Adapting a community pharmacy intervention to improve medication safety

BACKGROUND

Community pharmacies are an ideal location to address challenges of over-the-counter medication safety, yet many successful interventions are only tested in a few pharmacies without expansion, creating unrealized opportunities to improve patient care on a larger scale. Scaling up to numerous pharmacies can be challenging because each community pharmacy has unique needs and layouts and requires individualized adaptation.

OBJECTIVES

This paper reports techniques for (a) adapting a community pharmacy intervention to fit the unique physical layout and patient needs of health system pharmacy sites without increasing staff workload, (b) identifying strategies to gather feedback on adaptations from stakeholders, and (c) developing materials to share with pharmacy champions for them to independently implement and sustain the intervention in their organization.

PRACTICE DESCRIPTION

The study team collaborated with Aurora Pharmacy, Inc to develop an intervention designed to increase awareness of safe over-the-counter medication use for older adults.

PRACTICE INNOVATION

Senior Safe, a community pharmacy-based intervention, was designed, implemented, and tested using the Exploration, Preparation, Implementation, and Sustainment implementation framework.

EVALUATION METHODS

Senior Safe was adapted through pilot testing and a randomized control trial. Feedback was collected from key stakeholders, including pharmacy staff, older adults, and a research advisory group.

RESULTS

A finalized version of Senior Safe, as well as an implementation package, was provided to Aurora Pharmacy to integrate into all 63 sites.

CONCLUSION

This multiphase study illustrated that refining an intervention is possible and welcomed by pharmacy staff, but it requires time, resources, and funds to create an impactful, sustainable community pharmacy intervention.

A cost avoidance study of critical care pharmacists' interventions in a tertiary institution in Singapore

PURPOSE

The economic impact of critical care pharmacists in the intensive care unit (ICU) setting has not been evaluated in Singapore despite ICUs being high-cost areas. This study was conducted to determine the costs avoided as a result of pharmacists' interventions within multidisciplinary ICU teams in a tertiary hospital in Singapore.

METHODS

A single-center, retrospective observational study of accepted pharmacists' interventions was conducted over 6 months in 2020. We adopted a previously published systematic approach to estimate the costs avoided by the healthcare system through pharmacists' interventions. Interventions were independently reviewed by a critical care pharmacist, an intensivist, and an investigator. Cost avoidance was calculated in terms of the additional ICU length of stay that would have resulted had a pharmacist not intervened as well as the direct cost savings achieved.

RESULTS

There were 632 medication-related problems (MRPs) associated with the 527 accepted interventions, as some interventions involved multiple MRPs. The most common interventions included correcting inappropriate drug regimens (n = 363; 57%), recommending drug monitoring (n = 65; 10%) and addressing omission of drugs (n = 50; 8%). Over 6 months, gross cost avoidance and net cost avoidance achieved were $186,852 and $140,004, respectively, resulting in a ratio of potential monetary cost avoidance to pharmacist salary of 3.99:1. The top 3 interventions that resulted in the greatest cost avoidance were those that corrected inappropriate drug regimens ($146,870; 79%), avoided adverse drug events (ADEs) ($10,048; 5%), and led to discontinuation of medications without any indication ($7,239; 4%).

CONCLUSION

Pharmacists can reduce healthcare expenditure substantially through cost avoidance by performing various interventions in ICUs, particularly in the areas of correcting inappropriate drug regimens, avoiding ADEs, and discontinuing unnecessary medications.

Using xPIRT to Record Pharmacy Interventions: An Observational, Cross-Sectional and Retrospective Study

Medication errors and omissions can potentially cause harm, prolong a hospital stay, lead to co-morbidities and even death. Pharmacy interventions (PI) ensure that these errors are identified and addressed, leading to improved patient safety and prescriber practice. Particularly in community hospitals, many only having general practitioners and not specialist doctors in their medical teams, PIs assume a strategic role. The PIs recorded throughout 8 months (between November 2021 and June 2022) in the community hospital wards in Powys, Wales, UK, using xPIRT (Pharmacy Intervention Recording Tool), a new pharmacy intervention record toolkit, were subjected to a retrospective analysis. The data were organised by location, drug, severity, acceptance, cost avoidance and intervention type. Significant prescribing errors were identified, which can potentially be different from those recorded in acute settings. Our results also informed on the need for integrated electronic prescribing systems paired with a PI recording tool to address effectively prescribing inaccuracies. Overall, this study was able to identify pharmacy teams as key to improve patient safety and care while contributing to significant cost-savings, through the recording of PI using xPIRT.

Evaluation of Pharmacy Inquiries in Physician Order Reviews for Medication Safety: A Cross-Sectional Study

Background and Objectives: Despite the effort to prevent drug-related problems (DRPs) in healthcare settings, prescribing errors are common in the medication use process. In a Korean teaching hospital, pharmacists verify prescription orders during their routine order review process and document the details in a homegrown health information system (HIS). The objectives of this study were to identify the annual trends in pharmacy inquiries and to evaluate the prevalence of the inquiries by drug ingredients, including a description of the “pharmacy inquiry” screen in the HIS. Materials and Methods: A retrospective cross-sectional study was conducted to describe pharmacy inquiries related to preventing potential DRPs during order reviews and to evaluate the associated factors for discontinuation of prescription orders on medication among inquiries using data from January 2008 to December 2021. A descriptive analysis was performed using 128,188 inquiries, documented by 245 pharmacists for 14 years. Results: The frequency of inquiry steadily increased annually. The most frequent cause was “inappropriate dose or regimen” (49.1%) and “piperacillin and beta-lactamase inhibitor” was the most mentioned drug ingredient in the inquiries (3.4%). The overall acceptance rate of the pharmacists’ recommendation was 82.4%, and the cause of the highest acceptance was “inappropriate mix solution” (96.5%). Hospitalization and certain inquiry topics were significantly associated with discontinuation of prescription orders on inquired medications by clinicians. Conclusions: The findings indicate that pharmacy inquiries with integrated HIS could resolve inaccuracy during physicians’ order reviews and ensure safe patient care. As a tool for preventing prescribing errors, the pharmacy inquiry data can help maximize consistent improvement and optimize the medication use process in healthcare settings.

Assessment of the validity of the beta-lactam antibiotic allergy assessment tool for use in the rural context, QLD

OBJECTIVE(S)

The objective of the study was to validate a clinical aid to guide the assessment and management of a patient's listed beta-lactam antibiotic allergy for use in rural areas of Australia.

DESIGN

Rural generalists, pharmacists and junior doctors completed an online assessment of eight patient case studies using the tool.

SETTING

The study was conducted in the Southern Downs, QLD.

PARTICIPANTS

Twenty-seven rural generalists, nine pharmacists and eight junior doctors.

MAIN OUTCOME MEASURES

The sensitivity of the selected allergy phenotype and management option for each case study was calculated by profession and overall. Hazardous responses were reported by management category and profession.

RESULTS

The sensitivity overall for phenotype selection was 82.4% (95% CI, 78.0-86.2) and for management 88.1% (95% CI, 84.2-91.2). The sensitivity for phenotype selection was lower for junior doctors than other professions 73.4% (95% CI, 60.9-83.7), but did not reach statistical significance (p = 0.08). A total of 10/308 responses for management recommended the least restrictive option of direct delabelling or oral challenge, where the correct answer was skin prick testing or referral to an allergist.

CONCLUSION(S)

With further education the tool could be a key component of increased antimicrobial stewardship in rural areas in Australia.

Qualitative Exploration of Pharmacists' Feedback Following the Implementation of an "Allergic Rhinitis Clinical Management Pathway (AR-CMaP)" in Australian Community Pharmacies

Allergic Rhinitis (AR) is both a common and high burden disease, with the majority of AR sufferers purchasing suboptimal/inappropriate AR medication from community pharmacies. Unfortunately, it is still a challenge to translate the AR management guidelines that are available at both a global and national level into practice. This study aimed to explore the experiences and perceptions of community pharmacists with regards to the implementation of AR management guidelines in real-life everyday practice. This exploration took the form of a qualitative research study in which pharmacists were interviewed following the implementation of a guideline-driven AR management pathway in their pharmacies. Fifteen pharmacists from six pharmacies agreed to participate in a telephone interview. Five themes were identified that encompassed the sentiment of the pharmacists during the interviews: (1) impact of training on pharmacists’ approach to patients and AR management recommendations; (2) patient engagement and the importance of appropriate tools; (3) patient barriers to change in practice; (4) physical, logistical, and inter-professional barriers to change within the pharmacy environment; and (5) recommendations for improvement. The results of this study indicate that, following the implementation of an AR management pathway, pharmacists believe that their interactions with patients around their AR were enhanced through the use of appropriate tools and education. However, if optimal AR management is to be delivered within the community pharmacy setting, the undertaking needs to be collaborative with both pharmacy assistants and general practitioners.

An Advanced Pharmacy Practice Experience for Community Pharmacies Based on a Clinical Intervention Targeting Patients With Inflammatory Bowel Disease

Experiential education is a critical component of any pharmacy undergraduate curriculum. Establishing new, high-quality practice sites can be challenging. We designed a new advanced pharmacy practice experiential rotation suitable for implementation in most community pharmacy settings. The aim of this article is to describe the design of this rotation entitled the Targeted Pharmacy Intervention in Inflammatory Bowel Disease (TPI-IBD) and to determine its impact on student knowledge and confidence using a before-after survey design. The TPI-IBD utilizes a student-delivered intervention as a platform for experiential learning in community pharmacy practice. The TPI was focused on patients with IBD, and implementation was guided by a co-preceptor from the university in collaboration with onsite-preceptors at each pharmacy. The TPI-IBD rotation was delivered from 6 community pharmacies during 5 weeks in 2018. Students conducted standardized monitoring on patients with IBD and met weekly with the university preceptor for case presentations and therapeutic discussions. Electronic charts were maintained by students who were responsible for ensuring detailed documentation on each patient. Knowledge, confidence, and overall satisfaction were assessed by a survey given to students before and after the rotation. Students were highly satisfied with the learning experience and improvements in knowledge and confidence were clearly demonstrated. The TPI strategy was an effective way to expand rotation options in community pharmacy sites with minimal burden on local preceptors.

Effects of Pharmacy-Based Interventions on the Control and Management of Diabetes in Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

The aim of this systematic review and meta-analysis was to evaluate the effects of pharmacy-based interventions on clinical outcomes associated with diabetes-related complications as well as on nonclinical outcomes in people with diabetes.

METHODS

We searched 4 main databases (MEDLINE, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials) for studies that considered clinical and nonclinical outcomes of pharmacy-based interventions among people with diabetes. Clinical outcomes included patients' mean reductions of glycated hemoglobin (A1C) levels and body mass indexes (BMIs). Nonclinical outcomes included patients' healthcare utilization and quality of life. A meta-analysis was conducted to estimate the pooled net mean difference in clinical outcomes between the pharmacy-intervention and the control groups.

RESULTS

Of the 44 studies included in the systematic review, 32 studies reported results from randomized controlled trials measuring reductions of A1C levels in 4,132 patients. Meta-analysis revealed that the standardized absolute mean difference in reduction of A1C levels from baseline to the time of the last follow up significantly favoured the pharmacy intervention versus the control group (0.96%; 95% CI 0.71 to 1.22; p<0.001). Of the studies, 13 reported BMI kg/m² in 1,827 patients. The estimation of standardized absolute mean difference in reduction of BMI unit calculated through meta-analysis was 0.61 (95% CI 0.20 to 1.03; p=0.000) in favour of the pharmacy-intervention group.

CONCLUSIONS

Pharmacy-based interventions have significant positive effects on controlling 2 major risks factors associated with diabetes-related complications: A1C levels and BMI. However, there is a dearth of evidence about the effects of pharmacy-based intervention on nonclinical outcomes, including healthcare utilization and quality of life.

Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medication regimens

OBJECTIVES

To develop and evaluate an electronic tool to assist clinical pharmacists with reviewing potentially inappropriate medications (PIMs) in hospitalized elderly adults.

DESIGN

Pilot intervention.

SETTING

Academic tertiary care hospital.

PARTICIPANTS

Hospitalized adults aged 65 and older admitted to the general medicine, orthopedics, and urology services during a 3-week period in 2011 who were administered at least one medication from a list of 240 PIMs.

INTERVENTION

A computerized PIMS dashboard flagged individuals with at least one administered PIM or a high calculated anticholinergic score. The dashboard also displayed 48-hour cumulative narcotic and benzodiazepine administration. Participants were ranked to reflect the estimated risk of an adverse event using logical combinations of data (e.g., use of multiple sedatives in a nonmonitored location). In a pilot implementation, a clinical pharmacist reviewed the flagged records and delivered an immediate point-of-care intervention for the treating physician.

MEASUREMENTS

Clinician response to pharmacist intervention.

RESULTS

The PIMS dashboard flagged 179 of 797 individuals (22%) admitted over a 3-week period and 485 participant-medication pairs for review by the clinical pharmacist. Seventy-one participant records with 139 participant-medication pairs required additional manual review of the electronic medical record. Twenty-two participants receiving 40 inappropriate medication orders were judged to warrant an intervention, which was delivered by personal communication over the telephone or text message. Clinicians enacted 31 of 40 (78%) pharmacist recommendations.

CONCLUSION

An electronic PIM dashboard provided an efficient mechanism for clinical pharmacists to rapidly screen the medication regimens of hospitalized elderly adults and deliver a timely point-of-care intervention when indicated.

Effect of prescriber education on the use of medications contraindicated in older adults in a managed medicare population

OBJECTIVE

To measure the effect of pharmacy intervention programs on the percentage of older adult members filling prescriptions for one or more contraindicated medications in a managed Medicare population.

METHODS

Prescribers of potentially inappropriate (i.e., contraindicated) medications in a managed Medicare + Choice (now known as Medicare Advantage) health maintenance organization (HMO) were identified from drug claims each calendar quarter for letter and telephone contact. The initial study population was composed of members in the Medicare + Choice HMO who were aged 65 years or older and who utilized their managed care pharmacy benefit during the 4-year measurement period from 1999 fourth quarter (Q4) through 2003 Q4. The study population was expanded in 2003 Q1 to include all patients aged 65 years or older, including commercial HMO members and Medicare + Choice members. The prescribers of target (contraindicated) drugs were contacted by a letter that described the program and included a prescriber-specific list of patients who had received a potentially inappropriate drug. Each prescriber was requested to review the report and change the contraindicated drug to a more appropriate agent, lower the medication dose, or carefully monitor those patients who could not discontinue the drug. A clinical pharmacist contacted high-volume prescribers of target drugs (4 or more patients in a given quarter) by telephone to discuss the identified patients.

RESULTS

The incidence of inappropriate use of the target medications in older adults declined by 19%, from an absolute 5.3% of prescriptions in the base period (1999 Q4) to 4.3% at the end of the first 2-year period, in 2001 Q4. A change in the target drugs in 2002 Q1 from a list based upon the Beers' criteria to a list based in part on the Zhan et al. criteria was associated with a 45% reduction in the percentage (2.4%) of older adult members who received target drugs; this proportion remained essentially unchanged at 2.2% through 2003 Q4, the end of the second half of the 4-year intervention period.

CONCLUSIONS

A clinical intervention program targeting prescribers of drugs judged to be contraindicated in older adults was associated with a decline in the percentage of HMO members receiving one or more target contraindicated drugs. After a 4-year intervention period, 2.2% of older adult HMO members continued to receive one or more target contraindicated drugs.