Clinical pharmacy services, pharmacy staffing, and the total cost of care in United States hospitals

The balanced scorecard as a strategic management tool in hospital pharmacies: an experimental study

PURPOSE

A balanced scorecard (BSC) is an applied tool for implementing strategic management in various organizations. Implementing strategic management using the BSC approach has not received much attention in pharmacy departments. This study aims to provide a model for the strategic management of pharmacy departments using the BSC framework.

DESIGN/METHODOLOGY/APPROACH

This experimental study was conducted from 2015 to 2018 in a 300-bed hospital and regional healthcare centers affiliated with the Petroleum Industry Health Organization in Tehran province, Iran. After carefully reviewing the organization's mission and vision, the strategic objectives were determined via the internal matrix and the external matrix (IE matrix), and the strengths-weaknesses-opportunities-threats matrix (SWOT matrix) were examined. Then, six BSC measures and interventions were identified, and each was examined from the perspectives of finance, patient satisfaction, internal processes and learning/growth. Finally, the proposed strategy was evaluated.

FINDINGS

Results showed significant increases in patient satisfaction and gross profit. The observed increase range, from 0.09 to 0.29, indicates more effective operational management for optimal resource utilization. In addition, the pharmacy department was able to save US $539,137 by implementing prepared protocols for expensive medications. Similarly, the pharmacy department saved $442,899 during the two years of our strategic management plan by implementing the standard mechanism for returning unused medications to the pharmacy department after patients were discharged from various treatment units.

ORIGINALITY/VALUE

This study is among the first studies to demonstrate the simultaneous development, implementation and evaluation of the proposed strategy using the BSC in a pharmacy department in a public healthcare center. The BSC application improved the optimal use of resources and reduced costs while increasing patient satisfaction. It appears that the application of such an intervention may be as valuable to public pharmacies as it is to other private 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.

Seven key parameters that facilitate clinical pharmacy practice: a comparison between Israel and the United States

Clinical pharmacists have advanced training that enables them to manage medication therapy, including prescribing, titrating, and discontinuing medications, in order to achieve therapeutic goals. In some countries, such as the United States, advances in training, responsibility, legal frameworks, and public acceptance of new roles have proceeded in parallel to expand the scope and contribution of clinical pharmacists over several decades. In this manuscript, we detail seven discrete key parameters of professional advancement for clinical pharmacists, corresponding to the seven areas in which they must advance in order to contribute fully to delivering high-quality medical care. For each key parameter, we briefly summarize the progress made in the United States to date, as well as goals for future progress. We then compare this to the development of the analogous key parameter in Israel. We found that on some key parameters, the development of clinical pharmacy in Israel lags behind the United States. This manuscript can provide a roadmap for the future advancement of clinical pharmacy in Israel, toward its full realization as a profession that can contribute to delivering high-quality medical care.

Three ways to advocate for the economic value of the pharmacist in health care

Numerous studies have demonstrated positive therapeutic and economic outcomes associated with pharmacist-provided care. However, public policy on provider status with subsequent payment for non-dispensing services has been slow to reflect an expanded pharmacist role. It is important for the public to understand the value of a pharmacist outside of the drug distribution system. Pharmacists and other health care and public health practitioners must share this information to further knowledge and affect policies and systems that can most effectively include pharmacists fully in the health care system. The 3 main areas identified in which the pharmacist has economic impact are decreased total health expenditures, decreased unnecessary care, and decreased societal costs. Evidence supports the economic value of the pharmacist; however, public opinion and political movements supporting patients' access to pharmacist-provided care are variable. Strategies to advocate and effect change include advocating to elected leaders for policy change and advocating to other health professionals, patients, and community members to better their understanding of the positive economic value of pharmacist-provided care. Through prioritizing community outreach and legislator education, pharmacist advocates can leverage 3 key areas in which pharmacists have economic value to advance policy and increase patients' access to care.

Relationship between the number of hospital pharmacists and hospital pharmaceutical expenditure: a macro-level panel data model of fixed effects with individual and time

BACKGROUND

The rapid increase in pharmaceutical expenditure (PE) has been a main problem of global healthcare reform for decades. Previous studies demonstrated that pharmacists play an indispensable role in controlling PE, but macro-research evidence is scarce. Exploring the role of pharmacists from a macro-perspective is essential for pharmacy source allocation with an advantage of extensive applicability over regions. This study aimed to explore the relationship between the number of hospital pharmacists and hospital PE and to provide a macro-perspective evidence to curb the increasing PE and decline unnecessary medications.

METHODS

Data were extracted from China Health Statistics Yearbook from 2011 to 2018. A panel dataset with 31 provinces from 2010 to 2017 was constructed. Amongst them, 'Number of hospital pharmacists per 1 million of population' (HLPT) was selected as an independent variable, 'Per visit of hospital outpatient pharmaceutical expenditure' (OTPE) and 'Per capita of hospital inpatient pharmaceutical expenditure' (ITPE) were selected as dependent variables, and 'Number of hospital physicians per 1 million of population' (HLPN) and 'Drug price index' (DPI) were applied as control variables. Fixed-effect panel data analysis was performed to evaluate the relationship between the number of hospital pharmacists and hospital PE.

RESULTS

HLPT had a significant and negative relationships with OTPE (β₁ = - 0.0893, p = 0.0132) and ITPE (β₁ = - 4.924, p < 0.001). Considering the control variables, the significant and negative relationships with HLPT and OTPE remained unchanged (β₁ = - 0.141, p < 0.001; β₁ = - 4.771, p < 0.001, respectively), indicating that an increase in hospital pharmacist per 1 million of population led to a decrease of ¥474 million ($67.4 million) OTPE and ¥902 million ($128 million) ITPE in 2017. Overall, in 2017, an increase of 1 hospital pharmacist led to a decrease of approximately ¥1 million ($142 thousands) hospital PE nationwide.

CONCLUSION

This study confirmed the negative relationship between hospital pharmacists and hospital PE, indicating that hospital pharmacists might play a significant role in controlling PE. Pharmacists were encouraged to participate in more drug-therapy-related activities, such as medication reconciliation.

Antimicrobial stewardship staffing: How much is enough?

Antimicrobial stewardship improves patient care and reduces antimicrobial resistance, inappropriate use, and adverse outcomes. Despite high-profile mandates for antimicrobial stewardship programs across the healthcare continuum, descriptive data, and recommendations for dedicated resources, including appropriate physician, pharmacist, data analytics, and administrative staffing support, are not robust. This review summarizes the current literature on antimicrobial stewardship staffing and calls for the development of minimum staffing recommendations.

Decoding the Roadmap for Capacity Building of Pharmacology Academicians in Catering to Drug Information Center Services in a Developing Country

Background: Very few medical institutions are currently providing drug information center (DIC) services in low-resource countries. Objective: To assess whether academician pharmacologists of India are prepared to deliver countrywide services with regard to DICs. Methods: A cross-sectional knowledge attitude and practice study was planned in the form of an online survey. A hyperlink to the questionnaire was sent to academician pharmacologists via email, Facebook, and WhatsApp. Determinants associated with pharmacologists’ capacity and willingness in uplifting the DIC services were determined using logistic regression. Results: One hundred and thirteen academician pharmacologists responded. Participants who were working in limited functional DIC had 0.30 (95% confidence interval [CI] = 0.09-0.98) times association with answering that referring to promotional drug literature is an inappropriate practice for DIC services to that of nonfunctional DIC participants. However, the same had 5.28 (95% CI = 1.74-16.00) times association with referring to literature for establishing and running the services more as compared with participants with nonfunctional DIC. Participants from fully functional DICs in their departments had 6.31 (95% CI = 1.92-20.70) times association with identifying that adverse event reporting is not the function of DIC as compared with participants from a non-functional DIC. Participants with more academic experience had 6.7 (95% CI = 1.36 to 32.93) times association with an identification of challenges as compared with that of less experience participants. Conclusion: Academician pharmacologists need to be trained in critical appraisal of published literature and guided on how to establish and maintain the services for hospital clinicians. Senior pharmacology academicians’ advice will be crucial in strengthening the roadmap for capacity building.

Scoping Review of Interventions Associated with Cost Avoidance Able to Be Performed in the Intensive Care Unit and Emergency Department

A framework for evaluating pharmacists' impact on cost avoidance in the intensive care unit (ICU) and emergency department (ED) has not been established. This scoping review was registered (CRD42018091217) and conducted to identify, aggregate, and qualitatively describe the highest quality evidence for cost avoidance generated by clinical pharmacists on interventions performed in an ICU or ED. Searches were conducted in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception until April 2018. The level of evidence (LOE) for each specific category of intervention was evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation evidence-to-decision framework. The risks of bias for articles were evaluated using Newcastle Ottawa and Cochrane Collaboration tools. The values from all interventions were inflated to 2018 U.S. dollars using the consumer price index for medical care. Of the 464 articles initially identified, 371 were excluded and 93 were included. After reviewing references from the articles included, an additional 71 articles were also reviewed. The 38 cost intervention categories were supported by varying LOEs: IA (0 categories), IB (1 category), IIA (4 categories), IIB (0 categories), III (27 categories), and IV (6 categories), and articles mostly displayed low to moderate risks of bias. Pharmacists generate cost avoidance through a variety of interventions in critically and emergently ill patients. The quality of evidence supporting specific cost avoidance values is generally low. Quantification of and factors associated with the cost avoidance generated from pharmacists caring for these patients are of paramount importance.

Predictive Evaluation of Pharmaceutical Properties of Ulinastatin-Containing Vaginal Suppositories as a Hospital Preparation by Near-Infrared Spectroscopy

A vaginal suppository containing ulinastatin (UTI) was developed as a hospital pharmacy product from UTI injection solution and Witepsol^® S-55. After mixing at 50°C for 0-8 h, UTI suppositories were prepared, which had good UTI content uniformity. Because 2% surfactant was contained in S-55, the UTI injection solution formed a water-in-oil type emulsion as a suppository base. The measured residual moisture content (loss on drying (LOD)) in the prepared vaginal suppositories decreased as the mixing time increased, but their hardness (hardness test (HT)) increased. Near (N) IR spectra of UTI suppositories were measured after mixing for 0-8 h. The best calibration models to predict the HT and LOD of the suppositories were determined based on the NIR spectra by the leave-one-out method in a partial least-squares regression analysis (PLS). The validation result indicated that PLS models for HT and LOD were obtained based on the spectra treated by a combination of smoothing and normalized, respectively, and the model consisted of three latent variables. The plots between the predicted and measured pharmaceutical properties (HT and LOD) based on the calibration data were superimposed with those of the external validation data. The developed NIR spectroscopy method was applied to the preparation process monitoring for UTI vaginal suppositories. In the prepared vaginal suppositories, the predicted LOD decreased as the mixing time increased, and the measured LOD values superimposed well with the predicted values. In contrast, the predicted HT increased as the mixing time increased, and the measured values superimposed with the predicted values.

Impact of a pharmacist-physician collaborative care model on patient outcomes and health services utilization

PURPOSE

The impact of a pharmacist-physician collaborative care model on patient outcomes and health services utilization is described.

METHODS

Six hospitals from the Carilion Clinic health system in southwest Virginia, along with 22 patient-centered medical home (PCMH) practices affiliated with Carilion Clinic, participated in this project. Eligibility criteria included documented diagnosis of 2 or more of the 7 targeted chronic conditions (congestive heart failure, hypertension, hyperlipidemia, diabetes mellitus, asthma, chronic obstructive pulmonary disease, and depression), prescriptions for 4 or more medications, and having a primary care physician in the Carilion Clinic health system. A total of 2,480 evaluable patients were included in both the collaborative care group and the usual care group. The primary clinical outcomes measured were the absolute change in values associated with diabetes mellitus, hypertension, and hyperlipidemia management from baseline within and between the collaborative care and usual care groups.

RESULTS

Significant improvements (p < 0.01) in glycosylated hemoglobin, blood pressure, low-density-lipoprotein cholesterol, and total cholesterol were observed in the collaborative care group compared with the usual care group. Hospitalizations declined significantly in the collaborative care group (23.4%), yielding an estimated cost savings of $2,619 per patient. The return on investment (net savings divided by program cost) was 504%.

CONCLUSION

Inclusion of clinical pharmacists in this physician-pharmacist collaborative care-based PCMH model was associated with significant improvements in patients' medication-related clinical health outcomes and a reduction in hospitalizations.

Hospital clinical pharmacy services in Vietnam

Background Clinical pharmacy is key to the quality use of medicines. While there are different approaches in different countries, international perspectives may inform health service development. The Vietnamese Ministry of Health introduced a legal regulation of clinical pharmacy services in December 2012. Objective To describe the services, and to explore reported barriers and facilitators in implementing clinical pharmacy activities in Vietnamese hospitals after the introduction of Vietnamese Ministry of Health legal regulation. Setting Thirty-nine hospitals in Hanoi, Vietnam, including 22 provincial and 17 district hospitals. Method A mixed methods study was utilized. An online questionnaire was sent to the hospitals. In-depth interviews were conducted with pairs of nominated pharmacists at ten of these hospitals. The questionnaire focused on four areas: facilities, workforce, policies and clinical pharmacy activities. Main outcome measure Proportion of clinical pharmacy activities in hospitals. Themes in clinical pharmacy practice. Results 34/39 (87%) hospitals had established clinical pharmacy teams. Most activities were non-patient-specific (87%) while the preliminary patient-specific clinical pharmacy services were available in only 8/39 hospitals (21%). The most common non-patient-specific activities were providing medicines information (97%), reporting adverse drug reactions (97%), monitoring medication usage (97%). The patient specific activities varied widely between hospitals and were ad hoc. The main challenges reported were: lack of workforce and qualified clinical pharmacists. Conclusion While most hospitals had hospital-based pharmacy activities, the direct patient care was limited. Training, education and an expanded work forces are needed to improve clinical pharmacy services.

Pharmacist's Comprehensive Geriatric Assessment: Introduction and Evaluation at Elderly Patient Admission

BACKGROUND

The role of the clinical pharmacist within the healthcare system remains unclear.

OBJECTIVE

Our objective was to describe a pharmacist's comprehensive geriatric assessment (pCGA) at admission of elderly patients and to assess its relevance in terms of medication compliance and pharmacist interventions (PIs).

METHODS

We conducted a prospective interventional study over 29 months in a 34-bed medical/rehabilitation geriatric ward in a French geriatric hospital. At admission, patients received pharmaceutical care through a consistent three-step process: (1) pharmacists met with the patient to undertake cognitive screening and assess their medication adherence (using the Girerd score) and medication history; (2) medication reconciliation was conducted at admission to detect intentional and unintentional discrepancies in treatment; and (3) clinical medication review was carried out throughout the patient's stay. The pharmacist conveyed proposed interventions to optimise treatment to the physician through the electronic health record. The number and type of PIs and their rate of implementation were recorded.

RESULTS

In total, 539 patients aged >65 years were included; their mean age was 84 years. Cognitive screening showed that 45% of patients were confused at admission. Medication adherence assessment indicated that 50.2% had adherence problems. Medication reconciliation at admission detected discrepancies in 48%, with a mean of 1.09 unintended discrepancies per patient. Patients were taking an average of 7 ± 3 drugs. In total, 828 PIs were reported to physicians; 520 were accepted and implemented (62.8% acceptance rate).

CONCLUSION

This approach helps to avoid medication errors and enables the suggestion of relevant PIs, which were implemented by physicians in two-thirds of cases.

Critical Care Pharmacy Services in United States Hospitals

Background:

Critical care pharmacy activities have been described as fundamental, desirable, and optimal, but actual services provided have not been evaluated.

Objective:

To characterize the type and level of pharmacy services provided to intensive care units (ICUs).

Methods:

A 38 question survey was sent in 2 consecutive mailings to all US institutions (N = 3238) with an ICU. Questions were categorized according to clinical, educational, administrative, and scholarly activities, with levels of services stratified as fundamental, desirable, or optimal.

Results:

Completed surveys were received from 382 (11.8%) institutions encompassing 1034 ICUs. Direct clinical pharmacy activities were provided at 62.2% of ICUs. The pharmacists in those programs attended rounds 4.4 ± 1.5 days/wk, mean ± SD, and had a workweek that consisted of patient care (43% of hours worked), drug distribution (26.2%), administration (12.6%), education (10.9%), and scholarly activities (7.3%). Fundamental clinical activities performed during at least 75% of patient ICU days were providing drug information, drug therapy evaluation, drug therapy intervention, and pharmacokinetic monitoring. Conducting inservices (92.8%), a fundamental service, was the only educational activity frequently provided. Most respondents were involved with at least one multidisciplinary committee, and 45.5% conducted scholarly activities. Desirable or optimal activities were not frequently provided across all service categories.

Conclusions:

Clinical pharmacists are directly involved as caregivers in nearly two-thirds of ICUs in the US. Although they provide a range of clinical and administrative services, involvement in educational and scholarly activities is variable. The level of services provided is consistent with the criteria deemed fundamental for improving patient care. Higher-order services are far less likely to be provided.

An assessment of the basic medication safety practices in Khartoum State hospitals

Purpose

To assess the presence of medication safety practices in Khartoum State hospitals.

Methods

A previously used questionnaire was used to evaluate medication safety practices. The main practices evaluated were the presence of a medication safety committee and error-reporting system, look-alike sound-alike (LASA) medications list, control of concentrated electrolyte solutions, care transitions, information technology, drug information and other medication safety practices. The primary investigator visited a stratified sample from all the three cities that comprise Khartoum State and interviewed the pharmacy supervisor of each hospital. Descriptive statistics were performed using SPSS V.22.

Results

A total of 41 senior pharmacists or pharmacy supervisors from 41 hospitals were interviewed. Only 2% of the hospitals had a list of LASA medications and 5% had a list of error-prone abbreviations. Only 5% of the hospitals had a medication safety committee, and none of the hospitals had a medication safety officer. None of the hospitals involved pharmacists in obtaining medication histories. Concentrated electrolytes were available in the floor stock in 67% of the hospitals. Although 24% of the hospitals used a computer system in their pharmacy to enter prescriptions, none of these hospitals required entry of patient allergies before entering a drug order.

Conclusions

Most of the hospitals in Khartoum State did not implement basic medication safety practices. Therefore, the Ministry of Health in Sudan should enforce laws and regulations making implementation of medication safety practices mandatory to ensure patient safety.

Advanced Practice Pharmacists: a retrospective evaluation of the efficacy and cost of ClinicaL Pharmacist PractitionErs managing ambulatory Medicare patients in North Carolina (APPLE-NC)

BACKGROUND

Clinical Pharmacist Practitioners are advanced practicing pharmacists in North Carolina that provide disease-specific management. The purpose of this retrospective cohort study was to compare the efficacy and charges from referrals to a Clinical Pharmacist Practitioner by the primary care provider, to those managed by a primary care provider alone.

METHODS

Patients were separated into cohorts depending if they had at least two appointments with a Clinical Pharmacist Practitioner from November 2008 to November 2011. A primary care provider saw all patients at least twice during the study period. Cohorts were then matched by age, gender, and disease states. Medicare billed data was evaluated from outpatient visits related to hypertension, diabetes mellitus, and peripheral neuropathy, as well as emergency department visits and inpatient admissions. Cost of medications was estimated using 2009 AWP data corresponding to medication histories within the electronic medical record. Efficacy was defined as ability to reach disease state goal determined using national guidelines and reduction in pain score. Efficacy was analyzed by difference-in-differences test and all other numerical data tested by paired t-tests.

RESULTS

The Clinical Pharmacist Practitioners cohort experienced more outpatient visits (1338 vs. 858, p < 0.001), fewer emergency department visits (115 vs. 190, p < 0.05), and similar inpatient admissions (88 vs. 117, p > 0.05) than the primary care providers cohort, respectively. The Clinical Pharmacist Practitioners cohort showed changes in charges of +22.6 % for outpatient visits, -45.5 % emergency department visits, and -13.2 % inpatient admissions relative to the primary care provider cohort. There was no difference in average daily medication cost (Clinical Pharmacist Practitioners $38.52 vs. primary care providers $38.23, p = 0.97) or achievement of disease state goals.

CONCLUSION

APPLE-NC demonstrated that through referrals, Clinical Pharmacist Practitioners provide services comparable in charges and efficacy to primary care providers. Consequently, the current increased need for primary care practitioners can be met in part by increasing the utilization of advanced practice pharmacists for chronic disease management.

TRIAL REGISTRATION

This does not apply for this retrospective cohort study.

Evidence-based pharmaceutical care: The next chapter in pharmacy practice

INTRODUCTION

Pharmacy is a very dynamic profession and the role of the pharmacist is improving with the expansion of the scope of services and the introduction of new subspecialties over time. Moving from being medication dispensers to outcome-oriented and patient-focused care providers; pharmacists will carry more responsibility and commitment to improve their knowledge and practice. Being updated and evidence-based is a key tool to achieve effective pharmaceutical care services. The primary purpose of this article is to highlight the concept of "evidence based pharmaceutical care" as professional practice to improve the quality of pharmaceutical care.

METHODS

Literature for relevant evidence was searched by Medline (through PubMed), Cochrane library using the keywords: pharmaceutical care, evidence-based and pharmacy practice. Also a manual search through major journals for articles referenced in those located through PubMed was done.

RESULTS AND DISCUSSION

There is strong data showing that pharmaceutical care lead to improvement in health outcomes and cost-effective therapy. More efforts, policies and qualified staff are needed to establish the "evidence-based pharmaceutical care" as new daily professional practice. Evidence to support pharmacists in their emerging role as care providers is available to improve the efficacy and quality of pharmaceutical care. Education and specialized training practicing evidence based approach are vital to prepare pharmacists to provide high quality pharmaceutical care.

CONCLUSION

As care providers, pharmacists are effective in providing high quality patient care and being members in multidisciplinary clinical teams is needed to give them the opportunity. Evidence based pharmaceutical care is a natural and logical emerging concept in the modern pharmacy practice to achieve high quality and more effective pharmaceutical care but still more efforts and resources are needed to promote new attitude toward more professional career.

Improving medication adherence: a framework for community pharmacy-based interventions

Evidence supports that patient medication adherence is suboptimal with patients typically taking less than half of their prescribed doses. Medication nonadherence is associated with poor health outcomes and higher downstream health care costs. Results of studies evaluating pharmacist-led models in a community pharmacy setting and their impact on medication adherence have been mixed. Community pharmacists are ideally situated to provide medication adherence interventions, and effective strategies for how they can consistently improve patient medication adherence are necessary. This article suggests a framework to use in the community pharmacy setting that will significantly improve patient adherence and provides a strategy for how to apply this framework to develop and test new medication adherence innovations. The proposed framework is composed of the following elements: 1) defining the program's pharmacy service vision, 2) using evidence-based, patient-centered communication and intervention strategies, 3) using specific implementation approaches that ensure fidelity, and 4) applying continuous evaluation strategies. Within this framework, pharmacist interventions should include those services that capitalize on their specific skill sets. It is also essential that the organization's leadership effectively communicates the pharmacy service vision. Medication adherence strategies that are evidence-based and individualized to each patient's adherence problems are most desirable. Ideally, interventions would be delivered repeatedly over time and adjusted when patient's adherence circumstances change. Motivational interviewing principles are particularly well suited for this. Providing effective training and ensuring that the intervention can be delivered with fidelity within a specified workflow process are also essential for success. Utilizing this proposed framework will lead to greater and consistent success when implementing pharmacist-led medication adherence interventions in the community pharmacy setting.

The effect on potential adverse drug events of a pharmacist-acquired medication history in an emergency department: a multicentre, double-blind, randomised, controlled, parallel-group study

Background

Potential adverse drug events (PADEs) are defined as being potentially harmful unintentional medication discrepancies. Discrepancies regarding medication history (MH) often occur when a patient is being admitted to a hospital’s emergency department (ED); they are clinically important and represent a significant source of data regarding adverse drug events occurring during emergency admission to hospital. This study sought to measure the impact of pharmacist-acquired MH during admission to an ED; it focused on whether a patient’s current home medication regimen being available for a doctor when consulting a patient in an ED would have reduced potential adverse drug events.

Method

A multicentre, double-blind, randomised, controlled parallel-group study was carried out at 3 large teaching hospitals in Bogota, Colombia. Two hundred and seventy patients who had been admitted to an ED were enrolled; each had a standardised, comprehensive MH interview, focusing on a patient’s current home medication regimen prior to being seen by a doctor. Data recorded on the admission medication order form was available to be used by a doctor during consultation in the ED. The main outcome dealt with comparing the intervention and control groups regarding the percentage of patients having at least 1 potential adverse drug event.

Results

There were 811 PADE (3.35 per patient), 528 (65 %) on the standard care arm and 283 (35 %) on an intervention arm. Most PADEs were judged to have had the potential to cause moderate discomfort (42.6 %), 33.4 % were deemed unlikely to have caused harm and 23.9 % were judged to have had the potential to cause clinical deterioration.

Conclusion

Many patients suffer potentially adverse drugs events during the transition of care from home to a hospital. Patient safety-focused medication reconciliation during admission to an ED involving a pharmacist and drawing up a history of complete medication could contribute towards reducing the risk of PADES occurring and improve follow-up of patients’ medication-based therapy.

Trial registration

28/10/2012, ISRCTN63455839.

Expected net benefit of clinical pharmacy in intensive care medicine: a randomized interventional comparative trial with matched before-and-after groups

RATIONALE, AIMS AND OBJECTIVES

This study evaluated clinical pharmacy costs against drug costs.

METHOD

We conducted a randomized interventional comparative trial at the surgical intensive care unit (ICU) of Ghent University Hospital, Belgium (period B: group B1 with pharmacist consultation; control group B0). We obtained before (period A) and after (period C) control groups using 1:1 propensity score matching with B1 and B0. Mean daily ICU drug costs with standard error of the mean (SEM) were compared between B1 and B0 (primary analysis) and between matched pairs (AB1, AB0, CB1 and CB0; secondary analysis). For B, we performed a 1000 bootstrapping (by resampling B1 and B0), calculated the benefit-cost ratio using pharmacy time (gross salary) as cost (euros) and drug cost savings as benefit. We performed sensitivity analysis with and without outlier drug costs (i.e. twice the standard deviation).

PERSPECTIVE

Belgian health care payer.

RESULTS

In period B, 135 patients were randomized: B0, n = 60; B1, n = 75. Pharmacists provided recommendations in 148/706 (21.0%) therapies with 83.1% acceptance. Mean drug cost difference between B0 (430.6 euros, SEM 406.0) and B1 (221.2 euros, SEM 58.7) (P = 0.870) became significant after excluding outlier drug costs (B0, 184.4 euros, SEM 42.5; B1, 90.5 euros, SEM 17.7; P < 0.001). Recommendations were cost-beneficial (break-even drug costs or savings) in 53.8% of patients with a benefit-cost ratio of 25:1 (confidence interval -5:1 to 94:1). In sensitivity analysis excluding outlier drug costs, B0 costs were significantly higher than both A and C, indicating high baseline expenses in B0.

CONCLUSIONS

The randomized interventional comparative trial in a small ICU patient group suggested the potential cost-benefit of clinical pharmacy on daily ICU drug costs. However, after matching, this benefit was attenuated. A final conclusion demands a larger randomized trial adopting a similar design with matched controls. Future research should include clinical impact of recommendations.

Eliciting comprehensive medication histories in the emergency department: the role of the pharmacist

The Australian Pharmaceutical Advisory Committee guidelines call for a detailed medication history to be taken at the first point of admission to hospital. Accurate medication histories are vital in optimising health outcomes and have been shown to reduce mortality rates. This study aimed to examine the accuracy of medication histories taken in the Emergency Department of the Royal Adelaide Hospital. Medication histories recorded by medical staff were compared to those elicited by a pharmacy researcher. The study, conducted over a six-week period, included 100 patients over the age of 70, who took five or more regular medications, had three or more clinical co-morbidities and/or had been discharged from hospital in three months prior to the study. Following patient interviews, the researcher contacted the patient's pharmacist and GP for confirmation and completion of the medication history. Out of the 1152 medications recorded as being used by the 100 patients, discrepancies were found for 966 medications (83.9%). There were 563 (48.9%) complete omissions of medications. The most common discrepancies were incomplete or omitted dosage and frequency information. Discrepancies were mostly medications that treated dermatological and ear, nose and throat disorders but approximately 29% were used to treat cardiovascular disorders. This study provides support for the presence of an Emergency Department pharmacist who can compile a comprehensive and accurate medication history to enhance medication management along the continuum of care. It is recommended that the patient's community pharmacy and GP be contacted for clarification and confirmation of the medication history.

Pharmacist elicited medication histories in the Emergency Department: Identifying patient groups at risk of medication misadventure

The Australian Pharmaceutical Advisory Committee guidelines call for a detailed medication history to be taken at the first point of admission to an Emergency Department (ED). The elderly, in particular those residing in Residential Aged Care Facilities and those with a non-English speaking background, have been identified as patient groups vulnerable to medication misadventure.

Pharmacists' influences on prescribing: validating a clinical pharmacy services survey in the Western Pacific Region

BACKGROUND

Hospital pharmacists around the world are becoming increasingly involved in promoting the responsible use of medicines through clinical pharmacy services. This is reflected in the Basel Statements developed by the International Pharmaceutical Federation Hospital Pharmacy Section, particularly the theme 'Influences on Prescribing.' Some countries, particularly in Asia, are currently establishing clinical pharmacy services and would benefit from identification of facilitators.

OBJECTIVES

To validate a survey exploring clinical pharmacy services focusing on pharmacists' influences on prescribing, based on Basel Statements 28-31, and the factors that affect their implementation in the Western Pacific Region (WPR).

METHODS

Content and face validity of the survey (BS28-31) was established. This resulted in the BS28-31 consisting of 20 questions, which included a Clinical Pharmacy Services Facilitators (CPSF) scale (25 items) to measure respondents' perceptions of facilitators of clinical pharmacy services. The BS28-31 was emailed to hospital pharmacy directors in the WPR. The survey was made available in English, Japanese, Chinese, Vietnamese, Lao, Khmer, French and Mongolian. Principal components and internal consistency analyses were conducted to assess the reliability and construct validity of the CPSF scale.

RESULTS

The final survey was sent to a total of 2525 hospital pharmacy directors in the WPR of which 726 were returned from 31 nations yielding a response rate of 29%. Two items in the scale were removed due to low communalities (0.22 and 0.16). The resulting 23 item scale produced a parsimonious two-factor solution, divided into internal (e.g. individual pharmacist traits and pharmacy departmental structure/resources) and environmental facilitators (e.g. government support, patient and physician expectations). This two factor solution explained 51.5% of the variance. In addition, the Cronbach's α for the internal and environmental subscales were 0.94 and 0.78 respectively.

CONCLUSION

The BS28-31 survey was found to be a reliable and valid instrument for assessing hospital pharmacy directors' perceptions of clinical pharmacy services regarding pharmacists' influences on prescribing and their facilitators in the WPR.

Clinical pharmacist impact on care, length of stay, and cost in pediatric cystic fibrosis (CF) patients

BACKGROUND

Cystic fibrosis (CF) patients are often treated with aminoglycoside (AG) antibiotics during infective pulmonary exacerbations. Achieving pharmacokinetic and pharmacodynamic (PK/PD) targets to improve outcomes and counteract resistance is paramount.

PURPOSE

The primary objective was to compare the number of pediatric CF patients achieving AG PK/PD targets when a clinical pharmacist (CP) managed therapeutic drug monitoring (TDM) compared with usual care (UC).

METHODS

A retrospective cohort study was conducted on the records of 40 CF patients that received AGs and ≥2 serum samples between 1/2007 and 5/2009. Chi-square and Student's t-test were used to analyze nominal and continuous variables, respectively.

RESULTS

Twenty-nine patients with 52 courses of AGs were included the CP group, and 22 patients with 42 courses were included the UC group. Ninety-eight percent of patients in the CP group reached AG PK/PD targets compared with 71% in the UC group, P < 0.001. Patients in the CP group reached the AG PK/PD target in a mean of 1.9 ± 0.8 days compared with 4.8 ± 3.4 days in the UC group, P < 0.0001. The average LOS in the CP group was 9 ± 5 days compared with 12 ± 7.5 days in the UC group, P = 0.033. The mean number of levels per patient was 2.7 in the CP group compared with 5.2 (range of 2-20) in the UC group, P < 0.001. Resource utilization associated with drug levels, dosing adjustments and LOS were $26,549, $14,069, and $1,680,000 in the CP group as compared with $40,683, $27,812, and $1,940,000, respectively, in the UC group.

CONCLUSION

CP managed TDM resulted in a significantly higher percentage of pediatric CF patients achieving AG PK/PD targets 3 days sooner with an average LOS that was 3 days shorter. CP managed TDM resulted in significantly fewer dosage adjustments, drug levels, and cost associated with serum sampling, drug wastage, and LOS.

Pharmacists need recognition as providers to enhance patient care

OBJECTIVE

To demonstrate that pharmacists are vital but currently underutilized direct care providers and that full provider status and inclusion into advanced multidisciplinary team models is needed.

DATA SOURCES

Literature was accessed through Ovid MEDLINE from 1990 to the present using the terms pharmacy care, pharmacist care, medication therapy management, and pharmaceutical care. Web-based searching and backward citation tracking was conducted for context and additional citations.

DATA SYNTHESIS

There is strong data showing that pharmacists in patient care roles contribute to intermediate and final health outcomes improvements and cost-effectiveness. The general perception of pharmacists from prominent people in the Federal Government, some medical societies, and from physicians and nurses who work with pharmacists most closely is overwhelmingly positive. However, the penetration of pharmacists into complementary patient care roles is minimized by an antiquated reimbursement structure that needs to change. There are critical future primary care provider shortages that will be exacerbated under health care reform, and pharmacists can be a part of the solution if the reimbursement environment was altered.

CONCLUSIONS

For all the data and support for expanded direct patient care pharmacist services, pharmacists are marginalized by an antiquated reimbursement structure. Pharmacists need to be granted Medicare provider status, and new models of primary care need to include pharmacists in patient care roles in order to more fully meet the needs of patients.

The impact of clinical pharmacy services in China on the quality use of medicines: a systematic review in context of China's current healthcare reform

INTRODUCTION

Recently, China initiated an ambitious healthcare reform aiming to provide affordable and equitable basic health care to all by 2020. To meet these goals, new policies issued by China's Ministry of Health mandate clinical pharmacy services be integrated into China's hospitals. This review aims to highlight the impact of clinical pharmacy services on the quality use of medicines in hospitals in China.

METHODS

Both English and Chinese databases were used. For the English databases, Web of Science, Medline, International Pharmaceutical Abstracts and Embase were searched using the following keywords ('pharmacists' OR 'pharmacy' OR 'pharmaceutical services/pharmaceutical care') AND ('China'). For the Chinese database, Chinese Biomedical Literature Database on disc was searched using the following keywords ('clinical pharmacist' OR 'clinical pharmacy' OR 'pharmaceutical care' OR 'pharmaceutical services'). Articles were then retrieved from WanFang database and China Knowledge Resource Integrated Database.

RESULTS

A total of 75 published papers were included in this review. The majority of studies were conducted in the inpatient setting (68%), which included clinical pharmacy interventions such as educating doctors and patients, evaluating and monitoring the implementation of hospital policies and/or reviewing medications on the ward. In the outpatient setting, the majority of studies conducted involved educating patients. Clinical pharmacy services frequently focused on antimicrobials (44%). More than half of these studies employed an administrative intervention alongside the clinical pharmacy service.

CONCLUSION

Clinical pharmacy services in China, with its unique healthcare system and cultural nuances, appear to positively influence patient care and the appropriate use of medications. From the published literature, it is expected that clinical pharmacy services can make a strong contribution to China's healthcare reform with further governmental and educational support.

Intervention to reduce the use of unsafe abbreviations in a teaching hospital

OBJECTIVES

To determine the effectiveness of a two-phase intervention designed to reduce the use of unsafe abbreviations.

METHODS

An observational prospective study was conducted at the King Khalid University Hospital in Riyadh, Saudi Arabia during May-September 2009. A list of unsafe abbreviations was formulated based on the recommendations of the Institute for Safe Medication Practices. The first 7000 medication orders written at the beginning of each period were collected. Phase one of the intervention involved educating health care professionals about the dangers of using unsafe abbreviations. In the second phase of the intervention, a policy was approved that prohibited the use of unsafe abbreviations hospital-wide. Then, another educational campaign targeted toward prescribers was organized. Descriptive statistics are used in this paper to present the results.

RESULTS

At baseline, we identified 1980 medication abbreviations used in 7000 medication orders (28.3%). Three months after phase one of the intervention, the number of abbreviations found in 7000 medication orders had decreased to 1489 (21.3%). Six months later, after phase two of the intervention, the number of abbreviations used had decreased to 710 (10%). During this phase, the use of all abbreviations had declined relative to the baseline and phase one use levels. The decrease in the use of abbreviations was statistically significant in all three periods (P < 0.001).

CONCLUSION

The implementation of a complex intervention program reduced the use of unsafe abbreviations by 65%.

Medication safety practices in hospitals: A national survey in Saudi Arabia

BACKGROUND

Medication errors in hospitals are a worldwide concern. The World Health Organization has recommended the implementation of basic applications in healthcare systems to improve medication safety, but it is largely unknown whether these recommendations are adhered to by hospitals. We assessed the presence of core medication safety practices in Saudi Arabian hospitals.

METHODS

We developed and validated a survey to assess medication safety practices in hospitals. Major headings included Look-Alike Sound-Alike (LASA) medications, control of concentrated electrolyte solutions, transitions in care, information technology, drug information and other medication safety practices. Trained pharmacists visited samples of hospitals from all regions of Saudi Arabia.

RESULTS

Seventy-eight hospitals were surveyed. Only 30% of the hospitals had a medication safety committee and 9% of hospitals had a medication safety officer. Only 33% of hospitals had a list of LASA medications and 50% had a list of error-prone abbreviations. Concentrated electrolytes were available in floor stock in 60% of the hospitals. No hospital involved pharmacists in obtaining medication histories and only 37% of the hospitals provided a medication list to the patients at discharge. While 61% of hospitals used a computer system in their pharmacy to enter prescriptions, only 29% of these hospitals required entry of patient's allergies before entering a drug order.

CONCLUSIONS

Core practices to improve medication safety were not implemented in many hospitals in Saudi Arabia. In developing countries, an effort must be made at the national level to increase the adoption of such practices.

[Prioritization of healthcare programs by pharmacy students from France and from Quebec, according to the perceived impact of a decentralized pharmacist]

INTRODUCTION

Healthcare decision makers need to establish priorities and their decisions must be justified. However, few data is available on the prioritization process of the healthcare programs that should benefit from decentralized pharmacists.

PATIENTS AND METHODS

The main objective was to prioritize healthcare programs according to the perceived impact of a decentralized pharmacist for outpatient and inpatient clienteles. The secondary objective was to compare the prioritization made by pharmacy students from two Quebec universities and from one French university. Two different approaches were developed (perceived impact according to three indicators and according to the global impact).

RESULTS

The majority of healthcare programs with a high evidence based literature quality score (5/6 outpatient programs and 5/8 inpatient programs) were highly prioritized by at least two out of three cohorts. The median rank that was attributed for each healthcare program was significantly different between the three cohorts for 8/17 (47%) of outpatient programs and for 10/18 (56%) of inpatient programs.

DISCUSSION

A higher rank was attributed to healthcare programs when the evidence based literature quality score was high. The prioritization was also influenced by the difference in pharmaceutical practice between France and Quebec (e.g. sterilization and medical devices in France).

CONCLUSIONS

This study presented two approaches for the prioritization of healthcare programs that should benefit from a decentralized pharmacist, according to students from France and from Quebec.

Value of the Student Pharmacist to Experiential Practice Sites: A Review of the Literature

Objective:

To summarize the literature addressing clinical services provided by pharmacy students and the economic implications associated with those services.

Data Sources:

A literature search was performed through MEDLINE and International Pharmaceutical Abstracts from their inception through December 2011. Search terms included pharmacy students, doctor of pharmacy students, clinical interventions, documentations, and medication histories.

Study Selection and Data Extraction:

All research articles and abstracts published in English were included. Studies were excluded if they were not conducted in the US. Articles were reviewed and abstracted for number of interventions and proportion of total interventions performed by pharmacy students, type and duration of advanced practice experience, patient care location, time required for interventions, frequency of interventions that were accepted or implemented, and financial assessment of interventions when reported.

Data Synthesis:

A total of 29 fully published studies and 6 abstracts were identified. The majority of the studies evaluated the number of student recommendations made and the acceptance rate of those recommendations. On average, individual students made between 1.2 and 16 recommendations to prescribers per week. The acceptance rate ranged from 32% to 98%. In addition to recommendations, students performed intravenous to oral dose conversions and obtained medication histories. All of the studies that assessed the economic impact of student pharmacist involvement reported a cost savings or cost avoidance associated with having pharmacy students at the institution.

Conclusions:

Pharmacy students provide many recommendations with high acceptance rates. During their pharmacy practice experiences, students generally confer economic and clinical benefits that may exceed the costs associated with their supervision and training.

Effect of Medication Reconciliation on Medication Costs After Hospital Discharge in Relation to Hospital Pharmacy Labor Costs

Background:

Medication reconciliation aims to correct discrepancies in medication use between health care settings and to check the quality of pharmacotherapy to improve effectiveness and safety. In addition, medication reconciliation might also reduce costs.

Objective:

To evaluate the effect of medication reconciliation on medication costs after hospital discharge in relation to hospital pharmacy labor costs.

Methods:

A prospective observational study was performed. Patients discharged from the pulmonology department were included. A pharmacy team assessed medication errors prevented by medication reconciliation. Interventions were classified into 3 categories: correcting hospital formulary-induced medication changes (eg, reinstating less costly generic drugs used before admission), optimizing pharmacotherapy (eg. discontinuing unnecessary laxative), and eliminating discrepancies (eg, restarting omitted preadmission medication). Because eliminating discrepancies does not represent real costs to society (before hospitalization, the patient was also using the medication), these medication costs were not included in the cost calculation. Medication costs at 1 month and 6 months after hospital discharge and the associated tabor costs were assessed using descriptive statistics and scenario analyses. For the 6-month extrapolation, only medication intended for chronic use was included.

Results:

Two hundred sixty-two patients were included. Correcting hospital formulary changes saved €1 63/patient (exchange rate: EUR 1 = USD 1.3443) in medication costs at 1 month after discharge and €9.79 at 6 months. Optimizing pharmacotherapy saved €20.13/patient in medication costs at 1 month and €86.86 at 6 months. The associated labor costs for performing medication reconciliation were €41.04/patient. Medication cost savings from correcting hospital formulary-induced changes and optimizing of pharmacotherapy (€96.65/patient) outweighed the labor costs at 6 months extrapolation by €55.62/patient (sensitivity analysis €37.25–71.10).

Conclusions:

Preventing medication errors through medication reconciliation results in higher benefits than the costs related to the net time investment.

Community pharmacy services in the United Arab Emirates

OBJECTIVES

To identify the type and frequency of services provided through community pharmacies in the United Arab Emirates (UAE).

METHODS

A survey was conducted using an anonymous questionnaire distributed by hand to 700 community pharmacies. Items included information about the pharmacists and pharmacies, type of products sold, type and extent of enhanced services provided and perceived barriers to providing these services.

KEY FINDINGS

Most pharmacies provided a wide range of medicinal and non-medicinal products. The frequency with which services were provided was assessed on a scale of 1 (never) to 5 (always). Enhanced professional services were not provided to a large extent in most pharmacies. Fewer than one-third (29%) reported they always supplied printed information to patients (mean = 3.37, 95% confidence interval = 3.23-3.52); fewer than one-third (28%) counselled patients on a regular basis (3.25, 3.09-3.40); nearly two-thirds (62%) reported monitoring patients' adherence to therapy at least sometimes (2.96, 2.81-3.10). Most pharmacies (92%) in the UAE did not routinely keep patient records (2.09, 1.96-2.32). While just over a quarter of respondents claimed that they always reported medication errors (27%) and adverse drug reactions (28%), these activities were not often performed in around 40% of pharmacies.

CONCLUSIONS

This is the first study to explore the type and extent of professional services provided through community pharmacies in the UAE and provides baseline data critical to inform the development of strategies to improve the quality of community pharmacy services.

Accuracy of the medication history at admission to hospital in Saudi Arabia

OBJECTIVE

Inaccurate medication history at admission to hospitals leads to preventable adverse drug events, which in turn increase mortality, morbidity, and health care costs. The objective of this study was to investigate the role of pharmacists in identifying discrepancies in medication histories at admission to a tertiary referral hospital in Saudi Arabia.

METHODS

We performed a prospective observational study in a 1200 bed tertiary hospital in Riyadh, Saudi Arabia. Patients were included if they were aged 16 years or older, were taking 5 or more medications, and were able to communicate or were accompanied by a caregiver who could communicate. Over 2 months in 2009, a pharmacist interviewed patients to ascertain all medications used prior to hospitalization, then all discrepancies were discussed with the admitting physician and unintended discrepancies were reported as errors.

RESULTS

A pharmacist interviewed 60 patients who were taking 564 medications total. Of these patients, 65% were male, and their mean age was 62. Patients were taking an average of 9.4 medications. Twenty-two (37%) patients had at least one discrepancy, with the most common being omissions of medications (35%) and dosage errors (35%). The mean age for patients with discrepancies was 64.6 years, and without discrepancies, 60.8 years (P = 0.37).

CONCLUSION

Inaccurate medication history at admission to a hospital was common in Saudi Arabia. This has the potential to cause harm to patients if it remains undetected. Pharmacists could potentially play a major role in obtaining this medication history at the time of hospital admission.

Cost-effectiveness of ward-based pharmacy care in surgical patients: protocol of the SUREPILL (Surgery & Pharmacy In Liaison) study

Background

Preventable adverse drug events (pADEs) are widely known to be a health care issue for hospitalized patients. Surgical patients are especially at risk, but prevention of pADEs in this population is not demonstrated before. Ward-based pharmacy interventions seem effective in reducing pADEs in medical patients. The cost-effectiveness of these preventive efforts still needs to be assessed in a comparative study of high methodological standard and also in the surgical population. For these aims the SUREPILL (Surgery & Pharmacy in Liaison) study is initiated.

Methods/Design

A multi-centre controlled trial, with randomisation at ward-level and preceding baseline assessments is designed. Patients admitted to the surgical study wards for elective surgery with an expected length of stay of more than 48 hours will be included. Patients admitted to the intervention ward, will receive ward-based pharmacy care from the clinical pharmacy team, i.e. pharmacy practitioners and hospital pharmacists. This ward-based pharmacy intervention includes medication reconciliation in consultation with the patient at admission, daily medication review with face-to-face contact with the ward doctor, and patient counselling at discharge. Patients admitted in the control ward, will receive standard pharmaceutical care.

The primary clinical outcome measure is the number of pADEs per 100 elective admissions. These pADEs will be measured by systematic patient record evaluation using a trigger tool. Patient records positive for a trigger will be evaluated on causality, severity and preventability by an independent expert panel. In addition, an economic evaluation will be performed from a societal perspective with the costs per preventable ADE as the primary economic outcome. Other outcomes of this study are: severity of pADEs, number of patients with pADEs per total number of admissions, direct (non-)medical costs and indirect non-medical costs, extra costs per prevented ADE, number and type of pharmacy interventions, length of hospital stay, complications registered in a national complication registration system for surgery, number of readmissions within three months after initial admission (follow-up), quality of life and number of non-institutionalized days during follow-up.

Discussion

This study will assess the cost-effectiveness of ward-based pharmacy care on preventable adverse drug events in surgical patients from a societal perspective, using a comparative study design.

Trial registration

Netherlands Trial Register (NTR): NTR2258