Lorna Marie West

A systematic review of the literature on ‘medication wastage’: an exploration of causative factors and effect of interventions

Introduction Reducing any wastage, including that of medications, is a paramount objective in promoting appropriate utilisation of finite resources. The objective was to systematically review the published literature, the possible causative factors associated with medication wastage and the effectiveness of any interventions to reduce wastage. Method A systematic review of studies published in English was identified from the following databases: Cumulative Index to Nursing and Allied Health Literature, Embase, Medline, PubMed, Science Citation Index and The Cochrane Library. Data extraction and critical appraisal was undertaken independently by two researchers. Results and discussion Title, abstract and full paper screening reduced the 14,157 studies to 42. A general definition of medication wastage was reported in one paper only. ‘Medication changed’, ‘patient death’, ‘resolution of patient’s condition’ and ‘expired medications’ were most commonly cited reasons for wastage. Only two studies were identified reporting wastage as a research outcome measure following intervention. Conclusion The systematic review has identified a limited literature on medication wastage with a lack of consistency of terms. There is a paucity of robust research focusing on the impact of healthcare interventions on outcomes around medication wastage.

Applying the Delphi technique to define 'medication wastage'

Objective The aim of this study was to apply the consensus-based Delphi technique to define ‘medication wastage’ and its contributory factors. Method The Delphi technique was employed in this study, applying a minimum agreement consensus level of 75%. An expert panel comprising 26 professionals and six patients was recruited and communicated with by email. Round 1 comprised open-ended questions focusing on proposing a definition for ‘medication wastage’ and listing possible contributing factors. In round 2, respondents were requested to rank eight definitions of ‘medication wastage’, derived from round 1, in order of preference. Themes related to contributory factors were presented as 5-point Likert statements. Round 3 included statements that did not meet consensus in round 2. Results Twenty-seven consented to participate, 23 of whom responded to both rounds. Of the eight options for defining ‘medication wastage’, the highest ranked was ‘Medication wastage refers to any medication which expires or remains unused throughout the whole medicines supply chain. Also refers to the unnecessary or inappropriate consumption of medications by patients, or the unjustified non-adherence to treatment guidelines by healthcare professionals. Medication wastage poses a financial burden on patients themselves and the states economy and requires adequate education of all people concerned’. Themes related to factors associated with wastage included physical/environmental, social/psychological (patient/practitioner) and cultural. Conclusions A high level of consensus was achieved on a definition of medication wastage from a diverse panel of academics, practitioners, government officials, officials from non-governmental organisations, and patients in Malta.

Clinical pharmacist evaluation of medication inappropriateness in the emergency department of a teaching hospital in Malta

www.pharmacypractice.org (ISSN: 1886-3655) 181 ABSTRACT Appropriate prescribing remains an important priority in all medical areas of practice. Objective: The objective of this study was to apply a Medication Appropriateness Index (MAI) to identify issues of inappropriate prescribing amongst patients admitted from the Emergency Department (ED). Method: This study was carried out at Malta’s general hospital on 125 patients following a twoweek pilot period on 10 patients. Patients aged 18 years and over and on medication therapy were included. Medication treatment for inappropriateness was assessed by using the MAI. Under-prescribing was also screened for. Results: Treatment charts of 125 patients, including 697 medications, were assessed using a MAI. Overall, 115 (92%) patients had one or more medications with one or more MAI criteria rated as inappropriate, giving a total of 384 (55.1%) medications prescribed inappropriately. The mean SD MAI score per drug was 1.78 (SD=2.19). The most common medication classes with appropriateness problems were biguanides (100%), anti-arrhythmics (100%) and anti-platelets (96.8%). The most common problems involved incorrect directions (26%) and incorrect dosages (18.5%). There were 36 omitted medications with untreated indications. Conclusion: There is considerable inappropriate prescribing which could have significant negative effects regarding patient care.

Psychometric properties of the Belief about Medicines Questionnaire (BMQ) in the Maltese language

Background: Investigating beliefs about medicines has been of interest over the past years, with studies aiming to better understand theoretical reasons behind development of such beliefs. Objective: This study aimed to produce a culturally and contextually appropriate version of the Beliefs about Medicines Questionnaire (BMQ) in the Maltese language and to assess its psychometric properties. Methods: Medication beliefs were evaluated using the BMQ which is divided into two sections: BMQ-General (sub-scales: Overuse and Harm, 4 items per sub-scale) and BMQ-Specific (sub-scales: Necessity and Concerns, 5 items per sub-scale). Following translation/back translation, the Maltese version of the BMQ was applied to patients having asthma, diabetes, cardiovascular disease or depression who attended out-patients’ clinics at the main state general hospital in Malta between June and September 2013. Cronbach’s alpha coefficient, alpha, was used to determine internal consistency of the BMQ and Principal Component Analysis using Varimax rotation with Kaiser normalisation was carried out to analyse component loading of the items on the respective sub-scales. Results: The Maltese version of the BMQ showed acceptable internal consistency for the harm scale (alpha=0.56), the necessity scale (alpha=0.73) and the concerns scale (alpha=0.66), however the overuse scale gave poor internal consistency (alpha=0.48) due to the item on natural remedies which posed some difficulty in the Maltese sample. The final solution for Principal Component Analysis yielded a four-factor structure representing the 4 sub-scales of the BMQ, with results being comparable to previous studies out in different languages. Conclusion: The Maltese version of the BMQ was found to have acceptable psychometric properties for the beliefs about medicines in the Maltese population.

Applying lean methodology to improve parenteral chemotherapy and monoclonal antibody documentation processes based on Normalisation Process Theory

Objective To determine the impact of lean thinking on the original time required to prepare the necessary documentation in relation to the preparation of parenteral chemotherapy/monoclonal antibodies. Method Four pharmacists and one pharmacy technician from the oncology hospital (Malta) all participated in eight focus groups linked to the different constructs of Normalisation Process Theory (NPT): coherence, cognitive participation, collective action and reflexive monitoring. The value stream documentation process was mapped by analysing all steps in the process where each activity must add value for the patient; tools of lean thinking were applied. Points causing delay in processing were considered critical; possible changes to minimise time waste were discussed and implemented. Time spent on critical points was measured by timing in minutes each step of the process 1 month before and after the changes had been implemented and calculating the mean±SD. An audit was performed comparing the process with standard operating procedures to determine whether any steps required quality improvement. Results Three critical points were identified: time required to search for pharmacy patient medication records for chemotherapy/monoclonal antibodies required on the day; time to generate preparation labels; and time to generate worksheets. Overall, a total of 122±8.6 min (p=0.06) were saved per day, a 37% decrease from the original documentation time. Five deficiencies were identified in the documentation process audit; corrective action was proposed. Conclusions By applying lean thinking, non-value-added steps leading to time waste in the documentation process were eliminated. This concept could be implemented by using NPT as part of a strategic system to reduce waste.

Is there a need for a hospital pharmacy common training framework? Review of the literature on the impact of educational interventions on health outcome

Background With the update of the directive 2005/36/EU on the recognition of professional qualifications (2013/55/EU), the European Union (EU) legislation opened also to pharmacists the possibility to define specialisations via a common training framework (CTF). Objective The aim of this study was to review, synthesise and present published evidence on the impact of health educational interventions targeting healthcare professionals on patients’ health outcomes that support a hospital pharmacy CTF in EU. Method The search was carried out in Medline and Cumulative Index to Nursing & Allied Health Literature and was limited to English language full review articles or primary research published since 2000. Data were extracted independently and compared by three of the researchers. Results Ten papers (9 primary research studies and one literature review) were identified. Almost one-third of the studies (30%, n=3) targeted pharmacists in their research. The majority of studies (80%, n=8) have shown that higher education levels among healthcare professionals improved patient outcomes. No study discussed the importance of a CTF. Conclusion The review of the literature has demonstrated the need for education and training of health personnel to improve patient outcome. Controlled studies about pharmacist education and training in European countries showed that the benefit of a CTF is lacking.

The ‘Necessity–Concerns Framework’ as a means of understanding non-adherence by applying polynomial regression in three chronic conditions

Objective The ‘Necessity–Concerns Framework’ is an important framework which can support healthcare professionals in targeting patients’ medication beliefs and decisions on adherence. Our aim was to determine how the interdependence of ‘necessity’ and ‘concerns’ beliefs for medication adherence compares across three chronic conditions. Methods Patients diagnosed with asthma, cardiovascular conditions or diabetes attending out-patient clinics completed a self-administered questionnaire. The questionnaire gathered information regarding demographics, medication adherence using the ‘Tool for Adherence Behaviour Screening’, presence of unused medication in households and medication beliefs using the ‘Beliefs about Medicines Questionnaire-Specific’. Polynomial regression was applied to determine the multidimensional interdependence of ‘necessity’ and ‘concerns’ beliefs for adherence. P-values ≤ 0.05 were taken to be significant. Results Confirmatory polynomial regression rejected the differential score model in all three groups. For each condition, exploratory polynomial regression found that linear terms indicated the best fitting model for predicting adherence. In all groups, adherence increased as necessity beliefs increased and concerns decreased. Patients suffering from cardiovascular conditions and diabetes with low necessity and low concerns beliefs reported higher medication adherence compared to those with high necessity and high concerns beliefs. Discussion Alleviating patients’ concerns can enhance medication adherence and potentially curb the issue of medication wastage.

CPC-039 Delphi Approach to Defining and Contextualising Medicines Wastage in the Maltese Population

Background Reducing wastage, including medicines wastage, is a paramount objective in promoting appropriate use of finite resources and preventing negative consequences. A systematic review of the published research on medicines wastage identified a lack of standard terminology and definitions. Purpose The aim of this study was to apply an expert panel approach to achieve consensus in defining ‘medicines wastage’ in the context of the Maltese population. Materials and Methods The Delphi technique, a multi-staged survey attempting to achieve consensus, was employed. An expert panel comprising 26 professionals and six patients was recruited and communicated by email. Round 1 had initial open-ended questions on the panel’s understanding of the term ‘medicines wastage’ along with views on factors likely to be associated with wastage. Responses were analysed thematically. In round 2, respondents were requested to rank eight definitions of ‘medicines wastage’ in order of preference. Themes related to associated factors were presented as 5-point Likert statements. Results The first two rounds of data collection are complete. Twenty-seven consented to participate, 23 of whom have responded to both rounds. Of the eight options for defining ‘medicines wastage’, the highest ranked was ‘…refers to any medicine which expires or remains unused throughout the whole medicines supply chain. It also refers to the unnecessary or inappropriate consumption of medicines by patients, or the unjustified non-adherence to treatment guidelines by healthcare professionals. Medicines wastage imposes a financial burden on patients themselves and the state’s economy and requires adequate education of all people concerned.’ Themes related to factors associated with wastage included: physical/environmental; social/psychological (patient/practitioner); and cultural. Conclusions This research has generated a definition of ‘medicines wastage’ and a series of associated statements for further investigation. The research process followed in this study can easily be adapted and is therefore also highly relevant to hospital pharmacy practise across Europe. No conflict of interest.