The impact of a pharmacist on post-take ward round prescribing and medication appropriateness

Background Medication communication and prescribing on the post-take ward round following patient admission to hospital can be suboptimal leading to worse patient outcomes. Objective To evaluate the impact of clinical pharmacist participation on the post-take ward round on the appropriateness of medication prescribing, medication communication, and overall patient health care outcomes. Setting Tertiary referral teaching hospital, Brisbane, Australia. Method A pre-post intervention study was undertaken that compared the addition of a senior clinical pharmacist attending the post-take ward was compared to usual wardbase pharmacist service, with no pharmacist present of the post-take ward round. We assessed the proportion of patients with an improvement in medication appropriateness from admission to discharge, using the START/STOPP checklists. Medication communication was assessed by the mean number of brief and in-depth discussions, with health care outcomes measured by comparing length of stay and 28-day readmission rates. Main outcome measures: Medication appropriateness according to the START/STOPP list, number and type of discussions with team members and length of stay and readmission rate. Results Two hundred and sixty patients were recruited (130 pre- and 130-post-intervention), across 23 and 20 post-take ward rounds, respectively. Post-intervention, there was increase in the proportion of patients who had an improvement medication appropriateness (pre-intervention 25.4%, post-intervention 36.9%; p = 0.004), the number of in-depth discussions about patients’ medication (1.9 ± 1.7 per patient pre-intervention, 2.7 ± 1.7 per patient post-, p < 0.001), and the number relating to high-risk medications (0.71 ± 1.1 per patient pre-intervention, to 1.2 ± 1.2 per patient post-, p < 0.05). Length of stay and 28-day mortality were unchanged. Conclusion Clinical pharmacist participation on the post-take ward round leads to improved medication-related communication and improved medication appropriateness but did not significantly improve health care outcomes.

The effect of pharmacists on ward rounds measured by the STOPP/START tool in a specialized geriatric unit

WHAT IS KNOWN AND OBJECTIVE

The STOPP/START tool has been validated to assess elderly patients for potentially inappropriate prescribing. This study aimed to assess the effect of inclusion of a pharmacist on a physician-led ward round on potentially inappropriate prescribing in hospitalized elderly patients.

METHODS

This was an observational study of prescribing for patients using the STOPP/START tool at three points during hospital stay; admission to hospital, on transfer to the specialized geriatric unit and on discharge from hospital. Data were collected over 4 months pre- and post-introduction of a pharmacist to a physician-led ward round. Demographic and clinical data, including total number of medications and STOPP/START criteria met, were collected. The mean number of STOPP/START criteria at each time-point was compared for pre- and post-introduction of a pharmacist using a Mann-Whitney U-test. The mean number of criteria for each time-point within each group was compared using a paired Student's t-test.

RESULTS AND DISCUSSION

The demographic characteristics of the participants in the pre- and post-intervention groups were similar. The post-intervention group had numerically less STOPP/START criteria, mean 1·18 (1·37) compared to the pre-intervention group 1·50 (1·41), P = 0·07 at discharge. The pre-intervention group had no significant change in the criteria from admission 1·78 (1·57) to geriatric unit transfer 1·72 (1·54) (P = 0·37); however, there was a significant decrease from geriatric unit transfer 1·72 (1·54) to discharge 1·50 (1·41) (P = 0·02). The post-intervention group had a significant decrease from hospital admission 2·30 (1·91) to geriatric unit transfer 1·59 (1·60) (P < 0·01) and again to discharge 1·18 (1·37) (P < 0·01).

WHAT IS NEW AND CONCLUSION

Pharmacist participation on the ward round in a specialized geriatric unit resulted in a numerical improvement in prescribing quality as measured by the STOPP/START tool.

Phase I feasibility study of carboplatin plus capecitabine followed by maintenance capecitabine in patients (pts) with recurrent platinum-sensitive epithelial ovarian cancer (EOC)

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Background: In a previous study, we noted a response rate (RR) of 61% for the 3 drug combination of carboplatin, epirubicin and capecitabine in platinum-sensitive recurrent EOC. This combination however resulted in excessive grade (G) 3–4 haematological toxicity (55%) (BJC 2006; 94:74). The current trial therefore assessed the feasibility and efficacy of the 2 drugs, carboplatin and capecitabine as second- or third-line treatment. Methods: Pts were administered carboplatin (AUC5) day 1 and capecitabine at a starting dose of 750 mg/m2 bd, days 1–21, q21 (dose level 1). The capecitabine dose was deescalated to 625 mg/m2 (dose level -1) and 500 mg/m2 (dose level -2) according to toxicity. Pts with an objective response or stable disease received maintenance capecitabine (at the same dose level) for up to 12 months or until progression. Responses were assessed with RECIST criteria and CA-125. Results: 19 of the 20 pts enrolled were evaluable for toxicity and response. Dose-limiting toxicity was observed at dose level 1 (G3 fatigue, G3 diarrhoea, G3 neutropenia of > 14 days; n = 3/5), dose level -1 (G3 angina (n = 2), G3 vomiting, G3 palmar plantar erythema; n = 4/7) and dose level-2 (diarrhoea / fatigue; n = 1/7). One patient had a G3 carboplatin hypersensivity reaction. 8 pts received maintenance capecitabine which was well tolerated. The overall RR was 53% with 10 partial responses and 5 stable diseases. The median progression free survival (PFS) was 6.5 months (m) and the 6mPFS was 63% with 2 pts currently ongoing treatment. The median PFS on maintenance was 3.2 m. Conclusions: The combination was well tolerated at the recommended phase II dose of carboplatin (AUC 5) and capecitabine (500 mg/m2 bd) with partial responses in over half of the cases.

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Barriers to optimum management of heart failure by general practitioners

BACKGROUND

Published research offers clear pointers to the management of heart failure; however, the evidence for implementation into practice is sub-optimal.

AIM

To identify the salient barriers to adopting evidence-based management of heart failure in the community.

METHOD

Structured interviews were used to elicit the views of a stratified sample of 100 general practitioners (GPs) about the diagnosis and treatment of heart failure. Responses to three heart failure case scenarios provided an indication of the degree to which GPs' knowledge of heart failure and trial results might be applied to diagnosis and treatment intentions.

RESULTS

Participants were generally well aware of clinical trials that showed that prognosis could be improved by treatment, but trial results appeared to have little influence on treatment intentions in the three case scenarios. The major barriers to optimum management were the difficulties of differential diagnosis and the perceived properties of angiotensin-converting enzyme inhibitors (ACE-I) relative to diuretics. In the case scenarios, less than 30% reported that they would undertake basic investigations, such as chest X-ray or haemoglobin, or prescribe ACE-I. Over 70% perceived diuretics to be a useful diagnostic tool. The most frequent reasons for not prescribing ACE-I were the perceived inconvenience and risks of adverse effects (41%) and the view that most patients can be managed successfully on diuretics alone (27%). Over two-thirds of the sample were dissatisfied with the quality of information accompanying heart failure patients discharged from hospital.

CONCLUSION

Facilitating evidence-based management of heart failure in the community requires further support for GPs in the form of additional training in the diagnosis of heart failure and the optimum use of both ACE-I and diuretics, and by improved communication between GPs and hospital doctors on a case-by-case basis.