Rebekah Moles

Inappropriate Medication Use and Prescribing Indicators in Elderly Australians : Development of a Prescribing Indicators Tool

AbstractBackground: Evidence-practice gaps, adverse medication-related incidents and unplanned medical admissions to hospital are common in elderly Australians. Many prescribing indicator tools designed to address some of these problems have been reported in the literature, the most common of which is the Beers list of inappropriate medications in the elderly. However, many of these tools are not appropriate for the Australian healthcare environment without modification and validation, and there appears to be a need for a tool based on Australian data. Objective: To develop a list of prescribing indicators for elderly (aged >65 years) Australians based on the most frequent medications prescribed to Australians, and the most frequent medical conditions for which elderly Australians consult medical practitioners. Method: The most common reasons for elderly Australians to seek or receive healthcare were cross-referenced with the 50 highest-volume Pharmaceutical Benefits Scheme medications prescribed to Australians in 2006 to develop prescribing indicators in the elderly using Australian medication and medical condition information resources. Results: Forty-eight prescribing indicators were identified, consisting mainly of optimum as well as inappropriate medication choices for a large number of common medical conditions in the elderly. Conclusion: A prescribing indicators tool was developed. This tool is envisaged as forming an important part of the medication review process, which is aimed at addressing the common problem of adverse medication-related events in elderly Australians.

Validation of prescribing appropriateness criteria for older Australians using the RAND/UCLA appropriateness method

Objective To further develop and validate previously published national prescribing appropriateness criteria to assist in identifying drug-related problems (DRPs) for commonly occurring medications and medical conditions in older (≥65 years old) Australians. Design RAND/UCLA appropriateness method. Participants A panel of medication management experts were identified consisting of geriatricians/pharmacologists, clinical pharmacists and disease management advisors to organisations that produce Australian evidence-based therapeutic publications. This resulted in a round-one panel of 15 members, and a round-two panel of 12 members. Main outcome measure Agreement on all criteria. Results Forty-eight prescribing criteria were rated. In the first rating round via email, there was disagreement regarding 17 of the criteria according to median panel ratings. During a face-to-face second round meeting, discussion resulted in retention of 25 criteria after amendments, agreement for 14 criteria with no changes required and deletion of 9 criteria. Two new criteria were added, resulting in a final validated list of 41 prescribing appropriateness criteria. Agreement after round two was reached for all 41 criteria, measured by median panel ratings and the amount of dispersion of panel ratings, based on the interpercentile range. Conclusions A set of 41 Australian prescribing appropriateness criteria were validated by an expert panel. Use of these criteria, together with clinical judgement and other medication review processes such as patient interview, is intended to assist in improving patient care by efficiently detecting potential DRPs related to commonly occurring medicines and medical conditions in older Australians. These criteria may also contribute to the medication management education of healthcare professionals.

Educational interventions to improve prescribing competency: a systematic review

Objective To review the literature on educational interventions to improve prescribing and identify educational methods that improve prescribing competency in both medical and non-medical prescribers. Design A systematic review was conducted. The databases Medline, International Pharmaceutical Abstracts (IPA), EMBASE and CINAHL were searched for articles in English published between January 1990 and July 2013. Setting Primary and secondary care. Participants Medical and non-medical prescribers. Intervention Education-based interventions to aid improvement in prescribing competency. Primary outcome Improvements in prescribing competency (knows how) or performance (shows how) as defined by Millers competency model. This was primarily demonstrated through prescribing examinations, changes in prescribing habits or adherence to guidelines. Results A total of 47 studies met the inclusion criteria and were included in the systematic review. Studies were categorised by their method of assessment, with 20 studies assessing prescribing competence and 27 assessing prescribing performance. A wide variety of educational interventions were employed, with different outcome measures and methods of assessments. In particular, six studies demonstrated that specific prescribing training using the WHO Guide to Good Prescribing increased prescribing competency in a wide variety of settings. Continuing medical education in the form of academic detailing and personalised prescriber feedback also yielded positive results. Only four studies evaluated educational interventions targeted at non-medical prescribers, highlighting that further research is needed in this area. Conclusions A broad range of educational interventions have been conducted to improve prescribing competency. The WHO Guide to Good Prescribing has the largest body of evidence to support its use and is a promising model for the design of targeted prescribing courses. There is a need for further development and evaluation of educational methods for non-medical prescribers.

Factors Affecting the Implementation of Clinical Pharmacy Services in China

New policies in China have recently led to the implementation of clinical pharmacy services in hospitals. We explored the views of hospital administrators, pharmacy directors, clinical pharmacists, and dispensing pharmacists about the factors affecting clinical pharmacy services in China, using the framework approach and organizational theory. We conducted 30 interviews with 130 participants at 29 hospitals (both secondary and tertiary) in Beijing, Zhengzhou, Luoyang, and Shanghai. We found that the barriers to and facilitators of implementation of clinical pharmacy services slotted into the environment and participant dimensions of Scott’s adapted version of Leavitt’s organizational model. External support from government was perceived as crucial to promoting pharmacy services. It is proposed that the internationally recognized Basel Statements of the International Pharmaceutical Federation also provide a strong foundation for guiding China in implementing clinical pharmacy services.

A systematic review of simulated-patient methods used in community pharmacy to assess the provision of non-prescription medicines

Objective  To explore the use of simulated‐patient methods in community pharmacy for non‐prescription medicines.

Medication Use in Children with Asthma: Not a Child Size Problem

Objective. The global burden of pediatric asthma is high. Governments and health-care systems are affected by the increasing costs of childhood asthma—in terms of direct health-care costs and indirect costs due to loss of parental productivity, missed school days, and hospitalizations. Despite the availability of effective treatment, the current use of medications in children with asthma is suboptimal. The purpose of this review is to scope the empirical literature to identify the problems associated with the use of pediatric asthma medications. The findings will help to design interventions aiming to improve the use of asthma medications among children. Methods. A literature search using electronic search engines (i.e., Medline, International Pharmaceutical Abstracts (IPA), PubMed, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) and the search terms “asthma,” “children,” and “medicines” (and derivatives of these keywords) was conducted. Results. The search terms were expanded to include emergent themes arising out of search findings. Content themes relating to parents, children themselves, health-care professionals, organizational systems, and specific medications and devices were found. Within these themes, key issues included a lack of parental knowledge about asthma and asthma medications, lack of information provided to parents, parental beliefs and fears, parental behavioral problems, the high costs of medications and devices, the child’s self-image, the need for more child responsibility, physician nonadherence to prescribing guidelines, “off-label” prescribing, poor understanding of teachers, lack of access to educational resources, and specific medications. Conclusion. These key issues should be taken into account when modifying the development of educational tools. These tools should focus on targeting the children themselves, the parent/carers, the health-care professionals, and various organizational systems.

Development of an Aggregated System for Classifying Causes of Drug-Related Problems

Background: More than 20 different types of classification systems for drug-related problems (DRPs) and their causes have been developed. Classification is necessary to describe and assess clinical, organizational, and economic impacts of DRPs through documentation of collected data. However, many researchers have judged classification systems incomplete when describing their data, and have modified them or developed their own. This variability between systems has made study comparisons difficult. Objectives: To perform a category-by-category comparison of the content of selected DRP classification systems to construct an aggregated cause-of-DRP classification system containing the content of all systems. Method: DRP classification systems were identified after a literature review, with 7 chosen based on their use in varied health care settings, geographical diversity, frequency of use, and method of development. These systems were critically analyzed, and the content of each category was compared and aggregated where appropriate. A hierarchy of categories was constructed to include all content from all systems. Any modifications that previous studies may have made to the 7 systems were also cross-referenced to ensure that no concepts were missing from the newly aggregated system. Clinical examples to optimize application, and instructions for when or when not to use categories, were developed. Interrater agreement for classification of the causes of DRPs from 10 medication reviews was performed between 3 clinical pharmacists and the authors’ gold standard. Results: We found variation in developmental methods, category descriptions, number and types of categories, and validation methods between the 7 selected systems, together with intermingling of categories identified as causes of DRPs with DRPs themselves. A hierarchical classification system was constructed consisting of 9 cause-of-DRP categories, 33 subcategories, and 58 sub-subcategories, for which interrater agreements were 82.5%, 74.6%, and 58.8%, respectively. Conclusion: An aggregated classification system was constructed through a unique and transparent developmental process that may provide the most comprehensive description of causes of DRPs to date. This may facilitate teaching of pharmaceutical care, comparisons of clinical practice, and measurement of the effectiveness of pharmaceutical care interventions.

Medication-related burden and patients’ lived experience with medicine: a systematic review and metasynthesis of qualitative studies

Objective To explore medication-related burden (MRB) and patients’ lived experience with medicines (PLEM) without regard to particular medication therapies or medical conditions. Design Systematic review and metasynthesis of qualitative studies. Data sources MEDLINE, EMBASE, International Pharmaceutical Abstracts, PsycINFO, Global health, CINAHL and Web of Science were searched from January 2000 to August 2014 using medication burden and patients’ lived experience terms. Synthesis methods Synthesis was undertaken following metaethnography methods and a comparative thematic analysis technique. Results 34 articles from 12 countries with a total of 1144 participants were included. 3 major inter-related themes emerged central to PLEM: MRB, medication related beliefs and medication taking practice. The negative impact of MRB, due to its interference on patients’ daily lives and effects on well-being, its influence on patients’ beliefs and behaviours, and a potential risk for drug-related problems (DRPs) was evident. This resulted in non-adherence and poorer outcomes (unachieved therapeutic goals and damage to patients’ health). Patients who experienced MRB interference in their life over time begin to juggle their medicines. Others continue their medicines despite experiencing MRB resulting in compromised physical, social or psychological well-being. Conclusions There is a shared commonality of PLEM among the studies. MRB plays a central role in influencing patients’ health and well-being, beliefs and behaviour towards medicines. Given the complexity of MRB and its impact evident from this review, there is a need for healthcare practitioners to have insight into PLEM in therapeutic care plans. Understanding PLEM is an opportunity for practitioners to identify particular MRBs that patients encounter, and provide individualised care through selection of therapeutic care plans that suit a patients life. This may assist in helping to achieve patients’ medication-related needs, and improve medication therapy and health outcomes.

Application of a prescribing indicators tool to assist in identifying drug-related problems in a cohort of older Australians.

Objective  Drug‐related problems (DRPs) are common in older people, resulting in a disproportionate number of serious medication adverse events. Pharmacist‐led interventions have been shown to be effective in identifying and reducing DRPs such as medication interactions, omission of recommended medications and use of ineffective medications. In 2008 we proposed a prescribing indicators tool to assist in identifying DRPs as part of the Australian medication review process. The objective was to apply the proposed prescribing indicators tool to a cohort of older Australians, to assess its use in detecting potential DRPs.

Patients’ willingness to use a pharmacist-provided medication management service: The influence of outcome expectancies and communication efficacy

BACKGROUND Previous research has demonstrated that some patients who are at risk of experiencing medication-related problems express a lack of willingness to use pharmacist-provided medication management services. Little is known about the factors that influence willingness to use these services among patients who have not yet experienced the service. OBJECTIVES The aim of this study was to test a model of willingness to use the Australian Home Medicines Review (HMR) service. Specifically, this study aimed to determine the influence of positive and negative outcome expectancies and communication efficacy over willingness among patients who were eligible to receive the service but have not yet experienced it. METHODS A cross-sectional survey was conducted with patients who were recruited by 264 community pharmacists throughout Australia. Patients were included in the study if they had not yet experienced HMR but were taking more than 5 medicines daily or more than 12 doses daily. Measurement scales were developed using exploratory and confirmatory factor analyses. Structural equation modeling was used to test the model. RESULTS Questionnaires received from 286 patients (15.6%) were analyzed. Multi-item measurement scales were observed to have acceptable construct reliabilities (range, 0.69-0.94). Importantly, respondents held overall neutral expectations about the personal benefits of HMR (positive outcome expectancies) but high communication efficacy. Structural equation modeling revealed that positive outcome expectancies (β=0.56, P<.001) and communication efficacy (β=0.25, P<.05) influenced willingness to use, whereas negative outcome expectancies had no significant effect. CONCLUSIONS The extent to which patients believe that HMR would provide them with increased medicines knowledge, improve their medicines management capability, and reduce their medicine concerns had a significant influence over willingness to use the service. Because these expectancies are relatively low, there appears to be significant scope for increasing patient demand for these services. Patient-directed material about medication management services should highlight the provision of medication information.