Marie-Claude Vanier

Effectiveness of a medication discharge plan for transitions of care from hospital to outpatient settings

PURPOSE The effect of a medication discharge plan (MDP) on the rate of medication discrepancies between hospital and outpatient settings was evaluated. METHODS In a pragmatic, open, randomized, controlled trial, MDPs were completed for all patients before discharge from the hospital. Patients were then assigned to either an MDP group, for whom MDPs were sent to community pharmacies and treating physicians, or a usual care group, for whom an MDP was not sent. Discrepancies between MDPs and community pharmacy dispensing records and medication use reported by patients during a telephone interview were documented. The percentage of patients with discrepancies and the mean percentage of medications with discrepancies were compared between the two groups. The clinical severity of discrepancies was blindly evaluated. RESULTS A total of 83 patients agreed to participate in the study. The percentage of patients with at least one discrepancy was high and similar in both groups when MDPs were compared with pharmacy dispensing records and patient self-reports. Comparison of MDPs to pharmacy dispensing records revealed discrepancies for 13-15% of medications; more than a third were clinically significant. Comparison of MDPs to patient self-reports revealed discrepancies for 10-12% of medications; 48% were clinically significant. No significant differences were observed between the two groups. CONCLUSION The rate of medication discrepancies was not decreased in patients whose MDP was provided to their community pharmacy and physician at the time of hospital discharge compared with the rate in patients who received usual care.

A cluster randomized controlled Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia: the TEAM study

Background: Few studies have reported the efficacy of collaborative care involving family physicians and community pharmacists for patients with dyslipidemia. Methods: We randomly assigned clusters consisting of at least two physicians and at least four pharmacists to provide collaborative care or usual care. Under the collaborative care model, pharmacists counselled patients about their medications, requested laboratory tests, monitored the effectiveness and safety of medications and patients’ adherence to therapy, and adjusted medication dosages. After 12 months of follow-up, we assessed changes in low-density lipoprotein (LDL) cholesterol (the primary outcome), the proportion of patients reaching their target lipid levels and changes in other risk factors. Results: Fifteen clusters representing a total of 77 physicians and 108 pharmacists were initially recruited, and a total of 51 physicians and 49 pharmacists were included in the final analyses. The collaborative care teams followed a total of 108 patients, and the usual care teams followed a total of 117 patients. At baseline, mean LDL cholesterol level was higher in the collaborative care group (3.5 v. 3.2 mmol/L, p = 0.05). During the study, patients in the collaborative care group were less likely to receive high-potency statins (11% v. 40%), had more visits with health care professionals and more laboratory tests, were more likely to have their lipid-lowering treatment changed and were more likely to report lifestyle changes. At 12 months, the crude incremental mean reduction in LDL cholesterol in the collaborative care group was −0.2 mmol/L (95% confidence interval [CI] −0.3 to −0.1), and the adjusted reduction was −0.05 (95% CI −0.3 to 0.2). The crude relative risk of achieving lipid targets for patients in the collaborative care group was 1.10 (95% CI 0.95 to 1.26), and the adjusted relative risk was 1.16 (95% CI 1.01 to 1.34). Interpretation: Collaborative care involving physicians and pharmacists had no significant clinical impact on lipid control in patients with dyslipidemia. International Standard Randomized Controlled Trial register no. ISRCTN66345533.

Reliability, validity and ease of use of a portable point-of-care coagulation device in a pharmacist-managed anticoagulation clinic.

AbstractIn a pharmacist-managed anticoagulation clinic, portable point-of-care coagulation devices may facilitate patient monitoring by providing rapid INR measurement. Few studies, however, have validated this type of device. Objective: To evaluate the reliability, validity and ease of use of the CoaguChek S, a new portable coagulation device. Methods: A total of 100 patients followed at a pharmacist-managed anticoagulation clinic attended two study visits. INRs were measured using the CoaguChek S and the standard laboratory technique. Results: Reliability: The test-retest reliability (precision) of the CoaguChek S, estimated by the intraclass correlation coefficient (ICC) and a 95% confidence interval (95% CI), was high (0.98 (0.98–0.99)) and comparable to the standard laboratory technique (0.99 (0.98–0.99)). Interrater reliability was also high (0.97 (0.95–0.98)). Reliability coefficients did not vary with the test-strip lot number nor the CoaguChek S operator. Validity: When compared with standard laboratory procedure, the ICC (95% CI) was equal to 0.93 (0.91–0.95). The mean difference (95% CI) between INR measured by the laboratory and the CoaguChek S was equal to −0.02 units (−0.06–0.03). The mean absolute and relative absolute differences (95% CI) were equal to 0.24 units (0.21–0.27) and 9% (8%–10%), respectively. Differences tended to increase for INRs greater than 3 units as seen by a mean difference (95% CI) of −0.17 units (−0.35–0.02). This represented a mean absolute difference (95% CI) of 0.44 units (0.33–0.55) and a mean relative absolute difference of 12% (9%–15%). Concordance between therapeutic decisions based on CoaguChek S and laboratory results was high (Kappa = 0.68). In 34 cases (18%), the therapeutic decision would have been different. However, in 15 of these discordant observations, the difference between the CoaguCheck S and laboratory INR was ≤0.25 units. Ease of use: In 3% of cases, no INR could be measured by the CoaguChek S. The percentage of extra finger pricks and extra test-strips were equal to 25.8% and 23.7%, respectively. Conclusion: When used by health professionals in a pharmacist-managed anticoagulation clinic, the CoaguChek S is reliable, valid and easy to use. However, its validity tends to decrease as the INR increases, possibly due to the low sensitivity of the thromboplastin. If the CoaguChek S INR is supratherapeutic, we would therefore recommend confirming the results with a standard laboratory measurement.

How to help patients manage their dyslipidemia: A primary care physician-pharmacist team intervention

Dyslipidemia treatment in primary care is far from optimal — adherence and persistence to pharmacotherapy are low, and physicians tend not to titrate statin dosages. Consequently, a large proportion of patients do not attain their recommended lipid targets. This has serious clinical and economic consequences. Several studies have shown that community-pharmacist interventions and collaborative management of pharmacotherapy by physicians and pharmacists improve dyslipidemia treatment. In Quebec, as a result of legislative changes (Bill 90) made in 2002, community pharmacists may initiate and adjust drug therapy in accordance with a physician’s prescription and request laboratory analyses when needed. This new legislation increases the potential for a physician-pharmacist team approach to the management of dyslipidemic patients. In Quebec, in order to implement these collaborative practices, a treatment protocol has to be approved by members of a hospital’s Conseil des Medecins, Dentistes et Pharmaciens (Council of Doctors, Dentists, and Pharmacists). In this article, we present a treatment protocol for the management of statin therapy that was developed by pharmacists (LL, JV, DL, MCV, SP), family physicians (MTL, EH), and a cardiologist (JG) as part of a randomized controlled trial. The treatment protocol describes a physician-pharmacist team intervention for the management of patients with dyslipidemia in a primary care setting.