J. Simon Bell

Interrater agreement and interrater reliability: Key concepts, approaches, and applications

Evaluations of interrater agreement and interrater reliability can be applied to a number of different contexts and are frequently encountered in social and administrative pharmacy research. The objectives of this study were to highlight key differences between interrater agreement and interrater reliability; describe the key concepts and approaches to evaluating interrater agreement and interrater reliability; and provide examples of their applications to research in the field of social and administrative pharmacy. This is a descriptive review of interrater agreement and interrater reliability indices. It outlines the practical applications and interpretation of these indices in social and administrative pharmacy research. Interrater agreement indices assess the extent to which the responses of 2 or more independent raters are concordant. Interrater reliability indices assess the extent to which raters consistently distinguish between different responses. A number of indices exist, and some common examples include Kappa, the Kendall coefficient of concordance, Bland-Altman plots, and the intraclass correlation coefficient. Guidance on the selection of an appropriate index is provided. In conclusion, selection of an appropriate index to evaluate interrater agreement or interrater reliability is dependent on a number of factors including the context in which the study is being undertaken, the type of variable under consideration, and the number of raters making assessments.

Prevalence and Factors Associated With Polypharmacy in Long-Term Care Facilities: A Systematic Review

OBJECTIVE The objective of the study was to investigate the prevalence of, and factors associated with, polypharmacy in long-term care facilities (LTCFs). METHODS MEDLINE, EMBASE, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library were searched from January 2000 to September 2014. Primary research studies in English were eligible for inclusion if they fulfilled the following criteria: (1) polypharmacy was quantitatively defined, (2) the prevalence of polypharmacy was reported or could be extracted from tables or figures, and (3) the study was conducted in a LTCF. Methodological quality was assessed using an adapted version of the Joanna Briggs Institute Critical Appraisal Checklist. RESULTS Forty-four studies met the inclusion criteria and were included. Polypharmacy was most often defined as 5 or more (n = 11 studies), 9 (n = 13), or 10 (n = 11) medications. Prevalence varied widely between studies, with up to 91%, 74%, and 65% of residents taking more than 5, 9, and 10 medications, respectively. Seven studies performed multivariate analyses for factors associated with polypharmacy. Positive associations were found for recent hospital discharge (n = 2 studies), number of prescribers (n = 2), and comorbidity including circulatory diseases (n = 3), endocrine and metabolic disorders (n = 3), and neurological motor dysfunctioning (n = 3). Older age (n = 5), cognitive impairment (n = 3), disability in activities of daily living (n = 3), and length of stay in the LTCF (n = 3) were inversely associated with polypharmacy. CONCLUSIONS The prevalence of polypharmacy in LTCFs is high, varying widely between facilities, geographical locations and the definitions used. Greater use of multivariate analysis to investigate factors associated with polypharmacy across a range of settings is required. Longitudinal research is needed to explore how polypharmacy has evolved over time.

Psychotropic Prescribing in Long-Term Care Facilities : Impact of Medication Reviews and Educational Interventions

The objective of this literature review was to evaluate the evidence pertaining to the impact of medication reviews and/or educational interventions on psychotropic drug use in long-term care facilities. A computerized search was conducted using MEDLINE, Cochrane Central Register of Control Trials, CINAHL, EMBASE, International Pharmaceutical Abstracts and PsycINFO, from January 1980 to April 2007. Controlled studies or randomized controlled studies were included for review. The authors identified 26 studies evaluating the impact of medication reviews and/or educational interventions on psychotropic drug use in long-term care facilities. Eleven studies met the inclusion criteria for this review and the data from six of these studies were included in a meta-analysis. The pooled odds ratio (OR) from five studies on hypnotic prescribing showed a decrease in use postintervention (OR = 0.57, 95% confidence intervals [CI] = 0.41-0.79). The pooled OR from five studies on prevalence of antipsychotic prescribing postintervention was not significant (OR = 0.81, 95% CI = 0.63-1.04). Medication reviews and/or educational interventions are effective at reducing psychotropic drug prescribing. However, research on the benefits of these interventions in reducing psychotropic drug use on total health care costs and resident health outcomes is lacking.

Impact of mental health first aid training on pharmacy students' knowledge, attitudes and self-reported behaviour: a controlled trial

Objective: The aim of this study was to assess the impact of delivering Mental Health First Aid (MHFA) training for pharmacy students on their mental health literacy and stigma towards mental illness. Methods: A non-randomized controlled design was used, with all third year pharmacy students at the University of Sydney (n = 272) in 2009 invited to participate in one of two MHFA training courses, each of 12 hours duration. Of these, 174 students applied for MHFA training, of whom 60 were randomly selected and offered MHFA training. Outcome measures that were completed by all participants in the MHFA and non-MHFA groups before and after the MHFA training included an evaluation of mental health literacy, the 7-item social distance scale, and 16 items related to self-reported behaviour. Results: The survey instrument was completed by 258 participants at baseline (59 MHFA and 199 non-MHFA) and 223 participants at follow up (53 MHFA and 170 non-MHFA). The MHFA training improved the participants’ ability to correctly identify a mental illness (p = 0.004). There was a significant mean decrease in total social distance of 2.18 (SD 3.35) p <0.001 for the MHFA group, indicating less stigmatizing attitudes. There were improvements in recognition of helpful interventions with participants’ views becoming more concordant with health professional views about treatments for depression (p = 0.009) and schizophrenia (p = 0.08), and participants were significantly more confident (p < 0.01) to provide pharmaceutical services to consumers with a mental illness following the training. Conclusion: This study demonstrated that MHFA training can reduce pharmacy students’ mental health stigma, improve recognition of mental disorders and improve confidence in providing services to consumers with a mental illness in the pharmacy setting.

Anticholinergic Drug Use and Mortality Among Residents of Long‐Term Care Facilities: A Prospective Cohort Study

Few studies have investigated the possible association between use of anticholinergic drugs and mortality. The objectives of this study were to investigate the prevalence and determinants of anticholinergic drug use and the possible association between anticholinergic drug use and mortality. Data were obtained from 53 long‐term care wards in Helsinki, Finland, in 2003. Medication, diagnostic, and mortality data were available for 1004 residents. Each residents anticholinergic load was calculated using the Anticholinergic Risk Scale (ARS). Cox proportional hazards models were used to investigate the risk of death among users with a mild anticholinergic load (ARS score 1–2) and high load (ARS score ≥3) compared with nonusers of anticholinergic drugs. Age, sex, and nutritional status were used as covariates. Among the 1004 residents, 455 (45%) were nonusers of anticholinergic drugs, 363 (36%) had a mild anticholinergic load, and 186 (19%) had a high anticholinergic load. One‐year all‐cause mortality rates were 28%, 29%, and 27%, respectively. Higher ARS scores were not associated with mortality (ARS score 1–2: hazard ratio 1.08; 95% confidence interval, 0.84‐1.41; ARS score ≥3: hazard ratio 1.05; 95% confidence interval, 0.75‐1.46). Anticholinergic drug use was common; however, high ARS scores were not associated with mortality. Further research is needed using alternative models and among different resident populations.

Pharmacists' beliefs about treatments and outcomes of mental disorders: a mental health literacy survey

Objectives: To assess the beliefs of pharmacists about the helpfulness of interventions for schizophrenia and depression. Methods: A survey instrument containing a measure of mental health literacy was mailed to a random sample of 2000 pharmacists registered with the Pharmacy Board of New South Wales in November 2009. Vignettes of a person with either depression or psychosis were presented, followed by questions related to the recognition of the disorder, the helpfulness of various interventions, prognosis with and without professional help, the persons long-term functioning in various social roles and the likelihood of the person being discriminated against. Results: A total of 391 responses were received (response rate 19.5%). The majority of pharmacists correctly identified depression (92%) with fewer recognizing schizophrenia (79%). Pharmacists rated medicine use highly for both schizophrenia and depression but were also positive about the use of psychological therapies and lifestyle interventions. Pharmacists had negative views about admission to a psychiatric ward and the use of electroconvulsive therapy (ECT). However, younger pharmacists had significantly more positive views on the use of ECT (p = 0.001). The majority of pharmacists (74%) thought discrimination by the community was highly likely and rated long-term prognosis as poor without appropriate professional help. Their views on the likelihood of specific negative outcomes were mixed, with many pharmacists not recognizing the risk of suicide in schizophrenia and depression. However, both female (p = 0.002) and younger pharmacists (p < 0.001) were significantly more inclined to rate the likelihood of suicide as more likely in a person with schizophrenia or depression. Conclusions: The majority of pharmacists had a high degree of mental health literacy as indicated by the correct identification of, and support for evidence-based interventions for mental illnesses. Pharmacists should be aware that their attitudes and stigma towards mental illness may impact on the patient care they provide.

Drug-related problems in the community setting: pharmacists' findings and recommendations for people with mental illnesses.

AbstractBackground and objective: Adverse drug events are a leading cause of morbidity in Australia and internationally. People taking psychotropic drugs for mental illnesses may be particularly susceptible. This study aimed to classify and describe pharmacists’ Home Medicines Review (HMR) findings and recommendations for people with mental illnesses. Methods: This was a descriptive study conducted from March to November 2003. General practitioners and community pharmacists practising in two regions of metropolitan Sydney were invited to participate. General practitioners recruitedand referred community-dwelling people with mental illnesses to receive HMRs conducted by accredited pharmacists. Reviewing pharmacists interviewed 49 people in their homes. During the interviews the pharmacists provided drug information, assessed drug knowledge and beliefs, and assessed drug adherence. Pharmacists then produced written referenced reports that outlined drug-, patient-and prescriber-related findings and recommendations. These findings and recommendations were presented to the referring general practitioners at follow-up case conferences. Main outcome measures: Drugs were classified using the Anatomical Therapeutic Chemical Classification System. Pharmacists’ findings and recommendations were classified using the Clinical Pharmacy Activity Classification System. Results: The most common types of nervous system drugs taken by people who received a HMR were antidepressants (n = 39.33%), analgesics (n = 29.24%) and antipsychotics (n = 17.14%). Pharmacists reported 403 findings and made 360 recommendations for 49 people, with 90% of recommendations being accepted by the referring general practitioners. The most common findings related to potential adverse drug reactions (n = 53, for 47% of people), suspected adverse drug reactions (n = 48, for 55% of people), potential interactions (n = 30, for 37% of people), and people taking additional drugs unbeknown to their referring general practitioner (n = 26, for 25% of people). The most common recommendations were to switch a drug (n = 37, for 49% of people), suggest a non-drug treatment (n = 29, for 41% of people) and to suggest a new drug (n = 27, for 49% of people). At the time of referral, general practitioners documented people to be taking 7.8 ± 4.4 (mean ± SD) drugs each (range 1–18). Following home interviews, pharmacists determined people to be taking 9.1 ± 4.8 drugs (range 1–20). This difference wasstatistically significant (p < 0.001). Conclusions: Pharmacists identified a high incidence of drug-related problems among people receiving treatment for mental illnesses. Pharmacists also identified a higher incidence of overall drug use than documented by the referring general practitioners. HMRs and case conferences, undertaken collaboratively by general practitioners and pharmacists, may be a useful strategy to identify drug-related problems among people with mental illnesses.

Impact of high risk drug use on hospitalization and mortality in older people with and without Alzheimer's disease: a national population cohort study.

Background Evidence is lacking about outcomes associated with the cumulative use of anticholinergic and sedative drugs in people with Alzheimer’s disease (AD). This retrospective cohort study investigated the relationship between cumulative exposure to anticholinergic and sedative drugs and hospitalization and mortality in people with and without AD in Finland. Methods Community-dwelling people aged 65 years and over, with AD on December 31st 2005 (n = 16,603) and individually matched (n = 16,603) comparison persons (age, sex, region of residence) were identified by the Social Insurance Institution of Finland. Drug utilization data were extracted from the Finnish National Prescription Register. Exposure to anticholinergic and sedative drugs was defined using the Drug Burden Index (DBI). Hospitalization and mortality data were extracted from national registers. Cox and zero-inflated negative binomial analyses were used to investigate the relationship between DBI and hospitalization and mortality over a one-year follow-up. Results In total, 5.8% of people with AD and 3.7% without AD died during 2006. For every unit increase in DBI, the adjusted hazard ratio for mortality was 1.21 (95% confidence intervals [CI]: 1.09–1.33) among people with AD, and 1.37 (95%CI: 1.20–1.56) among people without AD. Overall, 44.3% of people with AD and 33.4% without AD were hospitalized. When using no DBI exposure as the reference group, the adjusted incidence rate ratio for length of hospital stay among high DBI group (≥1) in people with AD was 1.15 (95%CI: 1.05–1.26) and 1.63 (95%CI: 1.41–1.88) in people without AD. Conclusion There is a dose-response relationship between cumulative anticholinergic and sedative drug use and hospitalization and mortality in people with and without AD.

Pharmacy Students' Attitudes Toward and Professional Interactions With People With Mental Disorders

Background: Health professionals frequently exhibit negative attitudes toward people with mental disorders. It is not known whether stigmatising attitudes among pharmacy students predict less positive attitudes toward consumer participation in decision-making about medications. Aims: (1) To assess the attitudes of pharmacy students toward people with schizophrenia, and (2) to determine whether stigma predicts less positive attitudes toward concordant medication counselling. Method: All pharmacy students enrolled in a five-year degree program were invited to participate. Students completed the seven-item Social Distance Scale, six items related to stereotypical attributes of people with schizophrenia and the 14-item Leeds Attitudes Toward Concordance Scale. Results: Completed survey instruments were received from 157 students (94% response rate). Previous employment in a pharmacy and personal experience of a mental disorder were associated with low social distance. Later year of study, believing that people with schizophrenia are difficult to talk to, and believing people with schizophrenia have themselves to blame were predictive of high social distance. Low social distance and later year of study were associated with positive attitudes toward providing concordant medication counselling. Conclusion: Mental health stigma was common and predictive of less positive attitudes toward consumer participation in decision-making about medications.

Clinical medication review in Australia: a systematic review

BACKGROUND Clinical medication review (CMR) is a structured and collaborative service aimed at identifying and resolving medication-related problems (MRPs). This is the first systematic review of CMR research in Australia. OBJECTIVE To systematically review the processes and outcomes of CMR in community-settings in Australia. METHODS MEDLINE, EMBASE, International Pharmaceutical Abstracts (IPA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library and the grey literature were searched from 2000 to February 2015. All study designs were considered. Data extraction and quality assessment were performed independently by two investigators. RESULTS Nine controlled studies, 34 observational and uncontrolled studies, 11 qualitative studies (focus groups and interviews) and nine survey studies were included. The CMRs resulted in identification of MRPs (n = 15 studies, mean 3.6 MPRs per CMR) and improved adherence (n = 3). Reductions in numbers of medications prescribed (n = 3 studies), hospitalizations (n = 3), potentially inappropriate prescribing (n = 3) and costs (n = 6) were demonstrated. Comparisons to a control group, predominately non-recipients of CMR, were made in eleven of 43 studies. Evidence supports additional models that promote interprofessional collaboration and timely referral following hospital discharge. Qualitative research identified low awareness of CMR among eligible non-recipients, while benefits were perceived to outweigh barriers to implementation. Underserved populations include indigenous and culturally and linguistically diverse people, recipients of palliative care, those recently discharged from hospital, people with poor medication adherence, those in rural and remote areas, older males, and younger people with long-term, persistent or serious health problems. CONCLUSION The available evidence suggests CMR is beneficial in improving the quality use of medications and health outcomes. However, lack of comparator groups in many observational studies limited the strength of conclusions in relation to the impact on clinical outcomes. Addressing access gaps for underserved populations, implementing additional referral pathways, and facilitating greater collaboration between the health professionals represent opportunities for further improvement.