Lene Juel Kjeldsen

Medication reviews by clinical pharmacists at hospitals lead to improved patient outcomes: a systematic review

Suboptimal medication use may lead to morbidity, mortality and increased costs. To reduce unnecessary patient harm, medicines management including medication reviews can be provided by clinical pharmacists. Some recent studies have indicated a positive effect of this service, but the quality and outcomes vary among studies. Hence, there is a need for compiling the evidence within this area. The aim of this systematic MiniReview was to identify, assess and summarize the literature investigating the effect of pharmacist-led medication reviews in hospitalized patients. Five databases (MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane Library) were searched from their inception to 2011 in addition to citation tracking and hand search. Only original research papers published in English describing pharmacist-led medication reviews in a hospital setting including minimum 100 patients or 100 interventions were included in the final assessment. A total of 836 research papers were identified, and 31 publications were included in the study: 21 descriptive studies and 10 controlled studies, of which 6 were randomized controlled trials. The pharmacist interventions were well implemented with acceptance rates from 39% to 100%. The 10 controlled studies generally show a positive effect on medication use and costs, satisfaction with the service and positive as well as insignificant effects on health service use. Several outcomes were statistically insignificant, but these were predominantly associated with low sample sizes or low acceptance rates. Therefore, future research within this area should be designed using rigorous design, large sample sizes and includes comparable outcome measures for patient health outcomes.

Multifaceted Intervention Including Motivational Interviewing to Support Medication Adherence after Stroke/Transient Ischemic Attack: A Randomized Trial

Background and Purpose: Adherence to medication is often suboptimal after stroke and transient ischemic attack (TIA), which increases the risk of recurrent stroke and death. Complex interventions and motivational interviewing (MI) have been proven effective in other areas of medicine. The objective of this study was to investigate the effectiveness of a multifaceted intervention including MI in improving medication adherence for secondary stroke prevention. Methods: In this randomized controlled trial, TIA and stroke patients receiving a pharmacist intervention in a hospital setting were compared with patients receiving usual care. The intervention consisted of a focused medication review, an MI-approached consultation and 3 follow-up telephone calls and lasted for 6 months. The primary outcome was a composite medication possession ratio (MPR) for antiplatelets, anticoagulants and statins in the year after hospitalization, assessed by analyzing pharmacy records and reported as both a continuous rate and a binary outcome. Secondary outcomes included composite MPRs at 3, 6 and 9 months as well as adherence and persistence to specific thrombopreventive medications at 12 months. Clinical outcomes included a combined end point of cardiovascular death, stroke or acute myocardial infarction. Patient satisfaction with the service was assessed for the intervention patients. Results: The analyses included 102 intervention patients and 101 controls. At 12 months, the median MPRs (IQR) were 0.95 (0.77-1) in the intervention group and 0.91 (0.83-0.99) in the control group, and 28 and 21% of the patients, respectively, were nonadherent (MPR <0.80; risk difference: 7%; 95% CI: -5 to 19%). In both groups, the median MPR decreased over time. From 3 to 12 months, the MPR fell by 5% (p < 0.05) in the intervention group and by 9% (p < 0.05) in the control group, but between the groups, comparisons showed no statistically significant difference. No significant differences were found for adherence and persistence to specific thrombopreventive agents or for the clinical outcome. The intervention patients were satisfied with the service; about half of them reported increased knowledge about medication, and one third reported increased confidence with medication use. Pharmacists identified drug-related problems in one third of the patients. Conclusions: A multifaceted pharmacist intervention including MI did not improve adherence or persistence to secondary stroke prevention therapy and had no impact on clinical outcomes. However, due to the high adherence rates, only little room for improvement existed. Future studies should focus on patients at high risk of nonadherence and include outcomes more sensitive to the impact of behavioral interventions.

Improving Medication Adherence in Patients with Hypertension: A Randomized Trial

BACKGROUND AND PURPOSE In patients with hypertension, medication adherence is often suboptimal, thereby increasing the risk of ischemic heart disease and stroke. In a randomized trial, we investigated the effectiveness of a multifaceted pharmacist intervention in a hospital setting to improve medication adherence in hypertensive patients. Motivational interviewing was a key element of the intervention. METHODS Patients (n = 532) were recruited from 3 hospital outpatient clinics and randomized to usual care or a 6-month pharmacist intervention comprising collaborative care, medication review, and tailored adherence counseling including motivational interviewing and telephone follow-ups. The primary outcome was composite medication possession ratio (MPR) to antihypertensive and lipid-lowering agents, at 1-year follow-up, assessed by analyzing pharmacy records. Secondary outcomes at 12 months included persistence to medications, blood pressure, hospital admission, and a combined clinical endpoint of cardiovascular death, stroke, or acute myocardial infarction. RESULTS At 12 months, 20.3% of the patients in the intervention group (n = 231) were nonadherent (MPR <0.80), compared with 30.2% in the control group (n = 285) (risk difference -9.8; 95% confidence interval [CI], -17.3, -2.4) and median MPR (interquartile range) was 0.93 (0.82-0.99) and 0.91 (0.76-0.98), respectively, P = .02. The combined clinical endpoint was reached by 1.3% in the intervention group and 3.1% in the control group (relative risk 0.41; 95% CI, 0.11-1.50). No significant differences were found for persistence, blood pressure, or hospital admission. CONCLUSIONS A multifaceted pharmacist intervention in a hospital setting led to a sustained improvement in medication adherence for patients with hypertension. The intervention had no significant impact on blood pressure and secondary clinical outcomes.

Development of new concepts of non-adherence measurements among users of antihypertensives medicines.

Objective To identify various types of non-adherence among users of antihypertensive medications by establishing components of adherence measures and use these components for measuring the prevalence of non-adherence. Setting Twelve community pharmacies from the Danish county of Funen. Method Users of antihypertensive medication were included in the study. 2,914 medication users received questionnaires by mail. Participating patients were asked to fill in two questionnaire regarding demographics, self-reported blood pressure, and various adherence measures. Two factor analyses were conducted based on responses to questions. Main outcome measures Medication-taking behaviour and self-efficacy (beliefs about ability and capacity to accomplish a task), respectively. Other measures of non-adherence collected by questionnaire were also addressed in the data for comparison of prevalence with the developed concepts. Results 1,426 (49%) participants answered the questionnaires. The analyses resulted in two sets of components: three adherence behaviour measures and two self-efficacy measures which showed similarities in concepts. The adherence behaviour measures included two concepts of intentional nonadherence (associated with aspects of self-regulation and effect concerns, respectively) and one measure of non-intentional non-adherence. Prevalence of the developed measures of behaviour related non-adherence ranged from 10.3 to 34.9% depending on which type of non-adherence measure was used. Established measures of non-adherence resulted in prevalence between 2.2 and 39.6%. Conclusions The study showed that concepts of non-adherence measurements could be determined including self-efficacy aspects, unintentional non-adherence and intentional non-adherence related to self-regulation and effect concerns respectively. The prevalence of the adherence behaviour components were found to be between 10.3 and 34.9%, which is in the range of expected values. Associations between the new concepts of non-adherence measurement and characteristics of nonadherers remain to be established and would be a subject for further studies.

Drug and Therapeutics Committees in Danish Hospitals: A Survey of Organization, Activities and Drug Selection Procedures

To implement rational pharmacotherapy in hospitals, it is important to develop, implement and evaluate hospital drug formularies (HDFs). A report from Denmark recommended standardizing activities of the drug and therapeutics committees (DTCs) in Denmark, but little is known about their current organization. The aim of the study was to describe the organization of DTCs in Denmark, how HDFs are developed and implemented, and to what extent policies that support the use of HDFs exist. A questionnaire was developed based on previous research and guidelines and contained 20 questions, which were divided into the following subjects: structure, activities, drug selection and implementation. The questionnaire was sent to the chairmen of the nine DTCs in Denmark. The response rate was 100% (9/9). The DTCs varied in structure and activities; meetings were held between 2 and 6 times annually, and the duration of the meetings lasted between 1 and 2.5 hr. Eight (89%) DTCs developed HDFs, policies and guidelines (P&Gs) that supported the use of HDFs. Eight (89%) had established criteria for inclusion of drugs on the HDFs, and seven had developed criteria for generic substitution and therapeutic interchange. The number of trade names on the HDFs varied between 116 and 1195. The nine DTCs in Denmark varied considerably regarding structure and activity. The main activity was to develop formularies, and most of the committees developed policies that supported medication use.

Pharmacist-led medication review in an acute admissions unit: a systematic procedure description

Objectives Over the last decades, several papers have evaluated clinical pharmacy interventions in hospital settings with conflicting findings as results. Medication reviews are frequently a central component of these interventions. However, the term ‘medication review’ covers a plethora of principles and methodologies, and the practical procedure is seldom described in detail, which makes reproducing study findings difficult. The objective of this paper is to provide a detailed description of a procedure developed and used for pharmacist-led medication review in acute admissions units. Methods A procedure was developed based on clinical experience and inspiration from previous studies and literature on medication review models. The procedure was developed to fit the busy workflow in acute admissions units. Results The procedure consists of five steps: (1) collection of clinical patient data, (2) collection of information about the patients medical treatment, (3) patient interview, (4) critical examination of the patients medications and (5) recommendations for the hospital physician. Conclusions We have provided a detailed description of a procedure for pharmacist-led medication review. We do so, not to provide or advocate a single one-size-fits-all solution, but in an attempt to inspire a debate of the practical approach on how to execute a systematic medication review in order to develop and expand clinical pharmacy and achieve better patient outcomes.

Clinical Outcomes Used in Clinical Pharmacy Intervention Studies in Secondary Care

The objective was to investigate type, frequency and result of clinical outcomes used in studies to assess the effect of clinical pharmacy interventions in inpatient care. The literature search using Pubmed.gov was performed for the period up to 2013 using the search phrases: “Intervention(s)” and “pharmacist(s)” and “controlled” and “outcome(s)” or “effect(s)”. Primary research studies in English of controlled, clinical pharmacy intervention studies, including outcome evaluation, were selected. Titles, abstracts and full-text papers were assessed individually by two reviewers, and inclusion was determined by consensus. In total, 37 publications were included in the review. The publications presented similar intervention elements but differed in study design. A large variety of outcome measures (135) had been used to evaluate the effect of the interventions; most frequently clinical measures/assessments by physician and health care service use. No apparent pattern was established among primary outcome measures with significant effect in favour of the intervention, but positive effect was most frequently related to studies that included power calculations and sufficient inclusion of patients (73% vs. 25%). This review emphasizes the importance of considering the relevance of outcomes selected to assess clinical pharmacy interventions and the importance of conducting a proper power calculation.

The challenges of outcome research.

Cognitive pharmacy trials seek to identify interventions that benefit patients. The potential benefits of an intervention are primarily evaluated by outcome measures. The question then is: What is the optimal outcome measure? Unfortunately, the question remains unsolved. Several factors must be taken into consideration when conducting outcome research—particularly within cognitive pharmacy trials. The interventions are often complex and non-specific, and seek to improve symptom control, optimise the use of medications and reduce medication-related risks. “Hard” endpoints, such as mortality and hospital admissions, may not be the optimal outcome measures, since cognitive pharmacy interventions are unlikely to result in changes in these measures. Instead, adverse drug events or “soft” endpoints, such as quality of life, drug-related problems and patient satisfaction may be appropriate choices of outcome measures. Finally, it is not only outcome measures that may pose a challenge when conducting outcome research; other essential components include study design, type of intervention, the patient population, etc.

CPC-084 Medication Reviews by Clinical Pharmacists at Hospitals Lead to Improved Patient Outcomes: A Systematic Review

Background Suboptimal use of medicines may lead to morbidity, mortality and increased costs. In order to reduce unnecessary patient harm, an increasing number of hospitals have implemented pharmaceutical care interventions such as medicines reviews. Some recent studies indicate a positive effect of pharmacist-led medicines reviews in hospitals, but the quality and outcome measures vary among studies. Hence there is a need to compile evidence within this area. Purpose To identify, assess and summarise the literature investigating the effect of pharmacist-led medicines reviews in hospitalised patients. Materials and Methods Five databases were searched from their inception to 2011: MEDLINE, EMBASE, CINAHL, Web of Science (including a citation search of relevant papers) and the Cochrane Library. Relevant systematic reviews and personal archives were also hand-searched for studies for inclusion. Only original research papers published in English describing pharmacist-led medicines reviews in a hospital setting including a minimum of 100 patients were included in the final assessment. Results A total of 836 research papers were identified and 30 publications were included in the study. Twenty studies were descriptive studies while ten studies were controlled to some extent. Only six studies were randomised controlled trials. Generally, the interventions were well implemented with acceptance rates between 39–100%. The key findings indicated positive effects on quality of prescribing, quality of life, readmission rates and emergency department visits, time to readmission and costs. However, no effect on survival rates was found in addition to several other statistically insignificant results. Conclusions Only a few papers describing pharmacist-led medicines reviews in the hospital setting were designed as randomised controlled trials and were evaluated using hard endpoints. Future research within this area should be designed using rigorous methodology and include outcome measures for patient health outcomes. No conflict of interest.

A multifaceted pharmacist intervention to support medication adherence after stroke and transient ischemic attack

43rd ESCP international symposium on clinical pharmacy patient safety: bridging the gaps Copenhagen, Denmark, 22–24 October 2014