Claire Scullin

Provision of pharmaceutical care by community pharmacists: a comparison across Europe

Objective To investigate the provision of pharmaceutical care by community pharmacists across Europe and to examine the various factors that could affect its implementation. Methods A questionnaire-based survey of community pharmacies was conducted within 13 European countries. The questionnaire consisted of two sections. The first section focussed on demographic data and services provided in the pharmacy. The second section was a slightly adapted version of the Behavioral Pharmaceutical Care Scale (BPCS) which consists of three main dimensions (direct patient care activities, referral and consultation activities and instrumental activities). Results Response rates ranged from 10–71% between countries. The mean total score achieved by community pharmacists, expressed as a percentage of the total score achievable, ranged from 31.6 (Denmark) to 52.2% (Ireland). Even though different aspects of pharmaceutical care were implemented to different extents across Europe, it was noted that the lowest scores were consistently achieved in the direct patient care dimension (particularly those related to documentation, patient assessment and implementation of therapeutic objectives and monitoring plans) followed by performance evaluation and evaluation of patient satisfaction. Pharmacists who dispensed higher daily numbers of prescriptions in Ireland, Germany and Switzerland had significantly higher total BPCS scores. In addition, pharmacists in England and Ireland who were supported in their place of work by other pharmacists scored significantly higher on referral and consultation and had a higher overall provision of pharmaceutical care. Conclusion The present findings suggest that the provision of pharmaceutical care in community pharmacy is still limited within Europe. Pharmacists were routinely engaged in general activities such as patient record screening but were infrequently involved in patient centred professional activities such as the implementation of therapeutic objectives and monitoring plans, or in self-evaluation of performance.

Integrated medicines management – can routine implementation improve quality?

RATIONALE, AIMS AND OBJECTIVES Previous service development work in the area of integrated medicines management (IMM) has demonstrated clear quality improvements in a targeted group of patients within a hospital in Northern Ireland. In order to determine whether this programme could be transferable to routine practice and thereby assess its generalizability, research has been carried out to quantify the health care benefits of incorporating the concept of IMM as routine clinical practice. METHOD The IMM programme of care was delivered to all eligible patients (subject to inclusion criteria) across two hospital sites in Northern Ireland during normal pharmacy opening hours. All patients were followed up for a period of 12 months from their time of hospital admission. All patient data were collected using the custom-designed Electronic Pharmacist Intervention Clinical System at each stage of their hospital journey, that is, admission, inpatient stay and discharge. RESULTS Patients who received the IMM service benefited from a reduced length of hospital stay on their reference admission (1.42 days; P = 0.020) as well as a reduced length of stay during the first rehospitalization (5.86 days; P = 0.013). There was also a trend of a reduced number of readmissions and a longer time to readmission during the 12-month follow-up period. Potential significant opportunity cost savings were demonstrated as well as a significant improvement in medication appropriateness (discharge vs. reference admission). CONCLUSIONS The IMM programme of care has proven to be transferable to routine hospital care within two hospitals in Northern Ireland. It is anticipated that this current research will further inform the development of IMM as routine clinical practice across Northern Ireland and beyond.

Integrated medicines management to medicines optimisation in Northern Ireland (2000–2014): a review

Objective The objective of this review was to assess the improvement in medicines processes in Northern Ireland focusing mainly on secondary care and at the interface with primary care and also to consider the benefits of enabling technologies for the system. Methods The review was undertaken by examining all of the publications that had been produced together with relevant context articles that framed and supported the requisite process changes together with a synopsis of relevant enabling technologies that were devised. Key outputs were summarised and incorporated into the system review. Results The optimisation of the medicines process has led to benefits to patients in terms of morbidity and mortality in addition to a reduction in healthcare resource utilisation. Key findings include reduced length of stay, reduced readmission rates, improved Medicines Appropriateness Index, improved Medicines Administration Error rate, positive impact on Risk Adjusted Mortality Index and improved communication across the primary/secondary care interface. Enabling technology solutions were also implemented. Conclusions The journey from medicines management to optimisation has resulted in significant improvements in the quality and safety of medicines yielding health gain and economy and a return on investment of £5–8 for each £1 invested. The complementary role of pharmacy in the multidisciplinary team has been identified and evidenced. The next steps will be to further integrate with primary care and deliver improvements in medicines processes in that sector together with requisite enabling technologies.

A modified Delphi study to determine the level of consensus across the European Union on the structures, processes and desired outcomes of the management of polypharmacy in older people

Background Inappropriate use of multiple medicines (inappropriate polypharmacy) is a major challenge in older people with consequences of increased prevalence and severity of adverse drug reactions and interactions, and reduced medicines adherence. The aim of this study was to determine the levels of consensus amongst key stakeholders in the European Union (EU) in relation to aspects of the management of polypharmacy in older people. Methods Forty-six statements were developed on aspects of healthcare structures, processes and desired outcomes, with consensus defined at ≥ 80% agreement. Panel members were strategists (e.g. directors, leading clinicians and commissioners) from each of the 28 EU member states, with a target recruitment of five per member state. Three Delphi rounds were conducted via email, with panel members being provided with summative results and collated, anonymised comments at the commencement of Rounds 2 and 3. Results Ninety panel members were recruited (64.3% of target), with high participation levels throughout the three Delphi rounds (91.1%, 83.3%, 72.2%). During Round 1, consensus was obtained for 27/46 statements (58.7%), with an additional two statements in Round 2 and none in Round 3. Consensus was obtained for statements relating to: potential gain arising from polypharmacy management (3/4 statements); strategic development (7/7); change management (5/7) indicator measures (4/6); legislation (0/3); awareness raising (5/5); polypharmacy reviews (5/7); and EU vision (0/7). Analysis of free text comments indicated that the vision statements were too ambitious and not achievable by the specified timeframe of 2025. Conclusion Consensus was obtained amongst key EU strategists around many aspects of polypharmacy management in older people. Notably, no consensus was achieved in relation to statements relating to the need to alter legislation in areas of healthcare delivery, remuneration and practitioner scope of practice. While the vision for the EU by 2025 was considered rather ambitious, there is great potential and clear opportunity to advance polypharmacy management throughout the EU and beyond.

Enhanced clinical pharmacy service targeting tools: risk-predictive algorithms

RATIONALE, AIMS AND OBJECTIVES This study aimed to determine the value of using a mix of clinical pharmacy data and routine hospital admission spell data in the development of predictive algorithms. Exploration of risk factors in hospitalized patients, together with the targeting strategies devised, will enable the prioritization of clinical pharmacy services to optimize patient outcomes. METHODS Predictive algorithms were developed using a number of detailed steps using a 75% sample of integrated medicines management (IMM) patients, and validated using the remaining 25%. IMM patients receive targeted clinical pharmacy input throughout their hospital stay. The algorithms were applied to the validation sample, and predicted risk probability was generated for each patient from the coefficients. Risk threshold for the algorithms were determined by identifying the cut-off points of risk scores at which the algorithm would have the highest discriminative performance. Clinical pharmacy staffing levels were obtained from the pharmacy department staffing database. RESULTS Numbers of previous emergency admissions and admission medicines together with age-adjusted co-morbidity and diuretic receipt formed a 12-month post-discharge and/or readmission risk algorithm. Age-adjusted co-morbidity proved to be the best index to predict mortality. Increased numbers of clinical pharmacy staff at ward level was correlated with a reduction in risk-adjusted mortality index (RAMI). CONCLUSIONS Algorithms created were valid in predicting risk of in-hospital and post-discharge mortality and risk of hospital readmission 3, 6 and 12 months post-discharge. The provision of ward-based clinical pharmacy services is a key component to reducing RAMI and enabling the full benefits of pharmacy input to patient care to be realized.

Do patient bedside medicine lockers result in a safer and faster medicine administration round

Objective To determine if the introduction of patient bedside medicine lockers leads to a safer and faster medicine administration round. Methods The undisguised observer technique was utilised to observe the medicine administration round on four wards, two medical wards in Antrim Area Hospital (AAH) and two surgical wards in Causeway Hospital (CH), both before and after the introduction of patient bedside medicine lockers. All non-intravenous medicine administrations during the morning medicines administration round were observed and timed before and after the introduction of the lockers. Medicine administration errors (MAEs), time taken and reasons for delays were recorded and analysed. Results The MAE rate and the time spent on the medicine administration round both decreased after the introduction of patient bedside medicine lockers. The MAE rate dropped from 8.3% to 1.3% (p < 0.001) in the AAH site and from 9.9% to 3.2% (p = 0.029) in the CH site; the time spent per patient on medicine administration decreased from 6.80 ± 5.44 min pre-intervention to 3.03 ± 1.87 min post-intervention and from 7.35 ± 6.24 min pre-intervention to 6.95 ± 5.39 min post-intervention in AAH (p < 0.001) and CH (p > 0.05), respectively. Conclusions The introduction of patient bedside medicine lockers resulted in safer and faster medicine administration rounds.

A case study of polypharmacy management in nine European countries: implications for change management and implementation.

Background Multimorbidity and its associated polypharmacy contribute to an increase in adverse drug events, hospitalizations, and healthcare spending. This study aimed to address: what exists regarding polypharmacy management in the European Union (EU); why programs were, or were not, developed; and, how identified initiatives were developed, implemented, and sustained. Methods Change management principles (Kotter) and normalization process theory (NPT) informed data collection and analysis. Nine case studies were conducted in eight EU countries: Germany (Lower Saxony), Greece, Italy (Campania), Poland, Portugal, Spain (Catalonia), Sweden (Uppsala), and the United Kingdom (Northern Ireland and Scotland). The workflow included a review of country/region specific polypharmacy policies, key informant interviews with stakeholders involved in policy development and implementation and, focus groups of clinicians and managers. Data were analyzed using thematic analysis of individual cases and framework analysis across cases. Results Polypharmacy initiatives were identified in five regions (Catalonia, Lower Saxony, Northern Ireland, Scotland, and Uppsala) and included all care settings. There was agreement, even in cases without initiatives, that polypharmacy is a significant issue to address. Common themes regarding the development and implementation of polypharmacy management initiatives were: locally adapted solutions, organizational culture supporting innovation and teamwork, adequate workforce training, multidisciplinary teams, changes in workflow, redefinition of roles and responsibilities of professionals, policies and legislation supporting the initiative, and data management and information and communication systems to assist development and implementation. Depending on the setting, these were considered either facilitators or barriers to implementation. Conclusion Within the studied EU countries, polypharmacy management was not widely addressed. These results highlight the importance of change management and theory-based implementation strategies, and provide examples of polypharmacy management initiatives that can assist managers and policymakers in developing new programs or scaling up existing ones, particularly in places currently lacking such initiatives.

A HRG-based costing model for estimating pharmacy costs associated with surgical procedures

Objective:  The present study addresses pharmacy expenditure within a surgical directorate in a UK hospital. The aim of the study was to develop a health care resource group (HRG)‐based costing model that can be used to forecast pharmacy expenditure based on surgical casemix. Such a model will be of benefit as an expenditure projection tool at a time when hospitals are developing accelerated operation programmes in an attempt to decrease hospital waiting times.