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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trends in dispensing errors reported in Finnish community pharmacies in 2015-2020: a national retrospective register-based study

BACKGROUND

Community pharmacies are responsible for dispensing of medicines and related counselling in outpatient care. Dispensing practices have remarkably changed over time, but little is known about how the changes have influenced medication safety. This national study investigated trends in dispensing errors (DEs) related to prescribed medicines, which were reported in Finnish community pharmacies within a 6-year period.

METHODS

This national retrospective register study included all DEs reported to a nationally coordinated voluntary DE reporting system by Finnish community pharmacies during 2015-2020. DE rates, DE types, prescription types, individuals who detected DEs and contributing factors to DEs were quantified as frequencies and percentages. Poisson regression was used to assess the statistical significance of the changes in annual DE rates by type.

RESULTS

During the study period, altogether 19 550 DEs were reported, and the annual number of error reports showed a decreasing trend (n = 3 913 in 2015 vs. n = 2 117 in 2020, RR 0.54, p < 0.001). The greatest decrease in reported DEs occurred in 2019 after the national implementation of the Medicines Verification System (MVS) and the additional safety feature integrated into the MVS process. The most common error type was wrong dispensed strength (50% of all DEs), followed by wrong quantity or pack size (13%). The annual number of almost all DE types decreased, of which wrong strength errors decreased the most (n = 2121 in 2015 vs. n = 926 in 2020). Throughout the study period, DEs were most commonly detected by patients (50% of all DEs) and pharmacy personnel (30%). The most reported contributing factors were factors related to employees (36% of all DEs), similar packaging (26%) and similar names (21%) of medicinal products.

CONCLUSIONS

An overall decreasing trend was identified in the reported DEs and almost all DE types. These changes seem to be associated with digitalisation and new technologies implemented in the dispensing process in Finnish community pharmacies, particularly, the implementation of the MVS and the safety feature integrated into the MVS process. The role of patients and pharmacy personnel in detecting DEs has remained central regardless of changes in dispensing practices.

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

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

'Illuminating determinants of implementation of non-dispensing pharmacist services in home care: a qualitative interview study'

OBJECTIVES

Medication errors are leading causes of hospitalization and death in western countries and WHO encourages health care providers to implement non-dispensing pharmacist services in primary care to improve medication work. However, these services struggle to provide any impact on clinical outcomes. We wanted to explore health care professionals' views on medication work to illuminate determinants of the implementation success. The research was designed to inform and adapt implementation strategies for non-dispensing pharmacist services.

DESIGN

Semi-structured interview study with nine healthcare professionals.

SETTING

Four Norwegian home care wards.

SUBJECTS

Nine healthcare professionals working at different wards within one home care unit.

MAIN OUTCOME MEASURES

Determinants of implementation outcomes.

RESULTS

Contextual determinants of the implementation process were mainly related to characteristics of the setting such as poorly designed information systems, work overload, and chaotic work environments. The identified barriers question the innovation's appropriateness related to the setting's needs but also provide possibilities for tailoring pharmacist services to local medication work issues. The observable positive effects and the perceived advantage of the pharmacist services are likely to facilitate the implementation process.

CONCLUSION

Our study provided information on contextual elements that influence the implementation process of non-dispensing pharmacist services. Awareness of these factors can help develop strategies to help the organization succeed in in achieving program outcomes.

Enabling value-in-use with digital healthcare technologies: combining service logic and pragmatic constructivism

The paper discusses how healthcare providers can enable value-in-use (VIU) using digital technologies in complex healthcare service contexts. Technology providers and public healthcare organizations can have difficulties understanding one another, hindering the possibilities for value-in-use to emerge. Plenty of studies have investigated the value creation in healthcare, often looking at health as value for the patient. We focus on how healthcare providers can create value for themselves to improve their operations and justify the price of new technologies while fully acknowledging the value for the patient as well. The paper uses two in-depth interventionist case studies in Nordic health care: automated screening technology for hospital laboratories and medicine dispensing robotics for home care. We use a novel combination of pragmatic constructivism (PC) and service logic (SL) as method theories to understand the value creation in our cases. Our empirical evidence provide practical examples of how digital technologies can be used to change healthcare practices and how VIU can stem from these changes. As a contribution, we show that healthcare providers can enable value-in-use with digital technologies by altering how care is carried out without hindering what the outcome of the care is for the patient. Digital technologies are there to facilitate such change, but the change still requires that actors involved in care have intention to change how they work. While healthcare bears the responsibility for these changes, technology providers can also have plenty of opportunities for interaction to support or even co-create value together with their customers.

Implementation of E-prescription for Multidose Dispensed Drugs: Qualitative Study of General Practitioners' Experiences

Background

Increased use of pharmaceuticals challenges both capacity and safety related to medication management for patients and changes in how general practitioners (GPs) and other health personnel interact with and follow up with patients. E-prescribing of multidose drug dispensing (eMDD) is 1 of the national measures being tested in Norway.

Objective

The objective of this study is to explore GPs’ experiences with the challenges and benefits of implementing eMDD in Norway.

Methods

Qualitative in-depth and group interviews were conducted with a total of 25 GPs between 2018 and 2020. Transcribed files were saved in NVivo to conduct a step-by-step content analysis. NVivo is a software tool for organizing, managing, and analyzing qualitative data.

Results

The study revealed that eMDD offers many benefits. At the same time, there are several challenges related to information, training, and initiation, as well as to the responsibility for the medication, interactions, and the risk of incorrect medication. An important activity in the start-up phase was an information meeting with pharmacies and technology suppliers, as well as exchanging information and instructions with pharmacies on how to get started. Four analytic themes emerged through the extraction of data: (1) start-up with eMDD (“Be patient”); (2) the need for training; (3) interaction, safety, and efficiency; and (4) the working day with eMDD.

Conclusions

There is a variation in different GPs’ needs regarding training and information, and considerable variation in competence and motivation related to the use of digital tools. There are also different degrees of understanding the everyday work of the other actors in the medication chain. In particular, the harmonization of medication lists related to the use of time, expenditures, and challenges with technological solutions in the introduction phase was emphasized as a challenge. Overall, GPs who have started using the system report great benefits; these are largely related to an increased overview of patients’ total medication lists, less time spent on prescribing prescriptions, and increased collaboration with pharmacies and nurses, both in service from providers in homes and in nursing homes.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Supplementary information

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

From Paper to E-Prescribing of Multidose Drug Dispensing: A Qualitative Study of Workflow in a Community Care Setting

E-prescribing is now widespread and, in some countries, has completely replaced paper prescriptions. In Norway, almost all prescribing is electronic, except for multidose drug dispensing (MDD), which is still sent to the pharmacy by fax or ordinary mail. MDD is an adherence aid used by one-third of all patients receiving home care services. In this paper, we present results from a qualitative study evaluating the introduction of e-prescribing for MDD in a community health care setting. The focus is on the work and workflow for the pharmacists and nurses involved in the medication-handling process. We used the pragmatic process evaluation framework and the systematic text condensation method to analyse the data. We conducted 12 interviews with 34 nurses and pharmacists. This study shows that the e-prescribing of MDD led to greater integration between systems, both within the existing MDD system and across care levels, potentially improving patient safety. However, the structured prescriptions increased the need for clarifications, resulting in an increased overall workload. A greater understanding of the roles and responsibilities of the different professionals in the medication management chain and their needs would improve the workflow of the nurses and pharmacists involved.

Determination of the cross-contamination and validation of the cleaning process for an automated personalised dosing system

OBJECTIVE

To determine the degree of cross-contamination and to validate a cleaning process for an Automated Personalised Dosing System (APDS), respecting the permitted residue transfer limits.

METHOD

An analytical determination by high pressure liquid chromatography with mass spectrometry was performed for 11 drugs considered critical for their potential for contamination, toxicity (National Institute for Occupational Safety and Health (NIOSH) List 2016) and/or narrow therapeutic index. The test was carried out for three consecutive weeks, seven repetitions per week, in a state of maximum contamination and maximum cleanliness. The main validation criterion of the cleaning protocol was to quantify that the active ingredients measured were below the Permitted Daily Exposure index or fraction 1/1000 of the minimum daily dose, both in a state of maximum contamination and when the APDS is in a clean condition, for an average number of tablets consumed per person per day.

RESULTS

In all the samples analysed, some compound could always be quantified below 2% of the permitted transfer limits, highlighting the presence of paracetamol and carbamazepine. In the state of maximum contamination, the mean±SD values of paracetamol and carbamazepine were 5.83±1.56 µg and 0.22±0.07 µg, respectively, without significant differences in mean values over the 3 weeks of the study. After the cleaning protocol was executed, only paracetamol and carbamazepine were detected, with the average values being 4.67 µg (95% CI 3.92 to 5.43, p<0.05) and 0.07 µg (95% CI 0.03 to 0.10, p<0.05) lower than the state of maximum contamination, respectively.

CONCLUSIONS

In all cases the level of cross-contamination for an APDS was below the pre-established limits. The cleaning protocol has been validated, confirming APDS decontamination of the most critical medicines.

How smart medication systems are used to support older people's drug regimens: A systematic literature review

Smart medication systems are used to help older people, and the professionals and family who care for them, to organize and manage their daily drug regimes. However, synthetized knowledge on previous studies about how these improve everyday life is needed. We searched the PubMed, Scopus, CINAHL, PsycINFO, SocINDEX and Cochrane library databases from 2005 to 2019 and this review focused on nine of the 2,424 papers we identified. According to our analysis, smart medication systems make it possible to regulate medication times and doses and detect medication errors. With further development, smart medication systems could be more be effective at preventing medication errors, improving medication adherence by older people and freeing up healthcare professional, so that they can focus on other tasks. However, more research on different systems is needed to improve existing solutions and to understand how they can make older people more independent when it comes to their daily medication.

Characteristics of doctor-shoppers: a systematic literature review

Objective: Doctor-shopping has significant consequences for patients and payers and can indicate misuse of drugs, polypharmacy, less continuity of care, and increased medical expenses. This study reviewed the literature describing doctor-shoppers in the adult population. Methods: A systematic literature review was performed in PubMed and supplemented by a Google search of grey literature. Overall, 2885 records were identified; 43 papers served as a source of definition of a doctor-shopper, disease, treatment, patient characteristics, patient special needs, country. Results: Definitions of doctor-shopping were heterogeneous. Overall, 40% of studies examined the use of opioids, antidepressants, or psychoactive drugs, while the others focused on chronic or frequent diseases. Most studies were conducted in countries with easy access to healthcare resources (USA, France, Taiwan, Hong Kong). The prevalence of doctor-shopping ranged from 0.5% among opioid users in the USA to 25% of patients registered at general practices in Japan. Comorbidities, active substance abuse, greater distance from healthcare facility, younger age, longer disease and poor patient satisfaction increased doctor-shopping. Conclusions: Knowing the characteristics of doctor-shoppers may help identify such patients and reduce the associated waste of medical resources, but concerns about the misuse of drugs or healthcare resources should not prevent proper disease management.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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