Complex Pharmaceutical Care intervention in Pulmonary Care

Evolutionary trend analysis of the pharmaceutical management research field from the perspective of mapping the knowledge domain

Background

Pharmaceutical management is a new frontier subject between pharmacy, law and management, and related research involves the whole process of drug development, production, circulation and use. With the development of medical systems and the diversification of patients' drug needs, research in the field of pharmaceutical management is becoming increasingly abundant. To clarify the development status of this field, this study conducted a bibliometric analysis of relevant literature in the field based on the knowledge graph method for the first time and explored the evolutionary trends of research hotspots and frontiers.

Methods

Literature was obtained from the Web of Science Core Collection database. CiteSpace 6.2.R4 (Advanced), VOSViewer, Scimago Graphica, Pajek and the R programming language were used to visualize the data.

Results

A total of 12,771 publications were included in the study. The publications in the field of pharmaceutical management show an overall increasing trend. In terms of discipline evolution, early research topics tended to involve the positioning of pharmacists and pharmaceutical care and the establishment of a management system. From 2000 to 2005, this period tended to focus on clinical pharmacy and institutional norms. With the development of globalization and the market economy, research from 2005 to 2010 began to trend to the fields of drug markets and economics. From 2010 to 2015, research was gradually integrated into health systems and medical services. With the development of information technology, after 2015, research in the field of pharmaceutical management also began to develop in the direction of digitalization and intelligence. In light of the global pandemic of COVID-19, research topics such as drug supply management, pharmaceutical care and telemedicine services under major public health events have shown increased interest since 2020.

Conclusion

Based on the knowledge mapping approach, this study provides a knowledge landscape in the field of pharmaceutical management research. The results showed that the reform of pharmacy education, the challenge of drug management under the COVID-19 pandemic, digital transformation and the rise of telemedicine services were the hot topics in this field. In addition, the research frontier also shows the broad prospects of the integration of information technology and pharmaceutical management, the practical value of precision pharmaceutical services, the urgent need of global drug governance, and the ethical and legal issues involved in the application of artificial intelligence technology in drug design, which points out the direction for the future development of pharmaceutical practice.

The effect of a pharmacy-led transitional care program on medication-related problems post-discharge: A before-After prospective study

BACKGROUND

Medication-related problems are common after hospitalization, for example when changes in patients' medication regimens are accompanied by insufficient patient education, poor information transfer between healthcare providers, and inadequate follow-up post-discharge. We investigated the effect of a pharmacy-led transitional care program on the occurrence of medication-related problems four weeks post-discharge.

METHODS

A prospective multi-center before-after study was conducted in six departments in total of two hospitals and 50 community pharmacies in the Netherlands. We tested a pharmacy-led program incorporating (i) usual care (medication reconciliation at hospital admission and discharge) combined with, (ii) teach-back at hospital discharge, (iii) improved transfer of medication information to primary healthcare providers and (iv) post-discharge home visit by the patient's own community pharmacist, compared with usual care alone. The difference in medication-related problems four weeks post-discharge, measured by means of a validated telephone-interview protocol, was the primary outcome. Multiple logistic regression analysis was used, adjusting for potential confounders after multiple imputation to deal with missing data.

RESULTS

We included 234 (January-April 2016) and 222 (July-November 2016) patients in the usual care and intervention group, respectively. Complete data on the primary outcome was available for 400 patients. The proportion of patients with any medication-related problem was 65.9% (211/400) in the usual care group compared to 52.4% (189/400) in the intervention group (p = 0.01). After multiple imputation, the proportion of patients with any medication-related problem remained lower in the intervention group (unadjusted odds ratio 0.57; 95% CI 0.38-0.86, adjusted odds ratio 0.50; 95% CI 0.31-0.79).

CONCLUSIONS

A pharmacy-led transitional care program reduced medication-related problems after discharge. Implementation research is needed to determine how best to embed these interventions in existing processes.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications.

OBJECTIVES

The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes.

SEARCH METHODS

We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome.

MAIN RESULTS

The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.

AUTHORS' CONCLUSIONS

Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.

Identification of drug-related problems of elderly patients discharged from hospital

BACKGROUND

Drug-related problems (DRP) following hospital discharge are common among elderly patients using multiple drugs for the treatment of chronic diseases. The aim of this study was to investigate the occurrence of DRP in these patients using a specific tool for the identification of DRP by community pharmacists.

METHODS

An observational study involving 340 patients aged over 60 years using at least five prescription drugs and discharged from hospital. The occurrence of DRP was assessed by means of an identification tool specifically developed for use by community pharmacists, including a semistructured patient interview and a checklist of common DRP.

RESULTS

In total, 992 potential DRP were observed in the 340 patients (mean 2.9 ± 1.7). No drug prescribed but clear indication, an unnecessarily long duration of treatment, dose too low, and incorrect drug selection were the DRP most commonly observed. Ten percent of DRP occurring in 71 patients were drug-drug interactions. The number of DRP was related to the number of drugs prescribed. Frequently occurring DRP found using the patient interview were fear of side effects and no or insufficient knowledge of drug use. Medication of patients discharged from the pulmonary department and of those with type 2 diabetes was particularly associated with occurrence of DRP.

CONCLUSION

Following hospital discharge, DRP occur frequently among elderly patients using five or more drugs for the treatment of chronic disease. The number of DRP increased with the number of drugs used. An important task for community pharmacists is to identify, resolve, and prevent the occurrence of DRP among this patient group. Since DRP are associated with an increased risk of hospital readmissions, morbidity, and mortality, it is very important to develop intervention strategies to resolve and prevent DRP.

The pharmacists' potential to provide targets for interventions to optimize pharmacotherapy in patients with asthma

BACKGROUND

Despite of pharmacists' specialized knowledge of medication and his/her regular contact with patients, the expertise of the pharmacist may not be used enough yet. Furthermore, the potential of pharmacy dispensing data is underestimated.

OBJECTIVE

To provide targets for tailored interventions in asthma patients and to illustrate the potential value of pharmacists in the identification of these targets using individual pharmacy dispensing data.

SETTING

We performed a cross sectional retrospective analysis assessing the quality of asthma patients' pharmacotherapeutic treatment.

METHOD

Drug dispensing data from 2008 to 2009 were retrieved from a Dutch pharmacy database. All asthma patients were screened for potential suboptimal pharmacotherapy in 2009. Results were projected to a single community pharmacy to provide an estimate of the number of patients eligible for potential interventions.

MAIN OUTCOME MEASURES

(1) frequent use of short-acting β-agonists without preventive medication, (2) concomitant use of β-blockers, (3) multiple short courses of oral corticosteroids without using inhaled corticosteroids and 4) use of long-acting β-agonist without inhaled corticosteroids.

RESULTS

A total of 8,504 patients were eligible for analysis of the quality of their asthma treatment. 20.9 % of all asthma patients used >100 DDD short-acting β-agonists per year, whereas between 21.2 % (≥ 400 DDD) and 31.4 % (100-199 DDD) of these patients did not receive preventive medication. Approximately 5.2 % of the asthma patients are using β-blockers concomitantly and 21.8 % of them received non-cardioselective β-blockers. 6.3 % of the asthma patients received two or more oral courses of corticosteroids in 2008 and 17.4 % of these patients did not receive inhaled corticosteroids in 2009. 2.9 % of the patients used a long-acting β-agonists without inhaled corticosteroids. 8.4 % of the asthma patients using both long-acting β-agonists and inhaled corticosteroids received these drugs in two separate inhalers. We estimated that about 400 asthma patients could be identified in an average pharmacy population (8,000 patients) and 33 (95 % CI 22-44) of these patients would be eligible for interventions.

CONCLUSION

This study shows the potential for pharmacists to use their own pharmacy records to identify suboptimal therapy of asthma patients, who may be targets for tailored interventions.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

MAIN RESULTS

For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 81 interventions reported in 69 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

AUTHORS' CONCLUSIONS

For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Complex Pharmaceutical Care Intervention in Pulmonary Care

OBJECTIVE

The IPMP study (Interventions on the principle of Pulmonary Medication Profiles) investigates and describes the results of complex pharmaceutical care interventions provided to selected pulmonary patients to improve their drug use. This paper describes the patients' opinions about the care provided and the results of the intervention.

METHOD

Questionnaires investigating patients' opinions about provided pharmaceutical care were sent to 185 patients participating in the IPMP study after the intervention by their pharmacists had been finished. One year after the start of the intervention, patients were invited to a final consultation by their pharmacists to evaluate their drug use and their symptoms (n = 138). At this point in time pharmacists investigated the knowledge of the patients about the medication and their inhaler technique again.

MAIN OUTCOME MEASURE

The influence of the intervention on patients' symptoms. Change in drug-related problems, knowledge and skills concerning pulmonary medication after intervention. Satisfaction of the patients with the provided pharmaceutical care.

RESULTS

In total 141 out of 185 patients completed the questionnaire. Patients were satisfied with the intervention by their pharmacists and considered it important. The majority (67%) reported that they had learned more about their medication or the inhaler technique, resulting in significantly improved coping behaviour with their pulmonary medication compared with patients who valued the intervention as a nice conversation with their pharmacist only. Patients with improved ability to cope reported statistically significantly fewer symptoms compared with patients reporting no change in behaviour (chi-square test, P < 0.05). In the final consultation of 138 patients, pharmacists observed increased knowledge and skills and decreased drug-related problems. The patients concerned were pleased with the change in treatment and were more satisfied with their current medication as compared with their earlier reports.

CONCLUSION

Patients can be influenced effectively by the tailored intervention of pharmacists resulting in improved ability to cope with pulmonary medication and in fewer reported adverse effects and symptoms. Patients attributed these results to the intervention of the pharmacists.