Henk Buurma

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.

Drug related problems identified by European community pharmacists in patients discharged from hospital.

Objective: To examine the nature and frequency of DRPs in community pharmacies among patients discharged from hospitals in several countries, and to examine several variables related to these drug related problems.Method: The study was performed in 112 community pharmacies in Europe: Austria, Denmark, Germany, The Netherlands, Portugal and Spain. Community pharmacists asked patients with a prescription after discharge from hospital between February and April 2001 to participate in the study. A patient questionnaire was used to identify drug related problems. Pharmacists documented drug related problems, pharmacy interventions, type of prescriber and patient and pharmacy variables.Results: 435 patients were included in the study. Drug related problems were identified in 277 patients (63.7%). Uncertainty or lack of knowledge about the aim or function of the drug (133; 29.5%) and side effects (105; 23.3%) were the most common DRPs. Practical problems were reported 56 times (12.4%) by patients. Pharmacists revealed 108 problems (24.0%) concerning dosage, drug duplication, drug interactions and prescribing errors. Patients with more changes in their drug regimens (drugs being stopped, new drugs started or dosage modifications) and using more drugs were more likely to develop DRPs. Community pharmacists recorded 305 interventions in 205 patients with DRPs. Pharmacists intervened mostly by patient medication counselling (39.0%) and practical instruction to the patient (17.7%). In 26.2% the intervention was directed towards the prescriber. In 28 cases (9.2%) the pharmacists’ intervention led to a change of the drug regimen.Conclusion: This study shows that a systematic intervention by community pharmacists in discharged patients, or their proxies, is able to reveal a high number of DRPs that might be relevant for patient health outcomes. There should be more initiatives to insure continuity of care, since DRPs after discharge from hospital seem to be very common.

Clinical Risk Management in Dutch Community Pharmacies. The Case of Drug-Drug Interactions

AbstractBackground: The prevention of drug-drug interactions requires a systematic approach for which the concept of clinical risk management can be used. The objective of our study was to measure the frequency, nature and management of drug-drug interaction alerts as these occur in daily practice of Dutch community pharmacies. Methods: In total, 63 Dutch pharmacies collected all drug-drug interaction alerts during 153 research days (on average 2.4 days/pharmacy), as well as variables related to these alerts, such as involved medicines, first time or recurrent drug-drug interaction, same or different prescribers, patient data (age, sex) and information about the management of drug-drug interactions by the pharmacy. The latter was discriminated into internal procedures only and external action, such as communication with the patient, the prescriber or the anticoagulation clinic and prescription modification. All drug-drug interactions were classified into categories of clinical relevance (A–F) and available evidence (0–4). Results: A total of 43 129 prescription-only medicines were dispensed during the study period. On average, 16.8 interaction alerts per day per pharmacy were collected. Approximately 6% of all prescriptions generated a drug-drug interaction alert. Of all alerts (n = 2572), 31.1% occurred for the first time and with 21% two different prescribers were involved. The 20 most frequently occurring drug-drug interaction alerts accounted for approximately 76% of all alerts. Cardiovascular drugs, NSAIDs, oral contraceptives and antibacterials were most frequently involved. External action was taken in response to 27.3% of the alerts, meaning either a modification of one of the concerned prescriptions (n = 65; 9.3%), communication with the prescriber or anticoagulation clinic (n = 90; 12.8%) or communication with the patient or a relative (n = 547; 77.9%). Where there was no external action (n = 1860; 72.3%), pharmacists concluded in about two-thirds of cases that the drug-drug interaction had been managed in the past. Other reasons not to intervene externally were for instance: incorrect alert; acceptable drug-drug interaction; or outcome of the interaction considered irrelevant. Adjusted for several variables, a first alert was found to be a main determinant for external action. After stratifying for first alerts no other significant determinants were found. Conclusions: A high frequency of drug-drug interaction alerts was found. Most concerned recurrent alerts, which were the main reason not to act externally. Concerning the assessment phase in the risk-management process, drug-drug interactions with no or low evidence/relevance should be reconsidered. Concerning the management of drug-drug interactions in pharmacies, the opportunity to actively suppress alerts for a certain period of time should be studied in more detail. There are indicators that the management of patient-orientated advice could be improved and a greater degree of consistency developed for the management of first and recurrent interaction alerts.

Laxative prescribing in relation to opioid use and the influence of pharmacy-based intervention

Introduction: Opioid‐induced constipation is a common problem and can cause serious complications. It is widely advised that laxatives should be started concurrently with opiates, unless there is a clear indication not to do so.

Migraine prophylactic medication usage patterns in The Netherlands

This study aims to investigate usage patterns of specific migraine prophylactic medications in ergotamine and triptan patients commencing this treatment for the first time during 1 January 1992 until 31 December 1998. Usage patterns of specific migraine prophylactic drugs were evaluated for each patient by accessing data from a large prescription database and were characterized as continued, switch or stop use during the patient observation period. Several patient and medication-related factors were explored in order to identify a possible relationship with the specific usage pattern defined. Approximately 75% of the study population (n = 729) had terminated (stop or switch) prophylactic treatment after 1 year. Age < 40 years (relative risk (RR) 1.9; 95% confidence interval (CI) 1.2-3.2) and the concomitant use of non-steroidal anti-inflammatory drugs (RR 3.2; 95% CI 1.2-5.5) or specific abortive migraine drugs resulted in a faster onset of treatment modification (switch). Overall, migraine prophylactic treatment is used for a relatively short period, probably attributable to the common limitations associated with migraine prophylaxis, such as poor compliance and/or limited therapeutic efficacy. Patterns of use can be influenced by a variety of factors, including age, type of prescriber and certain co-medication. Patient interview studies are required to clarify these issues further.

Reduction in the intensity of abortive migraine drug use during coumarin therapy.

Objective.—To investigate the impact of coumarin therapy on migraine attack frequency.

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.

Single Use of Sumatriptan: A Patient Interview Study

Objective.—To investigate the possible reasons associated with the use of a single prescription of sumatriptan.

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.

Patterns of ergotamine and sumatriptan use in the Netherlands from 1991 to 1997

The objective of this study was to assess usage patterns of ergotamine and sumatriptan over a period of 6 years, primarily to evaluate the impact that sumatriptan has had on the prescription of ergotamine. This study used ergotamine and sumatriptan prescription data representing inhabitants of eight cities in the Netherlands and covering the period of 1991–1997. The yearly incidence of new users between 1991 and 1997 was estimated for both drugs as well as for the drug of first choice to be prescribed to patients initiating specific abortive migraine treatment with either ergotamine or sumatriptan. Intra-individual ergotamine and sumatriptan usage patterns, characterized by single (incidental), continuous (rate of retention) or switch use, were examined for five patient cohorts, each for a follow-up period of 1 year. During the year of sumatriptan introduction (1991–1992), the overall incidence of new use for both drugs was highest (5.4 per 1000 inhabitants). Hereafter, a substantial reduction of more than 50% was observed. From 1992 to 1996, the yearly incidence of ergotamine first-time use was significantly higher than that of sumatriptan and up to 1996 ergotamine was more than twice as likely than sumatriptan to be prescribed to patients initiating specific abortive treatment. Hereafter, sumatriptan was as likely as ergotamine to be prescribed as the drug of first choice, which coincided with the full reimbursement of sumatriptan tablets. Overall, neurologists were more likely than general practitioners (GPs), to prescribe sumatriptan as the drug of first choice. Approximately half of the total study population were identified as single-time users. This phenomonen occurred more frequently in the ergotamine cohorts. The sumatriptan cohorts displayed a slight yet significant stronger retention rate compared with the ergotamine cohorts. The overall impact of sumatriptan on ergotamine use in The Netherlands was marginal, predominantly due to GPs adherence to migraine treatment guidelines and reimbursement policies concerning sumatriptan tablets. Overall, incidental use was relatively high and may reflect the reported difficulties in diagnosing migraine, lack of patient–doctor consultation, or that anticipated benefits of the drug were not achieved. Further study is required to clarify these issues.