Henk-Frans Kwint

Effects of Medication Review on Drug-Related Problems in Patients Using Automated Drug-Dispensing Systems

Background: There are concerns that automated drug dispensing may increase inappropriate drug use. Automated dispensing could lead to perpetual repeating of drug therapies without the necessary re-evaluation.Objectives: The aim of this study was to examine the effect of a pharmacist-led medication review on drug-related problems (DRPs) in older patients receiving their drugs via automated dispensing.Methods: This was a pragmatic randomized controlled study conducted in primary care. Patients were recruited from six Dutch community pharmacies. They were eligible if they lived at home, were aged ≥65 years, and used five or more different drugs, of which at least one had to be dispensed via an automated system. Patients were randomly allocated to receive a medication review at the start of the study (intervention group) or after 6 months (waiting-list group). Each patient was independently reviewed by two pharmacist reviewers. The results of these medication reviews were sent to the community pharmacist to be discussed with the patient’s general practitioner (GP). The primary outcome measure was the number of DRPs leading to a recommendation for drug change. Secondary outcomes were the total number of drug changes and the number of drug changes related to a recommendation. In order to analyse drug changes, medication records were collected 6 months after the medication review or index date in the waiting-list group. Potential DRPs were classified using the DOCUMENT classification.Results: There were no baseline differences between the 63 patients in the intervention group and the 55 patients in the waiting-list group with respect to age, sex, number of drugs per patient and type of drug prescribed. The mean number of DRPs per patient at baseline in the intervention group and waiting list combined was 8.5, with no difference between the groups. At baseline, the mean number of DRPs leading to a recommendation for drug change was 4.5 per patient and did not differ between the two groups. After 6 months, the number of DRPs leading to a recommendation for drug change decreased by 29% in the intervention group versus 5% in the waiting-list group (p < 0.01). Recommendations for cessation of a drug were more frequently accepted than recommendations to add a new drug (82% vs 44%, p = 0.01).Conclusions: This study shows that patients using automated drug dispensing have a high number of DRPs. Medication review decreases the number of DRPs among these patients. We recommend that all patients with automatic drug dispensing should have a thorough medication review by pharmacists and prescribers.

The contribution of patient interviews to the identification of drug-related problems in home medication review.

What is known and Objective:  To determine to what extent patient interviews contribute to the identification of drug‐related problems (DRPs) in home medication reviews, in terms of number, type and clinical relevance.

Medication adherence and knowledge of older patients with and without multidose drug dispensing

OBJECTIVE we compared the self-reported medication adherence and knowledge of older patients receiving their drugs via multidose drug dispensing (MDD users) with patients receiving manually dispensed drugs (non-MDD users). METHODS MDD users (≥ 65 years, ≥ 5 oral chronic drugs) were randomly selected from eight Dutch community pharmacies. Non-MDD users (≥ 5 oral chronic drugs) were matched on age and gender. Medication adherence was assessed by using the Medication Adherence Reporting Scale (MARS) and medication knowledge by asking the indication of drugs. Cognitive function was measured with Mini-Mental State Examination (MMSE) for a sub selection of patients. RESULTS the percentage of patients being adherent to all drugs was higher for MDD users (n = 119, 81%) compared with non-MDD users (n = 96, 58%, P < 0.001).The percentage of patients with adequate knowledge was lower for MDD users (40%) compared with non-MDD users (79%, P < 0.001). The differences in adherence were independent of knowledge and MMSE scores. CONCLUSION this study shows that older patients receiving their drugs via MDD reported a higher medication adherence compared with patients receiving manually dispensed drugs, despite a lower knowledge and lower cognitive function among patients receiving MDD.

Completeness of medication reviews provided by community pharmacists

Little is known about the ability of community pharmacists who are inexperienced in medication review to identify drug‐related problems (DRPs). The objective of our study was to investigate the completeness of DRPs in terms of number, type and clinical relevance identified by community pharmacists when performing home medication reviews (HMRs).

Optimaliseren geneesmiddelengebruik door ouderen

SamenvattingKwint H-F, Faber A, Gussekloo J, Bouvy ML. Optimaliseren geneesmiddelengebruik door ouderen. Huisarts Wet 2015;58(3):134-8. In het kader van het proefschrift Improving appropriate medication use for older people in primary care hebben we onderzoek verricht naar het optimaliseren van de kwaliteit van het geneesmiddelengebruik door ouderen met polyfarmacie in de eerste lijn, waarbij de focus lag op medicatiebeoordeling en medicatie op rol. In dit artikel beschrijven we enkele onderzoeken uit dit proefschrift. We bespreken het effect van medicatiebeoordeling op farmacotherapiegerelateerde problemen, ziektegerelateerde uitkomsten en de kwaliteit van leven. Daarnaast richten we ons meer specifiek op de verschillende stappen van het proces van medicatiebeoordeling, zoals de bijdrage van de farmacotherapeutische anamnese en het mogelijke aandeel van expliciete STOPP-START-criteria bij de identificatie van farmacotherapiegerelateerde problemen. Voor gebruikers van medicatie op rol hebben we de mate van ongewenste farmacotherapie onderzocht en hebben we hun therapietrouw en medicatiekennis vergeleken met die van gebruikers van reguliere verpakkingen.De onderzoeken in dit proefschrift tonen de bijdragen van verschillende stappen van het proces van medicatiebeoordeling bij ouderen en de uitkomsten van dit proces. Onderzoeken onder oudere gebruikers van medicatie op rol geven inzicht in de kwaliteit van het geneesmiddelgebruik van deze specifieke groep. Vervolgonderzoek is gewenst. Zo willen we bijvoorbeeld weten welke specifieke groep ouderen het meest baat heeft bij een medicatiebeoordeling of gebruik van medicatie op rol.AbstractKwint H-F, Faber A, Gussekloo J, Bouvy ML. Optimizing medication use for elderly patients. Huisarts Wet 2015;58(3):134-8. The thesis Improving appropriate medication use for older people in primary care investigated how the medication use of elderly patients on polypharmacy in primary care can be optimized, with emphasis on the effects of medication review and multidose dispensing systems. In this article, we present a series of studies from this thesis. We describe the effect of medication review on drug-related problems, disease-specific outcomes, and health-related quality of life. Thereafter we focus on the different steps of the medication review process, such as the medication history and the possible role of explicit STOPP-START criteria in the identification of drug-related problems. We investigated the extent of inappropriate prescribing to older patients receiving their drugs via multidose drug dispensers and compared the self-reported medication adherence and knowledge of these patients with those of patients receiving manually dispensed drugs.In conclusion, the studies presented in the thesis show the importance of the different steps of the medication review process when prescribing for elderly patients and the outcomes achieved. Studies of older users of multidose drug dispensing systems provide insight into the quality of medication use in these individuals. Further research is needed, for example, to determine which older patients will benefit the most from medication review or use of multidose drug dispensing systems.

Immediate or deferred adjustment of drug regimens in multidose drug dispensing systems

Background: Multidose drug dispensing (MDD) is used to help patients take their medicines appropriately. Little is known about drug regimen changes within these MDD systems and how they are effectuated by the community pharmacist. Manual immediate adjustments of the MDD system could introduce dispensing errors. MDD guidelines therefore recommend to effectuate drug regimen changes at the start of a new MDD system. Objective: The aim of this study was to investigate the frequency, type, procedure followed, immediate necessity, and time taken to make MDD adjustments. Methods: This was a cross‐sectional study in eight community pharmacies in the Netherlands. All adjustments to MDD systems were systematically documented for 3 weeks by the community pharmacist. Results: Overall, 261 MDD adjustments involving 364 drug changes were documented for 250 patients: 127 (35%) drug changes involved the addition of a new drug, 124 (34%) a change in dosage, and 95 (26%) drug discontinuation. Of the MDD adjustments, 135 (52%) were effectuated immediately: 81 (31%) by adjusting the MDD system manually, 49 (19%) by temporarily dispensing the drug separately from the MDD system, and 5 (2%) by ordering a new MDD system. Pharmacists considered that 36 (27%) of the immediate MDD adjustments could have been deferred until the next MDD system was produced. Immediate adjustment took significantly longer than deferred adjustment (p < 0.001). Conclusions: This study shows that in patients using MDD systems, over half of the drug regimen changes are adjusted immediately. The necessity of these immediate changes should be critically evaluated. HighlightsA detailed analysis of drug regimen changes in users of multidose drug dispensing (MDD) systems.Half of the drug regimen changes in patients using MDD systems are effectuated by immediate adjustment.One quarter of these immediate adjustments could have been deferred.Immediate drug regimen changes in MDD systems are time consuming.Explicit agreements between prescribers and pharmacists can reduce the number of immediate drug regimen changes.

Drug-related problems identified during medication review before and after the introduction of a clinical decision support system

To facilitate the identification of drug‐related problems (DRPs) during medication review, several tools have been developed. Explicit criteria, like Beers criteria or STOPP (Screening Tool of Older Peoples’ Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria, can easily be integrated into a clinical decision support system (CDSS). The aim of this study was to investigate the effect of adding a CDSS to medication review software on identifying and solving DRPs in daily pharmacy practice.

STOPP-START-criteria kunnen medicatiebeoordeling niet vervangen

SamenvattingVerdoorn S, Kwint HF, Faber A, Gussekloo J, Bouvy ML. Screening met STOPP-START-criteria kan medicatiebeoordeling niet vervangen bij thuiswonende ouderen. Huisarts Wet 2016;59(10):439-42.AchtergrondDe STOPP- en START-criteria zijn opgesteld om ten onrechte gebruikte en ten onrechte achterwege gebleven medicatie bij ouderen op te sporen. Of daarmee alle farmacotherapiegerelateerde problemen (FTP’s) kunnen worden opgespoord is echter nog niet onderzocht. Wij gingen na in hoeverre de STOPP- en START-criteria te vergelijken zijn met een volledige medicatiebeoordeling.MethodeEénentwintig apothekers uit 13 apotheken in Zuidwest-Nederland voerden in 2011 samen met 65 huisartsen een volledige medicatiebeoordeling uit bij 457 thuiswonende 65-plussers die minimaal vijf geneesmiddelen gebruikten. Wij voerden een retrospectief dossieronderzoek uit in een geanonimiseerde database met de FTP’s van deze patiënten. Primaire uitkomsten waren aantal, type en implementatiegraad van de FTP’s waarop STOPP-START-criteria van toepassing waren.ResultatenDe mediane leeftijd van de patiënten was 77 jaar (interkwartielafstand 73-81) en 60% was vrouw. Van de 1656 in de database vastgelegde FTP’s was 81% niet te identificeren met de STOPP-START-criteria. START-criteria waren vaker van toepassing op de FTP’s dan STOPP-criteria (13 versus 5,7%; p < 0,01), maar de implementatiegraad van STOPP-criteria was hoger (56 versus 39%; p < 0,01). Aanbevelingen die geen verband hielden met de STOPP-START-criteria werden echter het vaakst doorgevoerd (66%; p = 0,047).ConclusieEen volledige medicatiebeoordeling volgens de impliciete methode, die berust op medische kennis en een gestructureerd gesprek met de patiënt, is de beste methode voor het opsporen van farmacotherapiegerelateerde problemen bij ouderen in de eerste lijn. Expliciete screeningsmethoden, zoals de STOPP-START-criteria, kunnen als hulpmiddel worden gebruikt