Marcel L. Bouvy

Effect of a pharmacist-led intervention on diuretic compliance in heart failure patients: a randomized controlled study

BACKGROUND Noncompliance is a major factor in the morbidity and unnecessary hospital readmissions for patients with heart failure. Several studies have aimed to reduce rehospitalizations in heart failure patients through a comprehensive, multidisciplinary approach. Medication compliance was rarely measured in these studies or, when it was measured, the method employed was seldom valid. We aimed at determining the effect of a pharmacist-led intervention on medication compliance in patients with heart failure. METHODS We conducted a randomized controlled trial into the effect of a pharmacist-led intervention on medication compliance in patients with heart failure (predominantly New York Heart Association [NYHA] II and III) treated with loop diuretics, presenting to a cardiology outpatient clinic or admitted to hospitals in The Netherlands. Patients in the intervention group received monthly consultations from their community pharmacist during a 6-month period. Patients in the control group received usual care. Primary endpoint was medication compliance, assessed with a medication event monitoring system, an electronic pill bottle that registers time of opening. Secondary endpoints were the number of rehospitalizations, death, and quality of life. RESULTS A total of 152 patients were randomized: 74 patients to the intervention arm and 78 patients to the usual care arm. Over the 6-month study period, patients in the intervention group had 140/7656 days without use of loop diuretics compared with 337/6196 days in the usual care group (relative risk 0.33 [confidence interval (CI) 95% 0.24-0.38]). Two consecutive days of nondosing occurred on 18/7656 days in the intervention group compared with 46/6196 days in the usual care group (relative risk 0.32 [CI 95% 0.19-0.55]). There were no significant differences in rehospitalizations, mortality, or disease-specific quality of life between groups. CONCLUSIONS A pharmacy-led intervention can improve medication compliance in patients with moderate to severe heart failure, even in those with relatively high compliance. Future interventions should also focus at less compliant patients.

Predicting mortality in patients with heart failure: a pragmatic approach.

Objective: To develop a comprehensive and easily applicable prognostic model predicting mortality risk in patients with moderate to severe heart failure. Design: Prospective follow up study. Setting: Seven general hospitals in the Netherlands. Patients: 152 outpatients with heart failure or patients admitted to hospital because of heart failure, who were included in a randomised trial to assess the impact of a pharmacist led intervention to improve drug compliance. Duration of follow up was at least 18 months. Main outcome measures: Multivariable logistic regression modelling was used to evaluate information from history, physical examination (for example, blood pressure), drug use, and quality of life questionnaires that independently contributed to the prediction of death. The area under receiver operating characteristic curves (AUC) was used to estimate the predictive ability of the prognostic models. Results: During the 18 months of follow up, 51 patients (34%) died. Independent predictors of mortality were diabetes mellitus, a history of renal dysfunction (or higher creatinine), New York Heart Association (NYHA) functional class III or IV, lower weight or body mass index, lower blood pressure, ankle oedema, and higher scores on a disease specific quality of life questionnaire. The use of β blockers was predictive of a better prognosis. These factors were used to derive various prediction formulas. A model based on medical history, weight, presence of oedema, and lower blood pressure had an AUC of 0.77. Addition of use of β blockers to this model improved the AUC to 0.80. Addition of NYHA class increased the AUC to 0.84. Data on quality of life did not improve the AUC further (AUC 0.85). Conclusions: A prognostic model produced on the basis of easily obtainable information from medical history and physical examination can adequately stratify heart failure patients according to their short term risk of death.

Prevalence and determinants of pharmacy shopping behaviour.

Background and objective:  Discontinuity of care bears the risk of medication errors and poor clinical outcomes. Little is known about the continuity of care related to pharmacies. Therefore, we studied the prevalence and determinants of pharmacy shopping behaviour in the Netherlands.

Drug related problems identified by European community pharmacists in patients discharged from hospital.

Objective: To examine the nature and frequency of DRPs in community pharmacies among patients discharged from hospitals in several countries, and to examine several variables related to these drug related problems.Method: The study was performed in 112 community pharmacies in Europe: Austria, Denmark, Germany, The Netherlands, Portugal and Spain. Community pharmacists asked patients with a prescription after discharge from hospital between February and April 2001 to participate in the study. A patient questionnaire was used to identify drug related problems. Pharmacists documented drug related problems, pharmacy interventions, type of prescriber and patient and pharmacy variables.Results: 435 patients were included in the study. Drug related problems were identified in 277 patients (63.7%). Uncertainty or lack of knowledge about the aim or function of the drug (133; 29.5%) and side effects (105; 23.3%) were the most common DRPs. Practical problems were reported 56 times (12.4%) by patients. Pharmacists revealed 108 problems (24.0%) concerning dosage, drug duplication, drug interactions and prescribing errors. Patients with more changes in their drug regimens (drugs being stopped, new drugs started or dosage modifications) and using more drugs were more likely to develop DRPs. Community pharmacists recorded 305 interventions in 205 patients with DRPs. Pharmacists intervened mostly by patient medication counselling (39.0%) and practical instruction to the patient (17.7%). In 26.2% the intervention was directed towards the prescriber. In 28 cases (9.2%) the pharmacists’ intervention led to a change of the drug regimen.Conclusion: This study shows that a systematic intervention by community pharmacists in discharged patients, or their proxies, is able to reveal a high number of DRPs that might be relevant for patient health outcomes. There should be more initiatives to insure continuity of care, since DRPs after discharge from hospital seem to be very common.

From "retailers" to health care providers : Transforming the role of community pharmacists in chronic disease management

Community pharmacists are the third largest healthcare professional group in the world after physicians and nurses. Despite their considerable training, community pharmacists are the only health professionals who are not primarily rewarded for delivering health care and hence are under-utilized as public health professionals. An emerging consensus among academics, professional organizations, and policymakers is that community pharmacists, who work outside of hospital settings, should adopt an expanded role in order to contribute to the safe, effective, and efficient use of drugs-particularly when caring for people with multiple chronic conditions. Community pharmacists could help to improve health by reducing drug-related adverse events and promoting better medication adherence, which in turn may help in reducing unnecessary provider visits, hospitalizations, and readmissions while strengthening integrated primary care delivery across the health system. This paper reviews recent strategies to expand the role of community pharmacists in Australia, Canada, England, the Netherlands, Scotland, and the United States. The developments achieved or under way in these countries carry lessons for policymakers world-wide, where progress thus far in expanding the role of community pharmacists has been more limited. Future policies should focus on effectively integrating community pharmacists into primary care; developing a shared vision for different levels of pharmacist services; and devising new incentive mechanisms for improving quality and outcomes.

Medication errors: the importance of safe dispensing

1. Although rates of dispensing errors are generally low, further improvements in pharmacy distribution systems are still important because pharmacies dispense such high volumes of medications that even a low error rate can translate into a large number of errors. 2. From the perspective of pharmacy organization and quality assurance, pharmacists should intensify their checking of prescriptions, in order to reduce prescription errors, and should implement strategies to communicate adequately with patients, in order to prevent administration errors. More and better studies are still needed in these areas. 3. More research is also required into: dispensing errors in out-patient health-care settings, such as community pharmacies in the USA and Europe; dispensing errors in hospitals and out-patient health-care settings in middle- and low-income countries; and the underlying causes of dispensing errors.

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.

Characteristics and Reasons Associated with Nonacceptance of Selective Serotonin-Reuptake Inhibitor Treatment

Background: Studies have shown that up to 38% of patients who start treatment with antidepressants fill only a single prescription at the pharmacy, apparently not accepting treatment. Objective: To determine characteristics and reasons associated with nonacceptance of selective serotonin-reuptake inhibitor (SSRf) treatment, Methods: A retrospective study was conducted in 37 community pharmacies in the Netherlands; patients who presented a prescription from a general practitioner (GP) for a newly started SSRI treatment were selected, Nonaccepters were defined as patients who filled only one SSRI prescription; patients who received at least 3 fills of an SSRI prescription were defined as accepters. Patient characteristics were obtained from automated dispensing records and from questionnaires. Areas of evaluation included sociodemographics, disease, and treatment. Nonaccepters were asked their reasons for not filling second prescriptions. Results: Of the patients who started SSRI treatment, 22.0% were nonaccepters, filling only a single prescription. Fifty-seven nonaccepters and 128 accepters were included in our analysis. Nonacceptance was more common among patients with a low level of education (OR 2.6; 95% CI 1.1 to 5.9) and in patients who reported nonspecific symptoms like fatigue, stress, and restlessness as the reason for SSRI use (OR 2.7; 95% CI 1.4 to 5.5). Of the nonaccepters, 29.8% (n = 17) did not start SSRI use, and 70.2% (n = 40) discontinued SSRI use within 2 weeks. Fear of adverse effects and the actual occurrence of adverse effects were main reasons for not accepting SSRI treatment. Of the nonaccepters, 55.0% discontinued treatment without informing their GPs. Conclusions: Acceptance of SSRI treatment is a decisive moment in a patients adherence to treatment initiated by his or her GP and deserves more attention; GPs and pharmacists should address treatment issues, especially in groups at risk for nonacceptance.

Laxative prescribing in relation to opioid use and the influence of pharmacy-based intervention

Introduction: Opioid‐induced constipation is a common problem and can cause serious complications. It is widely advised that laxatives should be started concurrently with opiates, unless there is a clear indication not to do so.

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.