Kurt E. Hersberger

Inappropriate prescribing : a systematic overview of published assessment tools

BackgroundCriteria to assess the appropriateness of prescriptions might serve as a helpful guideline during professional training and in daily practice, with the aim to improve a patient’s pharmacotherapy.ObjectiveTo create a comprehensive and structured overview of existing tools to assess inappropriate prescribing.MethodSystematic literature search in Pubmed (1991–2013). The following properties of the tools were extracted and mapped in a structured way: approach (explicit, implicit), development method (consensus technique, expert panel, literature based), focused patient group, health care setting, and covered aspects of inappropriate prescribing.ResultsThe literature search resulted in 46 tools to assess inappropriate prescribing.Twenty-eight (61%) of 46 tools were explicit, 8 (17%) were implicit and 10 (22%) used a mixed approach. Thirty-six (78%) tools named older people as target patients and 10 (22%) tools did not specify the target age group. Four (8.5%) tools were designed to detect inappropriate prescribing in hospitalised patients, 9 (19.5%) focused on patients in ambulatory care and 6 (13%) were developed for use in long-term care. Twenty-seven (59%) tools did not specify the health care setting. Consensus methods were applied in the development of 19 tools (41%), the others were based on either simple expert panels (13; 28%) or on a literature search (11; 24%). For three tools (7%) the development method was not described.ConclusionThis overview reveals the characteristics of 46 assessment tools and can serve as a summary to assist readers in choosing a tool, either for research purposes or for daily practice use.

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.

Pharmaceutical Care: the PCNE definition 2013

Background Twenty-three years after Hepler and Strand published their well-known definition of Pharmaceutical Care (PhC), confusion remains about what the term includes and how to differentiate it from other terms. The board of the Pharmaceutical Care Network Europe (PCNE) felt the need to redefine PhC and to answer the question: “What is Pharmaceutical Care in 2013”. Objective The aims of this paper were to review existing definitions of PhC and to describe the process of developing a redefined definition. Methods A literature search was conducted in the MEDLINE database (1964–January 2013). Keywords included “Pharmaceutical Care”, “Medication (Therapy) Management”, “Medicine Management”, and “Pharmacist Care” in the title or abstract together with the term “defin*”. To ease comparison between definitions, we developed a standardised syntax to paraphrase the definitions. During a dedicated meeting, a moderated discussion about the definition of PhC was organised. Results The initial literature search produced 186 hits, with eight unique PhC definitions. Hand searching identified a further 11 unique definitions. These 19 definitions were paraphrased using the standardised syntax (provider, recipient, subject, outcome, activities). Fourteen members of PCNE and 10 additional experts attended the moderated discussion. Working groups of increasing size developed intermediate definitions, which had similarities and differences to those retrieved in the literature search. At the end of the session, participants reached a consensus on a “PCNE definition of Pharmaceutical Care” reading: “Pharmaceutical Care is the pharmacist’s contribution to the care of individuals in order to optimize medicines use and improve health outcomes”. Conclusions It was possible to paraphrase definitions of PhC using a standardised syntax focusing on the provider, recipient, subject, outcomes, and activities included in PhC practice. During a one-day workshop, experts in PhC research agreed on a definition, intended to be applicable for the present time, representative for various work settings, and valid for countries inside and outside of Europe.

Screening for sleep disorders in community pharmacies – evaluation of a campaign in Switzerland

Background:  In 2003 the Swiss federation of pharmacists organized a campaign ‘sleep disturbances – daytime sleepiness’. The goal was to assist pharmacy clients in detecting likely causes of any sleep disturbance or daytime sleepiness through a free of charge screening, and to deliver targeted counselling. For pharmacy practice there are no screening or triage guidelines to assess the severity of sleep and wakefulness disturbances and potential causes for those disturbances. In this paper the outcome of the campaign in terms of feasibility, participation, observed response patterns, sale of over‐the‐counter (OTC) sleeping pills, and counselling activities is evaluated.

Classification of drug-related problems with new prescriptions using a modified PCNE classification system

Objectives To explore and classify drug-related problems (DRPs) with new prescriptions detected in community pharmacies using a modified PCNE (Pharmaceutical Care Network Europe) classification system. Setting Sixty-four Swiss community pharmacies offering internships for pharmacy students. Main outcome measures Occurrence, nature and pharmacist’s management of DRPs. Methods Fifth-year pharmacy students collected consecutively hospital discharge and primary care prescriptions. After training, they documented clinical and technical DRPs, causes and interventions. Results Prescriptions of 616 patients (43.0% discharged from hospital) were analysed. The patients’ median age was 56 years and they received a median of 3 (range 2–19) different drugs. In 121 (19.6%) prescriptions 141 clinical DRPs were detected. The most frequent clinical DRPs were potential drug–drug interactions (DDIs) (37.6%), drug choice (24.8%) and drug use problems (15.6%). These clinical DRPs led to a total of 299 interventions. There were 222 prescriptions (36.0%) that showed 278 technical DRPs, resulting in a total of 417 interventions. Most frequent technical DRPs were missing or unclear package size or therapy duration (32.7%) and missing or unclear dosing/application instructions (30.9%). Most DRPs (75.4%) could be managed by the pharmacist alone. The number of prescribed drugs was the main factor with an influence on the frequency of clinical and technical DRPs. Conclusion Clinical and technical DRPs are frequently observed in primary care as well as in hospital discharge prescriptions. The modified PCNE classification system, especially the amendment with a technical DRP category, proved to be useful and allowed the classification of all DRPs. Neither the setting (hospital discharge vs. primary care) nor the quality of electronically printed prescriptions, but only the number of prescribed drugs influenced the occurrence of clinical or technical DRPs.

Effect of drug reminder packaging on medication adherence: a systematic review revealing research gaps

BackgroundThis was a systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Evidence mapping was used to reveal the effect of drug reminder packaging on medication adherence, to identify research gaps and to make suggestions for future research.MethodsPubMed, Embase, CINAHL and PsycINFO were searched with an end date of September 2013 using the Medical Subject Headings (MeSH) term ‘medication adherence’ and 20 different search terms for ‘drug reminder packaging’, limited to the English and German languages. Additional references were identified through cross-referencing. All prospective controlled trials with an intervention using drug reminder packaging for patients taking at least one medication without the assistance of a health-care professional were included in the evidence mapping of the effect of drug reminder packaging on adherence and outcomes according to the Economic, Clinical and Humanistic Outcomes (ECHO) model.ResultsA total of 30 studies met the inclusion criteria: 10 randomized controlled trials, 19 controlled clinical trials and 1 cohort study. Drug reminder packaging had a significant effect on at least one adherence parameter in 17 studies (57%). The methodological quality was strong in five studies. Two studies provided complete information. Clear research gaps emerged.ConclusionsOverall, the studies showed a positive effect of drug reminder packaging on adherence and clinical outcomes. However, poor reporting and important gaps like missing humanistic and economic outcomes and neglected safety issues limit the drawing of firm conclusions. Suggestions are made for future research.

Management of drug‐interaction alerts in community pharmacies

Background and objective:  Drug‐interaction alert systems are commonly used in community pharmacies to identify potential drug–drug interactions. However, depending on the software default setting, pharmacists may override alerts because they are too numerous. We explored the handling of drug‐interaction alerts by community pharmacies in Switzerland.

Determination of risk factors for drug-related problems: a multidisciplinary triangulation process.

Introduction and objectives Drug-related problems (DRPs) constitute a frequent safety issue among hospitalised patients leading to patient harm and increased healthcare costs. Because many DRPs are preventable, the specific risk factors that facilitate their occurrence are of considerable interest. The objective of our study was to assess risk factors for the occurrence of DRPs with the intention to identify patients at risk for DRPs to guide and target preventive measures where they are needed most in patients. Design Triangulation process using a mixed methods approach. Methods We conducted an expert panel, using the nominal group technique (NGT) and a qualitative analysis, to gather risk factors for DRPs. The expert panel consisted of two consultant hospital physicians (internal medicine and geriatrics), one emergency physician, one independent general practitioner, one clinical pharmacologist, one clinical pharmacist, one registered nurse, one home care nurse and two independent community pharmacists. The literature was searched for additional risk factors. Gathered factors from the literature search and the NGT were assembled and validated in a two-round Delphi questionnaire. Results The NGT resulted in the identification of 33 items with 13 additional risk factors from the qualitative analysis of the discussion. The literature search delivered another 39 risk factors. The 85 risk factors were refined to produce 42 statements for the Delphi online questionnaire. Of these, 27 risk factors were judged to be ‘important’ or ‘rather important’. Conclusions The gathered risk factors may help to characterise and identify patients at risk for DRPs and may enable clinical pharmacists to guide and target preventive measures in order to limit the occurrence of DRPs. As a further step, these risk factors will serve as the basis for a screening tool to identify patients at risk for DRPs.

Needs and use of drug information sources in community pharmacies: a questionnaire based survey in German-speaking Switzerland

Methods: Postal survey to a random sample of 223 (26% out of 859) community pharmacies from the German-speaking part of Switzerland. The 48-item questionnaires were processed automatically with the Cardiff TELEform®-Software. In addition, a telephone-survey to a random sample of 20 non-responders was performed in order to test for non-response bias.Results: A total of 108 pharmacists (response rate 48%) reported that the official Swiss drug reference book is still the most popular source of drug information used to solve all kinds of drug related problems. The Internet as a source of drug information is of minor importance, even though 88% of the pharmacies have Internet access. Deficits in drug information were reported for paediatrics, phytotherapy, drugs during pregnancy/lactation and for therapy guidelines. According to 35% of the pharmacists, the importance of offering drug information to customers will increase in the future. Most of the pharmacists are not afraid that Internet pharmacies would replace them.Conclusions: The results show that the majority of the community pharmacists are only partially satisfied with the sources of drug information currently available. The Internet still plays a minor role for solving drug-related problems in daily practice, even though the available infrastructure makes the community pharmacies able to use the Internet more frequently. The pharmacists need more websites tailored to their needs. The pharmacists have clear visions about possible future developments. They do, however, have to adopt quickly to the changes ahead in order to remain competitive.

Polymedication Electronic Monitoring System (POEMS) – a new technology for measuring adherence

Introduction: Reliable and precise measurement of patient adherence to medications is feasible by incorporating a microcircuitry into pharmaceutical packages of various designs, such that the maneuvers needed to remove a dose of drug are detected, time-stamped, and stored. The principle is called “electronic medication event monitoring” but is currently limited to the monitoring of a single drug therapy. Aim: Our aims were introducing a new technology; a clear, self-adhesive polymer film, with printed loops of conductive wires that can be affixed to multidrug punch cards for the electronic adherence monitoring of multiple medication regimens (Polymedication Electronic Monitoring System, POEMS), and illustrating potential benefits for patient care. We present a preliminary report with one patient experience. Materials and methods: Our illustrative case was supplied with a pre-filled 7-day multiple medication punch card with unit-of-use doses for specific times of the day (six pills in the morning cavity, two pills in the evening cavity, and one pill in case of insomnia in the bedtime cavity), with the new electronic film affixed on it. Results: The intake times over 1 week were extremely skewed (median intake hours at 2:00 pm for the morning doses and at 6:40 pm for the evening doses). After an intervention aimed at optimizing the timing adherence, the morning and evening intake hours became more balanced, with 42.3% of correct dosing intervals (±3 h) for drugs with twice daily intake (vs. 0% before the intervention). Discussion: The electronic monitoring of the entire therapy revealed an intake pattern that would have remained undiscovered with any other device and allowed a personalized intervention to correct an inadequate medication intake behavior. POEMS may guide health professionals when they need to optimize a pharmacotherapy because of suspected insufficient adherence. Further, knowing the intake pattern of the entire pharmacotherapy can elucidate unreached clinical outcome, drug–drug interactions, and drug resistance. In the near future, one could imagine that medication adherence data over the entire therapy plan would be available as soon as the electronic wires are activated, so that a failure to take medication could be detected immediately and intervention could be taken if appropriate.