Steve Hudson

Appropriateness of prescribing among elderly patients in a dutch residential home observational study of outcomes after a pharmacist-led medication review

AbstractBackground: Clinically significant pharmacokinetic and pharmacodynamic changes occurring with age make older patients more prone to the consequences of inappropriate prescribing. The combination of higher use of medicines resulting from a higher disease burden with suboptimal treatment monitoring results in a higher risk of unwanted drug effects from sometimes inappropriate choice of drugs, doses and durations of treatment. Pharmacy services are increasingly being targeted to minimize the overall number of unnecessary and potential harmful medicines.n Objective: To investigate the impact of a pharmacist-led medication review on quality of prescribing by a healthcare professional team consisting of a general practitioner (GP), care home staff and a pharmacist.n Methods: This observational study compared outcome measurements before and after a pharmacist-led review of medications for patients under the care of a healthcare professional team consisting of a GP, care home staff and pharmacist. The procedure for conducting and recording the medication review consisted of the preparation of a patient medication profile, which combined the patient’s medical records with his or her complete prescription record (current and previous [last 3 years] medication history) and pharmaceutical record (electronic journal entries for the patient over the same period). Laboratory values were evaluated in clinical context. Recommendations for the pharmaceutical plan were discussed at a conference involving the clinical pharmacist and other healthcare team members. Patients were recruited for medication review over the 12-month period 1 April 2003 to 1 April 2004. Medication appropriateness was assessed by an independent panel of clinical pharmacists using the Medication Appropriateness Index (MAI).n Results: A total of 54 patients were eligible according to the inclusion criteria, of whom 24 were subsequently excluded for various reasons; thus, 30 patients were eligible for assessment on the MAI. There was a statistically significant difference between overall pre- and post-intervention summed MAI scores (p = 0.013). The pharmacist identified 115 drug-related problems, and the total number of accepted recommendations was 78 (67.8%). Use of a medication review as an intervention by a clinical pharmacist was associated with an improvement in appropriateness of prescribing.n Conclusion: This study provides evidence supporting the formal integration of a clinical pharmacist into the healthcare team with the aim of improving prescribing appropriateness for institutionalized elderly Dutch patients. Overall MAI scores for all long-term medications used by a group of elderly patients improved significantly after a pharmacist-led medication review. This is an important finding because quality of prescribing is assuming increasing importance as a means of preventing avoidable medication-related harm.

Scottish pharmacists' views and attitudes towards continuing professional development

Objectives To summarise Scottish pharmacists’ views and attitudes towards Continuing Professional Development (CPD). Setting Random sample of RPSGB registered Scottish pharmacists. Method A postal questionnaire of pharmacists’ CPD activity, views and attitudes was developed, piloted and sent to 2420 pharmacists. Questions were collated to produce total scores and to rate pharmacists’ motivation and attitudes to CPD separately. The number of CPD hours reported by sector and gender were compared (‘t’ test) and differences identified between hospital, community and primary care in relation to mean motivational attitudinal scores (Mann-Whitney test). Results Five hundred and forty three pharmacists completed the questionnaire (22.4% response rate). In this study 9.8% of the pharmacists reported spending no time on CPD. Comparisons of hours showed primary care pharmacists and hospital pharmacists reported similar times spent on CPD and significantly more time than community pharmacists (68xa0h and 66xa0h vs 45xa0h; Pxa0<xa00.05). No statistically significant differences between genders were revealed. Internal reliability on motivation and attitude scores ranged from 0.74–0.83 (Cronbach’s alpha). Although scores were similar across sectors of practice in terms of motivation and attitudinal questions, statistical differences were consistent; showing higher scores for separate motivation and attitude among pharmacists in primary care than in hospital or community practice sectors (Mann Whitney test; Pxa0<xa00.001). Community pharmacists had a statistically significantly lower attitude score than pharmacists in hospital or primary care sectors (Mann Whitney test; Pxa0<xa00.001). Conclusion There is a section of pharmacists still not participating in CPD. Primary care pharmacists reported most motivation and scored highest in attitude score. Community pharmacists appear to be the sector requiring most support to increase not only their motivation to CPD but also their confidence and ability in participation.

Design and validation of a medication assessment tool for cancer pain management

ObjectiveA clinical tool to examine prescribing in cancer pain management may provide a means to help establish acceptable standards of adherence to treatment guidelines. The study aim was to design and validate a Medication Assessment Tool for Cancer Pain Management (MAT-CP).SettingHospitals in Northern NorwayMethodThe MAT-CP was designed from guideline criteria based on a previously developed method. The tool was validated by peer review before and during field-testing on a study sample of cancer patients experiencing pain.Main outcome measurePerceived relevance, utility, and clarity of individual criteria, and reliability of their application to clinical documentation. Frequency of adherence to agreed definitions of guideline criteria.ResultsThe final tool comprised 36 criteria covering six different aspects of cancer pain management: (1) pain assessment and information transfer, (2) start of strong opioid therapy; (3) current continuous analgesia; (4) current intermittent analgesia; (5) follow-up of therapy, and; (6) other care issues. The tool was tested on 109 cancer patients experiencing pain (57 males), mean (SD) age 60.8 (11.5)xa0years. Guideline adherence overall was 61% (nxa0=xa01704 applicable criteria). The field-testing informed the modification of the MAT-CP to optimise its clarity and utility when applied to patients’ clinical documentation. Good inter- and intra-rater reliability (Cohen’s kappa κxa0=xa00.86 and κxa0=xa00.95, respectively) were demonstrated in the application. The preliminary application of the tool during field-testing has highlighted the following for further study: (a) Low adherence (<50%) to 14 standards concerning start of opioid treatment and pain therapy follow-up, clinical assessment of risk of gastro-intestinal adverse effects among patients on non-steroidal anti-inflammatory drugs (NSAID), current treatment of breakthrough pain, management of nausea/vomiting; (b) High adherence (>75%) to standards of prescribing of continuous analgesia.ConclusionA clinical tool to examine prescribing in cancer pain management has been designed. Face and content validity have been informed by field-testing. The tool requires further study among palliative care specialists as part of the validation required before it can be recommended for clinical use.

Adherence to medication guideline criteria in cancer pain management

The medication-assessment tool for cancer pain management (MAT-CP) is a novel tool for measuring the quality of drug use in chronic pain management in relation to guideline standards. MAT-CP has recently been revised and validated for use in the U.K. clinical setting. This article presents a measure of the adherence of current practice to specific cancer pain guideline criteria in two palliative care settings. Adult patients with malignant disease experiencing pain and/or receiving analgesics were identified by clinical pharmacists at two hospitals and five hospices in Scotland, United Kingdom. The MAT-CP was applied to data extracted from case notes. Results were quantified in terms of applicability and adherence to guideline criteria and the presence of insufficient data. MAT-CP was applied to 192 cancer patients experiencing pain; 103 (54%) were males and the mean (standard deviation) age was 68.5 (13.0) years. Overall guideline adherence was 75% (confidence interval [CI]: 74%, 77%; n=3460 applicable criteria). Low adherence (<50%) was seen for nine criteria, whereas 21 criteria were considered high-adherence criteria (>75%). Overall adherences for 56 (29%) hospitalized patients and 136 (71%) hospice patients were 65% (CI: 62%, 68%) and 79% (CI: 78%, 81%), respectively. Although good overall guideline adherence was found, there were gaps in both the hospice and hospital palliative care settings in the implementation of certain treatment recommendations, particularly in relation to pain assessment. The application of the tool has highlighted issues for feedback to health care providers and for further study.

Adherence to clinical guidelines in the prevention of coronary heart disease in type II diabetes mellitus

Objective The study aimed to assess adherence of prescribed medication in primary care to nationally recognised guideline criteria using case note review applying a previously developed medication assessment tool for coronary heart disease (MAT-CHD). Setting Primary care medical centre serving 17,991 patients. A sample of 208 from 463 patients with type 2 diabetes aged 20–75xa0years with or without a history of ischaemic heart disease (IHD). Method Patients’ records were accessed via medical and pharmacy databases. The criteria of the 23-item audit tool were applied to medical records from case notes in order to quantify adherence to individual guideline criteria. Main outcome measure Frequency of adherence to agreed definitions of medication use quality criteria. Results A total of 1,433 guideline criteria were applied and 1,107 (77.2%, CI: 75.0, 79.4) criteria standards were met with 326 (22.7%, CI: 20.6, 25.0) non-adherences. The overall adherence to guideline criteria was significantly lower for secondary prevention than for primary prevention (74.4 vs. 80.1%, Pxa0<xa00.05; Chi square). Justification recorded in the case notes was identified for 54 (17%, CI: 13, 21) of those non-adherences. Conclusion The MAT-CHD highlighted areas for review and possible improvement. The tool can be used in primary care from case record examination and offers a means of co-operation between community pharmacists and general practitioners in clinical guideline implementation.

The need for pharmaceutical care in the prevention of coronary heart disease: an exploratory study in acute myocardial infarction patients.

Aim: To determine guideline-related pharmaceutical care issues for the prevention of coronary heart disease in hospitalised patients admitted for myocardial infarction (MI).Methods: Consecutive patients admitted with a diagnosis of Q-wave MI to two large teaching hospitals were studied. Relevant patient medical and drug histories, co-morbidities and total cholesterol concentrations were recorded. Primary or secondary prevention treatment prior to admission was assessed using a data collection tool of 16 criteria developed from the Scottish Intercollegiate Guidelines Network (SIGN) guidelines.Main outcome measures: Frequency of adherence to defined clinical guideline criteria.Results: There were 167 patients reviewed (mean age 65 years, 111 males), representing possible candidates for primary prevention (n=98) or secondary prevention (n=69) based on absence or presence of past history of coronary heart disease (CHD), respectively. Possible primary prevention candidates: eight guideline-based criteria were developed from the SIGN guideline. There were 85 (87%) patients with a total cholesterol concentration available on admission of whom 56 (66%) had a predicted CHD risk ≥xa015% and 10 (12%) had CHD risk ≥xa030%. Of those with CHD risk ≥xa015% 6 (11%) had been receiving an anti-platelet agent and of those with CHD risk ≥xa030% only 1 (10%) was recorded as taking a statin. Of known hypertensives with CHD risk ≥xa015%, 21% (5/24) were not recorded as having received treatment. Secondary prevention candidates: a further eight guideline-based criteria were developed from the SIGN guidelines. There were 42/65 (65%) candidates for aspirin documented as receiving it. There were 22/47 (47%) of those who had a total cholesterol ≥xa05mmol/l and/or known history of hypercholesterolaemia receiving a statin (representing 76% of the known hypercholesterolaemic patients identified in the community). Of statin-treated patients with a cholesterol measured on admission, 44% (7/16) had cholesterol remaining ≥xa05mmol/l. β-blocker use was 27/62 (44%) and ACE inhibitors use was 11/31 (36%) of those eligible. Sublingual GTN was recorded in 36/69 (52%).Conclusion: The study has identified opportunities for improved pharmaceutical care in primary and secondary CHD prevention among those destined to suffer an MI. Candidates for secondary prevention are potentially identifiable from community pharmacy patient medication records from which the contribution of pharmacists in primary care might be targeted. The findings were obtained during a period of evolution of the evidence-base and so they establish a baseline for future work.

Pharmaceutical care of the patient with diabetes mellitus: pharmacists' priorities for services and educational needs in Scotland

Objective To determine the extent of service provision by pharmacists in Scotland to patients with diabetes. Also, to investigate pharmacists perceived education needs and their priorities for future service development to this patient group.

Factors affecting the views and attitudes of Scottish pharmacists to continuing professional development.

Objectivesu2002 To explore factors associated with Scottish pharmacists views and attitudes to continuing professional development (CPD).

Scenario analysis of the future of clinical pharmacy

The role of clinical pharmacy in the health care system is changing rapidly. This change is almost universal among different countries and is related to developments in medical technology, health economics, informatics, socio‐economic status, and professional relations.Transitions to new systems of clinical pharmacy are difficult to anticipate. Even with well defined targets, it remains uncertain what the future of clinical pharmacy will bring us. The construction of plausible scenarios may help us better in preparing for the new world ahead.At the annual congresses of ESCP in Prague 1995 (24th) and Lisbon 1996 (25th), a number of scenario analysis workshops with respect to the future of clinical pharmacy were organized. This paper gives a report of the results of these scenario sessions and reflects on the implications for future policy making. After we identified the driving forces behind the future of clinical pharmacy, various sets of assumptions were made and from them scenarios were constructed which are plausible: they could happen. This analysis provided a logical framework in which we ultimately depicted three alternating stories of the future of clinical pharmacy, named CLERK, CONTROLLER and CARE MANAGER. These scenarios are intended to help clinical pharmasists to break free of familiar mental maps and to stimulate creative thinking on the future.

Medication assessment tool to detect care issues from routine data: a pilot study in primary care

Background Medication assessment tools (MATs) may be implemented in routine electronic data sources in order to identify patients with opportunities for optimisation of medication therapy management (MTM) and follow-up by a multi-disciplinary team. Objective (1) To demonstrate the use of a MAT for cardiovascular conditions (MATCVC) as a means of profiling potential opportunities for MTM optimisation in primary care and (2) to assess the performance of MATCVC in identifying actual opportunities for better care. Setting Members of a pharmacotherapy discussion group, i.e. two single-handed general practitioners (GPs), three GP partners, and community pharmacists (CPs) from each of two community pharmacies, in a rural part of the Netherlands. Methods MATCVC comprises 21 medication assessment criteria, each of which is designed to detect a specific care issue and to check whether it is ‘addressed’ by provision of guideline recommended care or ‘open’ in the presence (‘open explained’) or absence (‘open unexplained’) of pre-specified explanations for guideline deviations. (1) Relevant data was extracted from linked GP and CP electronic records and MATCVC assessment was conducted to profile the population of CVC patients registered with both, participating CPs and GPs, in terms of ‘open unexplained’ care issues. (2) A purposive sample of patients with ‘open unexplained’ care issues was reviewed by each patient’s GP. Main outcome measures Number and proportion of ‘open unexplained’ care issues per MATCVC criterion and per patient. The number of patients with MATCVC detected ‘open unexplained’ care issues to be reviewed (NNR) in order to identify one that requires changes in MTM. Results In 1,876 target group patients, MATCVC identified 6,915 care issues, of which 2,770 (40.1xa0%) were ‘open unexplained’. At population level, ten MATCVC criteria had particularly high potential for quality improvement. At patient level, 1,277 (68.1xa0%) target group patients had at least one ‘open unexplained’ care issue. For patients with four or more ‘open unexplained’ care issues, the NNR was 2 (95xa0% CI 2–2). Conclusion The study demonstrates potential ways of using MATCVC as a key component of a collaborative MTM system. Strategies that promote documentation and sharing of explanations for deviating from guideline recommendations may enhance the utility of the approach.