Marja Airaksinen

Potentially inappropriate medication use among Finnish non-institutionalized people aged ≥65 years: a register-based, cross-sectional, national study.

BackgroundThe Beers criteria and their modifications are the most frequently used tools for measuring potentially inappropriate medication (PIM) use among older people. The prevalence of such use in various settings has been high, but no data have been reported for an entire national non-institutionalized elderly population, nor is there information on the reimbursement costs for those medications.ObjectiveTo determine the prevalence of PIM use according to the Beers 2003 criteria, independent of diagnoses, among Finnish non-institutionalized people aged ≥65 years, and the reimbursement costs for these medications.MethodsA register-based cross-sectional national study used drug reimbursement data from Finland’s Social Insurance Institution (SII). These data cover the entire non-institutionalized population aged ≥65 years in 2007. The number of persons who received reimbursements for each PIM according to the Beers 2003 criteria and the total annual reimbursement costs for PIMs were calculated. Indirect costs were excluded.ResultsOf the non-institutionalized population aged ≥65 years in Finland (n = 841 509), 14.7% (n = 123 545) had received PIMs according to the Beers 2003 criteria. Temazepam >15 mg/day was clearly the most commonly reimbursed PIM (4.4% of the population aged ≥65 years), followed by amitriptyline (2.0%) and diazepam (1.8%). The SII paid drug reimbursements of €2.9 million for PIMs, which was 0.7% of the total drug reimbursements (€421 million) for people aged ≥65 years in Finland in 2007.ConclusionsThe use of PIMs among outpatients aged ≥65 years in Finland (14.7%) was less than in several earlier large-scale studies in other countries (17–42%) and reimbursement costs were modest, mainly as a result of the limited availability in Finland of medicines identified as PIMs by the Beers 2003 criteria. However, benzodiazepines were commonly used and actions to improve medication safety should target reducing their use.

Content validation of a tool for assessing risks for drug-related problems to be used by practical nurses caring for home-dwelling clients aged ≥65 years: a Delphi survey

PurposeHome care services are becoming a critically important part of health care delivery as populations are aging. Those using home care services are increasingly older, more frail than previously, and use multiple medications, making them vulnerable to drug-related problems (DRPs). Practical nurses (PN) visit home-dwelling aged clients frequently and, thus, are ideally situated to identify potential DRPs and, if needed, to communicate them to physicians for resolution. This study developed and validated the content of a tool to be used by PNs for assessing DRP risks for their home-dwelling clients aged ≥65xa0years.MethodsThe first draft of the tool was based on two systematic literature reviews and clinical experience of our research group. Content validity of the tool was determined by a three-round Delphi survey with a panel of 18 experts in geriatric care and pharmacotherapy. An agreement by ≥80xa0% of the panel on an item was required.ResultsThe final tool consists of 18 items that assess risks for DRPs in home-dwelling aged clients. It is divided into four sections: (1) Basic Client Data, (2) Potential Risks for DRPs in Medication Use, (3) Characteristics of the Client’s Care and Adherence, and (4) Recommendations for Actions to Resolve DRPs.ConclusionsThe Delphi process resulted in a structured DRP Risk Assessment Tool that is focused on the highest priority DRPs that should be identified and resolved. The tool also assists the PNs to identify solutions to these problems, which is a unique feature compared to similarly purposed prior tools.

Barriers and facilitators to medication adherence: a qualitative study with general practitioners

Background General practitioners (GPs) manage the drug therapies of people with chronic diseases, and poor adherence to medication remains a major challenge. Objective This qualitative study examined GPs’ insights into non-adherence and ways of overcoming this problem. Methods We ran four focus groups comprising 16 GPs at the Kirkkonummi Health Centre (Southern Finland). Interviews were audiotaped, transcribed verbatim and analysed by inductive content analysis. Main results The two main themes in the discussions with the GPs were non-adherence in the care of chronic disease and increased need for medicine information. The medication management challenges identified were related to: patient-specific factors, the healthcare system, characteristics of drug therapies and the function and role of healthcare professionals as a team. To improve the situation, the GPs offered a number of solutions: improved coordination of care, better patient education and IT systems as well as enhanced interprofessional involvement in the follow-up of patients. Discussion and conclusions With an ageing population, the GPs were increasingly confronted with non-adherence in the care of chronic diseases. They had mostly a positive attitude towards organising care in a more interprofessional manner. To support medication adherence and self-management, the GPs appreciated pharmacists’ assistance especially with patients with polypharmacy and chronic diseases.

Feasibility of a practical nurse administered risk assessment tool for drug-related problems in home care:

Aim: To evaluate feasibility of a practical nurse-administered Drug-related Problem Risk Assessment Tool among home care clients ⩾65 years. Methods: Altogether, 36 practical nurses participated in the study. They were trained about the purpose and use of the tool. The training consisted of a day long interactive workshop and involved reviewing four self-selected clients’ medications using the tool (one as a pre-assignment before and three as post-assignments after the workshop). The data of this study were collected during the training. Triangulation, i.e. combination of methods and data, was used to evaluate the feasibility of the tool. Quantitative data were gathered from returned post-assignment tools and qualitative data from face-to-face discussions and open questions in feedback forms the practical nurses returned after the training. Results: Practical nurses spent 10–45 minutes reviewing one client’s medication using the tool (mean 20±8). They identified reliably 88% of the risk medicines used by the clients listed in the tool. Of the respondents (n=23) of the feedback forms, 43% reported that they felt it easy or quite easy to answer the questions of the tool. Generic names of medicines, time constraints, home-care workers’/client’s lack of interest to client’s pharmacotherapy and short client contacts were the most common barriers to use the tool. Conclusions: The Drug-Related Problem Risk Assessment Tool turned out to be feasible among practical nurses. The brief training on the content and use of the tool seems to be sufficient for ensuring reliable use of the tool.

Can Practical Nurses Identify Older Home Care Clients at Risk of Drug-Related Problems–Geriatricians’ Appraisal of Their Risk Screenings: A Pilot Study

Background: Home care (HC) clients are increasingly older, have many chronic diseases, and use multiple medicines and thus are at high risk for drug-related problems (DRPs). Objective: Establish the sensitivity of practical nurse (PN) administered DRP risk assessment tool (DRP-RAT) compared with geriatrician’s assessment of the medical record. Identify the clinically most significant DRPs needing action. Methods: Twenty-six PNs working in HC of Härkätie Health Center in Lieto, Finland, 46 HC clients (≥65 years), and a geriatrician participated in this pilot study. The geriatrician reviewed HC clients’ medications using 3 different methods. The reviews were based on the following: (1) the PN’s risk screening (ie, PN-completed DRP-RAT) and medication list, (2) health center’s medical records, and (3) methods 1 and 2 together. The main outcome was the number of “at-risk patients” (ie, the patient is at risk of clinically significant DRPs) by using each review method. Secondary outcomes were clinically most significant DRP-risk predicting factors identified by the geriatrician. Results: The geriatrician reviewed 45 clients’ medications using all 3 methods. Based on PN-completed DRP-RAT and medication list, 93% (42/45) of the clients were classified as “at-risk patients.” Two other review methods resulted in 45/45 (100%) “at-risk patients.” Symptoms suggestive of adverse drug reactions were the most significant risk predicting factors. Small sample size limits the generalizability of the results. Conclusions: The PN-completed DRP-RAT was able to provide clinically important timely patient information for clinical decision making. DRP-RAT could make it possible to more effectively involve PNs in medication risk management among older HC clients.

A national approach to medicines information research : A systematic review

Background: The Finnish Medicines Agency Fimea published the first National Medicines Information (MI) strategy in 2012. For the purpose of implementing the MI strategy into practice by the national MI Network, a comprehensive inventory of MI research in Finland was needed. Objective: To systematically review literature on MI research conducted in Finland by analyzing and classifying the studies, and identifying the gaps in MI research. Methods: Medline, Scopus and Medic databases were searched for peer‐reviewed MI publications by using key word screening criteria. The search and extraction process followed PRISMA Guidelines and covered the period from January 2000 to June 2016. Included studies were content analyzed according to MI practices identified, trends over time in research methodology and theory. Results: Included publications (n = 126) applied a variety of research methods, most often cross‐sectional surveys (n = 51, 40% of all studies), but more than half of the studies were qualitative (n = 68, 54%). Twelve were intervention studies of which 6 were randomized and had a control group. Studies were categorized into: patient counseling in different settings (n = 45); MI sources and needs of medicine users (n = 25); healthcare professionals (HCPs) competence in patient counseling and pharmacotherapy (n = 25); MI sources and needs of HCPs (n = 23); MI education and literacy (n = 13); and MI policies and strategies (n = 3). Most of the studies were descriptive, and only 6 studies applied a theory. Conclusions: Regardless of some methodological pitfalls, MI research conducted in Finland since 2000 provides multifaceted understanding of MI practices and their development needs. Research should shift towards larger research lines having a stronger theory base and study designs to deepen the understanding of MI practices and behaviors, and effectiveness of MI in different healthcare settings. Future research should cover also the use of electronic MI sources and services which apply modern information technology to clinical decision making and medication reviews, national MI policy, MI literacy, MI needs of HCPs and consumers. Highlights:Altogether 126 studies on medicines information practices in Finland were found.Patient counseling in different settings was the most studied practice.Survey was the most used single method, but more than half of all studies were qualitative.Research should shift towards medicines information literacy and use of electronic sources.Larger research lines with a stronger theory‐base and study designs are needed.

Trends in the long-term use of benzodiazepine anxiolytics and hypnotics: A national register study for 2006 to 2014

Long‐term benzodiazepine (BZD) treatment continues to be a debated topic. Because individual BZDs have different clinical profiles, we assessed the nationwide trends of long‐term BZD use at active substance level during years 2006 to 2014.

Use and accessibility of health and medication information sources among pharmacy students during their community pharmacy internship

INTRODUCTIONnEvidence-based health and medication information (HMI) sources and databases have a growing importance in daily professional practice in community pharmacies. Previous research suggests that students learn practical skills at the workplace through self-directed learning and practical experience rather than formal training. Thus, pharmacy internship is a key in ensuring pharmacy students competency to use HMI sources and databases. This study assessed what HMI sources pharmacy students had used and accessible during their first internship in community pharmacies in Finland.nnnMETHODSnThe data were collected as part of the obligatory assignments of the second year pharmacy students at the University of Helsinki during their first three-month internship in a community pharmacy in 2013 (nxa0=xa0152, response rate 100%).nnnRESULTSnThe most commonly used HMI sources during the first internship period were electronic product-specific databases assisting in medication counselling, such as the checklist type generic prescription medication information database integrated into pharmacy prescription processing system, used daily by 74% of the students having access to the database (nu202f=u202f121). Databases assisting in medication reviews were less commonly used although they were available in the majority of the pharmacies.nnnDISCUSSION AND CONCLUSIONnAlthough the majority of students had access to a wide range of HMI sources and databases during their internship, the actual use of sources other than product-specific medication information was limited, particularly the use of databases in assisting in medication reviews. It is important to facilitate their use in the second internship to acquire competences needed for their further use after graduation.

Patient involvement is essential in identifying drug‐related problems

The aim of this study is to evaluate how critical patient involvement is in pharmacist‐led clinical medication reviews and in identifying the most significant clinical drug‐related problems (DRPs).

Coordinating resources for prospective medication risk management of older home care clients in primary care: procedure development and RCT study design for demonstrating its effectiveness

BackgroundThe magnitude of safety risks related to medications of the older adults has been evidenced by numerous studies, but less is known of how to manage and prevent these risks in different health care settings. The aim of this study was to coordinate resources for prospective medication risk management of home care clients ≥u200965xa0years in primary care and to develop a study design for demonstrating effectiveness of the procedure.MethodsHealth care units involved in the study are from primary care in Lohja, Southern Finland: home care (191 consented clients), the public healthcare center, and a private community pharmacy. System based risk management theory and action research method was applied to construct the collaborative procedure utilizing each profession’s existing resources in medication risk management of older home care clients. An inventory of clinical measures in usual clinical practice and systematic review of rigorous study designs was utilized in effectiveness study design.DiscussionThe new coordinated medication management model (CoMM) has the following 5 stages: 1) practical nurses are trained to identify clinically significant drug-related problems (DRPs) during home visits and report those to the clinical pharmacist. Clinical pharmacist prepares the cases for 2) an interprofessional triage meeting (50–70 cases/meeting of 2xa0h) where decisions are made on further action, e.g., more detailed medication reviews, 3) community pharmacists conduct necessary medication reviews and each patients’ physician makes final decisions on medication changes needed. The final stages concern 4) implementation and 5) follow-up of medication changes. Randomized controlled trial (RCT) was developed to demonstrate the effectiveness of the procedure.The developed procedure is feasible for screening and reviewing medications of a high number of older home care clients to identify clients with severe DRPs and provide interventions to solve them utilizing existing primary care resources.Trial registrationThe study is registered in the Clinical Trials.gov (NCT02545257). Registration date September 9 2015.