[Opioid dependent patient with two prescribers]

Opioid use has risen again in the past year, partly due to overtaken operations. Some of the patients undergoing surgery already chronically use opioids. A fentanyl dependent patient enters the pharmacy with a oxycodone prescription from the orthopedist. The pharmacist doubts whether the orthopedist has the intention to continue the fentanyl use. The patient does not want the pharmacist to contact the orthopedist or the general practitioner who prescribes the fentanyl. The pharmacist experiences a dilemma with multiple handling options and reflects on them based on the professional values that are under pressure. What is the right action to take? A general practitioner and a medical ethicist reflect on the dilemma. The pharmacist experiences daily dilemmas regarding multiple prescribers for one patient. Prescribers can enhance medication safety by indicating on the prescription that they are aware of current treatments and whether a new medicine is a replacement or an addition to the therapy.

Using pharmacy dispensing data to predict falls in older individuals

Aims

Associations between individual medication use and falling in older individuals are well‐documented. However, a comprehensive risk score that takes into account overall medication use and that can be used in daily pharmacy practice is lacking. We, therefore, aimed to determine whether pharmacy dispensing records can be used to predict falls.

Methods

A retrospective cohort study was conducted using pharmacy dispensing data and self‐reported falls among 3454 Dutch individuals aged ≥65 years. Two different methods were used to classify medication exposure for each person: the drug burden index (DBI) for cumulative anticholinergic and sedative medication exposure as well as exposure to fall risk‐increasing drugs (FRIDs). Multinomial regression analyses, adjusted for age and sex, were conducted to investigate the association between medication exposure and falling classified as nonfalling, single falling and recurrent falling. The predictive performances of the DBI and FRIDs exposure were estimated by the polytomous discrimination index (PDI).

Results

There were 521 single fallers (15%) and 485 recurrent fallers (14%). We found significant associations between a DBI ≥1 and single falling (adjusted odds ratio: 1.30 [95% confidence interval {CI}: 1.02–1.66]) and recurrent falling (adjusted odds ratio: 1.60 [95%CI: 1.25–2.04]). The PDI of the DBI model was 0.41 (95%CI: 0.39–0.42) and the PDI of the FRIDs model was 0.45 (95%CI: 0.43–0.47), indicating poor discrimination between fallers and nonfallers.

Conclusion

The study shows significant associations between medication use and falling. However, the medication‐based models were insufficient and other factors should be included to develop a risk score for pharmacy practice.

Effectiveness of medication review on the number of drug-related problems in patients visiting the outpatient cardiology clinic: A randomized controlled trial

AIMS

To assess the effectiveness of medication review on the number of drug-related problems (DRPs) in outpatient cardiology patients.

METHODS

In this randomized controlled trial, a computer-assisted and pharmacist-led medication review with patient involvement (questionnaire and telephone call with pharmacist) was conducted in intervention patients prior to their visit to the cardiologist. The control group received usual care. Adult outpatient cardiology patients without support concerning the administration of medication, without a medication review in the past 6 months and who gave permission to access their electronic medication record were included. The primary outcome measure was the number of DRPs 1 month after the visit. Secondary outcome measures concerned the type of DRP and the type of medication involved in the DRPs.

RESULTS

In total, 75 patients (mean [standard deviation, SD] age 66.0 [12.5] years, 41% female) were included. Intervention (n = 90) and control group (n = 85) were comparable at baseline. The mean (SD) number of drugs used per patient was 7.9 (3.9). After 1 month, the mean (SD) number of DRPs was 0.3 (0.7) and 0.8 (1.0) and the median (range) number of DRPs was 0 (0-4) and 0 (0-4) in the intervention group and control group, respectively (P < .001). In the intervention group, 74% of the DRPs identified at T0 were solved at T1 vs 14% in the control group.

CONCLUSION

This randomized controlled trial suggests that a pharmacist-led medication review in patients with a scheduled visit to the outpatient cardiology clinic decreases the number of DRPs.

Moral reasoning among Dutch community pharmacists: testing the applicability of the Australian Professional Ethics in Pharmacy test

Background Moral reasoning competency is essential in healthcare practice, especially in situations of moral dilemmas when a professional has to choose a morally justifiable action among several suboptimal action options. The Australian Professional Ethics in Pharmacy test (PEP test) measures moral reasoning among pharmacists. In Australia three levels of moral reasoning (schemas) were measured (1) business orientation (2) rules and regulations, and (3) patient rights (i.e. most advanced schema). Objective To test the applicability of the PEP test to pharmacists working in the Netherlands. Setting Dutch community pharmacy. Methods The PEP test consists of 36 statements (items) accompanying 3 moral dilemma scenarios. It was translated into Dutch and completed by 390 pharmacists. Principle component analysis (PCA) was used to investigate construct validity and Cronbach's Alpha was used to indicate internal consistency of the Dutch version of the PEP test. The eligible grouped statements and perceived possible moral reasoning schemas were compared to the Australian findings. Main outcome measure Moral reasoning schemas. Results The PCA analysis resulted in 3 components (i.e. possible moral reasoning schemas) that together accounted 27% variance in the data. The statements that represented the moral reasoning schemas 'business orientation' and 'rules and regulations' were somewhat similar when comparing these with the statements that represented these schemas in the PEP test study. The most advanced moral reasoning schema identified in Dutch pharmacists contained different statements compared to the statements that represented that schema among Australian pharmacists. This schema was labelled 'professional ethics'. Conclusion The PEP test needs further adaptation to the Dutch pharmacy practice context: especially the statements that should reflect the most advanced moral reasoning schema, need more accurate representations of professional pharmacy ethics that guide pharmacists in the Netherlands. Moral reasoning tests for a specific professional setting or country should be developed and adapted by experts who share the same professional values and practice as the respondents.

Moral dilemmas reflect professional core values of pharmacists in community pharmacy

Objectives

The aim was to recognise the professional core values in the moral dilemmas of pharmacists in community pharmacy and to customise the descriptions of these values for community pharmacy practice.

Methods

The narratives of 128 moral dilemmas, collected from Dutch PharmD students and early career pharmacists who experienced these dilemmas in practice, were qualitatively analysed. An expert panel deductively coded relevant portions of these narratives with the core values as formulated by the Royal Dutch Pharmacists Association. Other values that emerged were inductively coded and if possible used to further customise the respective core values.

Key findings

The expert panel identified all four professional core values, that is, commitment to the patient's well‐being (117, 91.4%), reliable and caring (116, 90.6%), pharmaceutical expertise (72, 56.2%) and responsibility to society (30, 23.4%) in the 128 moral dilemma narratives. Thirteen other values that emerged in the analysis could all be used for the customisation of the professional core values in descriptions that better reflect community pharmacy practice.

Conclusions

Professional core values were identified in moral dilemma narratives of pharmacists in community pharmacy and customised for their practice. These customised core values can enable pharmacists to better recognise moral dilemmas in practice. This can add to the advancement of the profession as a pharmaceutical care practice.

Patients' perceptions of information received at the start of selective serotonin-reuptake inhibitor treatment: implications for community pharmacy

BACKGROUND

Pharmacists are increasingly acknowledging their responsibility to inform and counsel patients. However, it is unclear how these tasks are implemented and whether patients' needs are being fulfilled.

OBJECTIVE

To examine patients' perceptions of information received at the start of selective serotonin-reuptake inhibitor (SSRI) treatment, aiming to identify (1) information needs and (2) the potential role of the community pharmacist as information provider.

METHODS

A qualitative descriptive study comprising semi-structured telephone interviews was carried out with patients who had recently started a new course of SSRI treatment. Patients were recruited through 6 Dutch community pharmacies. The interviews were guided by the following topics: type of information obtained, unmet information needs, preferred information provider, and the role of the pharmacist.

RESULTS

Forty-one patients took part in an interview. Information needs varied widely among patients; overall, patients felt that they would benefit from information tailored to their needs. Many patients required more concrete and practical information on adverse effects and delayed onset of action than was provided. In addition, an explanation of the term dependency in the context of SSRI use and a discussion of the necessity for use and believed harms of long-term treatment were important to patients. Regardless of patients' needs, the role of the pharmacist was generally perceived as limited, and patients identified several pharmacy-related barriers to improved communication, including the timing of information (mainly restricted to first-time dispensing), lack of time and privacy, lack of empathy and a protocol-driven way of providing information, and inexperience of pharmacy technicians.

CONCLUSIONS

Patients starting treatment with antidepressants may benefit from information tailored to their personal needs. Along with the prescribing physician, community pharmacists could have an important role in informing and counseling patients.

Frequency, nature and determinants of pharmaceutical consultations provided in private by Dutch community pharmacists

OBJECTIVE

According to a report published by the federation of Dutch patients' associations, patients would like to see a pharmacist, who acts more as a personal adviser. This raised the question, how often Dutch community pharmacists have personal consultations with their patients in daily practice, on which factors this depends, and what kind of topics are discussed during these meetings.

SETTING

Community pharmacies in the Netherlands.

METHOD

A questionnaire was distributed among 800 randomly selected pharmacies. Questions were restricted to consultations characterized by one-to-one contact, drug therapy related content, and adequate privacy. These consultations were labelled as pharmaceutical consultations in private to distinguish them from other contacts between pharmacists and patients.

MAIN OUTCOME MEASURE

Number, content, and character of consultations.

RESULTS

198 (24.8%) community pharmacies responded. The pharmacists provide an average of roughly 1.2 consultations in private per working day. The vast majority of respondents provided face-to-face and telephone consultations (94.4 and 91.9%, respectively), only a minority gave consultations by e-mail (30.8%). These consultations primarily dealt with topics related to medication safety. The mean overall time spent was 290 min per month. A relatively high frequency of personal consultations was significantly associated with the absolute number of full-time equivalent pharmacists in the pharmacy.

CONCLUSION

The frequency of pharmaceutical consultations in private is low, but may be improved by reorganisation of the pharmacist's activities. The possibility of personal consultations by e-mail is not yet well-developed. Further research is needed to assess the patient's view of pharmaceutical consultations in private.

Drug dosage adjustments according to renal function at hospital discharge

BACKGROUND

Adequate dosing of medication in renal impairment to prevent hospitalizations and adverse reactions is a growing concern in the aging society. There are several dosing guidelines available, but structural use is uncommon.

OBJECTIVE

To perform a retrospective analysis of the incidence of required versus implemented dosage adjustments according to guidelines in patients with renal insufficiency at discharge and evaluate specific determinants responsible for the percentage of overlooked dosage adjustments.

METHODS

Medication and laboratory data were collected from patients at discharge during February and November 2004. For patients with a calculated creatinine clearance less than 51 mL/min/1.73 m(2), the necessity for dosage adjustments was evaluated by pharmacists. All data were collected for further research and subsequent statistical analysis.

RESULTS

At discharge, 237 of 647 (36.6%) patients had a calculated creatinine clearance less than 51 mL/min/1.73 m(2). Dosage adjustment based on renal function was necessary in 411 of 1718 (23.9%) of prescriptions. These adjustments were performed in 242 (58.9%) prescriptions and not performed in 169 (41.1%) cases. The risk of not adjusting the dosage was significantly associated with serum creatinine levels greater than 1.71 mg/dL and creatinine clearance less than 35 mL/min/1.73 m(2) (p < 0.05). The risk of not adjusting the dosage was also significantly associated with drugs producing severe consequences when dosing guidelines were overlooked (p < 0.05).

CONCLUSIONS

In patients with a calculated creatinine clearance less than 51 mL/min/1.73 m(2), dosing according to their renal function can be improved. Because of the need and the association found in this study, an alert system could help prescribers and pharmacists to adapt drug dosage in patients with renal impairment.

Disease and intolerability documentation in electronic patient records

BACKGROUND

Documentation of diseases and intolerabilities in electronic patient records (EPRs) in pharmacies is needed to produce an alert in case a contraindicated medicine is prescribed. Limited research is available concerning EPRs in pharmacies.

OBJECTIVE

To study the prevalence and quality of documentation of diseases and intolerabilities in EPRs in a sample of Dutch community pharmacies.

METHODS

Each participating pharmacy (N = 79) collected data on one day in May 2003 for each patient enrolled into the study (N = 687) concerning demographics, drug use, and documentation of diseases and intolerabilities.

RESULTS

In 57.4% of the EPRs, at least one disease and, in 7.9%, at least one intolerability was documented. Higher age, number of drugs used, and chronic disease score were associated with any documentation of a disease/intolerability in the EPR. The highest sensitivity scores (completeness) were found for diabetes (84.7%), asthma/chronic obstructive pulmonary disease (strict definition: 75.9%), and hypothyroidism (75.0%). Rather low values were found for prostatic hyperplasia (55.6%) and heart failure (29.4%). The positive predictive value (reliability) was high for hypothyroidism (100%) and diabetes (87.1%).

CONCLUSIONS

In a selection of Dutch pharmacies, at least one documented disease and/or intolerability was found in the EPR of almost 60% of the patients. Certain diseases were documented to a relatively high degree; others had poorer levels of documentation. For optimal surveillance of drug-disease interactions in pharmacies, the frequency and quality of disease and intolerability documentation need further improvement.