Parisa Aslani

Studies on diffusion in alginate gels. I. Effect of cross-linking with calcium or zinc ions on diffusion of acetaminophen

Abstract The permeability of acetaminophen in hydrated alginate and alginic acid gels was measured using side-by-side glass diffusion cells. Gel films were prepared by cross-linking sodium alginate films in aqueous solutions (0.1 to 0.7 M) of calcium or zinc acetate for 1 to 30 min at 25°C. Films prepared in 0.34 M cation solution for 15 min were either exposed to Simulated Gastric Fluid USP minus pepsin, or dried at 45°C to constant weight and then rehydrated, prior to a diffusion study. Acetaminophen permeability in the gel films decreased with increasing divalent cation concentration and cross-linking time until an apparent optimum was reached. The decreased permeability was suggested to be due to increased cross-linking in the gelled structure. The permeability of acetaminophen in the gel films decreased in the order alginic acid gel films > acid-exposed alginate gel films > divalent alginate gel films. Dehydration decreased the permeability of acetaminophen in the Ca alginate gel films. Overall, there was little difference between the permeability of acetaminophen in Ca or Zn alginate gel films.

Practice Change in Community Pharmacy: Quantification of Facilitators

Background: There has been an increasing international trend toward the delivery of cognitive pharmaceutical services (CPS) in community pharmacy. CPS have been developed and disseminated individually, without a framework underpinning their implementation and with limited knowledge of factors that might assist practice change. The implementation process is complex, involving a range of internal and external factors. Objective: To quantify facilitators of practice change in Australian community pharmacies. Methods: We employed a literature review and qualitative study to facilitate the design of a 43-item “facilitators of practice change” scale as part of a quantitative survey instrument, using a framework of organizational theory. The questionnaire was pilot-tested (n = 100), then mailed to a random sample of 2000 community pharmacies, with a copy each for the pharmacy owner, employed pharmacist, and pharmacy assistant. The construct validity and reliability of the scale were established using exploratory factor analysis and Cronbachs α, respectively. Results: A total of 735 (37%) pharmacies responded, with 1303 individual questionnaires. Factor analysis of the scale yielded 7 factors, explaining 48.8% of the total variance. The factors were: relationship with physicians (item loading range 0.59–0.85; Cronbachs α 0.90), remuneration (0.52–0.74; 0.82), pharmacy layout (0.52–0.79; 0.81), patient expectation (0.52–0.85; 0.82), manpower/staff (0.49–0.66; 0.80), communication and teamwork (0.37–0.65; 0.77), and external support/assistance (0.47–0.69; 0.74). Conclusions: All of the factors demonstrated good reliability and construct validity and explained approximately half of the variance. Implementing CPS requires support not only with the clinical aspects of service delivery, but also for the process of implementation itself, and remuneration models must reflect this. The identified facilitators should be used in a multilevel strategy to integrate professional services into the community pharmacy business, engaging pharmacists and their staff, policy makers, educators, and researchers. Further research is required to determine additional factors impacting the capacity of community pharmacies to implement change.

Implementing cognitive services in community pharmacy: a review of facilitators used in practice change

Objective To investigate facilitators of change in community pharmacy and their use in the implementation of cognitive pharmaceutical services (CPS).

Understanding practice change in community pharmacy: a qualitative research instrument based on organisational theory

Introduction: The past decade has seen a notable shift in the practice of pharmacy, with a strong focus on the provision of cognitive pharmaceutical services (CPS) by community pharmacists. The benefits of these services have been well documented, yet their uptake appears to be slow. Various strategies have been developed to overcome barriers to the implementation of CPS, with varying degrees of success, and little is known about the sustainability of the practice changes they produce. Furthermore, the strategies developed are often specific to individual programs or services, and their applicability to other CPS has not been explored. There seems to be a need for a flexible change management model for the implementation and dissemination of a range of CPS, but before it can be developed, a better understanding of the change process is required. Objectives: This paper describes the development of a qualitative research instrument that may be utilised to investigate practice change in community pharmacy. Specific objectives included gaining knowledge about the circumstances surrounding attempts to implement CPS, and understanding relationships that are important to the change process. Methods: Organisational theory provided the conceptual framework for development of the qualitative research instrument, within which two theories were used to give insight into the change process: Borums theory of organisational change, which categorises change strategies as rational, natural, political or open; and Social Network Theory, which helps identify and explain the relationships between key people involved in the change process. Results: A semi‐structured interview guide was produced, combining the factors affecting practice change found in the literature that warranted further investigation with the theoretical perspectives of organisational change and social networks. To address the research objectives, the instrument covered four broad themes: roles, experiences, strategies and networks.Conclusion: The qualitative research instrument developed in this study provides a starting point for future research to lead to a description and understanding of practice change in community pharmacy, and subsequent development of models for the sustainable implementation of CPS.

Enhancing patient education about medicines: factors influencing reading and seeking of written medicine information

Objective  To investigate the influence of patient factors on patients’ reading and seeking of written medicine information (WMI).

Drug related problems after discharge from an Australian teaching hospital.

Objective To reconcile patients’ medicines and to classify drug related problems identified during medication review conducted after discharge from hospital. Setting Patients were discharged from the cardiology unit of Westmead Hospital after recruitment into the Westmead Medicines Project which ran from 2004 to 2007. Method This retrospective study involved an analysis of drugs, diseases and drug related problems in medication review reports available for 76 out of 85 patients who received a Home Medicines Review (HMR). Data sources for medication reconciliation and analyses also included hospital discharge summaries (n = 70) and GP referrals for HMR (n = 44). Comprehensive clinical profiles were constructed for the 76 subjects whose drug related problems were identified, coded, and then classified from their HMR reports. Main outcome measures Number, type, distribution and international classification of drugs, diseases and drug-related problems. Results Patients were prescribed drugs for a broad range of cardiovascular, circulatory, endocrine, respiratory and digestive system diseases. Mean number of drugs per patient in discharge summaries: 8.7 ± SD 3.3 (range 3–19); in GP referrals: 8.9 ± SD 4.3 (range 2–23); and in HMR reports: 10.8 ± SD 4.0 (range 3–24). Mean number of diseases per patient in discharge summaries: 4.1 ± SD 2.9 (range 1–11); and in HMR reports: 4.7 ± SD 2.6 (range 1–12). A total of 398 drug related problems were identified for 71 (93.3%) patients with mean 5.6 ± SD 4.3 problems (range 1–21). The most frequently recorded problems were the patients’ uncertainty about drug aim: n = 128 (32.0%); potential interactions n = 89 (22.4%); and adverse reactions n = 60 (15.1%). Conclusion This study showed that patients recently discharged from a tertiary care hospital had a significant number of drug related problems. Classification of drugs and diseases revealed a broad range of non-cardiovascular medicines and conditions in the patients from an acute care cardiology unit. We found that home medicines review provided continuity of care and an opportunity for medication reconciliation which revealed marked differences in number of drugs, between hospital discharge and medicines review. The patients’ uncertainly about their drugs and their diverse range of co-morbidities indicated the need for timely counselling by pharmacists in the community.

Drug-related problems in the community setting: pharmacists' findings and recommendations for people with mental illnesses.

AbstractBackground and objective: Adverse drug events are a leading cause of morbidity in Australia and internationally. People taking psychotropic drugs for mental illnesses may be particularly susceptible. This study aimed to classify and describe pharmacists’ Home Medicines Review (HMR) findings and recommendations for people with mental illnesses. Methods: This was a descriptive study conducted from March to November 2003. General practitioners and community pharmacists practising in two regions of metropolitan Sydney were invited to participate. General practitioners recruitedand referred community-dwelling people with mental illnesses to receive HMRs conducted by accredited pharmacists. Reviewing pharmacists interviewed 49 people in their homes. During the interviews the pharmacists provided drug information, assessed drug knowledge and beliefs, and assessed drug adherence. Pharmacists then produced written referenced reports that outlined drug-, patient-and prescriber-related findings and recommendations. These findings and recommendations were presented to the referring general practitioners at follow-up case conferences. Main outcome measures: Drugs were classified using the Anatomical Therapeutic Chemical Classification System. Pharmacists’ findings and recommendations were classified using the Clinical Pharmacy Activity Classification System. Results: The most common types of nervous system drugs taken by people who received a HMR were antidepressants (n = 39.33%), analgesics (n = 29.24%) and antipsychotics (n = 17.14%). Pharmacists reported 403 findings and made 360 recommendations for 49 people, with 90% of recommendations being accepted by the referring general practitioners. The most common findings related to potential adverse drug reactions (n = 53, for 47% of people), suspected adverse drug reactions (n = 48, for 55% of people), potential interactions (n = 30, for 37% of people), and people taking additional drugs unbeknown to their referring general practitioner (n = 26, for 25% of people). The most common recommendations were to switch a drug (n = 37, for 49% of people), suggest a non-drug treatment (n = 29, for 41% of people) and to suggest a new drug (n = 27, for 49% of people). At the time of referral, general practitioners documented people to be taking 7.8 ± 4.4 (mean ± SD) drugs each (range 1–18). Following home interviews, pharmacists determined people to be taking 9.1 ± 4.8 drugs (range 1–20). This difference wasstatistically significant (p < 0.001). Conclusions: Pharmacists identified a high incidence of drug-related problems among people receiving treatment for mental illnesses. Pharmacists also identified a higher incidence of overall drug use than documented by the referring general practitioners. HMRs and case conferences, undertaken collaboratively by general practitioners and pharmacists, may be a useful strategy to identify drug-related problems among people with mental illnesses.

Shared decision-making and interprofessional collaboration in mental healthcare: a qualitative study exploring perceptions of barriers and facilitators.

Abstract Shared decision-making and interprofessional collaboration are important approaches to achieving consumer-centered care. The concept of shared decision-making has been expanded recently to include the interprofessional healthcare team. This study explored healthcare providers’ perceptions of barriers and facilitators to both shared decision-making and interprofessional collaboration in mental healthcare. Semi-structured interviews were conducted with 31 healthcare providers, including medical practitioners (psychiatrists, general practitioners), pharmacists, nurses, occupational therapists, psychologists and social workers. Healthcare providers identified several factors as barriers to, and facilitators of shared decision-making that could be categorized into three major themes: factors associated with mental health consumers, factors associated with healthcare providers and factors associated with healthcare service delivery. Consumers’ lack of competence to participate was frequently perceived by mental health specialty providers to be a primary barrier to shared decision-making, while information provision on illness and treatment to consumers was cited by healthcare providers from all professions to be an important facilitator of shared decision-making. Whilst healthcare providers perceived interprofessional collaboration to be influenced by healthcare provider, environmental and systemic factors, emphasis of the factors differed among healthcare providers. To facilitate interprofessional collaboration, mental health specialty providers emphasized the importance of improving mental health expertise among general practitioners and community pharmacists, whereas general health providers were of the opinion that information sharing between providers and healthcare settings was the key. The findings of this study suggest that changes may be necessary at several levels (i.e. consumer, provider and environment) to implement effective shared decision-making and interprofessional collaboration in mental healthcare.

Interventions promoting adherence to cardiovascular medicines

Background Cardiovascular diseases (CVDs) are a large burden on the healthcare system. Medicines are the primary treatment for these diseases; however, adherence to therapy is low. To optimise treatment and health outcomes for patients, it is important that adherence to cardiovascular medicines is maintained at an optimal level. Therefore, identifying effective interventions to improve adherence and persistence to cardiovascular therapy is of great significance. Aim of the Review This paper presents a review of the literature on interventions used in the community setting which aim to improve adherence to cardiovascular medicines in patients with hypertension, dyslipidaemia, congestive heart failure or ischaemic heart disease. Methods Several databases (Medline, EMBASE, PsychINFO, IPA, CINAHL, Pubmed, Cochrane) were searched for studies which were published from 1979–2009, evaluated interventions intended to improve adherence to cardiovascular medicines in the community setting, had at least one measure of adherence, and consisted of an intervention and comparison/control group. Results Among 36 eligible studies (consisting of 7 informational, 15 behavioural, 1 social, and 13 combined strategy interventions), 17 (1 informational, 10 behavioural, and 6 combined) reported a significant improvement in adherence and/or persistence. Behavioural interventions were the most successful. Twenty-one studies (4 informational, 9 behavioural, and 8 combined) also demonstrated improvements in clinical outcomes, though, effects were frequently variable, contradictory and not related to changes in adherence. Conclusion Several types of interventions are effective in improving adherence and/or persistence within the CVD area and in the community setting. Behavioural interventions have shown the greatest success (compared to other types of interventions); and adding informational strategies has not resulted in further improvements in adherence. Improving adherence and persistence to cardiovascular medicines is a dynamic process that is influenced by many factors, and one which requires long term multiple interventions to promote medicine taking in patients

A Systematic Review of Interventions Addressing Adherence to Anti-Diabetic Medications in Patients with Type 2 Diabetes—Impact on Adherence

Background The global prevalence of diabetes is increasing. Medications are a recommended strategy to control hyperglycaemia. However, patient adherence can be variable, impacting health outcomes. A range of interventions for patients with type 2 diabetes have focused on improving treatment adherence. This review evaluates the impact of these interventions on adherence to anti-diabetic medications and focuses on the methods and tools used to measure adherence. Method Medline, Embase, CINAHL, IPA, PUBmed, and PsychINFO were searched for relevant articles published in 2000–2013, using appropriate search terms. Results Fifty two studies addressing adherence to anti-diabetic medications in patients with type 2 diabetes met the inclusion criteria and were reviewed. Each study was assessed for research design, method(s) used for measuring medication adherence, and impact of intervention on medication adherence and glycaemic control. Fourteen studies were published in 2000–2009 and 38 in 2010–2013. Twenty two interventions led to improvements in adherence to anti-diabetic medications, while only nine improved both medication adherence and glycaemic control. A single strategy could not be identified which would be guaranteed to improve anti-diabetic medication adherence consistently. Nonetheless, most interventions were successful in influencing one or more of the outcomes assessed, indicating the usefulness of these interventions under certain circumstances. Self-report, particularly the Summary of Diabetes Self-Care Activities questionnaire was the most commonly used tool to assess medication adherence, although other self-report tools were used in more recent studies. Overall, there was a slight increase in the number of studies that employed multiple methods to assess medication adherence in studies conducted after 2008. Conclusion The diversity of interventions and adherence measurements prevented a meta-analysis of the impact of interventions on adherence to therapy, highlighting the need for more consistency in methods in the area of adherence research. Whilst effective interventions were identified, it is not possible to conclude on an effective intervention that can be generalised to all patients with type 2 diabetes.