Barriers and facilitators of medication reconciliation processes for recently discharged patients from community pharmacists' perspectives

A systematic review of outcomes reported in studies to optimise the medication use of patients at hospital discharge

INTRODUCTION

Care transitions, specifically hospital discharge, hold a risk for drug-related problems and medication errors. Effective interventions that optimise medication use during and after transitions are needed, yet there is no standardisation of the outcomes. This literature review aimed at collecting outcomes from studies investigating how to optimise medication use of patients following hospital discharge, and to categorise them, as a first step in the development of a core outcome set.

METHODS

We systematically reviewed quantitative and qualitative literature using Embase, PubMed, CINAHL and the EU Clinical Trial Register databases. Studies investigating the optimisation of medication use following hospital discharge were eligible. The quantitative literature review specifically included trials and protocols that evaluated the effect of an intervention for patients ≥ 65 years or multimorbid / polypharmacy patients, as they are at high risk of drug-related problems. The qualitative literature review focused on the patients' and healthcare professionals' views. Outcomes were summarised into unique outcome terms and categorised using an adapted version of the OMERACT filter 2.0.

RESULTS

The review included 75 quantitative and 20 qualitative studies. The interventions investigated in the quantitative literature mostly had multiple components performed either pre- or post-discharge. Sixty percent of the qualitative studies addressed the views of healthcare professionals, 40% the views of patients, and only one study addressed both. A median of 5 outcomes (range 1-17) were reported in the quantitative studies. In total, 91 unique outcomes were identified from the quantitative or qualitative literature, or both (73, 12 and 6 outcomes, respectively). Outcomes were categorised into five domains: 'medication' (n = 32 outcomes), 'economic impact/resource use' (n = 26), 'life impact' (n = 16), 'pathophysiological manifestations' (n = 15) and 'death' (n = 2). The top 5 most frequently measured outcomes in quantitative studies were number of readmissions (n = 54/75, 72%), mortality (n = 30/75, 40%), number of emergency department visits (n = 26/75, 35%), number of outpatient physician visits (n = 12/75, 16%), and medication adherence (n = 12/75, 16%).

DISCUSSION AND CONCLUSION

This study identified a large number of different outcomes, especially in the domains medication and economic impact/resource use. This heterogeneity impedes the identification of effective interventions and confirms the need for a core outcome set.

Application of behavioural theories, models, and frameworks in pharmacy practice research based on published evidence: a scoping review

BACKGROUND

Pharmacy practice research often focuses on the design, implementation and evaluation of pharmacy services and interventions. The use of behavioural theory in intervention research allows understanding of interventions' mechanisms of action and are more likely to result in effective and sustained interventions.

AIM

To collate, summarise and categorise the reported behavioural frameworks, models and theories used in pharmacy practice research.

METHOD

PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and EBSCO (CINAHL PLUS, British Education index, ERIC) were systematically searched to capture all pharmacy practice articles that had reported the use of behavioural frameworks, theories, or models since inception of the database. Results were filtered to include articles published in English in pharmacy practice journals. Full-text screening and data extraction were independently performed by two reviewers. A narrative synthesis of the data was adopted. Studies were reviewed for alignment to the UK Medical Research Council (MRC) framework to identify in which phase(s) of the research that the theory/model/framework had been employed.

RESULTS

Fifty articles met the inclusion criteria; a trend indicating an increasing frequency of behavioural theory/frameworks/models within pharmacy practice research was identified; the most frequently reported were Theory of Planned Behaviour and Theoretical Domains Framework. Few studies provided explicit and comprehensive justification for adopting a specific theory/model/framework and description of how it underpinned the research was lacking. The majority were investigations exploring determinants of behaviours, or facilitators and barriers to implementing or delivering a wide range of pharmacy services and initiatives within a variety of clinical settings (aligned to Phase 1 UK MRC framework).

CONCLUSION

This review serves as a useful resource for future researchers to inform their investigations. Greater emphasis to adopt a systematic approach in the reporting of the use of behavioural theories/models/frameworks will benefit pharmacy practice research and will support researchers in utilizing behavioural theories/models/framework in aspects of pharmacy practice research beyond intervention development.

Structured medication reviews in Parkinson's disease: pharmacists' views, experiences and needs - a qualitative study

Background

Executing structured medication reviews (SMRs) in primary care to optimize drug treatment is considered standard care of community pharmacists in the Netherlands. Patients with Parkinson's disease (PD) often face complex drug regimens for their symptomatic treatment and might, therefore, benefit from an SMR. However, previously, no effect of an SMR on quality of life in PD was found. In trying to improve the case management of PD, it is interesting to understand if and to what extent SMRs in PD patients are of added value in the pharmacist's opinion and what are assumed facilitating and hindering factors.

Objectives

To analyse the process of executing SMRs in PD patients from a community pharmacist's point of view.

Design

A cross-sectional, qualitative study was performed, consisting of face-to-face semi-structured in-depth interviews.

Methods

The interviews were conducted with community pharmacists who executed at least one SMR in PD, till data saturation was reached. Interviews were transcribed verbatim, coded and analysed thematically using an iterative approach.

Results

Thirteen pharmacists were interviewed. SMRs in PD were considered of added value, especially regarding patient contact and bonding, individualized care and its possible effect in the future, although PD treatment is found already well monitored in secondary care. Major constraints were time, logistics and collaboration with medical specialists.

Conclusion

Although community pharmacist-led SMRs are time-consuming and sometimes logistically challenging, they are of added value in primary care in general, and also in PD, of which treatment occurs mainly in secondary care. It emphasizes the pharmacist's role in PD treatment and might tackle future drug-related issues. Improvements concern multidisciplinary collaboration for optimized SMR execution and results.

Pharmacist-led medication reconciliation service for patients after discharge from tertiary hospitals to primary care in Singapore: a qualitative study

BACKGROUND

Medication discrepancies commonly occur when patients are transferred between care settings. Despite the presence of medication reconciliation services (MRS), medication discrepancies are still prevalent, which has clinical costs and implications. This study aimed to explore the perspectives of various stakeholders on how the MRS can be optimized in Singapore.

METHODS

This is a descriptive qualitative study. Semi-structured interviews with 30 participants from the National Healthcare Group, including family physicians (N = 10), pharmacists (N = 10), patients recently discharged from restructured hospitals (N = 7) and their caregivers (N = 3) were conducted. All transcribed interviews were coded independently by three coders and inductive thematic analysis approach was used.

RESULTS

Five core themes were identified. (1) The MRS enhanced healthcare services in various aspects including efficiency and health literacy; (2) There were several challenges in delivering the MRS covering processes, technology and training; (3) Issues with suitable patient selection and follow-up; (4) Barriers to scaling up of MRS that involve various stakeholders, cross-sector integration and environmental restrictions; and finally (5) Role definition of the pharmacist to all the stakeholders.

CONCLUSION

This study identified the role of MRS in enhancing healthcare services and explored the challenges encountered in the provision of MRS from family physicians, pharmacists, patients and their caregivers. These findings supported the need for a shift of MRS towards a more comprehensive medication review model. Future improvement work to the MRS can be conducted based on the findings.

Implementation of medication reconciliation in outpatient cancer care

BACKGROUND

Medication reconciliation (MedRec) is a process where providers work with patients to document and communicate comprehensive medication information by creating a complete medication list (best possible medication history (BPMH)) then reconciling it against what patient is actually taking to identify potential issues such as drug-drug interactions. We undertook an environmental scan of current MedRec practices in outpatient cancer care to inform a quality improvement project at our centre with the aim of 30% of patients having a BPMH or MedRec within 30 days of initiating treatment with systemic therapy.

METHODS

We conducted semi-structured interviews with key stakeholders from 21 cancer centres across Canada, probing on current policies, and barriers and facilitators to MedRec. Guided by the findings of the scan, we then undertook a quality improvement project at our cancer centre, comprising six iterative improvement cycles.

RESULTS

Most institutions interviewed had a process in place for collecting a BPMH (81%) and targeted patients initiating systemic therapy (59%); however, considerable practice variation was noted and completion of full MedRec was uncommon. Lack of resources, high patient volumes, lack of a common medical record spanning institutions and settings which limits access to medication records from external institutions and community pharmacies were identified as significant barriers. Despite navigating challenges related to the COVID-19 pandemic, we achieved 26.6% of eligible patients with a documented BPMH. However, uptake of full MedRec remained low whereby 4.7% of patients had a documented MedRec.

CONCLUSIONS

Realising improvements to completion of MedRec in outpatient cancer care is possible but takes considerable time and iteration as the process is complex. Resource allocation and information sharing remain major barriers which need to be addressed in order to observe meaningful improvements in MedRec.

Medication Discussions With Patients With Cardiovascular Disease in the Emergency Department: An Opportunity for Emergency Nurses to Engage Patients to Support Medication Reconciliation

INTRODUCTION

This study aimed to investigate the level of patient involvement in medication reconciliation processes and factors associated with that involvement in patients with cardiovascular disease presenting to the emergency department.

METHODS

An observational and cross-sectional design was used. Patients with cardiovascular disease presenting to the adult emergency department of an academic medical center completed a structured survey inclusive of patient demographics and measures related to the study concepts. Data abstracted from the electronic health record included the patient's medical history and emergency department visit data. Our multivariable model adjusted for age, gender, education, difficulty paying bills, health status, numeracy, health literacy, and medication knowledge and evaluated patient involvement in medication discussions as an outcome.

RESULTS

Participants' (N = 93) median age was 59 years (interquartile range 51-67), 80.6% were white, 96.8% were not Hispanic, and 49.5% were married or living with a partner. Approximately 41% reported being employed and 36.9% reported an annual household income of <$25,000. Almost half (n = 44, 47.3%) reported difficulty paying monthly bills. Patients reported moderate medication knowledge (median 3.8, interquartile range 3.4-4.2) and perceived involvement in their care (41.8 [SD = 9.1]). After controlling for patient characteristics, only difficulty paying monthly bills (b = 0.36, P = .005) and medication knowledge (b = 0.30, P = .009) were associated with involvement in medication discussions.

DISCUSSION

Some patients presenting to the emergency department demonstrated moderate medication knowledge and involvement in medication discussions, but more work is needed to engage patients.

Pharmacist discharge summary: Impact of inpatient to community pharmacist handoff at hospital discharge

BACKGROUND

Community pharmacists are often the initial health professionals whom patients encounter after hospital discharge but are rarely provided relevant discharge information.

OBJECTIVES

Implement a pharmacist-to-pharmacist discharge summary (P2PDS) to improve the safety of pharmacist care provision to patients transitioning home from the hospital.

PRACTICE DESCRIPTION

Inpatient pharmacists at an academic medical center conduct discharge medication reconciliation and release discharge electronic prescriptions to dispensing pharmacies.

PRACTICE INNOVATION

A multidisciplinary intersystem quality improvement project was conducted to demonstrate the impact of clinical information sharing via the P2PDS to community pharmacists.

EVALUATION METHODS

With input from community pharmacists, the P2PDS was created and implemented on inpatient units throughout the health system. Outcomes assessed included identification of medication discrepancies, enrollment into reimbursable medication management services, and pharmacist confidence when filling discharge prescriptions.

RESULTS

During the study period, community pharmacists identified a total of 388 medication discrepancies in 161 patients; 16% of discrepancies were considered "unintentional." Twenty-five discharging patients were identified for enrollment in medication management services, with 20 of these patients enrolling in all 3 services (medication delivery, synchronization, and medication packaging). The P2PDS increased community pharmacist confidence in discharge medication filling (40% vs. 95%, P < 0.001) and increased the percent of patients receiving community pharmacist medication reconciliation (14%-76%, P < 0.001).

CONCLUSION

Enhancing pharmacist communication across practice settings with a P2PDS decreases care fragmentation through identification of medication discrepancies and improves pharmacist confidence in patient care provision.

Implementation assessment of a patient personalized clinical pharmacy programme (5P project) into orthogeriatric care pathway

WHAT IS KNOWN AND OBJECTIVE

The orthogeriatric path (hip-fractured elderly patients) is composed of several transition points (emergency surgery, orthopaedic, geriatric and rehabilitation units). The intervention of clinical pharmacists can ensure the continuity of patients' drug management during their hospital stay. The aim of the study was to assess the implementation of clinical pharmacy activities in an orthogeriatric pathway, regarding its impact on medication error prevention, the healthcare professionals' and patients' satisfaction, and the estimated associated pharmaceutical workload.

METHODS

Participants were aged 75 or older and managed for proximal femoral fracture. Their admission prescription was reviewed. If they were evaluated at high risk of adverse event (AE), medication reconciliation (MedRec) and pharmaceutical interviews (admission, discharge, and targeted on oral anticoagulant) were added at different steps of their care pathway. The achievement and duration of each clinical pharmacy activity were recorded. The number of pharmaceutical interventions (PI) made during prescription review, and unintentional discrepancies (UID) identified during MedRec were collected. A satisfaction questionnaire was sent to patients and healthcare professionals.

RESULTS AND DISCUSSION

Among 455 included patients, 284 patients were considered at high risk of AE. Clinical pharmacy activity achievement rates varied between 12% and 98%. A total of 622 PI and 333 UID were identified. The overall patients' and healthcare professionals' satisfaction was rated from 63% to 100%. The total workload was estimated at 376 h: on average 16 min per prescription review, 43 min per admission MedRec, 26 min per discharge MedRec and 17 to 25 minutes per interview.

CONCLUSION

The implementation of the programme showed a high potential of drug management securing. To sustain it, additional pharmaceutical human resources and high-performance computing tools are needed.

Drug therapy-related problem management in Nigeria community pharmacy - process evaluation with simulated patient

BACKGROUND

Unresolved drug therapy-related problems (DTRPs) have economic and clinical consequences and are common causes of patients' morbidity and mortality. This study evaluated the ability of community pharmacists to identify and resolve DTRPs and assessed the perceived barriers to DTRP identification and resolution.

METHODS

A cross-sectional study which employed the use of three simulated patients (SPs) visit to 36 selected community pharmacies in 11 local government areas in Ibadan, Nigeria. The SPs played the role of a patient with prescription for multiple ailments (23-year-old male), type 2 diabetes and hypertensive patient with medication packs (45-year-old male) and hypertensive patient with gastric ulcer with a prescription (37-year-old female). They re-enacted three rehearsed vignettes when they spoke with the pharmacists. A five-member panel of experts predetermined the DTRPs present in the vignettes (n = 11), actions to take to investigate the DTRPs (n = 9) and recommendations to resolve the DTRPs (n = 9). Pharmacists' perceived barriers to the identification and resolution of DTRPs were assessed with a self-administered questionnaire. The percentage ability to detect and resolve DTRPs was determined and classified as poor ability (≤30%), fair ability (> 30 - ≤50%), moderate ability (> 50 - ≤70%) and high ability (> 70%).

RESULTS

One hundred and eight visits were made by the three SPs to the pharmacies. In total, 4.42/11 (40.2%) DTRPs were identified, 3.50/9 (38.9%) actions were taken, and 3.94/9 (43.8%) recommendations were made to resolve the identified DTRPs. The percentage ability of the community pharmacists to detect and resolve DTRPs varied slightly from one vignette to another (vignette 1-49.3%, vignette 2-39.1%, vignette 3-38.8%). But overall, it was fair (40.9%). Pharmacists' perceived barriers to DTRP detection and resolution included lack of access to patient's/client's medical history and lack of software for DTRP detection.

CONCLUSIONS

The community pharmacists displayed fair ability in detecting and resolving DTRPs. Several barriers preventing the optimal performance of pharmacist in DTRP identification and resolution were identified including inaccessibility of patient's/client's medical history. The regulatory authority of pharmacy education and practice in Nigeria need to mount Continuing Education Program to address this deficit among community pharmacists.

A systematic review of mental health professionals, patients and carers' perceived barriers and enablers to supporting smoking cessation in mental health settings

Introduction

Evidence-based smoking cessation and temporary abstinence interventions to address smoking in mental health settings are available, but the impact of these interventions is limited.

Aims and Methods

We aimed to identify and synthesize the perceived barriers and enablers to supporting smoking cessation in mental health settings. Six databases were searched for articles reporting the investigation of perceived barriers and enablers to supporting smoking cessation in mental health settings. Data were extracted and coded using a mixed inductive/deductive method to the theoretical domains framework, key barriers and enablers were identified through the combining of coding frequency, elaboration, and expressed importance.

Results

Of 31 included articles, 56 barriers/enablers were reported from the perspectives of mental healthcare professionals (MHPs), 48 from patient perspectives, 21 from mixed perspectives, and 0 from relatives/carers. Barriers to supporting smoking cessation or temporary abstinence in mental health settings mainly fell within the domains: environmental context and resources (eg, MHPs lack of time); knowledge (eg, interactions around smoking that did occur were ill informed); social influences (eg, smoking norms within social network); and intentions (eg, MHPs lack positive intentions to deliver support). Enablers mainly fell within the domains: environmental context and resources (eg, use of appropriate support materials) and social influences (eg, pro-quitting social norms).

Conclusions

The importance of overcoming competing demands on staff time and resources, the inclusion of tailored, personalized support, the exploitation of patients wider social support networks, and enhancing knowledge and awareness around the benefits smoking cessation is highlighted.

Implications

Identified barriers and enablers represent targets for future interventions to improve the support of smoking cessation in mental health settings. Future research needs to examine the perceptions of the carers and family/friends of patients in relation to the smoking behavior change support delivered to patients.

Pharmaceutical Interventions on Hospital Discharge Prescriptions: Prospective Observational Study Highlighting Challenges for Community Pharmacists

Background

Transition between hospital and ambulatory care is a delicate step involving several healthcare professionals and presenting a considerable risk of drug-related problems.

Objective

To investigate pharmaceutical interventions made on hospital discharge prescriptions by community pharmacists.

Method

This observational, prospective study took place in 14 community pharmacies around a Swiss acute care hospital. We recruited patients with discharge prescriptions (minimum three drugs) from the internal medicine ward of the hospital. The main outcome measures were: number and type of pharmaceutical interventions made by community pharmacists, time spent on discharge prescriptions, number of medication changes during the transition of care.

Results

The study included 64 patients discharged from the hospital. Community pharmacists made a total of 439 interventions; a mean of 6.9 ± 3.5 (range 1–16) interventions per patient. All of the discharge prescriptions required pharmaceutical intervention, and 61 (95%) necessitated a telephone call to the patients’ hospital physician for clarifications. The most frequent interventions were: confirming voluntary omission of a drug (31.7%), treatment substitution (20.5%), dose adjustment (16.9%), and substitution for reimbursement issues (8.8%). Roughly half (52%) of all discharge prescriptions required 10–20 min for pharmaceutical validation. The mean number of medication changes per patient was 16.4: 9.6 changes between hospital admission and discharge, 2.6 between hospital discharge and community pharmacy, and 4.2 between community pharmacy and a general practitioner’s appointment.

Conclusion

Hospital discharge prescriptions are complex and present a significant risk of medication errors. Community pharmacists play a key role in preventing and identifying drug-related problems.

Methods and Barriers to Communication Between Pharmacists During Transitions of Care

BACKGROUND

Effective communication between pharmacists across healthcare settings is essential to facilitate transitions of care (TOC) and improve patient outcomes.

OBJECTIVE

To explore pharmacists' communication methods and preferences and identify barriers to communication during TOC.

METHODS

A survey was distributed to a convenience sample of pharmacists in California, Connecticut, Illinois, Massachusetts, New Jersey, and Texas. The survey collected information on pharmacists' demographics, practice settings, and clinical services, and their methods, preferences, and barriers to communication during TOC.

RESULTS

A total of 308 responses were included in the analysis. The majority of pharmacists practiced in inpatient pharmacy (39.3%) followed by outpatient community pharmacy (23.4%). About 57.8% of pharmacists reported involvement in TOC services. Among respondents, most reported electronic health record (EHR) as their primary method of communication to receive (66.2%) and send (55.5%) information to perform TOC services. Additionally, EHR was reported as the preferred method of communication to receive (75.4%) and send (75.5%) information during TOC. The primary reasons pharmacists reported not utilizing patient health information were lack of information (38.4%), incorrect information (36.7%), delay in receiving information (36.7%), and lack of time (34.5%). Barriers to providing TOC services included poor communication during handoffs (44.2%) and difficulty obtaining needed patient medical information (43.9%).

CONCLUSION

This study identified methods and barriers to communication between pharmacists during TOC across healthcare settings. This provides an opportunity for future research to develop interventions to improve communication between pharmacists at different practice settings.

Importance of medication reconciliation in cancer patients

Cancer patients are a complex and vulnerable population whose medication history is often extensive. Medication reconciliations in this population are especially essential, since medication discrepancies can lead to dire outcomes. This commentary aims to describe the significance of conducting medication reconciliations in this often-forgotten patient population. We discuss additional clinical interventions that can arise during this process as well. Medication reconciliations provide the opportunity to identify and prevent drug-drug and herb-drug interactions. They also provide an opportunity to appropriately adjust chemotherapy dosing according to renal and hepatic function. Finally, reconciling medications can also provide an opportunity to identify and deprescribe inappropriate medications. While clinical impact appears evident in this landscape, evidence of economic impact is lacking. As more cancer patients are prescribed a combination of oral chemotherapies, intravenous chemotherapies and non-anticancer medications, future studies should evaluate the advantages of conducting medication reconciliations in these patient populations across multiple care settings.

Community Pharmacists' Experiences and Perception about Transitions of Care from Hospital to Home in a Midwestern Metropolis

Objectives: (1) To describe the experiences of community pharmacists in transitions of care (TOC) from hospital to home in a Midwestern metropolis; and (2) to develop instruments to measure perceived importance of TOC activities. Methods: Survey items were developed, including a six-item instrument to capture perceived importance of TOC activities. The items were piloted to examine face validity before dissemination to 310 community pharmacists. Descriptive statistics were reported. Principal component analysis and reliability analysis for the six-item instrument were performed to assess construct validity and Cronbach’s alpha, respectively. Results: The response rate was 37% (n = 118). The majority of community pharmacists estimated that they learned of a patient’s discharge on less than 10% of the occasions. There were 76 cases in which the discharged patients experienced either a prescription- or medication-related problem. For the six-item measurement of perceived importance, one component was yielded and all items loaded on the component with high values, which confirmed construct validity. The Cronbach’s alpha for these six items was 0.941, indicating high reliability. Conclusions: A large communication gap existed for community pharmacists to receive patient discharge information. The six-item instrument to measure perceived importance of TOC activities was valid and reliable.

Application of intervention mapping to develop and evaluate a pharmaceutical discharge letter to improve information transfer between hospital and community pharmacists

BACKGROUND

Insufficient information transfer is a major barrier in the transition from hospital to home. This study describes the systematic development and evaluation of an intervention to improve medication information transfer between hospital and community pharmacists.

OBJECTIVE

To develop and evaluate an intervention to improve the medication information transfer between hospital and community pharmacists based on patients', community and hospital pharmacists' needs.

METHODS

The intervention development and evaluation was guided by the six-step Intervention Mapping (IM) approach: (1) needs assessment to identify determinants of the problem, with a scoping review and focus groups with patients and healthcare providers, (2) formulation of intervention objectives with an expert group, (3) inventory of communication models to design the intervention, (4) using literature review and qualitative research with pharmacists and patients to develop the intervention (5) pilot-testing of the intervention in two hospitals, and (6) a qualitative evaluation of the intervention as part of a multicenter before-after study with hospital and community pharmacists.

RESULTS

Barriers in the information transfer are mainly time and content related. The intervention was designed to target a complete, accurate and timely medication information transfer between hospital and community pharmacists. A pharmaceutical discharge letter was developed to improve medication information transfer. Hospital and community pharmacists were positive about the usability, content, and comprehensiveness of the pharmaceutical discharge letter, which gave community pharmacists sufficient knowledge about in-hospital medication changes. However, hospital pharmacists reported that it was time-consuming to draft the discharge letter and not always feasible to send it on time. The intervention showed that pharmacists are positive about the usability, content and comprehensiveness.

CONCLUSION

This study developed an intervention systematically to improve medication information transfer, consisting of a discharge letter to be used by hospital and community pharmacists supporting continuity of care.

[Pharmaceutical cares as means of prevention against drug iatrogenic: Case of oral anticoagulant]

Oral anticoagulant can have a significant risk of adverse events, particularly when it is initiated, modified or interrupted. Pharmaceutical care through medication reconciliation could improve the benefit-to-risk ratio of these drugs. A prospective and interventional single center study was conducted from March through August 2018 in medicine and surgical units. Patients with an oral anticoagulant prescribed and coming from outpatient sector were included. These patients received a medication reconciliation at admission and discharge. Frequency and type of discrepancies were studied. Their gravity rating was assessed using the Cornish et al. scale. This study included 162 patients. The medication reconciliation at the admission allowed the detection of 133 unintentional discrepancies which 16 of them represented a high risk for the patient included nine errors about oral anticoagulant prescribing. Concerning the reconciliation at discharge, 51 unintentional discrepancies had been detected: 12 of them represented a high risk for the patient included eight errors about oral anticoagulant prescription. The acceptance rate of the discrepancies was 86% and reflected discrepancies severity. This result reached 96.4% if we took into account discrepancies with a severe clinical impact. This study highlighted oral anticoagulant represented relevant prioritization criteria to the long-lasting implementation of pharmaceutical care. This secures the management of the patient since the admission until the hospital discharge. The last step of our approach would be to study the needs about data transmission to the community caregivers.

Medication reconciliation process: Assessing value, adoption, and the potential of information technology from pharmacists' perspective

The Medication Reconciliation (MedRec) process aims to improve patient safety through safe prescription and medication administration. A validated survey was carried out to address aspects related to MedRec process, its obstacles, the role of information technology, and the required functionalities for optimizing the MedRec process. A total of 81% of the survey's respondents acknowledged the roles of EHR (62% of respondents), PHR (41%), and electronic medication registration list (33%) as necessary technology tools for MedRec. Most respondents emphasized the need to compile multiple medications' entries of information technology systems into one application (96.4%), allowing the entries from community pharmacies (90.6%). Further, incorporating information technology into the MedRec process presents a challenge in terms of legal responsibility (92 %) and the ability to integrate medications with other hospitals and community medications (78.6%). Findings affirm the need for a well-designed MedRec process aided with information technology solutions. The external data and user preferences should be considered when redesigning the MedRec process. The study also suggests initiating a policy that mandates sharing data necessary for creating a compiled medication list for each patient. MedRec is an indispensable tool for building a fruitful medication management system in a healthcare organization.

Implementation and sustainability of a medication reconciliation toolkit: A mixed methods evaluation

PURPOSE

MARQUIS (Multi-Center Medication Reconciliation Quality Improvement Study) provided participating hospitals with a toolkit to assist in developing robust medication reconciliation programs. Here we describe hospitals' implementation of the MARQUIS toolkit, barriers and facilitators, and important factors that may enhance the spread and sustainability of the toolkit.

METHODS

We used a mixed methods, quantitative-qualitative study design. We invited site leaders of the 5 hospitals that participated in MARQUIS to complete a Web-based survey and phone interview. The Consolidated Framework for Implementation Research guided question development. We analyzed the collected data using descriptive statistics (for survey responses) and thematic content analysis (for interview results).

RESULTS

Site leaders from each MARQUIS hospital participated. They reported that MARQUIS toolkit implementation augmented their hospitals' existing but limited medication reconciliation practices. Survey results indicated executive leadership support for toolkit implementation but limited institutional support for hiring staff (reported by 20% of respondents) and/or budgetary support for implementation (reported by 60% of respondents). Most participating hospitals (80%) shifted staff responsibilities to support medication reconciliation. Interview findings showed that inner setting (ie, organizational setting) and process factors (eg, designation of champions) both inhibited and facilitated implementation. Hospitals adopted a variety of toolkit interventions (eg, discharge medication counseling) using a range of implementation strategies, including development of educational tools and tip sheets for staff members and electronic health record templates.

CONCLUSION

Despite limited institutional support, hospitals can successfully implement, spread, and sustain the MARQUIS toolkit by shifting staff responsibilities, adding pharmacy staff, and using a variety of strategies to facilitate implementation. Although leadership support and resources for data collection and dissemination facilitated implementation, limited staff buy-in and competing priorities may hinder implementation.

Evaluation of a Pharmacist-Led Diabetes Collaborative Drug Therapy Management Service

OBJECTIVE

To evaluate the pharmacist-led diabetes collaborative drug therapy management services in a family medicine and internal medicine clinic.

DESIGN

Mixed methods of evaluation based on the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

RESULTS

Reach: 71.3% of patients who were independently consulted (n = 184/258) and 1.6% (n = 11/680) of patients who triggered a best practice advisory (BPA) were enrolled. Effectiveness: 27.7% of patients (n = 54/195) enrolled were lost to follow-up. Adoption: 55% of eligible providers (n = 77/140) have placed a consult. Implementation: Providers independently choose to refer patients and are also prompted to place consults by a BPA that triggers for patients with an HbA1c ≥ 9%. Common reasons providers did not place a consult include: alignment with workflow, patient refusal, and patients followed by other services. Regarding patient perceptions, patients valued the service. Patients reported increased accountability with disease state maintenance and increased self-efficacy. Regarding how to improve the service, patients wanted more information on expectations before engaging with the pharmacist. Patients suggested to replicate this service for pain, cancer, and blood pressure management. Maintenance: 96.7% of providers (n = 30/31) reported they were very likely/likely to place a consult in the future and 60% of providers (n = 18/30) reported they were very likely/likely to place a consult when prompted by the BPA.

CONCLUSION

These results can be utilized to make improvements to the pharmacist-led diabetes collaborative drug therapy management service to ensure sustainability. This study also provides lessons learned and strategies for future adoption, implementation, and maintenance of similar services for other disease states.

Qualitative study of medication review in Flanders, Belgium among community pharmacists and general practitioners

Objective Examining the implementation barriers and facilitators of this service as provided by Belgian community pharmacists in collaboration with general practitioners. Setting Community pharmacies in Flanders. Method Qualitative study through interviews of pharmacists and general practitioners. Main outcome measure Opinions and experiences of pharmacists and general practitioners about type 3 medication review. Results Sixteen community pharmacists and thirteen general practitioners were interviewed and generally gave a positive assessment of the project. The general practitioners saw the pharmaceutical and pharmacotherapeutic recommendations of the pharmacists as an added value for the patients. The pharmacists indicated that performing an medication review was time-consuming, but that it improved their professional relationship with general practitioners and patients. They reported obstacles in obtaining information: cumbersome access to individual patient data (laboratory values) and difficulties in finding and choosing adequate medical information sources. Moreover, pharmacists indicated that there is a need for adequate reimbursement and additional training to make the implementation sustainable. Conclusion Both pharmacists and general practitioners were enthusiastic about medication reviews. The implementation improved the interprofessional collaboration. However, important barriers remain, such as the considerable investment of time and the difficulty in gathering all the necessary information. The sustainable implementation of type 3 medication review in Belgium requires adequate reimbursement and additional training.

Medication management surrounding transitions of care: A qualitative assessment of community pharmacists' preferences (MEMO TOC)

Background

Multiple medication changes during hospitalization increase the risk of errors upon discharge. Community pharmacists may face barriers to providing pharmaceutical care because of the lack of clinical information and communication from hospitals. Studies implementing handover to community pharmacists upon hospital discharge reported improved patient outcomes, but interventions were time-consuming.

Methods

One-on-one interviews and a focus group were conducted to identify community pharmacists' barriers to providing care to patients recently discharged from hospital and to determine their preferences for hospital discharge prescriptions. Transcripts were qualitatively analyzed using an inductive semantic approach.

Results

Four one-on-one interviews and an 8-participant focus group were conducted. Participants described barriers to providing care to discharged patients, including lack of communication, incomplete prescriptions, and limited clinical information. Participants identified that the most valuable information to include comprised laboratory values, hospital contact information and annotation of medication changes. These items would improve their abilities to provide timely and high-quality pharmaceutical care.

Interpretation

Our results were similar to prior literature identifying a lack of communication and clinical information as barriers to providing care to recently discharged patients. Unexpectedly, study participants did not rate medication indication as a strongly preferred information item.

Conclusions

Hospital discharge prescriptions lack information, which makes it challenging for community pharmacists to provide pharmaceutical care. Discharge prescriptions should include additional clinical information. Can Pharm J (Ott) 2020;153:xx-xx.

Pharmacists' Perspectives on the Use of My Health Record

(1) Background: My Health Record (MHR) is a relatively new nationwide Australian digital health record system accessible by patients and a range of healthcare professionals. Pharmacists will be key contributors and users of the MHR system, yet little is known about the perceived barriers and benefits of use. (2) Objective: To explore pharmacists' perspectives related to potential benefits and barriers associated with use of MHR. (3) Methods: An online survey was developed and face-validated. The survey was advertised to Australian pharmacists on pharmacy professional bodies' websites. This was a cross-sectional study using an anonymous questionnaire. Descriptive statistics were used to describe the distribution of the data. Chi-square, Kendall's tau coefficient (tau-c) and Kruskal-Wallis tests were used to examine the relationships where appropriate. (4) Results: A total of 63 pharmacists completed the survey. The majority of respondents worked in a metropolitan area (74%), and the most common workplace setting was community pharmacy (65%). Perceived benefits identified by responders include that the use of MHR would help with continuity of care (90%), and that it would improve the safety (71%) and quality (75%) of care they provided. Importantly, more than half of pharmacists surveyed agreed that MHR could reduce medication errors during dispensing (57%) and could improve professional relationships with patients (57%) and general practitioners (59%). Potential barriers identified by pharmacists included patients' concerns about privacy (81%), pharmacists' own concern about privacy (46%), lack of training, access to and confidence in using the system. Sixty six percent of respondents had concerns about the accuracy of information contained within MHR, particularly among hospital and general practice pharmacists (p = 0.016) and almost half (44%) had concerns about the security of information in the system, mainly pharmacists working at general practice and providing medication review services (p = 0.007). Overall satisfaction with MHR varied, with 48% satisfied, 33% neither satisfied nor dissatisfied, and 19% dissatisfied, with a higher satisfaction rate among younger pharmacists (p = 0.032). (5) Conclusions: Pharmacists considered that the MHR offered key potential benefits, notably improving the safety and quality of care provided. To optimize the use of MHR, there is a need to improve privacy and data security measures, and to ensure adequate provision of user support and education surrounding the ability to integrate use of MHR with existing workflows and software.

Effects of interorganisational information technology networks on patient safety: a realist synthesis

OBJECTIVE

Health services in many countries are investing in interorganisational networks, linking patients' records held in different organisations across a city or region. The aim of the systematic review was to establish how, why and in what circumstances these networks improve patient safety, fail to do so, or increase safety risks, for people living at home.

DESIGN

Realist synthesis, drawing on both quantitative and qualitative evidence, and including consultation with stakeholders in nominal groups and semistructured interviews.

ELIGIBILITY CRITERIA

The coordination of services for older people living at home, and medicine reconciliation for older patients returning home from hospital.

INFORMATION SOURCES

17 sources including Medline, Embase, CINAHL, Cochrane Library, Web of Science, ACM Digital Library, and Applied Social Sciences Index and Abstracts.

OUTCOMES

Changes in patients' clinical risks.

RESULTS

We did not find any detailed accounts of the sequences of events that policymakers and others believe will lead from the deployment of interoperable networks to improved patient safety. We were, though, able to identify a substantial number of theory fragments, and these were used to develop programme theories.There is good evidence that there are problems with the coordination of services in general, and the reconciliation of medication lists in particular, and it indicates that most problems are social and organisational in nature. There is also good evidence that doctors and other professionals find interoperable networks difficult to use. There was limited high-quality evidence about safety-related outcomes associated with the deployment of interoperable networks.

CONCLUSIONS

Empirical evidence does not currently justify claims about the beneficial effects of interoperable networks on patient safety. There appears to be a mismatch between technology-driven assumptions about the effects of networks and the sociotechnical nature of coordination problems.

PROSPERO REGISTRATION NUMBER

CRD42017073004.

The effects of interoperable information technology networks on patient safety: a realist synthesis

Background

Interoperable networks connect information technology systems of different organisations, allowing professionals in one organisation to access patient data held in another one. Health policy-makers in many countries believe that they will improve the co-ordination of services and, hence, the quality of services and patient safety. To the best of our knowledge, there have not been any previous systematic reviews of the effects of these networks on patient safety.

Objectives

The aim of the study was to establish how, why and in what circumstances interoperable information technology networks improved patient safety, failed to do so or increased safety risks. The objectives of the study were to (1) identify programme theories and prioritise theories to review; (2) search systematically for evidence to test the theories; (3) undertake quality appraisal, and use included texts to support, refine or reject programme theories; (4) synthesise the findings; and (5) disseminate the findings to a range of audiences.

Design

Realist synthesis, including consultation with stakeholders in nominal groups and semistructured interviews.

Settings and participants

Following a stakeholder prioritisation process, several domains were reviewed: older people living at home requiring co-ordinated care, at-risk children living at home and medicines reconciliation services for any patients living at home. The effects of networks on services in health economies were also investigated.

Intervention

An interoperable network that linked at least two organisations, including a maximum of one hospital, in a city or region.

Outcomes

Increase, reduction or no change in patients’ risks, such as a change in the risk of taking an inappropriate medication.

Results

We did not find any detailed accounts of the ways in which interoperable networks are intended to work and improve patient safety. Theory fragments were identified and used to develop programme and mid-range theories. There is good evidence that there are problems with the co-ordination of services in each of the domains studied. The implicit hypothesis about interoperable networks is that they help to solve co-ordination problems, but evidence across the domains showed that professionals found interoperable networks difficult to use. There is insufficient evidence about the effectiveness of interoperable networks to allow us to establish how and why they affect patient safety.

Limitations

The lack of evidence about patient-specific measures of effectiveness meant that we were not able to determine ‘what works’, nor any variations in what works, when interoperable networks are deployed and used by health and social care professionals.

Conclusions

There is a dearth of evidence about the effects of interoperable networks on patient safety. It is not clear if the networks are associated with safer treatment and care, have no effects or increase clinical risks.

Future work

Possible future research includes primary studies of the effectiveness of interoperable networks, of economies of scope and scale and, more generally, on the value of information infrastructures.

Study registration

This study is registered as PROSPERO CRD42017073004.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 40. See the NIHR Journals Library website for further project information.

An evaluation of community pharmacies' actions under value-based payment

OBJECTIVE

To determine actions taken by community pharmacies to be successful under a value-based pharmacy program (VBPP).

METHOD

An exploratory sequential mixed methods approach was used to evaluate pharmacies participating in the VBPP, with qualitative data collected and analyzed in the first phase, followed by quantitative measurement through a 30-item survey instrument in the second phase.

RESULTS

The qualitative data showed that participating pharmacies were more involved with adherence and cardiovascular and diabetes metrics than with other metrics. Depression metrics received the lowest overall involvement. For total cost of care, different approaches were used; 5 pharmacies used the dashboard to identify likely high-cost patients they could try to manage, and 4 pharmacies monitored adherence to avoid complications that could contribute to increased cost. For the survey response rate was 72.6% (n = 53). The mean perception of level of success was 53.06 ± 20.15 (mean ± SD). Activities with the highest priority were adherence (1.98 ± 0.97) and diabetes care (2.04 ± 0.83), and the activity with the lowest priority was depression care (3.60 ± 1.10). The most frequently mentioned challenge was time availability, and the most common improvement suggestion was better communication between the insurer and providers.

CONCLUSION

In conclusion, this study found that community pharmacies were transforming their practices to be successful under a commercial value-based payment program. The pharmacies tended to build on care processes already established (e.g., medication adherence, patients with diabetes or cardiovascular conditions) and developed new processes to address emerging metrics and associated patient needs (e.g., collecting and documenting blood pressure and hemoglobin A1c levels). Future research is needed to identify best practices for patient care and pharmacy success under broad VBPPs such as the one studied here.

The impact of community-pharmacist-led medication reconciliation process: Pharmacist-patient-centered medication reconciliation

Background and Purpose:

Patients and their healthcare providers’ are in need to access a correct and complete list of all patients’ active bills for safe and effective clinical care. Currently, Healthcare Information Systems are not providing a proper access to the patients’ medications lists. Thus, this study aimed to evaluate the impact of community pharmacist-led medication reconciliation process in community pharmacies in the UAE through applying a pharmacist–patient-centered medication reconciliation (PPCMR).

Materials and Methods:

This was an interventional study of medication reconciliation process in 25 pharmacies in the UAE during July 1, 2019 till September 1, 2019. The participant pharmacists were surveyed and interviewed to gather more information about the barriers and enablers of the process before and after the implementation of PPCMR.

Results:

After the implementation of PPCMR, medication reconciliation service was available in 84% of the pharmacies compared to 40% before the PPCMR (Z = –2.84, P = 0.005). The main workforce barriers to implement this service were reduced to 27% compared to 47% before the PPCMR. The operational barriers for the service were decreased from 56% to 28%. The facilitators in delivering the service in community pharmacies were improved from 29% to 63%. The active collaboration between the pharmacists and physicians was enhanced from 28% to 72% (Z = –3.2, P = 0.001) in the participated pharmacies. There is a statistically significant difference toward the impact of the PPCMR on the whole medication reconciliation service χ²(df = 3) = 200, P < 0.001.

Conclusion:

Community pharmacists are not always accessible or well placed to provide a medication reconciliation service. The implementation of PPCMR in each community pharmacy will raise the expectations regarding the appropriateness of medication management and use.

A RCT evaluating a pragmatic in-hospital service to increase the quality of discharge prescriptions

OBJECTIVE

To improve discharge prescription quality and information transfer to improve post-hospital care with a pragmatic in-hospital service.

DESIGN

A single-centre, randomized controlled trial.

SETTING

Internal medicine wards in a Swiss teaching hospital.

PARTICIPANTS

Adult patients discharged to their homes, 76 each in the intervention and control group.

INTERVENTION

Medication reconciliation at discharge by a clinical pharmacist, a prescription check for formal flaws, interactions and missing therapy durations. Important information was annotated on the prescription.

MAIN OUTCOME MEASURES

At the time of medication dispensing, community pharmacy documented their pharmaceutical interventions when filling the prescription. A Poisson regression model was used to compare the number of interventions (primary outcome). The significance of the pharmaceutical interventions was categorized by the study team. Comparative analysis was used for the significance of interventions (secondary outcome).

RESULTS

The community pharmacy staff performed 183 interventions in the control group, and 169 in the intervention group. The regression model revealed a relative risk for an intervention of 0.78 (95% CI 0.62-0.99, p = 0.04) in the intervention group. The rate of clinically significant interventions was lower in the intervention group than in the control group (72 of 169 (42%) vs. 108 of 183 (59%), p < 0.01), but more economically significant interventions were performed (98, 58% vs. 80, 44%, p < 0.01).

CONCLUSIONS

The pragmatic in-hospital service increased the quality of prescriptions. The intervention group had a lower risk for the need for pharmaceutical interventions, and clinically significant interventions were less frequent. Overall, our pragmatic approach showed promising results to optimize post-discharge care.

Factors influencing the implementation of clinical pharmacy services for hospitalized patients: A mixed-methods systematic review

BACKGROUND

Despite the evidence of benefits, clinical pharmacy services (CPS) are not uniformly implemented across healthcare institutions. Understanding the influencing factors and identifying the domains in which they act is the first step to a successful implementation.

OBJECTIVE

To identify the factors that affect the implementation of CPS for inpatients and to categorize them.

METHODS

Cochrane Library, Embase, CINAHL, IPA, Medline/PubMed, and Lilacs databases were researched up until January 2018. The search strategy was developed using text words or MESH terms related to the following four domains: "clinical pharmacy," "influencing factors," "implementation," and "hospital." Two reviewers selected original research articles that reported the factors influencing the implementation of CPS in hospitals, extracted data, and assessed the quality of the studies. After framework synthesis and categorization of the factors, a diagrammatic approach was used to present the results.

RESULTS

Fifty-three factors were identified in the 21 studies that were included in this review. The most cited influencing factors were uniformly distributed across the following four domains: Attitudinal, POlitical, TEChnical and Administrative (APOTECA domains). However, in terms of level (pharmacist, healthcare team, patient, institution, and national organization), the "pharmacist" group had the highest concentration of factors. "Clinical skills and knowledge" was the most frequently cited implementation factor, followed by "time to implement CPS."

CONCLUSION

Our findings showed the multifactorial nature of CPS implementation process. We suggest that factors from all four APOTECA domains need to be fully considered and strategies need to be addressed for all five groups of interest to successfully implement CPS in hospitals. Future studies on the influence of implementation stages, interrelationships of implementing factors, and strategies to overcome barriers could accelerate the successful adoption of these services.

REGISTRATION

PROSPERO register CRD42016050140.

Pharmacists' Perceptions on Their Role, Activities, Facilitators, and Barriers to Practicing in a Post-Intensive Care Recovery Clinic

Background: Complex medication regimen changes burden intensive care unit (ICU) survivors and their caregivers during the transition to home. Intensive care unit recovery clinics are a prime setting for pharmacists to address patients' and their caregivers' medication-related needs. The purpose of this study was to describe ICU recovery clinic pharmacists' activities, roles, and perceived barriers and facilitators to practicing in ICU recovery clinics across different institutions. Methods: An expert panel of ICU recovery clinic pharmacists completed a 15-item survey. Survey items addressed the pharmacists' years in practice, education and training, activities performed, their perceptions of facilitators and barriers to practicing in an ICU recovery clinic setting, and general ICU recovery clinic characteristics. Descriptive statistics were used. Results: Nine ICU recovery clinic pharmacists participated. The average number of years in practice was 16.5 years (SD = 13.5, range = 2-38). All pharmacists practiced in an interprofessional ICU recovery clinic affiliated with an academic medical center. Seven (78%) pharmacists always performed medication reconciliation and a comprehensive medication review in each patient visit. Need for medication education was the most prevalent item found in patient comprehensive medication reviews. The main facilitators for pharmacists' successful participation in an ICU recovery clinic were incorporation into clinic workflow, support from other health care providers, and adequate space to see patients. The ICU recovery clinic pharmacists perceived the top barriers to be lack of dedicated time and inadequate billing for services. Conclusions: The ICU recovery clinic pharmacists address ICU survivors' medication needs by providing direct patient care in the clinic. Strategies to mitigate pharmacists' barriers to practicing in ICU recovery clinics, such as lack of dedicated time and adequate billing for pharmacist services, warrant a multifaceted solution, potentially including advocacy and policy work by national pharmacy professional organizations.

Medication Discrepancies in Community Pharmacies in Switzerland: Identification, Classification, and Their Potential Clinical and Economic Impact

Background: Transitions of care are high-risk situations for the manifestation of medication discrepancies and, therefore, present threats for potential patient harm. Medication discrepancies can occur at any transition within the healthcare system. Methods: Fifth-year pharmacy students assessed a best possible medication list (BPML) during a medication review (based on medication history and patient interview) in community pharmacies. They documented all discrepancies between the BPML and the latest medication prescription. Discrepancies were classified using the medication discrepancy taxonomy (MedTax) classification system and were assessed for their potential clinical and economic impact. Results: Overall, 116 patients with a mean age and medication prescription of 74 (± 10.3) years and 10.2 (± 4.2), respectively, were analyzed. Of the 317 discrepancies identified, the most frequent type was related to strength and/or frequency and/or number of units of dosage form and/or the total daily dose. Although, the majority of discrepancies were rated as inconsequential (55.2%) on health conditions, the remainder posed a potential moderate (43.2%) or severe impact (1.6%). In 49.5% of the discrepancies, the current patients’ medication cost less than the prescribed. Conclusion: Community pharmacies are at a favorable place to identify discrepancies and to counsel patients. To improve patient care, they should systematically perform medication reconciliation whenever prescriptions are renewed or added.

A developmental evaluation of an intraprofessional Pharmacy Communication Partnership (PROMPT) to improve transitions in care from hospital to community: A mixed-methods study

BACKGROUND

People transitioning from hospital- to community-based care are at increased risk of experiencing medication problems that can lead to adverse drug events and poor health outcomes. Community pharmacists provide medication expertise and support during care transitions yet are not routinely included in communications between hospitals and other primary health care providers. The PhaRmacy COMmunication ParTnership (PROMPT) intervention facilitates medication management by optimizing information sharing between pharmacists across care settings. This developmental evaluation sought to assess the feasibility and acceptability of implementing the PROMPT intervention, and to explore how contextual factors influenced its implementation.

METHODS

PROMPT was implemented for 14 weeks (January-April, 2018) in the general internal medicine units at two teaching hospitals in Toronto, Canada. PROMPT featured two contact points between hospital and community pharmacists around patient discharge: (1) faxing an enhanced discharge prescription and discharge summary to a patient's community pharmacy and (2) a follow-up phone call from the hospital pharmacist to the community pharmacist. Our mixed-method evaluation involved electronic patient records, process measures using tracking forms, telephone surveys and semi-structured interviews with participating community and hospital pharmacists.

RESULTS

The intervention involved 45 patients with communication between 12 hospital and 45 community pharmacists. Overall, the intervention had challenges with feasibility. Issues with fidelity included challenges with the medical discharge summary being available at the time of faxing and hospital pharmacists' difficulties with incorporating novel elements of the program into their existing practices. However, both community and hospital pharmacists recognized the potential benefits to patient care that PROMPT offered, and both groups proposed recommendations for further improvements. Suggestions included enhancing hospital staffing and resources.

CONCLUSION

Improving intraprofessional collaboration, through interventions such as PROMPT, positions pharmacists as leaders of medication management services across care settings and has the potential to improve patient care; however, more co-design work is needed to enhance the intervention and its fidelity.

Exploring the association of the discharge medicines review with patient hospital readmissions through national routine data linkage in Wales: a retrospective cohort study

OBJECTIVE

To evaluate the association of the discharge medicines review (DMR) community pharmacy service with hospital readmissions through linking National Health Service data sets.

DESIGN

Retrospective cohort study.

SETTING

All hospitals and 703 community pharmacies across Wales.

PARTICIPANTS

Inpatients meeting the referral criteria for a community pharmacy DMR.

INTERVENTIONS

Information related to the patient's medication and hospital stay is provided to the community pharmacists on discharge from hospital, who undertake a two-part service involving medicines reconciliation and a medicine use review. To investigate the association of this DMR service with hospital readmission, a data linking process was undertaken across six national databases.

PRIMARY OUTCOME

Rate of hospital readmission within 90 days for patients with and without a DMR part 1 started.

SECONDARY OUTCOME

Strength of association of age decile, sex, deprivation decile, diagnostic grouping and DMR type (started or not started) with reduction in readmission within 90 days.

RESULTS

1923 patients were referred for a DMR over a 13-month period (February 2017-April 2018). Provision of DMR was found to be the most significant attributing factor to reducing likelihood of 90-day readmission using χ² testing and classification methods. Cox regression survival analysis demonstrated that those receiving the intervention had a lower hospital readmission rate at 40 days (p<0.000, HR: 0.59739, CI 0.5043 to 0.7076).

CONCLUSIONS

DMR after a hospital discharge is associated with a reduction in risk of hospital readmission within 40 days. Linking data across disparate national data records is feasible but requires a complex processual architecture. There is a significant value for integrated informatics to improve continuity and coherency of care, and also to facilitate service optimisation, evaluation and evidenced-based practice.

Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study

OBJECTIVES

Medication reconciliation (MedRec) is an important patient safety strategy and is widespread in US hospitals and globally. Nevertheless, high quality MedRec has been difficult to implement. As part of a larger study investigating MedRec interventions, we evaluated and compared organisational contextual factors and team cohesion by hospital characteristics and implementation team members' profession to better understand the environmental context and its correlates during a multi-site quality improvement (QI) initiative.

DESIGN

We conducted a cross-sectional observational study using a web survey (contextual factors) and a national hospital database (hospital characteristics).

SETTING

Hospitals participating in the second Multi-Centre Medication Reconciliation Quality Improvement Study (MARQUIS2).

PARTICIPANTS

Implementation team members of 18 participating MARQUIS2 hospitals.

OUTCOMES

Primary outcome: contextual factor ratings (ie, organisational capacity, leadership support, goal alignment, staff involvement, patient safety climate and team cohesion). Secondary outcome: differences in contextual factors by hospital characteristics.

RESULTS

Fifty-five team members from the 18 participating hospitals completed the survey. Ratings of contextual factors differed significantly by domain (p<0.001), with organisational capacity scoring the lowest (mean=4.0 out of 7.0) and perceived team cohesion and goal alignment scoring the highest (mean~6.0 out of 7.0). No statistically significant differences were observed in contextual factors by hospital characteristics (p>0.05). Respondents in the pharmacy profession gave lower ratings of leadership support than did those in the nursing or other professions group (p=0.01).

CONCLUSIONS

Hospital size, type and location did not drive differences in contextual factors, suggesting that tailoring MedRec QI implementation to hospital characteristics may not be necessary. Strong team cohesion suggests the use of interdisciplinary teams does not detract from cohesion when conducting mentored QI projects. Organisational leaders should particularly focus on supporting pharmacy services and addressing their concerns during MedRec QI initiatives. Future research should correlate contextual factors with implementation success to inform how best to prepare sites to implement complex QI interventions such as MedRec.

Effect of clinical pharmacist encounters in the transitional care clinic on 30-day re-admissions: A retrospective study

Hospitalized patients who meet specific criteria at discharge are referred to the transitional care clinic team consisting of a nurse practitioner and/or physician and a clinical pharmacist. In collaboration with the providers, the pharmacist reviews medications for appropriateness, assesses adherence, recommends medication changes and provides education. The purpose of this study was to measure the effect of an outpatient transitional care clinical pharmacist on 30-day re-admissions in an urban setting serving a population of low socioeconomic status. After receiving IRB approval, this single-center retrospective study analyzed records of 573 patient visits of which nearly 75% included a clinical pharmacist interaction. Rates of 30-day re-admissions were not statistically different among the two groups, however, it was found that each added co-morbidity significantly increased the patients' 30-day re-admission rate by 26%.

Problems in continuity of medication management upon transition between primary and secondary care: patients' and professionals' experiences

BACKGROUND AND OBJECTIVES

Patients often experience drug-related problems at admission or after discharge from hospital. The objective of this study was to identify the main problems in medication management at transition between settings of care, as experienced by health care professionals (HCPs) and patients.

METHODS

Focus group discussions were organised between December 2009 and February 2010; nine focus groups with primary and secondary care HCPs and patients and two with stakeholders. Focus group discussions were audiotaped and observation files were constructed. For the analysis, a thematic framework approach was used. Between November 2015 and April 2016, 19 additional interviews and 1 focus group were performed with general practitioners (GP) and community pharmacists (CP).

RESULTS

This qualitative study provided a long list of problems that could be summarised in five clusters: (1) problems at admission, e.g. incomplete list of medication, absence of information in case of emergency admission; (2) problems at discharge, e.g. lack of communication with GP, insufficient supplies of medication for the weekend; (3) problems as to professions, e.g. GP's opinion different to that of the medical specialist; (4) problems as to patients and family, e.g. failure to understand treatment; (5) problems as to processes, e.g. medication substitutions.

CONCLUSION

HCPs and patients experience many problems in medication management at transition between settings of care. The fact that these problems occur at different stages and persist over time stresses the necessity for multilevel solutions.

Discharge report for the community pharmacist: Development and validation of a prototype

BACKGROUND

The potential benefit of community pharmacist's involvement in continuity of care is well-known. However, it is not standard practice to exchange information with the community pharmacist (CP) after hospitalization.

OBJECTIVE

To construct and validate an evidence-based prototype of a discharge report for the community pharmacist.

METHODS

First, a review of literature, guidelines and established initiatives was performed to construct a preliminary discharge report. Secondly, the content of the discharge report was reviewed and optimized using semi-structured individual interviews with CPs and general practitioners (GPs).

RESULTS

The review identified six guidelines for information exchange with the CP originating from three countries, 17 research papers and three local initiatives. Overall, 49 different elements for a discharge document were identified. Based on recurring elements, a preliminary discharge report was created. Interviews with ten CPs and nine GPs provided insights into which information is considered crucial for patient safety and why. This allowed an optimization of the document. The final discharge report consists of three categories: administrative, medication and medical data. The medication data includes medication registered at hospital admission as well as at hospital discharge, drug indications, reasons for initiating, adjusting or discontinuing therapies and start/stop dates. The medical data contains reasons for hospitalization, comorbidities and allergies.

CONCLUSIONS

The literature review and semi-structured interviews resulted in an evidence-based prototype of a discharge report for the community pharmacist. This document contains both administrative, medical and medication data.

Pharmacists and medication reconciliation: a review of recent literature

Background: Adverse drug event (ADE) errors are common and costly in health care systems across the world. Medication reconciliation is a means to decrease these medication-related injuries and increase quality of care. Research has shown that medication reconciliation accuracy and efficiency improved when pharmacists are directly involved in the process. Objective: We review studies examining how pharmacists impact the medication reconciliation process and we discuss pharmacists' future roles during the medication reconciliation process and then barriers pharmacy staff may face during this critical process. Methods: A comprehensive literature search from MEDLINE and manual searching of bibliographies was performed for the time period January 2012 through November 2018. Conclusion: Although the issue of rising costs and injury due to medication errors in our health care system are not solvable via medication reconciliation alone, it is the first and perhaps most critical piece of the medication management puzzle. As such, numerous organizations have called for pharmacists to expand their roles in the medication reconciliation process due to their expertise in medication management.

Impact of a community pharmacy transitions-of-care program on 30-day readmission

OBJECTIVES

The primary objective of this study was to evaluate the impact of a transitions-of-care (TOC) program on both all-cause and related 30-day hospital readmission. The secondary objective was to evaluate which patient-specific factors, if any, are predictive of 30-day hospital readmissions.

DESIGN, SETTING, AND PARTICIPANTS

A TOC program in an outpatient pharmacy, driven primarily by student pharmacists, provided telephone-based counseling to recently discharged patients. The calls were conducted within 2 to 7 days after discharge and focused on medication counseling and reconciliation, as well as promotion of a physician follow-up visit. The goal of this program was to decrease hospital readmissions among patients discharged with a cardiovascular-related diagnosis. Patient-specific information was recorded in a spreadsheet, including discharge diagnosis, and readmission diagnosis for those who returned to an inpatient facility within 30 days. This study was a retrospective chart review. Data were manually extracted from the program's data spreadsheet and the institution's electronic medical record for patients referred to the TOC program from June through November 2017. Patients discharged to hospice, prison, or a long-term care facility were excluded from analysis. Researchers collected information on patient demographics, diagnoses, and readmissions. Data analyses were performed with the use of SAS 9.4.

OUTCOME MEASURES

The primary outcome measure was 30-day all-cause readmission, and the secondary measure was 30-day related readmission.

RESULTS

A total of 1219 encounters were examined. Compared with those patients without TOC participation, those who used the TOC program had a 67% decreased odds of all-cause 30-day readmission (odds ratio [OR] 0.33, 95% confidence interval [CI] 0.22-0.48; P < 0.0001) and a 62% decreased odds of a related readmission (OR 0.38, 95% CI 0.18-0.82; P = 0.008).

CONCLUSION

Community pharmacists and Advanced Pharmacy Practice Experience-level student pharmacists have the potential to make a significant impact on reducing hospital readmission rates.

Enhanced communication between inpatient and community pharmacists to optimize medication management during transitions of care

OBJECTIVES

To describe the Pharmacy Communication Partnership (PROMPT) program's approach to improving medication management for patients during transitions from hospital to the community.

SETTING

Two general internal medicine units within a multisite academic hospital in Canada.

PRACTICE INNOVATION

Designed by an interprofessional working group, PROMPT uses evidence-informed approaches to facilitate communication between pharmacists in different settings: faxing of the discharge prescription and medical discharge summary to a patient's community pharmacy, followed by a telephone call to the community pharmacist.

EVALUATION

A multimethod cross-sectional study used telephone surveys and retrospective chart reviews to describe: 1) the characteristics of patients that hospital pharmacists thought would benefit from PROMPT and the community pharmacies that served them; 2) the number and nature of communication attempts made by community and hospital pharmacists; and 3) community pharmacists' views about PROMPT's potential impact on continuity of care and potential program enhancements.

RESULTS

A convenience sample of 100 patients (median age 77 years, interquartile range 66 to 83) who received care from 86 pharmacies were used to evaluate the program. The majority of community pharmacists participating in the surveys considered the intervention to be helpful. Of the 53.7% (n = 44/82) community pharmacists who received discharge summaries, 93.2% (n = 41/44) found the summaries to be useful. Themes arising from community pharmacists' comments were categorized into 3 topics: 1) the benefits of PROMPT; 2) topics of discussion and clarification during telephone calls with hospital pharmacists; and 3) future program improvements.

CONCLUSION

Community pharmacists described PROMPT as a time-efficient and helpful bridge linking community pharmacy to hospital inpatient care. Opportunities for future research include determining the characteristics of patients who may benefit most from PROMPT, determining the optimal components of discharge information needed by community pharmacists to enhance medication management, and evaluating whether follow-up telephone calls from the hospital to community pharmacists are necessary for all patients.

Workflow process mapping to characterize office-based primary care medication use and safety: A conceptual approach

BACKGROUND

We developed the PCMedSafety conceptual framework to illustrate primary care medication safety transformation opportunities. PCMedSafety demonstrates the interrelationship between the practice-level primary care delivery system, medication workflow processes for common medication-related activities, and medication use and safety outcomes. This framework was used to conceptualize a workflow process mapping approach to characterize and evaluate the safety of medication-related activities performed in primary care practices.

OBJECTIVES

In this article, we conceptually describe how workflow process mapping of primary care medication-related activities can be used to: (1) understand and characterize common office-based primary care medication-related workflows, and (2) identify medication-related workflow process gaps and deviations and their impact on medication use and safety within office-based primary care.

METHODS

Workflow process mapping of primary care medication-related activities consists of 9 major steps, including: (1) identification of a primary care practice, (2) establishment of a workflow mapping team, (3) selection of medication-related activities, (4) development of ideal-state workflow process map(s), (5) selection of data elements and development of data collection form(s), (6) development of a workflow observation schedule, (7) completion of direct workflow observations, (8) development of observed workflow process map(s), and (9) data analysis to identify medication safety workflow gaps and deviations.

CONCLUSION

The medication workflow process mapping approach illustrated in this article can be used by primary care executive leadership, clinician leaders, primary care providers, and clinical pharmacists to identify, resolve, and prevent medication safety concerns within a primary care practices. Workflow gaps and deviations identified through workflow process mapping can be used to inform practice-specific opportunities for: (1) team-based primary care redesign to integrate clinical pharmacists into the expanded primary care team; (2) workforce development, including staff/provider training and role delegation for common primary care medication-related activities; and (3) improvements in workflow efficiency and consistency to reduce preventable medication errors.

Women's Beliefs on Early Adherence to Adjuvant Endocrine Therapy for Breast Cancer: A Theory-Based Qualitative Study to Guide the Development of Community Pharmacist Interventions

Adjuvant endocrine therapy (AET) taken for a minimum of five years reduces the recurrence and mortality risks among women with hormone-sensitive breast cancer. However, adherence to AET is suboptimal. To guide the development of theory-based interventions to enhance AET adherence, we conducted a study to explore beliefs regarding early adherence to AET. This qualitative study was guided by the Theory of Planned Behavior (TPB). We conducted focus groups and individual interviews among women prescribed AET in the last two years (n = 43). The topic guide explored attitudinal (perceived advantages and disadvantages), normative (perception of approval or disapproval), and control beliefs (barriers and facilitating factors) towards adhering to AET. Thematic analysis was conducted. Most women had a positive attitude towards AET regardless of their medication-taking behavior. The principal perceived advantage was protection against a recurrence while the principal inconvenience was side effects. Almost everyone approved of the woman taking her medication. The women mentioned facilitating factors to encourage medication-taking behaviors and cope with side effects. For adherent women, having trouble establishing a routine was their main barrier to taking medication. For non-adherent women, it was side effects affecting their quality of life. These findings could inform the development of community pharmacy-based adherence interventions.

Community Pharmacist Preferences in Transition of Care Communications

OBJECTIVE

To determine community pharmacist preferences in transition of care (TOC) communications.

METHODS

In this cross-sectional study, data were gathered via electronic survey of community pharmacists regarding their preferences for TOC communications. The survey was distributed via email by the North Carolina Board of Pharmacy. Results were analyzed using descriptive statistics.

RESULTS

Survey responses were received from 343 community pharmacists (response rate = 6.1%). Responders most commonly worked in an independent, single store (29.2%, n = 100) or national chain (29.2%, n = 100) pharmacy setting. Preferred method for a TOC communication was via electronic health record (63.0%, n = 184). Preferred TOC communication content are mentioned as follows: active (93.2%, n = 274) and discontinued (86.4%, n = 254) medications and reason for hospitalization (85.0%, n = 250). The top 3 self-identified barriers to utilizing a TOC communication: lack of care coordination with community pharmacy (35.0%, n = 14), lack of support from other health-care providers (22.5%, n = 9), and absence of compensation for providing the service (17.5%, n = 7). When asked if TOC communications were available, 97.5% (n = 278) indicated it would be useful.

CONCLUSION

Community pharmacists acknowledged a need for TOC communications and shared their preferences in the content and method of communication. Future research is warranted to implement TOC communications between a health system and community pharmacy.

Beliefs influencing community pharmacists' interventions with chronic kidney disease patients: A theory-based qualitative study

BACKGROUND

Drug-related problems (DRPs) are highly prevalent in chronic kidney disease (CKD) patients. Community pharmacists are ideally positioned to manage these DRPs. However, little is known about the factors influencing their interventions with CKD patients.

OBJECTIVES

Using the theory of planned behavior (TPB), this qualitative study sought to: (1) explore the behavioral beliefs (perceived advantages and disadvantages), normative beliefs (perceived expectations of significant others) and control beliefs (perceived barriers and facilitators) influencing community pharmacists' interventions related to identifying and managing DRPs in CKD; and (2) compare these beliefs among three DRPs prevalent in CKD patients.

METHODS

Community pharmacists in Quebec, Canada participated in face-to-face individual semi-structured interviews. The topic guide was based on the TPB. Three vignettes were presented to stimulate community pharmacists' thoughts about their interventions regarding: (1) the use of an inappropriate over-the-counter laxative; (2) prescriptions of anti-inflammatory medications; and (3) non-adherence to antihypertensive medication. Integral transcripts of audio recordings were analyzed using thematic analysis. The findings on each of the three DRPs were systematically compared.

RESULTS

Fifteen community pharmacists participated in the study. All expressed a positive attitude toward DRP management, mentioning advantages such as gaining the patient's loyalty as a client and avoiding CKD complications. Participants mentioned that patients and physicians generally approve their interventions, but the dynamics of these relationships may vary depending on the DRP. Common barriers in the management of the three DRPs were the pharmacists' limited time and heavy workloads. The pharmacists felt that the main disadvantage is that these interventions interrupt the workflow in the pharmacy.

CONCLUSION

Community pharmacists hold positive views of their interventions in CKD. However, enhancing community pharmacists' involvement in CKD care may require measures to facilitate pharmacists' proactivity, inter-professional collaboration and a work organization adapted to clinical activities.

"PErCEIVE in Umbria": evaluation of anti-influenza vaccination's perception among Umbrian pharmacists

Vaccines recommendations are available for both healthcare professionals and the general public, but although the vaccination is the most effective method to prevent infectious diseases, the coverage is still behind the recommended rate. In Italy, according to a recent study, the anti-flu vaccination rate among healthcare worker range between 9% to 30%. The aim of our study was to identify knowledge, attitude and behaviours regarding influenza vaccination among community pharmacists in order to increase the coverage rate among healthcare professional. "PErCEIVE (Pharmacist Perception on Influenza Vaccine) in Umbria" was a cross sectional survey among community pharmacists in Umbria conducted between 16th November 2015 to 29th February 2016. The questionnaire was anonymous, on-line self-administered survey. Statistical analysis were performed using STATA/SE 12 software. The response rate was 28.91% (n = 72/249). Among the studied population 76.39% (n = 55) had never performed influenza vaccine during the previous 5 years. Regarding source of information, only 15.28% of the subjects (n = 11) consulted the scientific publications, vs 52.78% (n = 38) who did not show any kind of interest upon the influenza vaccine. Our results show a low attitude to be vaccinated among pharmacists together with a low grade of awareness regarding the important role that pharmacists might play in order to reduce influenza burden, to promote health literacy among their patients and to decrease the risk of patients infection. Pharmacists might be crucial healthcare workers involved in health promotion, in vaccines' uptake and practices progression.