p<0.01; HR 1.48, 95% CI 1.33 to 1.64, p<0.01, respectively). There was no statistically significant association between polypharmacy and stroke or systemic embolism or intracranial bleeding. Among other examined outcomes, polypharmacy was associated with cardiovascular death, hospitalisation, reduced quality of life and poorer physical function.

Conclusions

Polypharmacy is highly prevalent in the AF population and is associated with numerous adverse outcomes.

PROSPERO registration number

CRD42018105298.

Drug-related problems in prescribing for coronary artery diseases in Vietnam: cross-sectional study

OBJECTIVES

To determine the prevalence, patterns and determinants of drug-related problems (DRPs) in prescribing for coronary artery diseases (CADs) in Vietnam.

METHODS

Retrospective cross-sectional study on outpatients with CADs at a general hospital in Can Tho, Vietnam. DRPs were classified according to Pharmaceutical Care Network Europe definitions. We determined the prevalence and patterns of DRPs. Logistic regression was used to identify the determinants of DRPs.

RESULTS

Among 683 patients (mean age 63.4; 64.3% female), the prevalence of DRPs was 61.1%. DRPs comprised inappropriate indication (3.5%), inappropriate dosage (22.2%), wrong frequency of use (24.2%), wrong time of taking medications (4.1%), taking medications at the wrong time around meals (19.2%) and drug interactions (19.3%). Patients who took ≥ 5 drugs were more likely to have DRPs (adjusted odds ratio = 1.96; 95% confidence interval = 1.31-2.93). Patients without health insurance were more likely to have inappropriate indication (ORa = 2.93; 95%CI = 1.28-6.70). Taking medications at inappropriate times around meals was common among men (ORa = 1.82; 95%CI = 1.23-2.69) and among those with health insurance (ORa = 1.66; 95%CI = 1.05-2.63). Patients < 65 years old were more likely to be prescribed inappropriate doses (ORa = 1.67; 95%CI = 1.15-2.45). Prescriptions with ≥ 5 drugs were more likely to be taken at inappropriate frequency (ORa = 1.87; 95%CI = 1.09-3.21) and to cause drug interactions (ORa = 6.48; 95%CI = 2.59-16.24).

CONCLUSIONS

DRPs are common among patients with CADs in Vietnam. The number of DRPs increases with the number of drugs in prescriptions. Further studies should identify other potential determinants of DRPs and effective interventions to improve prescribing practice in Vietnam.

Medication-Related Problems in Outpatients With Decompensated Cirrhosis: Opportunities for Harm Prevention

People with decompensated cirrhosis are often prescribed a complex regimen of therapeutic and prophylactic medications. In other chronic diseases, polypharmacy increases the risk of medication misadventure and medication-related problems (MRPs), with associated increased morbidity, mortality, and health care costs. This study examined MRPs in a cohort of ambulatory patients with a history of decompensated cirrhosis who were enrolled in a randomized controlled trial of a pharmacist-led, patient-oriented medication education intervention and assessed the association between MRPs and patient outcomes. A total of 375 MRPs were identified among 57 intervention patients (median, 6.0; interquartile range, 3.5-8.0 per patient; maximum 17). Nonadherence (31.5%) and indication issues (29.1%) were the most prevalent MRP types. The risk of potential harm associated with MRPs was low in 18.9% of instances, medium in 33.1%, and high in 48.0%, as categorized by a clinician panel using a risk matrix tool. Patients had a greater incidence rate of high-risk MRPs if they had a higher Child-Pugh score (incidence rate ratio [IRR], 1.31; 95% confidence interval [CI], 1.09-1.56); greater comorbidity burden (IRR, 1.15; 95% CI, 1.02-1.29); and were taking more medications (IRR, 1.12; 95% CI, 1.04-1.22). A total of 221 MRPs (58.9%) were resolved following pharmacist intervention. A greater proportion of high-risk MRPs were resolved compared to those of low and medium risk (68.9% versus 49.7%; P < 0.001). During the 12-month follow-up period, intervention patients had a lower incidence rate of unplanned admissions compared to usual care (IRR, 0.52; 95% CI, 0.30-0.92). Conclusion: High-risk MRPs are prevalent among adults with decompensated cirrhosis. Pharmacist intervention facilitated identification and resolution of high-risk MRPs and was associated with reduced incidence rate of unplanned hospital admissions in this group.

Role and impact of pharmacists in Spain: a scoping review

Background The role of the pharmacist has evolved greatly over the last decades, expanding to patient-oriented activities, administrative tasks and public health functions. However, considerable differences emerge across regions. Aim of the review To gather evidence in order to describe and highlight the different characteristics of the pharmacists' role and the impact of their activities in Spain. Method A review of the existing literature was conducted. The literature search was undertaken in PubMed between 01/01/2006 and 15/08/2017. Results were screened and reviewed to extract previously established criteria such as author(s), publication year, language, study design, setting, pharmaceutical activity, patient care programs, targeted diseases and intervention description using DEPICT2 tool. Pharmaceutical intervention were classified into eight outcome measures and categorized by types of outcomes reported: descriptive or impact evaluation regarding the effect of the service (positive, neutral or negative). Results The search strategy resulted in 473 articles and 108 articles met the inclusion criteria. The most common design was observational (n = 76, 70%). Most articles were published after 2011 (75%), in English (69%). Studies were conducted in hospitals (60%) and community pharmacies (30%). Of the 24 pharmaceutical activities identified, medication review was the activity most frequently studied (n = 42), followed by patient education (n = 29), risk and prevention (n = 27) and medication reconciliation (n = 19). Only 39 articles (36%) had outcome measures with impact evaluation. Of the 223 impact outcome measures, 48% (107/223) had a positive effect. Conclusion This review shows the substantial scientific production focusing on pharmacy practice in Spain over the last years. The evidence reviewed reflects the pharmacist role at various professional settings, providing a wide variety of activities on diverse targeted diseases and patient care programs, in line with the increasing specialization of clinical pharmacists over the last years.

Drug therapy problems and contributing factors in the management of heart failure patients in Jimma University Specialized Hospital, Southwest Ethiopia

BACKGROUND

Drug therapy problem (DTP) is any unwanted incident related to medication therapy that actually or potentially affects the desired goals of treatment. Heart failure (HF) patients are more likely to experience DTP owing to multiple prescriptions and comorbidities. Despite the serious negative impact of DTP on treatment outcomes, there is a dearth of study on DTP among HF patients in Ethiopia.

OBJECTIVE

The main aim of this study was to assess the prevalence and contributing factors of DTP among ambulatory HF patients in Jimma University Specialized Hospital, Ethiopia.

METHODS

A hospital based prospective observational study was conducted. Written informed consent was obtained from each patient after full explanation of the study. Data were collected through patient interview and expert review of medical, medication and laboratory records of one-year follow-up from May 2015 to April 2016. DTPs were identified using Cipolle's method followed by consensus review with experts. Binary logistic regression was performed to identify factors contributing to DTP. A p<0.05 was considered statistically significant in all analyses.

RESULT

Of 340 study participants; male to female ratio was equivalent, the mean (± SD = standard deviation) age was 50.5±15.6 years. Eight hundred eighty DTPs were identified equating 2.6 ±1.8 DTPs per patient. The frequently identified DTPs were dosage too low (27.8%), ineffective drug therapy (27.6%) and need additional drug therapy (27.4%). Most commonly implicated drugs were beta-blockers (34.4%), angiotensin converting enzyme inhibitors (24.8%), statins (16.5%) and antithrombotics (13.1%). Factors contributing to DTP were age >50 years (AOR [adjusted odd ratio] = 5.43, 95%CI [95% confidence interval] = 2.03-14.50); negative medication belief (AOR = 3.50, 95%CI = 1.22-10.05); poor involvement of patients in the therapeutic decision makings (AOR = 4.11, 95%CI = 1.91-8.88); number of co-morbidity≥2(AOR = 5.26, 95%CI = 2.38-11.65) and number of medications ≥5 (AOR = 3.68, 95%CI = 1.28-10.51).

CONCLUSION

DTPs are common among ambulatory care HF patients. Patients with older age, negative medication belief, polypharmacy, co-morbidities and those who were poorly involved in the therapeutic decision were more likely to experience DTP. Despite traditional prescription refilling, an integrated multidisciplinary approach involving patients and clinically trained pharmacists should be implemented in the patient care process at ambulatory care clinics in order to improve overall outcomes and reduce DTPs and associated burdens in HF patients.

Assessment of drug related problems among type 2 diabetes mellitus patients with hypertension in Hiwot Fana Specialized University Hospital, Harar, Eastern Ethiopia

Objective

This study was conducted to assess magnitude and pattern of drug related problems among patients with type 2 diabetes mellitus (T2DM) and hypertension.

Results

This study identified 364 drug related problems (DRPs) across the three categories of drug related problems, giving an average of 1.8 DRPs per patient. The effect of drug treatment being not optimal 179 (49.2%), untreated indication and symptoms 77 (21.1%), unnecessary drug-treatment 39 (10.7%) and adverse drug reactions 69 (19%) were the most frequent categories of DRPs identified. In general, high prevalence of drug-related problems was identified among patients with T2DM hypertension. The effect of drug treatment being not optimal, untreated indication and symptoms, unnecessary drug-treatment and adverse drug reactions were the most frequent categories of drug related problems identified. Therefore, the clinicians should work to improve patient care through prevention and resolving drug related problems since it can affect the quality of the care significantly.

Domain Management Approach to Heart Failure in the Geriatric Patient: Present and Future

Heart failure (HF) is a quintessential geriatric cardiovascular condition, with more than 50% of hospitalizations occurring in adults age 75 years or older. In older patients, HF is closely linked to processes inherent to aging, which include cellular and structural changes to the myocardium, vasculature, and skeletal muscle. In addition, HF cannot be considered in isolation of physical functioning, or without the social, psychological, and behavioral dimensions of illness. The role of frailty, depression, cognitive impairment, nutrition, and goals of care are each uniquely relevant to the implementation and success of medical therapy. In this paper, we discuss a model of caring for older adults with HF through a 4-domain framework that can address the unique multidimensional needs and vulnerabilities of this population. We believe that clinicians who embrace this approach can improve health outcomes for older adults with HF.

Evaluation of a Clinical Pharmacist Intervention on Clinical and Drug-Related Problems Among Coronary Heart Disease Inpatients: A pre-experimental prospective study at a general hospital in Indonesia

Objectives

This study aimed to evaluate the role of a clinical pharmacist intervention in decreasing subsequent clinical and drug-related problems (DRPs) among coronary heart disease (CHD) inpatients with at least one previous DRP.

Methods

This pre-experimental study with a pre-post design was carried out from January to April 2017 among inpatients with at least one previous DRP at a general hospital in Tangerang District, Banten, Indonesia. Clinical and DRPs were documented prospectively by a clinical pharmacist, with DRPs classified using Version 6.2 of the DRP classification scheme of the Pharmaceutical Care Network Europe Foundation. The intervention consisted of a discussion of identified DRPs with physicians, patients, pharmaceutical logistics clerks, nurses and nutritionists. Following this, any subsequent clinical and DRPs were re-identified and further interventions were conducted as necessary.

Results

A total of 75 inpatients were included in the study. Pre-intervention, there were 443 DRPs and 202 clinical problems. The most frequent DRPs were adverse drug reactions (52.6%), followed by drug effects (41.8%). Most DRPs were of moderate severity and would have resulted in moderate consequences had the pharmacist not intervened. The interventions resulted in a significant reduction in the number of DRPs, type of DRPs and number of clinical problems (P <0.05 each). Patients with complications were 26.047 times more likely to have no reduction or an increased number of clinical problems compared to patients without complications (P <0.05).

Conclusion

Clinical pharmacist interventions were found to reduce subsequent DRPs and clinical problems among CHD patients with at least one previous DRP.

Evaluating the Safety and Tolerability of Sacubitril/Valsartan for HFrEF Managed Within a Pharmacist Clinic

OBJECTIVE

The objective of this research was to describe the use of pharmacist-managed sacubitril/valsartan therapy in a multi-center, outpatient cardiac group.

BACKGROUND

Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor (ARNi), is a novel agent for the treatment of heart failure. An ARNi is recommended by national guidelines to be used in place of angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) therapy for patients who remain symptomatic.

METHODS

A retrospective chart review was performed to identify patients initiated and fully titrated on sacubitril/valsartan therapy from July 7, 2015 to March 7, 2017.

RESULTS

Fifty-two of the 72 symptomatic heart failure with reduced ejection fraction (HFrEF) patients prescribed sacubitril/valsartan during the 21-month period were included in this analysis. The average ejection fraction was 26%. The average age was 69 years. At baseline, 26.9% of patients were not on ACEi/ARB therapy and 13.5% were on target-dose therapy. After completing the uptitration process, the maximally tolerated dose of sacubitril/valsartan was 5.8% low-dose, 7.7% mid-dose, and 86.5% target-dose. Loop and thiazide diuretic use decreased significantly. There was a significant mean reduction in systolic blood pressure of 6 mmHg with no significant changes in serum creatinine, blood urea nitrogen, or potassium levels.

CONCLUSIONS

With close monitoring and follow-up, ARNi therapy was a safe alternative to ACEi/ARB therapy for chronic symptomatic HFrEF when initiated within a pharmacist clinic.

A Description of Patient and Provider Experience and Clinical Outcomes After Heart Failure Shared Medical Appointment

Background:

Shared medical appointments (SMAs) are clinical visits in which several patients meet with 1 or more providers at the same time.

Objective:

To describe the outcomes of an interdisciplinary SMA for veterans recently discharged for heart failure (HF).

Methods:

A retrospective chart review for patients’ readmission rates, survival, medication adherence, and medication-related problems. For qualitative outcomes, we performed semistructured interviews on 12 patients who had undergone HF SMAs and their respective caregivers focusing on care satisfaction, HF knowledge, disease self-care, medication reconciliation, and peer support.

Results:

The cohort comprised 70 patients—49% had left ventricular function <40% and 50% were prescribed >10 medications. Medication-related problems occurred in 60% of patients. Interviews revealed overall satisfaction with HF-SMA, but patients felt overwhelmed with HF instructions, perceived lack of peer support and self-efficacy, and feelings of hopelessness related to HF.

Conclusion:

Shared medical appointments are well-perceived. Medication problems and need for medication management are prevalent along with patient’s lack of self-efficacy in HF care. Multiple HF-SMA visits may be needed to reinforce concepts, reduce confusion, and garner peer support.

Patient-oriented education and medication management intervention for people with decompensated cirrhosis: study protocol for a randomized controlled trial

BACKGROUND

People with decompensated cirrhosis require complex medical care and are often prescribed an intricate and frequently changing medication and lifestyle regimen. However, many patients mismanage their medications or have poor comprehension of their disease and self-management tasks. This can lead to harm, hospitalization, and death.

METHODS/DESIGN

A patient-oriented education and medication management intervention has been developed for implementation at a tertiary hospital hepatology outpatient center in Queensland, Australia. Consenting patients with decompensated cirrhosis will be randomly allocated to education intervention or usual care treatment arms when they attend routine follow-up appointments. In the usual care arm, participants will be reviewed by their hepatologist according to the current model of care in the hepatology clinic. In the intervention arm, participants will be reviewed by a clinical pharmacist to receive the education and medication management intervention at baseline in addition to review by their hepatologist. Intervention participants will also receive three further educational contacts from the clinical pharmacist within the following 6-month period, in addition to routine hepatologist review that is scheduled within this time frame. All participants will be surveyed at baseline and follow-up (approximately 6 months post-enrollment). Validated questionnaire tools will be used to determine participant adherence, medication beliefs, illness perceptions, and quality of life. Patients' knowledge of dietary and lifestyle modifications, their current medications, and other clinical data will be obtained from the survey, patient interview, and medical records. Patient outcome data will be collected at 52 weeks.

DISCUSSION

The intervention described within this protocol is ready to adapt and implement in hepatology ambulatory care centers globally. Investigation of potentially modifiable variables that may impact medication management, in addition to the effect of a clinical pharmacist-driven education and medication management intervention on modifying these variables, will provide valuable information for future management of these patients.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry identifier: ACTRN12616000780459 . Registered on 15 June 2016.

Impact of a Pharmacist-Managed Heart Failure Postdischarge (Bridge) Clinic for Veterans

Background: Hospitals that provide early postdischarge follow-up after heart failure (HF) hospitalization tend to have lower rates of readmission. However, HF postdischarge (bridge) clinics have not been extensively evaluated. Objective: To assess the impact of a pharmacist-managed HF bridge clinic in a veteran population. Methods: HF patients hospitalized from November 2010 to August 2013 were identified. Retrospective chart review was conducted of 122 HF patients seen at bridge clinic compared with 122 randomly selected HF patients not seen at this clinic (usual care). Primary end point was 90-day all-cause readmission and death. Secondary outcomes were 30-day all-cause readmission and death, time to first postdischarge follow-up, first all-cause readmission. Results: Bridge clinic patients were at higher baseline risk of readmission and death; other characteristics were similar. 90-day death and all-cause readmission trended lower in bridge clinic patients (adjusted hazard ratio [HR] = 0.64; 95% CI = 0.40-1.02; P = 0.06). Time to first follow-up was shorter in bridge clinic patients (11 ± 6 vs 20 ± 23 days; P < 0.001); time to first all-cause readmission trended longer (40 ± 20 vs 33 ± 25days; P = 0.11). 30-day death and all-cause readmission was significantly lower in bridge clinic patients (adjusted HR = 0.44; 95% CI = 0.22-0.88; P = 0.02). Conclusions: In veteran patients hospitalized for HF, pharmacist-managed HF bridge clinic significantly reduced the time to initial follow-up compared with usual care. Improved short-term outcomes and trend toward improvement of longer-term outcomes in bridge clinic patients was shown.

Impact of a pharmaceutical care programme for patients with chronic disease initiated at the emergency department on drug-related negative outcomes: a randomised controlled trial

Background

The resolution of potential drug-related problems is a priority of pharmaceutical care programmes.

Objectives

To assess the clinical impact on drug-related negative outcomes of a pharmaceutical care programme focusing on the resolution of potential drug-related problems, initiated in the emergency department for patients with heart failure (HF) and/or chronic obstructive pulmonary disease (COPD).

Methods

Controlled trials, in which older adults (≥65 years) receiving four or more medications admitted to the emergency department for ≥12 hours for worsening of HF and/or COPD were randomised (1:1) to either a pharmaceutical care programme focusing on resolving potential drug-related problems initiated at the emergency department (intervention group (IG)) or standard care (control group). Comparisons between the groups were made for the proportion of patients with drug-related negative outcomes, number of drug-related negative outcomes per patient, mean stay, patients readmitted within 180 days and 180-day mortality.

Results

118 patients were included, 59 in each group. Fewer patients in the IG had drug-related negative outcomes (37 (62.7%) vs 47 (79.7%) in the control group (p=0.042)). Fewer drug-related negative outcomes per patient occurred in the IG (56 (0.95 per patient) vs 85 (1.44 per patient) in the control group (p=0.01)). The mean stay was similar between groups (194.7 hours in the IG vs 242.5 hours in the control group (p=0.186)). No difference in revisits within 180 days was found (32 (54.24%) in the IG vs 22 (37.3%) in the control group (p=0.065)). 180-Day mortality was detected in 11 (18.6%) patients in the IG compared with 13 (22%) in the control group (p=0.647).

Conclusion

A pharmaceutical care programme focusing on resolving potential drug-related problems initiated at the emergency department has a favourable clinical impact, as it reduces the number and prevalence of drug-related negative outcomes. No difference was found in other outcome variables.Trial registration number NCT02368548.

Characterization of Drug-Related Problems Occurring in Patients Receiving Outpatient Antimicrobial Therapy

Background:

Despite the numerous benefits of outpatient parenteral antimicrobial therapy (OPAT), appreciable risks of drug-related problems (DRPs) exist. No studies to date comprehensively assess DRPs in this population.

Objectives:

Objectives of this study were to (1) characterize the frequency and types of DRPs experienced by patients discharged on OPAT and (2) determine the fraction of adverse drug reactions (ADRs) resulting in hospital readmission or emergency department (ED) presentation and changes in therapy.

Methods:

This was a retrospective chart analysis evaluating consecutive adult patients discharged on OPAT between May 2015 and October 2015. Patients were assessed for the presence of DRPs until the cessation of antimicrobial treatment, including oral step-down therapy. The outcome of each ADR was recorded, including those resulting in hospital readmissions, presentation to the ED, or changes in antimicrobials.

Results:

Among 144 patients discharged on OPAT, 199 DRPs occurred in 91 (63.2%) patients. Harm and potential impaired efficacy occurred in 76.9% and 23.1%, respectively. The ADRs comprised 59% of DRPs, occurring in 44.4% of patients. The second most common DRP type was drug interactions (DIs), accounting for 22.6% of DRPs. Rifampin, fluoroquinolones, and daptomycin had the highest frequencies of preventable DRPs in the form of DIs, whereas cephalosporins had the fewest DRPs. Approximately 26% of ADRs caused changes in therapy and 9% resulted in hospital readmission or ED utilization.

Conclusion:

DRPs with the potential to cause patient harm or impair treatment efficacy often occur with OPAT, most commonly ADRs and DIs. Enhanced monitoring and transitions of care management may reduce the incidence of these DRPs.

Patterns of scheduled follow-up appointments following hospitalization for heart failure: insights from an urban medical center in the United States

Objectives

Although postdischarge outpatient follow-up appointments after a hospitalization for heart failure represent a potentially effective strategy to prevent heart failure readmissions, patterns of scheduled follow-up appointments upon discharge are poorly described. We aimed to characterize real-world patterns of scheduled follow-up appointments among adult patients with heart failure upon hospital discharge.

Patients and methods

This was a retrospective cohort study performed at a large urban academic center in the United States among adults hospitalized with a principal diagnosis of congestive heart failure between January 1, 2013, and December 31, 2014. Patient demographics, administrative data, clinical parameters, echocardiographic indices, and scheduled postdischarge outpatient follow-up appointments were collected.

Results

Of the 796 patients hospitalized for heart failure, just over half of the cohort had a scheduled follow-up appointment upon discharge. Follow-up appointments were less likely among patients who were white and had heart failure with preserved ejection fraction and more likely among patients with Medicaid and chronic obstructive pulmonary disease. In an adjusted multivariable regression model, age ≥65 years was inversely associated with a scheduled follow-up appointment upon hospital discharge, despite higher rates of several cardiovascular and noncardiovascular comorbidities.

Conclusion

Just half of the patients discharged home following a hospitalization for heart failure had a follow-up appointment scheduled, representing a missed opportunity to provide a recommended care transition intervention. Despite a greater burden of both cardiovascular and noncardiovascular comorbidities, older adults (age ≥65 years) were less likely to have a follow-up appointment scheduled upon discharge compared with younger adults, revealing a disparity that warrants further investigation.

Drug-related problems in a sample of outpatients with chronic diseases: a cross-sectional study from Jordan

Optimization of drug therapy and preventing drug-related problems (DRPs) are major factors to improve health care, reduce expenditure, and potentially save lives. This study aimed at describing the types, numbers, and frequencies of DRPs in the outpatient settings of a group of hospitals in Jordan. The study was set in the cardiology, endocrine, and respiratory outpatient clinics of five major hospitals in Jordan. Patients who visited the above clinics during the period from September 2012 to December 2013, were candidates for this study. Each included subject was fully assessed for DRPs by clinical pharmacists according to a specially designed and validated pharmaceutical care manual. The main outcome measures were the number and types of DRPs. Data were collected from 2,898 patients (mean age ± standard deviation: 56.59±13.5 years). The total number of identified DRPs was 32,348, with an average of 11.2 DRPs per patient. The most common DRPs were a need for additional or more frequent monitoring, a problem in patients' adherence to self-care activities or nonpharmacological therapy, and that the patient was not given instruction in or did not understand nonpharmacological therapy or self-care advice. The numbers of DRPs per patient in our sample were associated with older age (>57 years), being unmarried, having an education level of high school or less, not having health insurance, and the presence of certain clinical conditions, including hypertension, diabetes mellitus, dyslipidemia, ischemic heart disease, cardiac catheterization, heart failure, and gout. In conclusion, implementation of clinical pharmacy services is a strategy to limit DRPs. Certain patient populations are more vulnerable to DRPs.

Drug-related problems vary with medication category and treatment duration in Taiwanese heart failure outpatients receiving case management

BACKGROUND/PURPOSE

Heart failure (HF) patients are at high risk of having drug-related problems (DRPs). We aim to describe the frequency, types, and temporal occurrence of DRPs in Taiwanese HF outpatients receiving case management.

METHODS

In this study, we included 141 patients from HF clinics in three hospitals in Taiwan from October 2008 to December 2010. Nurse case managers at each of the participating sites registered case report forms (CRFs) for patients during clinic visits. DRPs were classified using the Pharmaceutical Care Network Europe Foundation (PCNE) classification system and documented by pharmacists after reviewing CRFs and participating in multidisciplinary team discussions.

RESULTS

For 141 clinic participants, the average duration of medication use was 17 months, and 796 DRPs were reported. The DRPs most frequently recorded were the need for laboratory tests (32.7% of total DRPs), followed by potential interaction (29.6%), nonallergic side effects (13.3%), and insufficient awareness of health and disease (9.5%). The drugs most frequently causing a DRP were angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, diuretics, warfarin, spironolactone, and β-blockers. The incidence rates of total DRPs was maximal during the initial 3 months of medication treatment, whereas the incidence rates of each category of DRPs showed multiform changes over time among various drug classes.

CONCLUSION

In Taiwan where the clinical pharmacist system is not well organized, HF outpatients still had a high prevalence of DRPs despite intensive monitoring by nurse case managers. Clinical pharmacists play critical roles in detecting potential DRPs during long-term medication treatment for this population.

Risk factors for developing drug-related problems in patients with cardiovascular diseases attending Gondar University Hospital, Ethiopia

Background:

Cardiovascular diseases (CVDs) are often accompanied with comoribidities and complications leading to taking multiple drugs and thus are more liable to be exposed to drug-related problems (DRPs). DRPs can occur at any stages of medication process from prescription to follow-up treatment. However, a few studies have assessed the specific risk factors for occurrence of at least one potential DRP per patient with CVDs in sub-Saharan African region.

Aim:

We aim to assess the risk factors for developing potential DRPs in patients with CVDs attending Gondar University Referral Hospital (GUH).

Methodology:

This was a cross-sectional study. A structured systematic data review was designed focusing on patients with CVDs (both out and inpatients) with age >18 years of both genders attending GUH from April to June 2015. All DRPs were assessed using drugs.com and Medscape. The causes of DRPs were classified using Pharmaceutical Care Network Europe version 6.2. Risk factors that could cause DRPs were assessed using binary logistic regression showing odds ratio with 95% confidential interval. Statistical significance was set at P < 0.05.

Results:

A total of 227 patients with CVDs were reviewed with a mean age of 52.0 ± 1.7 years. Majority were females (143, 63%), outpatients (133, 58.6%), and diagnosed with heart failure (71, 31.3%). Diuretics (199, 29.5%) were the most commonly prescribed drugs. A total of 265 DRPs were identified, 63.4% of patients have at least one DRP (1.17 ± 1.1). The most common DRPs were found to be an inappropriate selection of drug (36.1%) and dose (24.8%). The most identified risk factors causing DRPs were: Need of additional drug therapy and lack of therapeutic monitoring.

Conclusion:

The most identified risk factors for developing DRPs were the need of additional drug therapy and lack of therapeutic monitoring. There is a need for clinical pharmacist interventions to monitor and prevent the risk of developing DRPs and contribute to improve the clinical outcome in patients with CVDs.

Comprehensive therapeutic approach for patients with heart failure and comorbidity

The prevalence of heart failure increases with age and is accompanied by other diseases, which are encompassed within a «cardiometabolic phenotype». Their interrelation changes the evolution and treatment that each disease would have in isolation. Patients with heart failure and comorbidity are frail and complex. They require a comprehensive assessment (not just biomedical), which includes functional, cognitive, affective and psychosocial aspects. The overall treatment, which is not covered in the clinical practice guidelines, should adapt to each and every one of the comorbidities. Polypharmacy should be avoided as much as possible, due to its interactions and reduced adherence. Treatment needs to be optimised and adapted to the evolutionary phase of the disease and the specific needs of each patient. The complexity of the care process for patients with heart failure and comorbidities requires the coordination of healthcare providers and support from family and others involved in the patient's care.

[Chronic heart failure in the elderly patient]

The prevalence and incidence of heart failure (HF) is increasing, especially in the elderly population, and is becoming a major geriatric problem. Elderly patients with HF usually show etiopathogenic, epidemiological, and even clinical characteristics significantly different from those present in younger patients. Their treatment, however, derives from clinical trials performed with only a few elderly subjects. Moreover, beyond the cardiovascular disease itself, it is essential to evaluate the patient as a whole, given the interrelationship between HF and the characteristic geriatric syndromes of the elderly patient. This review examines the peculiarities in the most prevalent "real world" HF patient.