Types of interventions made by clinical pharmacists in the IMPROVE study. Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers

Impact of Clinical Pharmacist-led Interventions in Turkey

Detecting drug-related problems (DRPs) is important in pharmaceutical care in for better therapeutic outcomes. Clinical pharmacists-led comprehensive medication management plays a crucial role in the rational use of drugs by preventing, identifying, and resolving DRPs. In this review, we aimed to determine the effect of interventions on patient outcomes performed by clinical pharmacists in Turkey. A systematic literature search was performed on PubMed, Google Scholar, EMBASE, Cochrane Library, and Turkish databases (ULAKBIM, Dergipark). The main categories were "clinical pharmacist", "intervention", and "Turkey". Two reviewers reviewed each article independently. Two independent reviewers screened all records and extracted data; disagreements were resolved through a consensus. Randomized controlled studies, pre- to post-intervention comparison studies, and cross-sectional studies including pharmacist-led interventions were included in the review. This review included 15 articles evaluating clinical pharmacist interventions. Ten studies (66.7%) focused on DRPs and pharmacist interventions to these problems, while the remaining 5 (33.3%) studies focused on patient education and adherence issues. Studies were conducted in oncology (33.3%), geriatrics (20.0%), chest diseases (13.3%), psychiatry (6.7%), cardiology (6.7%), and infectious diseases (6.7%) clinics. When results of studies are reviewed, most of the interventions were made at the prescriber level followed by the drug level and patient level. Problems were solved in 54.2-93.2% of DRPs, and adherence, patient knowledge, or skills were improved in most of the studies. Most of the studies were carried out within the scope of a postgraduate or doctorate thesis and yet various positive outcomes such as the prevention of side effects, increased quality of life, and decreased duration of hospital stay were observed with high positive rates of interventions, which indicate that other healthcare workers are ready to collaborate with the clinical pharmacists in Turkey.

Potentially inappropriate prescribing for adults with diabetes mellitus: a scoping review protocol

OBJECTIVE

This scoping review aims to explore and map studies investigating potentially inappropriate prescribing (PIP) for adults with diabetes mellitus.

INTRODUCTION

Inappropriate prescribing for people with diabetes mellitus has been reported by various authors focusing on different aspects of inappropriateness. A preliminary search revealed no published reviews on PIP for adults with diabetes mellitus. As a result, it is difficult to obtain a comprehensive map of PIP in this patient group.

INCLUSION CRITERIA

This scoping review will consider all studies on PIP for adults with the diagnosis of type 1 or type 2 diabetes mellitus from any clinical setting. Studies conducted in pediatric populations or in adults with pre-diabetes or gestational diabetes will be excluded.

METHODS

A three-step search strategy (i.e. an initial limited search in PubMed and ProQuest Central databases, a main search of eight databases and gray literature, and manual searches of reference lists of included articles) will be utilized. No language restrictions will be applied. All retrieved articles will be screened against the inclusion/exclusion criteria at title, abstract, and full-text stages. Data to be extracted from each study will include, but not be limited to, country, objective, study population, study methodology, type of PIP studied, examples of PIP events, medications involved, and criteria used for PIP identification. Data will be extracted by study team members using an online application for conducting systematic synthesis of evidence.

Comparison of drug-related problem risk assessment tools for older adults: a systematic review

PURPOSE

This study aims to systematically review studies describing screening tools that assess the risk for drug-related problems (DRPs) in older adults (≥ 60 years). The focus of the review is to compare DRP risks listed in different tools and describe their development methods and validation.

METHODS

The systematic search was conducted using evidence-based medicine, Medline Ovid, Scopus, and Web of Science databases from January 1, 1985, to April 7, 2016. Publications describing general DRP risk assessment tools for older adults written in English were included. Disease, therapy, and drug-specific tools were excluded. Outcome measures included an assessment tool's content, development methods, and validation assessment.

RESULTS

The search produced 15 publications describing 11 DRP risk assessment tools. Three major categories of risks for DRPs included (1) patient or caregiver related risks; (2) pharmacotherapy-related risks; and (3) medication use process-related risks. Of all the risks included in the tools only 8 criteria appeared in at least 4 of the tools, problems remembering to take the medication being the most common (n=7). Validation assessments varied and content validation was the most commonly conducted (n = 9). Reliability assessment was conducted for 6 tools, most commonly by calculating internal consistency (n = 3) and inter-rater reliability (n = 2).

CONCLUSIONS

The considerable variety between the contents of the tools indicates that there is no consensus on the risk factors for DRPs that should be screened in older adults taking multiple medicines. Further research is needed to improve the accuracy and timeliness of the DRP risk assessment tools.

PaCIR: A tool to enhance pharmacist patient care intervention reporting

OBJECTIVES

To develop a pharmacist patient care services intervention reporting checklist to be used in conjunction with existing primary reporting tools. The tool should enhance consistent reporting of pharmacist patient care interventions. Tool use in pharmacist-patient care intervention reporting may increase: (1) likelihood for inclusion in higher order analyses and (2) successful replication.

METHODS

Adhering to principles of the Equator Network, a modified Delphi approach was used. An expert group identified guidance need, conducted a thorough literature search confirming need, developed a comprehensive list of potential elements, refined the list via multiple rounds, finalized language and structure, and published the checklist. Multiple rounds of iterative input were completed face to face, in conference calls, and during public comment periods. The finalized list of elements was organized into a logical flow with the use of clear and concise language and then transformed into an intuitive checklist.

RESULTS

The core task force identified 9 critical components over a 4-year period Collectively, the input represented more than 200 stakeholders. Stakeholders overwhelmingly supported the inclusion (89%; n = 29) and clarity (91%; n = 26) of each element. The final 9 elements were organized into a checklist to enhance pharmacist patient care intervention reporting (PaCIR). Accompanying each element is a specific explanation justifying its inclusion. An appendix containing published and created examples of how authors may satisfactorily meet each element is provided.

CONCLUSION

Use of the PaCIR checklist will enhance the quality of reporting of pharmacist patient care intervention studies. This enhanced quality can support replication of the studies and increase the likelihood these studies will be considered for inclusion in systematic reviews and meta-analyses. Researchers are urged to consider use of reporting guides such as PaCIR during the project design phase.

Ensuring consistent reporting of clinical pharmacy services to enhance reproducibility in practice: an improved version of DEPICT

RATIONALE, AIMS AND OBJECTIVES

DEPICT (Descriptive Elements of Pharmacist Intervention Characterization Tool) was created in response to the frequently reported issue of poor intervention description across studies assessing the impact of clinical pharmacy activities. The aim of this study was to create an improved version of DEPICT (i.e. DEPICT 2) to better characterize clinical pharmacy services in order to ensure consistent reporting, therefore enhancing reproducibility of interventions in practice.

METHOD

A qualitative approach through a thematic content analysis was performed to identify components of pharmacist interventions described in 269 randomized controlled trials. A preliminary version of DEPICT 2 was applied independently by two authors to a random sample of 85 of the 269 RCTs and reliability determined by the prevalence-adjusted bias-adjusted kappa (PABAK) or the intraclass correlation coefficient (ICC). The final version of DEPICT 2 was compared against DEPICT 1.

RESULTS

The final version of DEPICT 2 comprised 146 items and 11 domains. The inter-rater agreement analysis showed that DEPICT presented good to optimal reproducibility, with a mean PABAK value of 0.87 (95% CI 0.85-0.89) and a mean ICC value of 0.88 (95% CI 0.62-1.14). The mean difference between items checked in the two versions (DEPICT 2 - DEPICT 1) was 10.58 (95% CI 9.55-11.61), meaning that approximately 11 more components were identified in the new version of DEPICT.

CONCLUSIONS

DEPICT 2 is a reliable tool to characterize components of clinical pharmacy services, which should be used to ensure consistent reporting of interventions to allow their reproducibility in practice.

Understanding the landscape of MTM programs for Medicare. Part D: Results from a study for the Centers for Medicare & Medicaid services

OBJECTIVES

To describe the features of medication therapy management (MTM) programs, including eligibility criteria, enrollment, services, and reimbursement, and to describe the criteria used to evaluate MTM programs and assess the evidence of relevance to Medicare.

DESIGN

Descriptive, exploratory, nonexperimental study.

SETTING

United States between July 2007 and June 2008.

PARTICIPANTS

60 key informants from 46 different organizations and case studies with 28 representatives from four MTM programs.

INTERVENTION

Literature review, key informant interviews, and evaluation of case studies.

MAIN OUTCOME MEASURES

MTM program features and evidence of effectiveness.

RESULTS

MTM programs used a variety of practice models. Medicare MTM programs used different eligibility criteria than MTM programs sponsored by Medicaid or other payers. MTM programs that required patients to opt-in had less success in enrolling participants than those using opt-out. Most MTM programs conducted annual medication reviews. Most non-Medicare MTM programs provided face-to-face interventions, whereas Medicare MTM programs relied more on telephone or mail; no research tested the effectiveness of different modes. Almost all MTM programs used pharmacists to provide services. Little research on Medicare MTM programs was available. Costs were commonly measured in the MTM literature, although results were inconsistent. A few studies demonstrated significant improvements in intermediate outcomes (e.g., low-density lipoprotein cholesterol), while less studies demonstrated an impact on serious sequelae (e.g., emergency department visits).

CONCLUSION

Medicare MTM programs were still evolving when this study was conducted, and we found limited evidence to determine which beneficiaries would benefit most from MTM, which features achieved the desired outcomes, and which outcomes should be measured to compare MTM program performance.

Delivering a home-based medication review, process measures from the HOMER randomised controlled trial

Objectives

The HOme-based MEdication Review (HOMER) trial investigated whether home-based medication review by pharmacists could decrease hospital re-admission in older people. This trial demonstrated that the intervention increased admissions by 30% (P=0.009). This unexpected finding provoked significant interest. This paper describes the intervention in detail and the process measures recorded by review pharmacists, and investigates whether results differed according to pharmacist characteristics.

Method

437 patients were randomised to the intervention, which involved two pharmacist home visits within two and eight weeks of discharge, and 435 were randomised to usual care. An analysis was undertaken of the process measures and to determine whether admission rates differed within the intervention group according to the type of pharmacist performing the review. Setting Norfolk or Suffolk patients aged over 80 years discharged to their own home after an emergency admission (any cause), and taking two or more medications daily.

Key findings

Twenty-two pharmacists participated. The majority (68%) were experienced community pharmacists (mean age = 42 years), 71% had a postgraduate qualification. Pharmacists identified adverse drug reactions in 33% of patients and made a mean of 1.6 recommendations/comments per visit undertaken. At least 35% of these were enacted. Pharmacists reduced inappropriate drug storage from 7% to 2% of visited patients by their second visit (P = 0.04), and reduced hoarding of unnecessary drugs from 40% of visited patients to 19% (P < 0.001). Finally, the rate of admission within the intervention group did not vary significantly according to experience or type of pharmacist delivering the intervention.

Conclusion

The HOMER intervention was conducted in a similar way to interventions in many other medication review studies. Given the HOMER trial's counter-intuitive findings it is clear that there is an urgent need to refine this intervention, identify the most suitable location for its delivery, and develop training that can ensure it is delivered to best effect.

Impact of pharmacist consultation versus a decision aid on decision making regarding hormone replacement therapy

Objective

To compare the effects of pharmacist consultation versus a decision aid on women's decisional conflict regarding use of hormone replacement therapy (HRT) and subsequent satisfaction with the decision-making process.

Setting

A family medicine clinic in Canada.

Method

The study was a prospective, randomised comparative trial. Peri- and post-menopausal female patients aged 48 to 52 years were invited to participate. Volunteers (n=128) received either a private consultation with a pharmacist or a take-home decision aid. Data collection was undertaken prior to the intervention and again following an appointment with a physician to discuss HRT. Outcome measures included: perception of being informed about HRT, decisional conflict, satisfaction with the education and the decision made regarding HRT, and adherence to HRT if prescribed. Telephone follow-up occurred three and 12 months after the physician appointment.

Key findings

After discussing HRT with their physicians, 35 of 91 women (38.5%) chose HRT, 15 (16.5%) declined it and 41 (45.1%) opted to delay their decision. Both interventions significantly increased women's perception of being informed about this form of therapy and decreased decisional conflict. Satisfaction with the education and with the HRT decision was high. More postmenopausal women in the pharmacist group reached a yes/no decision than in the decision aid group. Of those initiating HRT during the study (n =18), 16.7% had discontinued it at 12 months.

Conclusion

Consultation with a pharmacist and use of a decision aid are both effective methods for decreasing decisional conflict in peri- and post-menopausal women considering HRT.

Drug-related problems in elderly general practice patients receiving pharmaceutical care†

Objective

To describe the types of drug-related problems identified by pharmacists providing pharmaceutical care to elderly patients in the primary care or general medicine setting, and the impact of their recommendations on drug-related outcomes.

Methods

Searches of the MEDLINE, EMBASE, CINAHL, HealthSTAR, and International Pharmaceutical Abstracts electronic databases from 1990 to 2002 were conducted and a manual search of references from retrieved articles and references on file was performed. Large (n> 100) randomised, controlled studies comparing the provision of pharmaceutical care to usual care in seniors in primary care or general medicine settings were included. Two reviewers evaluated articles based on inclusion criteria and extracted data from the intervention arm of each study, resolving discrepancies by consensus. Nine original articles were included for analysis.

Key findings

The mean number of drug-related problems (DRPs) identified per patient was 3.2 and the mean number of recommendations made per patient was 3.3. The most common DRP identified was not taking/receiving a prescribed drug appropriately (35.2%, range 4.7–49.3%). The most common recommendations made involved patient education (37.2%, range 4.6–48.2%). Implementation rates were generally high for all types of recommendations, with the highest being for provision of patient education (81.6%). The small number of studies available examining measures of drug utilisation and costs, health services utilisation, and patient outcomes produced inconsistent results, making it difficult to draw conclusions.

Conclusions

Substantial numbers and a wide range of DRPs were identified by pharmacists who provided pharmaceutical care to seniors in the primary care and general medicine setting. Pharmacists' drug-therapy recommendations were well accepted; however, further study is needed to determine the impact of these recommendations on health-related outcomes.

Development of an evidence-based checklist for the detection of drug related problems in type 2 diabetes

Objective To develop an evidence-based checklist to identify potential drug related problems (PDRP) in patients with type 2 diabetes. Setting The evidence based checklist was applied to records of ambulatory type 2 diabetes patients in New South Wales, Australia. Method After comprehensive review of the literature, relevant medication groups and potential drug related problems in type 2 diabetes were identified. All the relevant information was then structured in the form of a checklist. To test the utility of the evidence-based checklist a cross-sectional retrospective study was conducted. The PDRP checklist was applied to the data of 148 patients with established type 2 diabetes and poor glycaemic control. The range and extent of DRPs in this population were identified, which were categorized using the PCNE classification. In addition, the relationship between the total as well as each category of DRPs and several of the patients’ clinical parameters was investigated. Main outcome measure: Number and category of DRPs per patient. Results The PDRP checklist was successfully developed and consisted of six main sections. 682 potential DRPs were identified using the checklist, an average of 4.6 (SD = 1.7) per patient. Metabolic and blood pressure control in the study subjects was generally poor: with a mean HbA1c of 8.7% (SD = 1.5) and mean blood pressure of 139.8 mmHg (SD = 18.1)/81.7 mmHg (SD = 11.1). The majority of DRPs was recorded in the categories ‘therapy failure’ (n = 264) and ‘drug choice problem’ (n = 206). Potentially non-adherent patients had a significantly higher HbA1c than patients who adhered to therapy (HbA1c of 9.4% vs. 8.5%; P = 0.01). Conclusion This is the first tool developed specifically to detect potential DRPs in patients with type 2 diabetes. It was used to identify DRPs in a sample of type 2 diabetes patients and demonstrated the high prevalence of DRPs per patient. The checklist may assist pharmacists and other health care professionals to systematically identify issues in therapy and management of their type 2 diabetes patients and enable earlier intervention to improve metabolic control.

Identification of medication-related problems and health care provider acceptance of pharmacist recommendations in the DiabetesCARE program

OBJECTIVES

To evaluate the efficacy of pharmacist recommendations to health care providers, as part of PharmacistCARE, a single-center, pharmacist-run, diabetes medication therapy management (MTM) service. If the recommendation was accepted, a secondary objective was to measure the length of time for acceptance.

DESIGN

Prospective assessment.

SETTING

University of Kentucky (UK), from March 2003 through December 2006.

PATIENTS

172 adult patients with diabetes enrolled in the UK Health Plan who participated in the DiabetesCARE program.

INTERVENTION

Pharmacists provided medication therapy-related recommendations to health care providers.

MAIN OUTCOME MEASURES

Acceptance of pharmacist recommendations by health care providers, length of time to acceptance, and cost savings attained with formulary recommendations.

RESULTS

A total of 692 recommendations were sent to health care providers; 425 (61.4%) were accepted. A total of 578 clinical recommendations were related to drug therapy problems; 348 (60.2%) were accepted by health care providers. Median time to acceptance for clinical recommendations was 13.5 days (0-229). Formulary recommendations accounted for 114 (16%) of the total recommendations, 77 (67.5%) were accepted, and median time to acceptance was 47.2 days (0-172). Average monthly cost savings per accepted formulary recommendation was $13.59 for the health plan and $13.85 for the patient.

CONCLUSION

A similar percentage of health care provider acceptance (61.4%) was seen compared with previous studies of pharmacists' interventions in different practice settings. To our knowledge, this is the first study to evaluate time to acceptance of pharmacist recommendations to health care providers, including the resolutions made through collaborative drug therapy management. Lastly, the current study reinforces the assertion that pharmacists can positively affect cost savings for both the patient and health plan, through formulary management.

The Iowa Continuity of Care study: Background and methods

PURPOSE

The background and methods of an ongoing study to determine the effects of hospital pharmacists' enhanced communication with patients and their community providers are described.

SUMMARY

The Iowa Continuity of Care study is a randomized, prospective trial enrolling 1000 patients with selected medical conditions admitted to one large Midwest hospital. Patients will be randomized to a control group (usual care), minimal intervention, or enhanced intervention. For the intervention groups, a pharmacist case manager (PCM) will provide admission medication verification with the patients' community pharmacists, medication teaching, and discharge counseling. Patients in the enhanced intervention group will have a discharge care plan faxed to their outpatient physician and community pharmacist and will receive a follow-up phone call from the PCM three to five days after discharge; the PCM will continue to facilitate communication between the patient and community providers until all medication problems are resolved. A blinded research nurse will collect data, including adverse drug event (ADE) data, at admission and 30 and 90 days after discharge. The primary outcome measures include medication appropriateness, ADEs, emergency department visits, unscheduled office visits, and rehospitalizations. Data will be collected from the inpatient electronic medical record, outpatient physician medical records, and community pharmacist records and directly from patients. A cost-effectiveness analysis will be performed.

CONCLUSION

This study will address the value of a PCM in improving communication of care plans between the inpatient and community settings and thereby optimizing medication use.

Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis

We set out to determine the effects of pharmacist-led medication review in older people by means of a systematic review and meta-analysis covering 11 electronic databases. Randomized controlled trials in any setting, concerning older people (mean age > 60 years), were considered, aimed at optimizing drug regimens and improving patient outcomes. Our primary outcome was emergency hospital admission (all cause). Secondary outcomes were mortality and numbers of drugs prescribed. We also recorded data on drug knowledge, adherence and adverse drug reactions. We retrieved 32 studies which fitted the inclusion criteria. Meta-analysis of 17 trials revealed no significant effect on all-cause admission, relative risk (RR) of 0.99 [95% confidence interval (CI) 0.87, 1.14, P = 0.92], with moderate heterogeneity (I(2) = 49.5, P = 0.01). Meta-analysis of mortality data from 22 trials found no significant benefit, with a RR of mortality of 0.96 (95% CI 0.82, 1.13, P = 0.62), with no heterogeneity (I(2) = 0%). Pharmacist-led medication review may slightly decrease numbers of drugs prescribed (weighted mean difference = -0.48, 95% CI -0.89, -0.07), but significant heterogeneity was found (I(2) = 85.9%, P < 0.001). Results for additional outcomes could not be pooled, but suggested that interventions could improve knowledge and adherence. Pharmacist-led medication review interventions do not have any effect on reducing mortality or hospital admission in older people, and can not be assumed to provide substantial clinical benefit. Such interventions may improve drug knowledge and adherence, but there are insufficient data to know whether quality of life is improved.

A composite screening tool for medication reviews of outpatients: general issues with specific examples

Regular performance of medication reviews is prominent among methods that have been advocated to reduce the extent and seriousness of drug-related problems, such as adverse drug reactions, drug-disease interactions, drug-drug interactions, drug ineffectiveness and cost ineffectiveness. Several screening tools have been developed to guide practising healthcare professionals and researchers in reviewing the medication patterns of elderly patients; however, each of these tools has its own limitations. This review discusses a wide range of general prescription-, treatment- and patient-related issues that should be taken into account when reviewing medication patterns by implicit screening. These include generic and therapeutic substitution; potentially superfluous or inappropriate medications; potentially inappropriate dosages or duration of treatment; drug-disease and drug-drug interactions; under-treatment; making use of laboratory test results; patient adherence, experiences and habits; appropriate dosage forms and packaging. A broad selection of specific examples and references that can be used as a basis for explicit screening of medication patterns in outpatients is also offered.

Effect of pharmacist-led patient education on adherence to tuberculosis treatment

PURPOSE

The purpose of this study was to assess the effect of a clinical pharmacist-directed patient education program on the therapy adherence of first-time tuberculosis (TB) patients and to identify the major pharmaceutical care needs and issues of first-time TB and multidrug-resistant (MDR)-TB patients.

METHODS

In the first part of the study, first-time TB patients were randomized either to the No EDU group (n = 58) where patients received routine medical and nursing care or to the EDU group (n = 56) where patients were also provided with clinical pharmacist-directed patient education. The patient's adherence to treatment was evaluated by attendance at scheduled visits, medication counting, and urine analysis for the presence of isoniazid metabolites. In the second part of the study, the pharmaceutical care needs and issues were determined for first-time TB patients and for MDR-TB patients (n = 40).

RESULTS

The adherence of patients who received pharmacist-directed patient education was greater than that of patients who did not. The attendance at scheduled visits and urine analysis for the presence of isoniazid metabolites yielded better results in respect to adherence for the EDU group (p < 0.05), while medication counting did not differ between the two groups. The major pharmaceutical care needs of first-time TB patients were for pain control, nutrient replacement, appropriate prescribing, respiratory control, and diabetic control. Similar findings were recorded for MDR-TB patients.

CONCLUSION

Patients' adherence to TB treatment improved when a pharmacist provided patient education on medication use and addressed patients' pharmaceutical care issues.

Pharmacotherapy interventions undertaken by pharmacists in the Fleetwood phase III study: the role of process control

BACKGROUND

The Fleetwood Model incorporates prospective review, direct communication with the prescriber, and formalized pharmacotherapy planning in patients at highest risk for medication-related problems.

OBJECTIVES

To describe the intervention activities performed by consultant pharmacists and dispensing pharmacists in the context of the Fleetwood Phase III Study.

METHODS

We report on a total of 4272 residents living in 12 nursing homes included in the intervention arm of the demonstration project. The intervention period was January through December 2004. Using pharmacotherapy planning software with a Web-based interface, daily interchange of information from the commercial pharmacy software, as well as laptop-based software for use in the nursing homes, pharmacists documented the reason for the intervention, the level of service, and the extent to which the recommendations were accepted.

RESULTS

There were 2118 Fleetwood interventions performed on 4272 residents (intervention rate: 9.48/100 resident months), with 81% of interventions performed by consultant pharmacists. The top 5 reasons for Fleetwood interventions by dispensing pharmacists were: missing information/clarification needed (19.8%), drug-age precautions (14.4%), excessive duration alert (9.5%), suboptimal regimen (8.7%), and laboratory test needed (7.3%). The top 5 reasons for involvement of the consultant pharmacists were: laboratory test needed (13.1%), missing information/clarification needed (13%), unnecessary drug (10.3%), product selection opportunity (10.3%), and excessive duration alert (9.1%).

CONCLUSIONS

Extending the federally mandated medication review process in nursing homes to incorporate elements of the Fleetwood Model is possible. The recommendation acceptance rates for pharmacist interventions are high.

Medication Errors in an Internal Medicine Department. Evaluation of a Computerized Prescription System

OBJECTIVE

Evaluation of a computerized physician order entry in an Internal Medicine Department, with a unit-dose distribution system.

SETTING

Pharmacy Department, Internal Medicine Department. S. Francisco Xavier Hospital, Lisbon, Portugal.

METHOD

This study was carried out in December 2001 and January 2002. After two years experience of the CPOE system, medication errors were evaluated prospectively, in an internal medical department of a 360-bed academic hospital. Data were collected once a week. Pharmacists reviewed all medical prescriptions as part of their routine work. Medication errors detected were recorded on a data collection form with a design based on the types of errors as defined by the American Society of Hospital Pharmacists (ASHP). Completed forms were reviewed and medication errors were classed according to ASHP guidelines.

RESULTS

A total of 2268 orders were monitored (162 patients). In these orders, 73 medication errors (22.4% of the patients) were detected and documented (59 prescribing errors and 14 monitoring errors). The most common prescribing errors were deficiencies related to the right class but wrong drug (28.3%): omeprazole vs. ranitidine/sucralfate in stress ulcer prophylaxis; incorrect dose (30%) and unclear orders (13.3%). Errors related to incorrect frequency of administration (5%); maintenance of IV route (5%); duplicated drug therapy (11.7%); drug interactions (1.7%) and length of therapy (3.3%) were also detected. The 14 monitoring errors detected were failures to review a prescribed regimen for appropriateness and detection of problems.

CONCLUSIONS

Computerized prescription order entry has demonstrated effectiveness in eliminating medication errors related to transcribing and patient identification. Nevertheless, medication errors related to prescription and monitoring still occur. The use of clinical decision support systems and pharmacist involvement is vital to achieve maximum medication safety and reduce medication error rates.

Impact on medication use and adherence of Australian pharmacists' diabetes care services

OBJECTIVE

To assess the effect of a specialized service implemented in community pharmacies for patients with type 2 diabetes on medication use and medication-related problems.

DESIGN

Parallel group, multisite, control versus intervention, repeated measures design, with three different regions in New South Wales, Australia, used as intervention regions, then matched with control regions as much as possible.

INTERVENTION

After initial training, pharmacists followed a clinical protocol for more than 9 months, with patient contact approximately monthly. Each patient received an adherence assessment at the beginning and end of the study, adherence support, and a medication review as part of the intervention.

MAIN OUTCOME MEASURES

Risk of nonadherence using Brief Medication Questionnaire (BMQ) scores and changes to medication regimen.

RESULTS

Compared with 82 control patients, 106 intervention patients with similar demographic and clinical characteristics had significantly improved self-reported nonadherence as reflected in total BMQ scores after 9 months. The mean (+/-SD) number of medications prescribed at follow-up in intervention participants decreased significantly, from 8.2+/-3.0 to 7.7+/-2.7. No reduction was observed among the control patients (7.6+/-2.4 and 7.3+/-2.4). The overall prevalence of changes to the regimen was also significantly higher in the intervention group (51%) compared with controls (40%).

CONCLUSION

Community pharmacists trained in medication review and using protocols in collaboration with providers improved adherence in patients with type 2 diabetes, reduced problems patients had in accessing their medications, and recommended medication regimen changes that improved outcomes.

Repeat prescribing: scale, problems and quality management in ambulatory care patients

The reported scale of repeat prescriptions ranges from 29% to 75% of all items prescribed, depending on the definition of repeat prescribing and other variables. It is likely that a substantial part of repeat prescribing by general practitioners (GPs) occurs without direct doctor-patient contact. While this reduces the workload for the GP and is convenient for the patient, it does not provide the adequate control that is needed to ensure that every repeat prescription is still appropriate, effective and well tolerated, and that it is still being viewed upon and taken by the patient as intended. Infrequent therapy reviews may lead to failure to prevent, identify and solve drug-related problems and drug wastage, and may, thereby, have a negative impact on the effectiveness, safety or cost of the medications prescribed. Studies evaluating the repeat prescribing process have shown that GPs and medical practices vary widely in their degree of administrative and clinical control of repeat prescriptions. Contrary to the opinion that GPs cannot change prescribing behaviour when the prescription is initiated by a medical specialist, GPs have their own responsibility for controlling the repeats of such prescriptions. Intervention studies suggest that a medication review by a pharmacist can help to reduce drug-related problems with repeat prescriptions, and the effectiveness of the intervention may be increased by combining the medication review with a consultation of the patient's medical records and a patient interview. In several studies, such an intervention was relatively inexpensive and, therefore, feasible. However, these conclusions should be viewed with appropriate caution because a number of caveats pertain. There is still no evidence that these types of intervention improve health-related quality of life or reduce healthcare cost, and so far only a few trials have produced any evidence of clinical improvement. As implicit and explicit screening criteria have their own benefits and limitations, a combined application may offer a more thorough assessment but may also be more complex and time consuming. Further studies on the development and evaluation of repeat prescription management models are needed, preferably focussing on improving clinical, humanistic and economic outcomes. New studies should investigate the effects of: different types of interventions; different organisational models; different target populations; and selecting and training different types of healthcare professionals. Future studies should also assess whether results are sustained, the optimal time interval between reviews of repeat prescriptions, and the possibilities offered by new computerised support technologies.

Collaboration Between Community Pharmacists and Family Physicians: Lessons Learned from the Seniors Medication Assessment Research Trial

OBJECTIVES

To learn about the experiences of specially trained expanded role pharmacists (ERPs) and family physicians in a program in which they worked together to optimize drug therapy for elderly patients (aged 65 and older) and to identify shortcomings of the program, obstacles to its implementation, and strategies to overcome these obstacles.

DESIGN

Qualitative opinion analysis.

PARTICIPANTS

Six family physicians and six community-based ERPs who had participated in a randomized controlled trial (Seniors Medication Assessment Research Trial [SMART]).

INTERVENTION

In-depth interviews.

MAIN OUTCOME MEASURES

Themes that emerged from the interviews regarding the strengths and weaknesses of and ways to improve the program.

RESULTS

ERPs and physicians differed in their perceptions of appropriate roles for ERPs. ERPs saw the program as an opportunity to take on new professional roles. Physicians appreciated the information they received from ERPs about their patients' adherence and use of nonprescription medications, but they did not want ERPs to directly counsel their patients. Some physicians questioned the value of the program for some patients, since the inclusion criteria for patients were broad and not all patients meeting the criteria needed intense interventions by ERPs. Both ERPs and physicians identified the need to refine the referral process and to work out professional role relationships and ongoing collaboration more fully. If the program were to be implemented as a routine service, physicians were concerned about the demands on their staff and office space and the need for an external compensation mechanism.

CONCLUSION

Issues to be addressed for future programs include clarification of the roles of pharmacist and physician when the professionals work together, targeting of appropriate patients for the program, identification of a more efficient way to deliver recommendations, and development of an appropriate compensation mechanism.

The Asheville Project: short-term outcomes of a community pharmacy diabetes care program

OBJECTIVE

To assess short-term clinical, economic, and humanistic outcomes of pharmaceutical care services (PCS) for patients with diabetes in community pharmacies.

DESIGN

Intention-to-treat, pre-post cohort-with-comparison group study.

SETTING

Twelve community pharmacies in Asheville, N.C.

PATIENTS AND OTHER PARTICIPANTS

Eighty-five patients with diabetes who were employees, dependents, or retirees from two self-insured employers; community pharmacists who completed a diabetes certificate program and received reimbursement for PCS.

INTERVENTIONS

Patients scheduled consultations with pharmacists over 7 to 9 months. Pharmacists provided education, self-monitored blood glucose (SMBG) meter training, clinical assessment, patient monitoring, follow-up, and referral. Group 1 patients began receiving PCS in March 1997, and group 2 patients began in March 1999.

MAIN OUTCOME MEASURES

Change from baseline in the two employer groups in glycosylated hemoglobin (A1c) values, serum lipid concentrations, health-related quality of life (HRQOL), satisfaction with pharmacy services, and health care utilization and costs.

RESULTS

Patients used SMBG meters at home, stored all readings, and brought their meters with them to 87% of the 317 PCS visits (3.7 visits per patient). Patients' A1c concentrations were significantly reduced, and their satisfaction with pharmacy services improved significantly. Patients experienced no change in HRQOL. From the payers' perspective, there was a significant dollars 52 per patient per month increase in diabetes costs for both groups, with PCS fees and diabetes prescriptions accounting for most of the increase. In contrast, both groups experienced a nonsignificant but economically important 29% decrease in nondiabetes costs and a 16% decrease in all-diagnosis costs.

CONCLUSION

A clear temporal relationship was found between PCS and improved A1c, improved patient satisfaction with pharmacy services, and decreased all-diagnosis costs. Findings from this study demonstrate that pharmacists provided effective cognitive services and refute the idea that pharmacists must be certified diabetes educators to help patients with diabetes improve clinical outcomes.

Practice-based research: lessons from community pharmacist participants

We designed this project to determine community pharmacists' opinions regarding the challenges and motivations of their recent participation in a pharmacy practice-based research study At the conclusion of a randomized, multicenter study, 87 community pharmacist-investigators were sent a questionnaire that explored four areas: motivating factors to participate, barriers to participation, communication tools used by study coordinators, and design issues for future studies. Fifty-eight (67%) completed questionnaires were returned. Key factors motivating participation in the study were desire to improve the profession and opportunity to learn. Time was the greatest barrier to participation. Pharmacy practice-based research has two distinct advantages. First, it translates clinical knowledge into direct application in the community. Second, it provides needed data to demonstrate the value of enhanced pharmacy practice. Thorough understanding of pharmacists' opinions is necessary to optimize the design of future studies.

Clinical and economic impact of ambulatory care clinical pharmacists in management of dyslipidemia in older adults: the IMPROVE study. Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers

We examined the impact of ambulatory care clinical pharmacist interventions on clinical and economic outcomes of 208 patients with dyslipidemia and 229 controls treated at nine Veterans Affairs medical centers. This was a randomized, controlled trial involving patients at high risk of drug-related problems. Only those with dyslipidemia are reported here. In addition to usual medical care, clinical pharmacists were responsible for providing pharmaceutical care for patients in the intervention group. The control group did not receive pharmaceutical care. Seventy-two percent of the intervention group and 70% of controls required secondary prevention according to the National Cholesterol Education Program guidelines. Significantly more patients in the intervention group had a fasting lipid profile compared with controls (p=0.021). The absolute change in total cholesterol (17.7 vs 7.4 mg/dl, p=0.028) and low-density lipoprotein (23.4 vs 12.8 mg/dl, p=0.042) was greater in the intervention than in the control group. There were no differences in patients achieving goal lipid values or in overall costs despite increased visits to pharmacists. Ambulatory care clinical pharmacists can significantly improve dyslipidemia in a practice setting designed to manage many medical and drug-related problems.

An economic analysis of a randomized, controlled, multicenter study of clinical pharmacist interventions for high-risk veterans: the IMPROVE study. Impact of Managed Pharmaceutical Care Resource Utilization and Outcomes in Veterans Affairs Medical Centers

STUDY OBJECTIVE

To determine if clinical pharmacists could affect economic resource use and humanistic outcomes in an ambulatory, high-risk population.

DESIGN

Prospective, randomized, controlled study.

SETTING

Nine Veterans Affairs medical centers.

PATIENTS

Patients who were at high risk for medication-related problems.

INTERVENTION

Patients were randomized to usual medical care with input from a clinical pharmacist (intervention group) or just usual medical care (control group).

MEASUREMENTS AND MAIN RESULTS

Of 1,054 patients enrolled, 523 were randomized to the intervention group and 531 to the control group. The number of clinic visits increased in the intervention group (p=0.003), but there was no difference in clinic costs. Mean increases in total health care costs were $1,020 for the intervention group and $1,313 for the control group (p=0.06).

CONCLUSION

Including the cost of pharmacist interventions, overall health care expenditures were similar for patients randomized to see a clinical pharmacist versus usual medical care.

Ambulatory care pharmacy services: has the agenda changed?

OBJECTIVE

To provide an extensive review of ambulatory care clinical pharmacy services and evaluate the services and research data in the field.

DATA SOURCES

MEDLINE was searched from January 1992 through July 1999. Search terms included pharmacy, clinical pharmacy, and pharmaceutical care, cross-referenced with ambulatory care, primary care, family medicine, and managed care.

STUDY SELECTION

Relevant peer-reviewed studies and reports since our previous article in 1992 were selected and described. Literature prior to 1992 was briefly reviewed.

DATA SYNTHESIS

The relevant literature was reviewed and some examples from the authors' institutions are provided. Much research has continued to be published documenting the value of clinical pharmacy services in ambulatory care, including in community pharmacy, anticoagulation services, family medicine, primary care clinics, Veterans Affairs Medical Centers, and managed care. However, these innovative services are underrepresented in the community at large. The vast majority of the public does not have access to these types of services.

CONCLUSIONS

There will be continued and dramatic expansion of ambulatory care pharmacy services in the new decade beginning in the year 2000. It will be critical that standards of practice be very high. We believe there is a critical need for visible demonstration projects and large multicenter research projects that demonstrate the value of these services.