Evidence-based and pragmatic steps for pharmacists to improve patient adherence

All strategies and tools to improve the potential outcomes of medications therapy are a waste of time if the clients do not take their medication as prescribed. The aim of this paper is to help pharmacists to help their clients to improve outcomes of medicines based on improving their compliance to evidence-based pharmacotherapy. To reach a good compliance (result), you have to have agreement and concordance (method) between the practitioner and the client. Barriers and strategies for this, including identifying compliance problems and reasons for it, methods for improving information and communication, the client's participation, and responsibility for their own health, are presented mainly based on Cochrane reviews. Also some general pragmatic suggestions for how pharmacists can assist their clients the best are given.

Inhibition of sodium-linked glucose reabsorption normalizes diabetes-induced glomerular hyperfiltration in conscious adenosine A₁-receptor deficient mice

AIM

Glomerular hyperfiltration is commonly observed in diabetics early after the onset of the disease and predicts the progression of nephropathy. Sustained hyperglycaemia is also closely associated with kidney hypertrophy and increased electrolyte and glucose reabsorption in the proximal tubule. In this study, we investigated the role of the increased tubular sodium/glucose cotransport for diabetes-induced glomerular hyperfiltration. To eliminate any potential confounding effect of the tubuloglomerular feedback (TGF) mechanism, we used adenosine A₁-receptor deficient (A1AR(-/-)) mice known to lack a functional TGF mechanism and compared the results to corresponding wild-type animals (A1AR(+/+)).

METHODS

Diabetes was induced by an intravenous bolus injection of alloxan. Glomerular filtration rate (GFR) was determined in conscious mice by a single bolus injection of inulin. The sodium/glucose cotransporters were inhibited by phlorizin 30 min prior to GFR measurements.

RESULTS

Normoglycaemic animals had a similar GFR independent of genotype (A₁AR(+/+) 233 ± 11 vs. A₁AR(-/-) 241 ± 25 μL min(-1)), and induction of diabetes resulted in glomerular hyperfiltration in both groups (A₁AR(+/+) 380 ± 25 vs. A₁AR(-/-) 336 ± 35 μL min(-1); both P < 0.05). Phlorizin had no effect on GFR in normoglycaemic mice, whereas it reduced GFR in both genotypes during diabetes (A₁AR(+/+) 365 ± 18 to 295 ± 19, A₁AR(-/-) 354 ± 38 to 199 ± 15 μL min(-1); both P < 0.05). Notably, the reduction was more pronounced in the A₁AR(-/-) (P < 0.05).

CONCLUSION

This study demonstrates that increased tubular sodium/glucose reabsorption is important for diabetes-induced hyperfiltration, and that the TGF mechanism is not involved in these alterations, but rather functions to reduce any deviations from a new set-point.

Health economic evaluation of the Lund Integrated Medicines Management Model (LIMM) in elderly patients admitted to hospital

OBJECTIVE

To evaluate the cost effectiveness of a multidisciplinary team including a pharmacist for systematic medication review and reconciliation from admission to discharge at hospital among elderly patients (the Lund Integrated Medicines Management (LIMM)) in order to reduce drug-related readmissions and outpatient visits.

METHOD

Published data from the LIMM project group were used to design a probabilistic decision tree model for evaluating tools for (1) a systematic medication reconciliation and review process at initial hospital admission and during stay (admission part) and (2) a medication report for patients discharged from hospital to primary care (discharge part). The comparator was standard care. Inpatient, outpatient and staff time costs (Euros, 2009) were calculated during a 3-month period. Dis-utilities for hospital readmissions and outpatient visits due to medication errors were taken from the literature.

RESULTS

The total cost for the LIMM model was €290 compared to €630 for standard care, in spite of a €39 intervention cost. The main cost offset arose from avoided drug-related readmissions in the Admission part (€262) whereas only €66 was offset in the Discharge part as a result of fewer outpatient visits and correction time. The reduced disutility was estimated to 0.005 quality-adjusted life-years (QALY), indicating that LIMM was a dominant alternative. The probability that the intervention would be cost-effective at a zero willingness to pay for a gained QALY compared to standard care was estimated to 98%.

CONCLUSIONS

The LIMM medication reconciliation (at admission and discharge) and medication review was both cost-saving and generated greater utility compared to standard care, foremost owing to avoided drug-related hospital readmissions. When implementing such a review process with a multidisciplinary team, it may be important to consider a learning curve in order to capture the full advantage.

In-hospital medication reviews reduce unidentified drug-related problems

PURPOSE

To examine the impact of a new model of care, in which a clinical pharmacist conducts structured medication reviews and a multi-professional team collates systematic medication care plans, on the number of unidentified DRPs in a hospital setting.

METHODS

In a prospective two-period study, patients admitted to an internal medicine ward at the University Hospital of Lund, Sweden, were included if they were ≥ 65 years old, used ≥ 3 medications on a regular basis and had stayed on the ward for ≥ 5 weekdays. Intervention patients were given the new model of care and control patients received conventional care. DRPs were then retrospectively identified after study completion from blinded patient records for both intervention and control patients. Two pairs of evaluators independently evaluated and classified these DRPs as having been identified/unidentified during the hospital stay and according to type and clinical significance. The primary endpoint was the number of unidentified DRPs, and the secondary endpoints were the numbers of unidentified DRPs within each type and clinical significance category.

RESULTS

The study included a total of 141 (70 intervention and 71 control) patients. The intervention group benefited from a reduction in the total number of unidentified DRPs per patient during the hospital stay: intervention group median 1 (1st-3rd quartile 0-2), control group 9 (6-13.5) (p < 0.001), and also in the number of medications associated with unidentified DRPs per patient: intervention group 1 (0-2), control group 8 (5-10) (p < 0.001). All sub-categories of DRPs that were frequent in the control group were significantly reduced in the intervention group. Similarly, the DRPs were less clinically significant in the intervention group.

CONCLUSIONS

A multi-professional team, including a clinical pharmacist, conducting structured medication reviews and collating systematic medication care plans proved very effective in reducing the number of unidentified DRPs for elderly in-patients.

Clinical implementation of systematic medication reconciliation and review as part of the Lund Integrated Medicines Management model--impact on all-cause emergency department revisits

WHAT IS KNOWN AND OBJECTIVE

Interventions involving medication reconciliation and review by clinical pharmacists can reduce drug-related problems and improve therapeutic outcomes. The objective of this study was to examine the impact of routine admission medication reconciliation and inpatient medication review on emergency department (ED) revisits after discharge. Secondary outcomes included the combined rate of post-discharge hospital revisits or death.

METHODS

This prospective, controlled study included all patients hospitalized in three internal medicine wards in a university hospital, between 1 January 2006 and 31 May 2008. Medication reconciliation on admission and inpatient medication review, conducted by clinical pharmacists in a multiprofessional team, were implemented in these wards at different times during 2007 and 2008 (intervention periods). A discharge medication reconciliation was undertaken in all the study wards, during both control and intervention periods. Patients were included in the intervention group (n = 1216) if they attended a ward with medication reconciliation and review, whether they had received the intervention or not. Control patients (n = 2758) attended the wards before implementation of the intervention.

RESULTS AND DISCUSSION

No impact of medication reconciliation and reviews on ED revisits [hazard ratio (HR), 0.95; 95% confidence interval (CI), 0.86-1.04]or event-free survival (HR, 0.96; 95% CI, 0.88-1.04) was demonstrated. In the intervention group, 594 patients (48.8%) visited the ED, compared with 1416 (51.3%) control patients. In total, 716 intervention (58.9%) and 1688 (61.2%) control patients experienced any event (ED visit, hospitalization or death). Because the time to a subsequent ED visit was longer for the control as well as the intervention groups in 2007 than in 2006 (P < 0.05), we re-examined this cohort of patients; the proportion of patients revisiting the ED was similar in both groups in 2007 (P = 0.608).

WHAT IS NEW AND CONCLUSION

Routine implementation of medication reconciliation and reviews on admission and during the hospital stay did not appear to have any impact on ED revisits, re-hospitalizations or mortality over 6-month follow-up.

Errors in medication history at hospital admission: prevalence and predicting factors

Background

An accurate medication list at hospital admission is essential for the evaluation and further treatment of patients. The objective of this study was to describe the frequency, type and predictors of errors in medication history, and to evaluate the extent to which standard care corrects these errors.

Methods

A descriptive study was carried out in two medical wards in a Swedish hospital using Lund Integrated Medicines Management (LIMM)-based medication reconciliation. A clinical pharmacist identified each patient's most accurate pre-admission medication list by conducting a medication reconciliation process shortly after admission. This list was then compared with the patient's medication list in the hospital medical records. Addition or withdrawal of a drug or changes to the dose or dosage form in the hospital medication list were considered medication discrepancies. Medication discrepancies for which no clinical reason could be identified (unintentional changes) were considered medication history errors.

Results

The final study population comprised 670 of 818 eligible patients. At least one medication history error was identified by pharmacists conducting medication reconciliations for 313 of these patients (47%; 95% CI 43-51%). The most common medication error was an omitted drug, followed by a wrong dose. Multivariate logistic regression analysis showed that a higher number of drugs at admission (odds ratio [OR] per 1 drug increase = 1.10; 95% CI 1.06-1.14; p < 0.0001) and the patient living in their own home without any care services (OR = 1.58; 95% CI 1.02-2.45; p = 0.042) were predictors for medication history errors at admission. The results further indicated that standard care by non-pharmacist ward staff had partly corrected the errors in affected patients by four days after admission, but a considerable proportion of the errors made in the initial medication history at admission remained undetected by standard care (OR for medication errors detected by pharmacists' medication reconciliation carried out on days 4-11 compared to days 0-1 = 0.52; 95% CI 0.30-0.91; p=0.021).

Conclusions

Clinical pharmacists conducting LIMM-based medication reconciliations have a high potential for correcting errors in medication history for all patients. In an older Swedish population, those prescribed many drugs seem to benefit most from admission medication reconciliation.