Annemieke Floor-Schreudering

Prevalence and determinants of pharmacy shopping behaviour.

Background and objective:  Discontinuity of care bears the risk of medication errors and poor clinical outcomes. Little is known about the continuity of care related to pharmacies. Therefore, we studied the prevalence and determinants of pharmacy shopping behaviour in the Netherlands.

Documentation Quality in Community Pharmacy: Completeness of Electronic Patient Records After Patients' First Visits

Background: When patients visit a community pharmacy for the first time, the creation of an electronic patient record (EPR) with relevant and up-to-date data is a prerequisite for adequate medication surveillance and patient counseling. Objective: To investigate the level of completeness of documentation in the EPR after a patients first visit to a Dutch community pharmacy. Methods: In each participating pharmacy, newly enlisted (<3 mo) patients to whom at least one medication had been dispensed were enrolled in this survey. For each patient who could be interviewed, pharmacy master students used a structured questionnaire to gather relevant, mandatory patient data (ie, basic characteristics, current drugs used, diseases, intolerabilities, specific conditions) and nonmandatory patient data (eg, diagnostic and monitoring data, personal experiences and habits, drug use problems) from the patients EPR and from a structured telephone interview with the patient. Data retrieved from the patients EPR were compared with data provided by the patient during the telephone interview. Results: Of 403 selected patients, 154 (38.2%) could be interviewed by telephone. Poor documentation of telephone numbers in the EPR was the main reason for nonresponse (134/249). Interviewers found that 67.7% of prescription drugs, 0% of over-the-counter drugs, 19.6% of diseases, 3.7% of intolerabilities, and none of the specific conditions reported by patients had been documented in the EPR. Nonmandatory data (personal experiences and habits, drug use problems) reported during the patient interview had not been documented in the EPR. Conclusions: The EPR after a patients first visit to the community pharmacy is often incomplete. For new patients, the pharmacist should more proactively and systematically gather patient information, and all relevant information should be recorded, preferably in coded form, in the pharmacy information system to allow more adequate clinical risk management.

Checklist for standardized reporting of drug–drug interaction management guidelines

PurposeInconsistencies and omissions in drug–drug interaction (DDI) management guidelines may lead to harm and suboptimal therapy. The purpose of this study was to define a checklist for DDI management guidelines to help developers produce high-quality guidelines that will support healthcare providers in clinical practice.MethodsWe carried out a two-round Delphi process with an international panel of healthcare providers, most of whom are pharmacists involved in providing DDI information, in order to select those items that should be addressed in DDI management guidelines (including grading systems that could be used).ResultsTwenty-three panellists reached consensus on 19 items in two main domains. These were consolidated into a checklist of 15 elements for standardized reporting in management guidelines. For each element a description is provided to specify what information should be documented in that specific element.ConclusionsIt was possible to reach a broad consensus on which relevant items should be included in a checklist for the development of DDI management guidelines.

Clinical Risk Management of Interactions Between Natural Products and Drugs

Clinical risk management offers a systematic approach to minimize healthcare-related risks by paying attention to: (1) risk identification and assessment; (2) development and execution of risk reduction strategies; (3) evaluation of risk reduction strategies. This paper reviews these key areas for the risk of interactions between natural products and drugs (NPDIs) to explore how the impact of these interactions on public health can be minimized. It argues that specific components of clinical risk management need to be evaluated, before adoption, and then actively implemented if proven valuable.

Nature and frequency of drug therapy alerts generated by clinical decision support in community pharmacy

The purpose of this study is to investigate the nature, frequency, and determinants of drug therapy alerts generated by a clinical decision support system (CDSS) in community pharmacy in order to propose CDSS improvement strategies.

Missed Drug Therapy Alerts as a Consequence of Incomplete Electronic Patient Records in Dutch Community Pharmacies

Background: Complete and up-to-date medical and pharmaceutical information in the electronic patient record (EPR) is a prerequisite for risk management in community pharmacy. Objectives: To analyze which information is missing in the EPR and which drug therapy alerts, therefore, fail to appear. Methods: Pharmacy students selected patients who were dispensed a prescription drug and enlisted for >3 months in the participating pharmacies. Patients received a questionnaire in which they were asked to verify their medication history, and to provide additional patient information. For each enrolled patient, the students collected all relevant information from the EPR. Self-reported data from the patient were compared with data retrieved from the EPR. Missed information in the EPR was evaluated based on national professional guidelines. Results: Questionnaires were received from 67% of the selected patients (442/660). Prescription drugs were missing in the EPR of 14% of the 442 patients, nonprescription drugs in 44%, diseases in 83%, and intolerabilities in 16%. In 38% of the patients (166/442), drug therapy alerts failed to appear because of missing information: drug-disease interactions in 34% of the patients, duplicate medications in 4%, drug-drug interactions (DDIs) in 4%, and drug intolerabilities in 2%. Among the (non-)prescription drugs missing, NSAIDs were most frequently responsible for the missed alerts. Diseases most frequently associated with missed alerts were gastroesophageal reflux disease, renal insufficiency, asthma/chronic obstructive pulmonary disease, and heart failure. Conclusions: Relevant patient information was frequently missing in the EPRs. The nonappearance of drug therapy alerts may have had clinical consequences for patients.

Clarity and Applicability of Drug-Drug Interaction Management Guidelines: A Systematic Appraisal by General Practitioners and Community Pharmacists in the Netherlands

AbstractBackground: Despite the availability and daily use of computerized drug-drug interaction surveillance systems, exposure to potentially relevant drug-drug interactions (DDIs) continues. DDI management guidelines are often inadequate and clear management options are lacking, which attributes to overriding of DDI signals. Although general criteria for the development and reporting of high-quality clinical practice guidelines have been identified, it appears these have not yet been applied to DDI management guidelines. Objectives: The aim of the study was to assess the clarity and applicability of guidelines for the management of potentially harmful DDIs. Methods: We selected 13 DDIs that are potentially harmful for patients and frequently occur in community pharmacy practice in the Netherlands. The clarity and applicability of the management guidelines of these DDIs were appraised using the appropriate two domains — ‘Clarity and presentation’ and ‘Applicability’, of the validated Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. The appraisal was performed by 12 community pharmacists and 12 general practitioners. The standardized domain scores and mean item scores for ‘Clarity and presentation’ and ‘Applicability’ were compared. Results: All DDI management guidelines were generally found to score well on ‘Clarity and presentation’, but poorly with respect to ‘Applicability’ (standardized domain scores 68.0 vs 26.1%). Within the domain ‘Clarity and presentation’, the item ‘tools for application’ received the lowest scores. Within the domain ‘Applicability’, cost implications, organizational barriers and key review criteria were all poorly documented. All guidelines presented non-directive advice using words such as ‘consider’ and ‘regularly’. Conclusions: Developers of DDI management guidelines should take the appropriate domains of the AGREE Instrument into consideration in their development processes. The applicability of DDI management guidelines should be pretested before publishing. To improve guideline quality, more attention should particularly be paid to the available tools for applications and cost implications.

NSAID-antihypertensive drug interactions: which outpatients are at risk for a rise in systolic blood pressure?

Background Management guidelines for drug–drug interactions between non-steroidal anti-inflammatory drugs (NSAIDs) and antihypertensives recommend blood pressure monitoring in hypertensive patients. We measured the short-term effect of initiating NSAIDs on systolic blood pressure (SBP) in users of antihypertensives, aiming to investigate which outpatients are at risk for an increase in SBP in daily clinical practice. Design A cohort study with a nested case-control design in Dutch community pharmacies. Methods Patients with a drug–drug interaction alert for a newly initiated NSAID and antihypertensive were interviewed and their SBP was measured at T0, after one week (T1) and after two weeks (T2). We evaluated risk factors for exceeding a predefined limit of change (PLoC) in SBP (≥10 mmHg to ≥140 mmHg) at T1 and T2 versus T0. Results For 112 patients the SBP at T0 was measured. Two patients were excluded (T0 SBP ≥180 mmHg). PLoC was exceeded in 10 patients (10.4%) at T1 and in seven patients (8.0%) at T2. Patients using etoricoxib (odds ratio (OR), 21.0; 95% confidence interval (CI), 3.7–120.6) and patients using >1 defined daily dose of an NSAID (OR, 3.3; 95% CI, 1.1–10.0) were at increased risk of a rise in SBP. Conclusions A newly initiated NSAID has an immediate clinically relevant effect on SBP in some users of antihypertensives. Management guidelines for NSAID-antihypertensive drug–drug interactions should advise SBP monitoring before and after initiation of an NSAID or intensification of NSAID therapy. Monitoring is especially relevant in patients prescribed high dosages of NSAIDs. Etoricoxib should not be used in hypertensive patients.

Lower alert rates by clustering of related drug interaction alerts

Objective: We aimed to investigate to what extent clustering of related drug interaction alerts (drug-drug and drug-disease interaction alerts) would decrease the alert rate in clinical decision support systems (CDSSs). Methods: We conducted a retrospective analysis of drug interaction alerts generated by CDSSs in community pharmacies. Frequently generated combinations of alerts were analyzed for associations in a 5% random data sample (dataset 1). Alert combinations with similar management recommendations were defined as clusters. The alert rate was assessed by simulating a CDSS generating 1 alert per cluster per patient instead of separate alerts. The simulation was performed in dataset 1 and replicated in another 5% data sample (dataset 2). Results: Data were extracted from the CDSSs of 123 community pharmacies. Dataset 1 consisted of 841 572 dispensed prescriptions and 298 261 drug interaction alerts. Dataset 2 was comparable. Twenty-two frequently occurring alert combinations were identified. Analysis of these associated alert combinations for similar management recommendations resulted in 3 clusters (related to renal function, electrolytes, diabetes, and cardiovascular diseases). Using the clusters in alert generation reduced the alert rate within these clusters by 53–70%. The overall number of drug interaction alerts was reduced by 11% in dataset 1 and by 12% in dataset 2. This corresponds to a decrease of 21 alerts per pharmacy per day. Discussion and conclusion: Using clusters of drug interaction alerts with similar management recommendations in CDSSs can substantially decrease the overall alert rate. Further research is needed to establish the applicability of this concept in daily practice.

Moral dilemmas of community pharmacists: a narrative study

Background Pharmacists are increasingly involved in patient care. This new role in a complex healthcare system with demanding patients may lead to moral dilemmas. There has been little research into pharmacy ethics, and existing data are limited by their retrospective nature and small sample sizes. A thematic overview of the moral dilemmas experienced by community pharmacists is still missing. Objective To make a thematic overview of moral dilemmas experienced in daily pharmacy practice. Setting Dutch community pharmacy. Methods Dutch community pharmacists wrote a narrative about a moral dilemma they had experienced in clinical practice. The narratives were analysed using qualitative content analysis to identify underlying themes. Main outcome measure Themes of moral dilemmas. Results Twenty-two themes were identified in 128 narratives. These moral dilemmas arose predominantly during pharmacists’ contact with patients and other health professionals. The relationship between the pharmacist, patient and other health professionals was complicated by other parties, such as legal representatives, health insurance companies, and regulators. Conclusion The moral dilemmas experienced by community pharmacists are more diverse than previously reported. The main dilemmas arose in their professional contacts, frequently when their professional autonomy was challenged by the behaviour of patients and other health professionals.