Integrated medicines management - can routine implementation improve quality?

Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) - a randomized controlled trial

Background

Suboptimal medication use contributes to a substantial proportion of hospitalizations and emergency department visits in older adults. We designed a clinical pharmacist intervention to optimize medication therapy in older hospitalized patients. Based on the integrated medicine management (IMM) model, the 5-step IMMENSE intervention comprise medication reconciliation, medication review, reconciled medication list upon discharge, patient counselling, and post discharge communication with primary care. The objective of this study was to evaluate the effects of the intervention on healthcare use and mortality.

Methods

A non-blinded parallel group randomized controlled trial was conducted in two internal medicine wards at the University Hospital of North Norway. Acutely admitted patients ≥ 70 years were randomized 1:1 to intervention or standard care (control). The primary outcome was the rate of emergency medical visits (readmissions and emergency department visits) 12 months after discharge.

Results

Of the 1510 patients assessed for eligibility, 662 patients were asked to participate, and 516 were enrolled. After withdrawal of consent and deaths in hospital, the modified intention-to-treat population comprised 480 patients with a mean age of 83.1 years (SD: 6.3); 244 intervention patients and 236 control patients. The number of emergency medical visits in the intervention and control group was 497 and 499, respectively, and no statistically significant difference was observed in rate of the primary outcome between the groups [adjusted incidence rate ratio of 1.02 (95% CI: 0.82–1.27)]. No statistically significant differences between groups were observed for any of the secondary outcomes, neither in subgroups, nor for the per-protocol population.

Conclusions

We did not observe any statistical significant effects of the IMMENSE intervention on the rate of emergency medical visits or any other secondary outcomes after 12 months in hospitalized older adults included in this study.

Trial registration

The trial was registered in clinicaltrials.gov on 28/06/2016, before enrolment started (NCT02816086).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08648-1.

Effect of medicines management versus standard care on readmissions in multimorbid patients: a randomised controlled trial

OBJECTIVE

To investigate the effect of pharmacist-led medicines management in multimorbid, hospitalised patients on long-term hospital readmissions and survival.

DESIGN

Parallel-group, randomised controlled trial.

SETTING

Recruitment from an internal medicine hospital ward in Oslo, Norway. Patients were enrolled consecutively from August 2014 to the predetermined target number of 400 patients. The last participant was enrolled March 2016. Follow-up until 31 December 2017, that is, 21-40 months.

PARTICIPANTS

Acutely admitted multimorbid patients ≥18 years, using minimum four regular drugs from minimum two therapeutic classes. 399 patients were randomly assigned, 1:1, to the intervention or control group. After excluding 11 patients dying in-hospital and 2 erroneously included, the primary analysis comprised 386 patients (193 in each group) with median age 79 years (range 23-96) and number of diseases 7 (range 2-17).

INTERVENTION

Intervention patients received pharmacist-led medicines management comprising medicines reconciliation at admission, repeated medicines reviews throughout the stay and medicines reconciliation and tailored information at discharge, according to the integrated medicines management model. Control patients received standard care.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint was difference in time to readmission or death within 12 months. Overall survival was a priori the clinically most important secondary endpoint.

RESULTS

Pharmacist-led medicines management had no significant effect on the primary endpoint time to readmission or death within 12 months (median 116 vs 184 days, HR 0.82, 95% CI 0.64 to 1.04, p=0.106). A statistically significantly increased overall survival was observed during 21-40 months follow-up (HR 0.66, 95% CI 0.48 to 0.90, p=0.008).

CONCLUSIONS

Pharmacist-led medicines management had no statistically significant effect on time until readmission or death. A statistically significant increased overall survival was seen. Further studies should be conducted to investigate the effect of such an intervention on a larger scale.

TRIAL REGISTRATION NUMBER

NCT02336113.

"Clearly they are in the circle of care, but . . .": A qualitative study exploring perceptions of personal health information sharing with community pharmacists in an integrated care model

Background

Ontario's Health Links approach to care is an integrated care model designed to optimize care for patients with complex needs. Currently, community pharmacists have no formalized role. This study aimed to explore stakeholders' perceptions about privacy and its impact on community pharmacists' involvement with integrated care models.

Methods

A qualitative study using semistructured telephone-based interviews was conducted. Participants worked in Ontario as pharmacists, providers in Health Links or team-based models or decision-makers in Health Links or health regions. Thematic analysis followed the Qualitative Analysis Guide of Leuven.

Results

Twenty-two participants were interviewed, and all but one commented on privacy or information sharing in integrating community pharmacists with integrated care models. The 4 themes identified were as follows: 1) what does the circle of care look like? 2) value of sharing information, 3) uncertainty of what information to share and 4) perceptions on how to share information.

Interpretation

The concerns surrounding privacy of personal health information and who is included in the circle of care represented an important barrier for integration. Enablers to mitigate privacy concerns included relationship building between community pharmacists, patients and other health care professionals and mutual access to information-sharing platforms such as electronic health records.

Conclusion

Providers' and decision-makers' perceptions about community pharmacists and privacy affect information sharing and are incongruent with Ontario's Personal Health Information Protection Act. Education is needed for health care professionals on legislation, especially as health systems move towards integrated care models to improve care. Can Pharm J (Ott) 2020;153:xx-xx.

A novel approach to medicines optimisation post-discharge from hospital: pharmacist-led medicines optimisation clinic

Background There is a major drive within healthcare to reduce patient readmissions, from patient care and cost perspectives. Pharmacist-led innovations have been demonstrated to enhance patient outcomes. Objective To assess the impact of a post-discharge, pharmacist-led medicines optimisation clinic on readmission parameters. Assessment of the economic, clinical and humanistic outcomes were considered. Setting Respiratory and cardiology wards in a district general hospital in Northern Ireland. Method Randomised, controlled trial. Blinded random sequence generation; a closed envelope-based system, with block randomisation. Adult patients with acute unplanned admission to medical wards subject to inclusion criteria were invited to attend clinic. Analysis was carried out for intention-to-treat and per-protocol perspectives. Main Outcome Measure 30-day readmission rate. Results Readmission rate reduction at 30 days was 9.6% (P = 0.42) and the reduction in multiple readmissions over 180-days was 29.1% (P = 0.003) for the intention-to-treat group (n = 31) compared to the control group (n = 31). Incidence rate ratio for control patients for emergency department visits was 1.65 (95% CI 1.05-2.57, P = 0.029) compared with the intention-to-treat group. For unplanned GP consultations the equivalent incident rate ratio was 2.00 (95% CI 1.18-3.58, P = 0.02). Benefit to cost ratio in the intention-to-treat and per-protocol groups was 20.72 and 21.85 respectively. Patient Health Related Quality of Life was significantly higher at 30-day (P < 0.001), 90-day (P < 0.001) and 180-day (P = 0.036) time points. A positive impact was also demonstrated in relation to patient beliefs about their medicines and medication adherence. Conclusion A pharmacist-led post-discharge medicines optimisation clinic was beneficial from a patient care and cost perspective.

Clinical Pharmacy Services in Older Inpatients: An Evidence-Based Review

BACKGROUND

Hospital admissions in older adults are frequently drug related and avoidable. Clinical pharmacy interventions during hospital stay might reduce drug-related harm and reduce hospital visits. Moreover, several recent positive clinical pharmacy investigations incorporated a transitional care component to further improve medication use after discharge. It is currently unclear what the strength of evidence is and what the exact components should be of such clinical pharmacy interventions in older adults.

OBJECTIVE

An evidence-based review was performed to determine the status of the evidence and also to explore whether a clinical pharmacy intervention incorporating transitional care was associated with reduced hospital visits after discharge.

METHODS

Prospective controlled investigations were included if they contained a clinical pharmacy intervention that was initiated before discharge in older inpatients. Relevant quasi-experimental and randomized controlled trials were searched in MEDLINE. First, an evidence-based review was performed, including a description of the study design, characteristics, and outcomes. Major components of successful clinical pharmacy interventions were described and potential implications for clinical practice and research were determined. Second, the Fisher's exact test was used to explore the association between transitional care and reduced hospital visits. Third, based on these findings, a medication review proposal was developed to improve medication use in older adults.

RESULTS

Thirty-five studies were included, with 26 randomized controlled trials. Median patient follow-up after discharge was 90 days (interquartile range 37-180 days) and investigators enrolled a median of 210 (interquartile range 110-498) study participants. On average, patients were aged 77.5 years (interquartile range 73-82.2 years). Nine randomized controlled trials had sufficient power to detect a reduction in hospital visits after discharge; this was reduced in three randomized controlled trials. Post-discharge follow-up was not associated with reduced post-discharge hospital visits (20 randomized controlled trials: follow-up vs. no follow-up: 6/11 vs. 1/9, p = 0.070). There was a significant reduction in post-discharge hospital visits in patients aged 75 years or older (12 randomized controlled trials: follow-up vs. no follow-up: 5/7 vs. 0/5, p = 0.028). A medication review proposal was developed, consisting of six steps.

CONCLUSIONS

Three powered randomized controlled trials were identified that found a significant association between a pharmacist-led intervention in older adults and a reduction in post-discharge hospital visits. In clinical practice, an intervention consisting of medication reconciliation, review, counseling, and post-discharge follow-up should be provided to such high-risk inpatients. Regarding research priorities, large, multi-center randomized controlled trials should be performed to generate more evidence on the impact of clinical pharmacy interventions on the patient trajectory and economic outcomes.

A Collaborative Medication Review Including Deprescribing for Older Patients in an Emergency Department: A Longitudinal Feasibility Study

Medication review for older patients with polypharmacy in the emergency department (ED) is crucial to prevent inappropriate prescribing. Our objective was to assess the feasibility of a collaborative medication review in older medical patients (≥65 years) using polypharmacy (≥5 long-term medications). A pharmacist performed the medication review using the tools: Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) criteria, a drug–drug interaction database (SFINX), and Renbase^® (renal dosing database). A geriatrician received the medication review and decided which recommendations should be implemented. The outcomes were: differences in Medication Appropriateness Index (MAI) and Assessment of Underutilization Index (AOU) scores between admission and 30 days after discharge and the percentage of patients for which the intervention was completed before discharge. Sixty patients were included from the ED, the intervention was completed before discharge for 50 patients (83%), and 39 (61.5% male; median age 80 years) completed the follow-up 30 days after discharge. The median MAI score decreased from 14 (IQR 8-20) at admission to 8 (IQR 2-13) 30 days after discharge (p < 0.001). The number of patients with an AOU score ≥1 was reduced from 36% to 10% (p < 0.001). Thirty days after discharge, 83% of the changes were sustained and for 28 patients (72%), 1≥ medication had been deprescribed. In conclusion, a collaborative medication review and deprescribing intervention is feasible to perform in the ED.

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.

Ensuring continuity of patient care across the healthcare interface: Telephone follow-up post-hospitalization

AIMS

To implement pharmacist-led, postdischarge telephone follow-up (TFU) intervention and to evaluate its impact on rehospitalization parameters in polypharmacy patients, via comparison with a well-matched control group.

METHOD

Pragmatic, prospective, quasi-experimental study. Intervention patients were matched by propensity score techniques with a control group. Guided by results from a pilot study, clinical pharmacists implemented TFU intervention, added to routine integrated medicines management service.

RESULTS

Using an intention to treat approach, reductions in 30- and 90-day readmission rates for intervention patients compared with controls were 9.9% [odds ratio = 0.57; 95% confidence interval (CI): 0.36-0.90; P < 0.001] and 15.2% (odds ratio = 0.53; 95% CI: 0.36-0.79; P = 0.021) respectively. Marginal mean time to readmission was 70.9 days (95% CI: 66.9-74.9) for intervention group compared with 60.1 days (95% CI: 55.4-64.7) for controls. Mean length of hospital stay compared with control was (8.3 days vs. 6.7 days; P < 0.001). Benefit: cost ratio for 30-day readmissions was 29.62, and 23.58 for 90-day interval. Per protocol analyses gave more marked improvements. In intervention patients, mean concern scale score, using Beliefs about Medicine Questionnaire, was reduced 3.2 (95% CI: -4.22 to -2.27; P < 0.001). Mean difference in Medication Adherence Report Scale was 1.4 (22.7 vs. 24.1; P < 0.001). Most patients (83.8%) reported having better control of their medicines after the intervention.

CONCLUSIONS

Pharmacist-led postdischarge structured TFU intervention can reduce 30- and 90-day readmission rates. Positive impacts were noted on time to readmission, length of hospital stay upon readmission, healthcare costs, patient beliefs about medicines, patient self-reported adherence and satisfaction.

The Connected Community Pharmacy: Benefits for Healthcare and Implications for Health Policy

The need for interoperability of healthcare Information Technology (IT) systems in order to provide safe, efficient, and coordinated healthcare is universally recognized. Various health economies, such as the United Kingdom, the United States, and Australia, are seeking to develop regional, state-wide, or national systems of healthcare interoperability. In England, the community pharmacy network is a significant health provider, with important implications for provision of healthcare in deprived areas because of its accessibility. Historically, however, community pharmacies have operated on a silo basis, and have not shared information on their activities with, or been able to access information from, other National Health Service (NHS) healthcare providers. The development of services such as the Electronic Prescription Service and the Summary Care Record in England have helped to connect community pharmacy with the NHS infrastructure, and more comprehensive systems and datasets are proposed to integrate community pharmacy with the NHS in future. This paper will review the benefits of the connected community pharmacy, based on developments to date and reviewing evidence from other countries. It will describe some of the future developments that will support the connected community pharmacy in England, and discuss some of the implications for pharmacists and health policy makers.

Multifaceted Pharmacist-led Interventions in the Hospital Setting: A Systematic Review

Clinical pharmacy services often comprise complex interventions. In this MiniReview, we conducted a systematic review aiming to evaluate the impact of multifaceted pharmacist-led interventions in a hospital setting. We searched MEDLINE, Embase, Cochrane Library and CINAHL for peer-reviewed articles published from 2006 to 1 March 2018. Controlled trials concerning hospitalized patients in any setting receiving patient-related multifaceted pharmacist-led interventions were considered. All types of outcome were accepted. Inclusion and data extraction were performed. Study characteristics were collected, and risk of bias assessment was conducted utilizing the Cochrane Risk of Bias tools. All stages were conducted by at least two independent reviewers. The review was registered in PROSPERO (CRD42017075808). A total of 11,896 publications were identified, and 28 publications were included. Of these, 17 were conducted in Europe. Six of the included publications were multi-centre studies, and 16 were randomized trials. Usual care was the comparator. Significant results on quality of medication use were reported as positive in eleven studies (n = 18; 61%) and negative in one (n = 18, 6%). Hospital visits were reduced significantly in seven studies (n = 16; 44%). Four studies (n = 12; 33%) reported a positive significant effect on either length of stay or time to revisit, and one study reported a negative effect (n = 12; 6%). All studies investigating mortality (n = 6), patient-reported outcome (n = 7) and cost-effectiveness (n = 1) showed no significant results. This MiniReview indicates that multifaceted pharmacist-led interventions in a hospital setting may improve the quality of medication use and reduce hospital visits and length of stay, while no effect was seen on mortality, patient-reported outcome and cost-effectiveness.

Prospective Validation of Clinical Criteria to Identify Emergency Department Patients at High Risk for Adverse Drug Events

Objectives

Adverse drug events (ADEs) cause or contribute to one in nine emergency department (ED) presentations in North America and are often misdiagnosed. EDs have insufficient clinical pharmacists to complete medication reviews in all incoming patients, even though pharmacist‐led medications reviews have been associated with improved health outcomes. Our objective was to validate clinical decision rules to identify patients presenting with ADEs so they could be prioritized for pharmacist‐led medication review.

Methods

This multicenter, prospective study was conducted in two tertiary and one community hospital in Canada. We enrolled 1,529 adults presenting to EDs over 12 months. We applied two clinical decision rules and collected baseline variables prior to assessments by clinical pharmacists and physicians. We compared the physician and pharmacist diagnoses with the decision rule results. The primary outcome was a moderate or severe ADE, defined as an unintended and harmful event related to medication use or misuse, which required a change in medical therapy, diagnostic testing, consultation, or admission. An independent committee adjudicated uncertain and discordant cases. We calculated the diagnostic accuracy of both rules.

Results

Among 1,529 patients, 184 (12.0%) were diagnosed with an ADE. Rule 1 contained the variables 1) having a preexisting medical condition or having taken antibiotics within 1 week and 2) age > 80 years or having a medication change within 28 days. They had a sensitivity of 91.3% (95% confidence interval [CI] = 86.3%–95.0%) and a specificity of 37.9% (95% CI = 35.3%–40.6%) for ADEs.

Conclusions

Our study validated clinical decision rules that can be applied by clinical pharmacists to limit the number of patients requiring medication review, while identifying the majority of patients presenting with clinically significant ADEs.

Reducing potentially inappropriate drug prescribing in nursing home residents: effectiveness of a geriatric intervention

AIMS

Potentially inappropriate drug prescribing (PIDP) is frequent in nursing home (NH) residents. We aimed to investigate whether a geriatric intervention on quality of care reduced PIDP.

METHODS

We performed an ancillary study within a multicentric individually-tailored controlled trial (IQUARE trial). All NH received a baseline and 18-month audit regarding drug prescriptions and other quality of care indicators. After the initial audit, NHs of the intervention group benefited of an in-site intervention (geriatric education for NH staff) provided by a geriatrician from the closest hospital. The analysis included 629 residents of 159 NHs. The main outcome was PIDP, defined as the presence of at least one of the following criteria: (i) drug with an unfavourable benefit-to-risk ratio; (ii) with questionable efficacy; (iii) absolute contraindication; (iv) significant drug-drug interaction. Multivariable multilevel logistic regression models were performed including residents and NH factors as confounders.

RESULTS

PIDP was 65.2% (-3.6% from baseline) in the intervention group (n = 339) and 69.9% (-2.3%) in the control group (n = 290). The intervention significantly decreased PIDP [odds ratio (OR) = 0.63; 95% confidence interval 0.40-0.99], as a special care unit in NH (OR = 0.60; (0.42 to 0.85)), and a fall in the last 12 months (OR = 0.63; 0.44-0.90). Charlson Comorbidity Index [ORCCI = 1 vs. 0  = 1.38; 0.87-2.19, ORCCI ≥ 2 vs. 0  = 2.01; (1.31-3.08)] and psychiatric advice and/or hospitalization in a psychiatric unit (OR = 1.53; 1.07-2.18) increased the likelihood of PIDP.

CONCLUSION

This intervention based on a global geriatric education resulted in a significant reduction of PIDP at patient level.

Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (IMMENSE study): study protocol for a randomised controlled trial

INTRODUCTION

Drug-related problems (DRPs) are common in the elderly, leading to suboptimal therapy, hospitalisations and increased mortality. The integrated medicines management (IMM) model is a multifactorial interdisciplinary methodology aiming to optimise individual medication therapy throughout the hospital stay. IMM has been shown to reduce readmissions and drug-related hospital readmissions. Using the IMM model as a template, we have designed an intervention aiming both to improve medication safety in hospitals, and communication across the secondary and primary care interface. This paper presents the study protocol to explore the effects of the intervention with regard to healthcare use, health-related quality of life (HRQoL) and medication appropriateness in elderly patients.

METHODS AND ANALYSIS

A total of 500 patients aged ≥70 years will be included and randomised to control (standard care) or intervention group (1:1). The intervention comprises five steps mainly performed by pharmacists: (1) medication reconciliation at admission, (2) medication review during hospital stay, (3) patient counselling about the use of medicines, (4) a comprehensible and patient-friendly medication list with explanations in discharge summary and (5) postdischarge phone calls to the primary care level. The primary outcome is the difference between intervention and control patients in the rate of emergency medical visits (acute readmissions and visits to emergency department) 12 months after discharge. Secondary outcomes include length of index hospital stay, time to first readmission, mortality, hip fractures, strokes, medication changes, HRQoL and medication appropriateness. Patient inclusion started in September 2016.

ETHICS AND DISSEMINATION

The trial was approved by the Norwegian Centre for Research Data and the Norwegian Data Protection Authority. We aim to publish the results in international peer-reviewed open access journals, at national and international conferences, and as part of two PhD theses.

TRIAL REGISTRATION NUMBER

NCT02816086.

Limited effect of structured medication report as the only intervention at discharge from hospital

Objective

To investigate whether a structured medication report at discharge from the hospital could reduce the number of medication discrepancies in primary care.

Method

The study was performed as an open, randomised controlled study including patients transferred from one hospital in Norway to nursing home or home care. Both groups received epicrisis on discharge. In addition, the intervention group received a structured medication report. After discharge, the medication list in primary care service was compared with the list at discharge and medication discrepancies identified. In addition, these medication lists were retrospectively compared with the lists prior to admission to the hospital and at admission to hospital. A questionnaire on time spent and quality of the medication information was filled in by nurses in primary care.

Results

Medication discrepancies were found for 72% (26) of the patients in the intervention group and 76% (42) in the control group (P=0.918). Most common was drugs omitted or committed to the medication lists in primary care service. Typically, the committed drugs in primary care were omitted drugs after admission to the hospital. Nurses used significantly less time (66%) obtaining medication information in the intervention group (P=0.041).

Conclusions

Structured medication report as the only intervention did not reduce the medication discrepancies after discharge from hospital. There is a need for reconciliation at admission to ensure the quality of the medication report. Structured medication report resulted in the nurses spending less time on collecting medication information in primary care service.

Impact of the Collaborative Pharmaceutical Care at Tallaght Hospital (PACT) model on medication appropriateness of older patients

Objectives

A high prevalence of potentially inappropriate prescribing (PIP) has been identified in older patients in Ireland. The impact of the Collaborative Pharmaceutical Care at Tallaght Hospital (PACT) model on the medication appropriateness of acute hospitalised older patients during admission and at discharge is reported.

Methods

Uncontrolled before-after study. The study population for this study was medical patients aged ≥65 years, using ≥3 regular medicines at admission, taken from a previous before-after study. Standard care involved clinical pharmacists being ward-based, contributing to medication history taking and prescription review, but not involved at discharge. The innovative PACT model involved clinical pharmacists being physician team-based, leading admission and discharge medication reconciliation and undertaking prescription review, with authority to change the prescription during admission or at discharge. The primary outcome was the Medication Appropriateness Index (MAI) score applied pre-admission, during admission and at discharge.

Results

Some 108 patients were included (48 PACT, 60 standard). PACT significantly improved the MAI score from pre-admission to admission (mean difference 2.4, 95% CI 1.0 to 3.9, p<0.005), and from pre-admission to discharge (mean difference 4.0, 95 CI 1.7 to 6.4, p<0.005). PACT resulted in significantly fewer drugs with one or more inappropriate rating at discharge (PACT 15.0%, standard 30.5%, p<0.001). The MAI criteria responsible for most inappropriate ratings were 'correct directions' (4.8% PACT, 17.3% standard), expense (5.3% PACT, 5.7% standard) and dosage (0.6% PACT, 4.0% standard). PACT suggestions to optimise medication use were accepted more frequently, and earlier in the hospital episode, than standard care (96.7% PACT, 69.3% standard, p<0.05).

Conclusions

Collaborative pharmaceutical care between physicians and pharmacists from admission to discharge, with authority for pharmacists to amend the prescription, improves medication appropriateness in older hospitalised Irish patients.

Enhanced clinical pharmacy service targeting tools: risk-predictive algorithms

RATIONALE, AIMS AND OBJECTIVES

This study aimed to determine the value of using a mix of clinical pharmacy data and routine hospital admission spell data in the development of predictive algorithms. Exploration of risk factors in hospitalized patients, together with the targeting strategies devised, will enable the prioritization of clinical pharmacy services to optimize patient outcomes.

METHODS

Predictive algorithms were developed using a number of detailed steps using a 75% sample of integrated medicines management (IMM) patients, and validated using the remaining 25%. IMM patients receive targeted clinical pharmacy input throughout their hospital stay. The algorithms were applied to the validation sample, and predicted risk probability was generated for each patient from the coefficients. Risk threshold for the algorithms were determined by identifying the cut-off points of risk scores at which the algorithm would have the highest discriminative performance. Clinical pharmacy staffing levels were obtained from the pharmacy department staffing database.

RESULTS

Numbers of previous emergency admissions and admission medicines together with age-adjusted co-morbidity and diuretic receipt formed a 12-month post-discharge and/or readmission risk algorithm. Age-adjusted co-morbidity proved to be the best index to predict mortality. Increased numbers of clinical pharmacy staff at ward level was correlated with a reduction in risk-adjusted mortality index (RAMI).

CONCLUSIONS

Algorithms created were valid in predicting risk of in-hospital and post-discharge mortality and risk of hospital readmission 3, 6 and 12 months post-discharge. The provision of ward-based clinical pharmacy services is a key component to reducing RAMI and enabling the full benefits of pharmacy input to patient care to be realized.

Drug related problems identified by community pharmacists on hospital discharge prescriptions in New Zealand

BACKGROUND

There can be a lack of transfer of information between hospitals and community pharmacies following patient discharge, which puts patients at a high risk of suffering drug related problems (DRPs). Community pharmacy plays a vital role in identifying and solving these discharge DRPs and taking action before these DRPs can lead to patient harm.

OBJECTIVE

To identify the types and quantities of DRPs that community pharmacies detect within a single district health board (DHB) in New Zealand.

SETTING

One DHB in New Zealand that contains 50 community pharmacies, which receive discharge prescriptions from two local hospitals.

METHOD

All community pharmacies in the DHB area (n = 50) were invited to participate in the 2 week study which involved documenting the number of hospital discharge prescriptions received, and then the number and type of DRPs identified and what interventions were required.

MAIN OUTCOME MEASURE

The number and type of DRPs identified as a proportion of all discharge prescriptions received during the 2 week study period.

RESULTS

Initially a total of 38 pharmacies agreed to participate in this study, however only 32 pharmacies provided data for the entire 2 week period. Over a 2 week period a total of 1,374 hospital discharge prescriptions were presented to these pharmacies. From these prescriptions 344 (25 %) required further action to be taken by the pharmacist. These 344 prescriptions consisted of a total of 396 individual DRPs. Actions classified as "Supply and/or Funding" accounted for 43 % (171), which represented the largest class of all actions required from hospital discharge prescriptions. This class consisted of "Special Authority" problems, medications not being available, non-subsidised items on the prescription and other supply/funding problems. "Errors" accounted for 38 % (151) which included errors of omission (20 %) and errors of commission (18 %).

CONCLUSION

This study found a significant number of DRPs identified by community pharmacists on hospital discharge prescriptions. These included missing and incorrect information which required clarification with prescribers. Interventions need to be put in place to reduce the number of errors and improve clarity of hospital discharge prescriptions. Better information sharing and understanding of medications available in primary care will reduce the potential for DRPs.

Medication reviews by clinical pharmacists at hospitals lead to improved patient outcomes: a systematic review

Suboptimal medication use may lead to morbidity, mortality and increased costs. To reduce unnecessary patient harm, medicines management including medication reviews can be provided by clinical pharmacists. Some recent studies have indicated a positive effect of this service, but the quality and outcomes vary among studies. Hence, there is a need for compiling the evidence within this area. The aim of this systematic MiniReview was to identify, assess and summarize the literature investigating the effect of pharmacist-led medication reviews in hospitalized patients. Five databases (MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane Library) were searched from their inception to 2011 in addition to citation tracking and hand search. Only original research papers published in English describing pharmacist-led medication reviews in a hospital setting including minimum 100 patients or 100 interventions were included in the final assessment. A total of 836 research papers were identified, and 31 publications were included in the study: 21 descriptive studies and 10 controlled studies, of which 6 were randomized controlled trials. The pharmacist interventions were well implemented with acceptance rates from 39% to 100%. The 10 controlled studies generally show a positive effect on medication use and costs, satisfaction with the service and positive as well as insignificant effects on health service use. Several outcomes were statistically insignificant, but these were predominantly associated with low sample sizes or low acceptance rates. Therefore, future research within this area should be designed using rigorous design, large sample sizes and includes comparable outcome measures for patient health outcomes.