Cognitive processes in pharmacists' clinical decision-making

BACKGROUND

Pharmacists' clinical decision-making is a core process in pharmaceutical care. However, the practical aspects and effective teaching methods of this process remain largely unexplored.

OBJECTIVE

To examine the cognitive processes involved in pharmacists' perceptions of how they make clinical decisions in pharmacy practice.

METHODS

Semi-structured, face-to-face interviews were conducted with pharmacists working in community, outpatient, and hospital care in the Netherlands between August and December 2021. Participants were explicitly asked for examples when asked how they make clinical decisions in practice and how they teach this to others. After transcribing audio-recorded interviews, an inductive thematic analysis was conducted to identify cognitive processes. A theoretical model of clinical decision-making was then used and adapted to structure the identified processes.

RESULTS

In total, 21 cognitive processes were identified from interviews with 16 pharmacists working in community (n = 5), outpatient (n = 2), and hospital care (n = 9). These cognitive processes were organized into 8 steps of the adapted theoretical model, i.e. problem and demand for care consideration, information collection, clinical reasoning, clinical judgment, shared decision-making, implementation, outcomes evaluation, and reflection. Pharmacists struggled to articulate their clinical decision-making and went back-and-forth in their explanations of this process. All pharmacists emphasized the importance of identifying the problem and described how they collect information through reviewing, gathering, recalling, and investigating. Clinical reasoning entailed various cognitive processes, of which comprehending the problem in the patient's context was deemed challenging at times. Pharmacists seemed least active in evaluating patient outcomes and reflecting on these outcomes.

CONCLUSIONS

Pharmacists use multiple cognitive processes when making clinical decisions in pharmacy practice, and their back-and-forth explanations emphasize its dynamic nature. This study adds to a greater understanding of how pharmacists make clinical decisions and to the development of a theoretical model that describes this process, which can be used in pharmacy practice and education.

Factors influencing pharmacists' clinical decision making in pharmacy practice

BACKGROUND

Pharmacists' clinical decision-making is considered a core process of pharmaceutical care in pharmacy practice, but little is known about the factors influencing this process.

OBJECTIVE

To identify factors influencing clinical decision-making among pharmacists working in pharmacy practice.

METHODS

Semi-structured interviews were conducted with pharmacists working in primary, secondary, and tertiary care settings in the Netherlands between August and December 2021. A thematic analysis was conducted using an inductive approach. The emerged themes were categorized into the Capability-Opportunity-Motivation-Behaviour (COM-B) model domains.

RESULTS

In total, 16 pharmacists working in primary care (n = 7), secondary care (n = 4) or tertiary care (n = 5) were interviewed. Factors influencing pharmacists' capability to make clinical decisions are a broad theoretical knowledge base, clinical experience, and skills, including contextualizing data, clinical reasoning, and clinical judgment. The pharmacy setting, data availability, rules and regulations, intra- and interprofessional collaboration, education, patient perspectives, and time are mentioned as factors influencing their opportunity. Factors influencing pharmacists' motivation are confidence, curiosity, critical thinking, and responsibility.

CONCLUSIONS

The reported factors covered all domains of the COM-B model, implying that clinical decision-making is influenced by a combination of pharmacists' capability, opportunity, and motivation. Addressing these different factors in pharmacy practice and education may improve pharmacists' clinical decision-making, thereby improving patient outcomes.

Communication and relationship building in pharmacy education: Experiences from a student-patient buddy project

BACKGROUND AND PURPOSE

In order to deliver patient-centred pharmaceutical care, pharmacy students need to develop the appropriate competences and skills. During their regular study program, they have limited long-term patient contact. We therefore implemented a student-patient buddy project to give students opportunity to practice and learn from the patient contact.

EDUCATIONAL ACTIVITY AND SETTING

A student-patient buddy project was implemented in a 10-week first-year master experiential learning course, including a community pharmacy internship. The pharmacist paired the student with a community-dwelling patient. Student learning activities included: (1) three meetings at the university to prepare and discuss buddy contact moments, (2) three buddy contact moments, (3) discussion with the internship providing pharmacist, and (4) a written reflection report.

FINDINGS

In total, 66 students participated from April to June 2021. Most students found patient contact fun and a useful learning experience. Students mentioned that patients were very open and there was opportunity to build a relationship. The first conversation was experienced as exciting and sometimes difficult. Understanding the person was perceived as important. Internship pharmacists were positive about the project and saw learning benefits for students, as well as added value for the pharmacy, mainly because patients seemed to appreciate the contact.

SUMMARY

A student-patient buddy project is a good way to expand the limited long-term "real" patient care experiences of pharmacy students. This enables them to practice communication and building relationships with patients.

Problems with continuity of care identified by community pharmacists post-discharge

WHAT IS KNOWN AND OBJECTIVE

Medication discrepancies are common at hospital discharge, and medication reconciliation is widely endorsed as a preventive strategy. However, implementation is difficult for instance due to the unreliability of patients medication histories. In the Netherlands, community pharmacies are well-informed about their patients' pre-admission medication status which enables thorough post-discharge reconciliation. Our aim was to study the frequency and nature of medication discrepancies, missing patient's knowledge and administrative problems at admission to primary care.

METHODS

A cross-sectional study was conducted in pharmacies belonging to the Utrecht Pharmacy Practice network for Education and Research in the Netherlands. Structured checklists were used to evaluate all discharge prescriptions presented by adult patients discharged from the hospital to their own home during the study period. The primary outcome was all possible problems with continuity of care, defined as (i) the number and type of medication discrepancies, (ii) administrative problems and (iii) the necessity for patient education.

RESULTS AND DISCUSSION

In forty-four pharmacies, checklists were completed for 403 patients. Most discharge prescriptions (92%) led to one or more problems with continuity of care (n = 1154, mean 2·9 ± 2·0), divided into medication discrepancies (31%), administrative problems (34%) and necessity for further education (35%). Medication discrepancies (n = 356) resulted mainly from missing pre-admission medication (n = 106) and dose regimen changes (n = 55) on the discharge prescription. Administrative problems (n = 392) originated mainly from administrative incompleteness (n = 177), for example missing reimbursement authorization forms, or supply issues (n = 150), for example insufficient pharmacy stock. The patients' lack of medication knowledge post-discharge was illustrated by the high need for patient education (n = 406).

WHAT IS NEW AND CONCLUSION

Community pharmacists are still confronted with problems due to inadequate documentation at discharge which can inflict harm to patients if not properly addressed. To reduce these problems, a rigorous implementation of the medication reconciliation process at all transition points, standardized electronic transfer of all medication-related information and interdisciplinary collaboration are crucial.

Health literacy of patients admitted for elective surgery

Aim

Patients with limited health literacy have poorer surgical outcomes. However, current studies assessing the prevalence of limited health literacy in patients expecting surgery are small scale. We aimed to provide insight into the health literacy level of patients undergoing planned surgery.

Subject and Methods

Patients aged ≥18 years visiting the preoperative screening department were approached in the waiting area and invited to participate in a brief interview including the Functional Communicative Critical Health Literacy (FCCHL).

Results

In total, 225 patients (84.9% response) were studied. Based on the FCCHL, 37.3% of the patients were classified as having limited health literacy. The mean score in the critical domain (2.7 ± 0.9) was lower than scores in the functional (3.3 ± 0.6) and communicative (3.3 ± 0.6) domains.

Conclusion

More than one third of the patients admitted to the hospital for surgery had limited health literacy. Healthcare professionals should be aware of the different health literacy levels and tailor their information provision strategies accordingly.

ST13 polymorphisms and their effect on exacerbations in steroid-treated asthmatic children and young adults

BACKGROUND

The clinical response to inhaled corticosteroids (ICS) is associated with single nucleotide polymorphisms (SNPs) in various genes. This study aimed to relate variations in genes in the steroid pathway and asthma susceptibility genes to exacerbations in children and young adults treated with ICS.

METHODS

We performed a meta-analysis of three cohort studies: Pharmacogenetics of Asthma Medication in Children: Medication with Anti-Inflammatory effects (n = 357, age: 4-12 years, the Netherlands), BREATHE (n = 820, age: 3-22 years, UK) and Paediatric Asthma Gene Environment Study (n = 391, age: 2-16 years, UK). Seventeen genes were selected based on a role in the glucocorticoid signalling pathway or a reported association with asthma. Two outcome parameters were used to reflect exacerbations: hospital visits and oral corticosteroid (OCS) use in the previous year. The most significant associations were tested in three independent validation cohorts; the Childhood Asthma Management Programme (clinical trial, n = 172, age: 5-12 years, USA), the Genes- environment and Mixture in Latino Americans II- study (n = 745, age: 8-21, USA) and the Pharmacogenetics of adrenal suppression cohort (n = 391, age: 5-18, UK) to test the robustness of the findings. Finally, all results were meta-analysed.

RESULTS

Two SNPs in ST13 (rs138335 and rs138337), but not in the other genes, were associated at a nominal level with an increased risk of exacerbations in asthmatics using ICS in the three cohorts studied. In a meta-analysis of all six studies, ST13 rs138335 remained associated with an increased risk of asthma-related hospital visits and OCS use in the previous year; OR = 1.22 (P = 0.013) and OR = 1.22 (P = 0.0017), respectively.

CONCLUSION AND CLINICAL RELEVANCE

A novel susceptibility gene, ST13, coding for a cochaperone of the glucocorticoid receptor, is associated with exacerbations in asthmatic children and young adults despite their ICS use. Genetic variation in the glucocorticoid signalling pathway may contribute to the interindividual variability in clinical response to ICS treatment in children and young adults.

Biomarkers of therapy responsiveness in asthma: pitfalls and promises

Asthma is one of the most common chronic diseases worldwide. There is a large inter-individual variability in response to asthma treatment. Most patients respond well to standard therapy; however, a small proportion of the patients remain symptomatic despite treatment with high dosages of corticosteroids. Uncontrolled asthma leads to a decreased quality of life. Therefore, it is important to identify individuals who will respond poorly to standard asthma medication, especially to standard maintenance therapy with inhaled corticosteroids, at an early stage. Response to anti-inflammatory therapy is generally monitored by the assessment of clinical symptoms, which only partially correlates with underlying airway inflammation. The identification of specific inflammatory biomarkers might help to guide treatment or predict a corticosteroid response more accurately. Some inflammatory biomarkers are already finding their way into clinical practice (e.g. fraction of nitric oxide in exhaled breath), whereas others are predominantly used as a research tool (e.g. profiles of volatile organic compounds). Currently, there is no inflammatory biomarker used in routine clinical practice to predict a corticosteroid response. More knowledge on the underlying biological mechanism(s) of heterogeneous therapeutic responses could help to identify novel biomarkers. This review will focus on inflammatory patterns and genetic variations that may underlie differences in treatment response in patients with asthma, and will provide an overview of inflammatory biomarkers that could potentially serve as response predictors.

FCER2 T2206C variant associated with chronic symptoms and exacerbations in steroid-treated asthmatic children

BACKGROUND

The T2206C FCER2 variant was found previously to be associated with IgE levels, exacerbation rates and decreased FCER2 expression in children on inhaled corticosteroids (ICS) participating in a clinical trial. This finding has not been replicated. We sought to replicate the association between the FCER2 gene and exacerbations in children with asthma. In addition, we tested the hypothesis that the T2206C variant may be associated with other markers of steroid resistance such as asthma symptom scores and asthma medication use.

METHODS

The influence of the T2206C variant on asthma exacerbations (emergency department visits or hospitalization), symptoms scores and medication use was explored using data from two populations of asthmatic children using ICS: Pharmacogenetics of Asthma medication in Children: Medication with ANti-inflammatory effects study (n = 386) and BREATHE study (n = 939).

RESULTS

The T2206C variant was associated with increased risk of asthma-related hospital visits in both cohorts (OR: 1.91, 95% CI: 1.08-3.40), and meta-analysis with previously published results was highly significant (OR: 2.38, 95% CI: 1.47-3.85, P = 0.0004). The FCER2 variant was also associated with increased risk of uncontrolled asthma measured by Asthma Control Questionnaire (OR: 2.64, 95% CI: 1.00-6.98) and was associated with increased daily steroid dose (OR: 2.46, 95% CI: 1.38-4.39).

CONCLUSION

The association between the FCER2 T2206C variant and asthma-related hospitalizations in steroid-treated asthma appears robust and may also be associated with other indicators of lack of ICS efficacy such as asthma symptoms and a requirement for higher daily doses of ICS. Our results suggest that the FCER2 T2206C variant might be a useful pharmacogenetic predictor of steroid refractory patients.