Quality indicators for pharmaceutical care: a comprehensive set with national scores for Dutch community pharmacies

Is there a need for standardization of medication counseling in community pharmacies?

Medication counseling is one of the most important duties in community pharmacies aiming to ensure rational pharmacotherapy and medication safety. However, based on research evidence, the quality of medication counseling in pharmacies is often low and shown to vary between different patient groups. This Commentary raises a question whether there is a need to standardize medication counseling in community pharmacies to ensure quality of care for every customer? The law obligates to counsel about medications when dispensing medicines in many countries, however, on a very general level. It seems clear that the general level in which medication counseling is required in law is not enough to ensure the quality of medication counseling, and thus, some standards are needed. However, these standards should take into account the multidisciplinary nature of the pharmacotherapy process as well as the different patient groups and situations that patients face. Most importantly, such standards should not inhibit interaction between the patient and the pharmacist, and they should encourage tailored medication counseling that is based on the individual needs of the patient.

Developing a quality framework for community pharmacy: a systematic review of international literature

OBJECTIVE

To identify the defining features of the quality of community pharmacy (CP) services and synthesise these into an evidence-based quality framework.

DESIGN

Systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

International research evidence (2005 onwards) identified from six electronic databases (Embase, PubMed, Scopus, CINAHL, Web of Science and PsycINFO) was reviewed systematically from October 2022 to January 2023. Search terms related to 'community pharmacy' and 'quality'.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Titles and abstracts were screened against inclusion or exclusion criteria, followed by full-text screening by at least two authors. Qualitative, quantitative and mixed-method studies relevant to quality in CP were included.

DATA EXTRACTION AND SYNTHESIS

A narrative synthesis was undertaken. Following narrative synthesis, a patient and public involvement event was held to further refine the quality framework.

RESULTS

Following the title and abstract screening of 11 493 papers, a total of 81 studies (qualitative and quantitative) were included. Of the 81 included studies, 43 investigated quality dimensions and/or factors influencing CP service quality; 21 studies assessed patient satisfaction with and/or preferences for CP, and 17 studies reported the development and assessment of quality indicators, standards and guidelines for CPs, which can help define quality.The quality framework emerging from the global literature consisted of six dimensions: person-centred care, access, environment, safety, competence and integration within local healthcare systems. Quality was defined as having timely and physical access to personalised care in a suitable environment that is safe and effective, with staff competent in the dispensing process and pharmacy professionals possessing clinical knowledge and diagnostic skills to assess and advise patients relative to pharmacists' increasingly clinical roles.

CONCLUSION

The emerging framework could be used to measure and improve the quality of CP services. Further research and feasibility testing are needed to validate the framework according to the local healthcare context.

Pharmaceutical Care Network Europe definition of quality indicators for pharmaceutical care: a systematic literature review and international consensus development

BACKGROUND

Over the past 40 years, the tasks of pharmacists have shifted from logistic services to pharmaceutical care (PhC). Despite the increasing importance of measuring quality of care, there is no general definition of Quality Indicators (QIs) to measure PhC. Recognising this, a working group in a European association of PhC researchers, the Pharmaceutical Care Network Europe (PCNE), was established in 2020.

AIM

This research aimed to review existing definitions of QIs and develop a definition of QIs for PhC.

METHOD

A two-step procedure was applied. Firstly, a systematic literature review was conducted to identify existing QI definitions that were summarised. Secondly, an expert panel, comprised of 17 international experts from 14 countries, participated in two surveys and a discussion using a modified Delphi technique to develop the definition of QIs for PhC.

RESULTS

A total of 182 QI definitions were identified from 174 articles. Of these, 63 QI definitions (35%) cited one of five references as the source. Sixteen aspects that construct QI definitions were derived from the identified definitions. As a result of the Delphi study, the panel reached an agreement on a one-sentence definition of QIs for PhC: "quality indicators for pharmaceutical care are validated measurement tools to monitor structures, processes or outcomes in the context of care provided by pharmacists".

CONCLUSION

Building upon existing definition of QIs, an international expert panel developed the PCNE definition of QIs for PhC. This definition is intended for universal use amongst researchers and healthcare providers in PhC.

Validation of quality indicators for evaluating geriatric pharmacotherapy services in primary care: a mixed methods study

OBJECTIVE

To assess measurement properties of 121 face and content validated quality indicators (QIs) for medication safety in geriatric pharmacotherapy in primary care.

DESIGN

A mixed methods study: a 6-month observational study in primary care (July-December 2020) and in-depth semistructured online interviews with participants (February-March 2021).

SETTING

Sixty community pharmacies in Japan.

PARTICIPANTS

Patients aged 75 years and older who were regularly taking six or more prescription medicines for ˃4 weeks were eligible. The observational study included 457 patients. The interviews were undertaken with 26 community pharmacists, including pharmacy managers and owners.

PRIMARY AND SECONDARY OUTCOME MEASURES

Five measurement properties of QIs (applicability, improvement potential, acceptability, implementation issues and sensitivity to change) were evaluated. A web application was developed for data reporting and data visualisation.

RESULTS

This study showed that 53 QIs met the measurement properties of applicability, improvement potential, acceptability and implementation issues. Of 53 QIs, 17 also had a high sensitivity to change. Interviews identified eight themes (indicator characteristics, web application, policy, patient, time, competence, pharmacy administration and collaboration) in relation to the consequence of implementation of QIs.

CONCLUSIONS

A set of 121 QIs for geriatric pharmacotherapy was field tested for their five measurement properties. This QI set can be used to identify patients who may benefit from clinician reviews of their medicines. These QIs may be applied at different levels within the healthcare system: patient, pharmacy, regional and national levels. Further mechanisms to automatically collect and report data should be established to facilitate sustainable quality improvement initiatives.

Job Satisfaction and Burnout Levels of the Human Resources of a Public Oncology Hospital During the COVID-19 Pandemic

To investigate job satisfaction and burnout levels among the personnel of a public oncology hospital amid the COVID-19 pandemic, a cross-sectional survey was designed. The study was carried out from December 2021 to January 2022 through the application of an anonymous, structured, self-completed, closed-ended questionnaire, consisting of the Job Satisfaction Survey (JSS) and the Copenhagen Burnout Inventory (CBI) in a convenience sample comprised by 117 employees of "Agioi Anargyroi" General Oncology Hospital (response rate: 98%). It was observed that while overall job satisfaction was reduced, several of its determining dimensions like supervision, relationship with co-workers, or work nature were increased. Also, an average overall burnout of 49% was observed across all participants, with women, nurses, and those with a lower educational level experiencing it more intensely. The COVID-19 pandemic outbreak affected negatively healthcare professionals who experienced significant personal and occupational burnout, consequently reducing their job satisfaction.

Adherence to coprescribing of laxatives with opioids and associated characteristics in general practices in the Netherlands

BACKGROUND

Guidelines recommend to prescribe a laxative with an opioid to prevent constipation. We aimed to determine the adherence by general practitioners (GPs) to this recommendation and to explore which GP- and patient related factors were associated with it from the perspective of the GP.  METHODS: We conducted an observational study using GPs' prescription data from the Nivel Primary Care Database combined with a questionnaire asking for reasons of non-adherence. The proportion of first opioid prescriptions prescribed together with a laxative was determined as primary outcome. Possible explanatory factors such as the quality of registration, the level of collaboration with the pharmacy, familiarity with the recommendation and use of a clinical decision support system were explored, as were the self-reported reasons for non-adherence (classified as either GP-related or patient-related). We assessed the association of factors with the primary outcome using univariable multilevel logistic regression analysis.

RESULTS

The recommendation was measured in 195 general practices. The median proportion of first opioid prescriptions prescribed together with a laxative in these practices was 54% (practice range 18-88%). None of the determinants was consistently associated with the primary outcome. GPs from 211 practices filled out the questionnaire and the most frequently mentioned reason not to prescribe a laxative was that the patient has laxatives in stock, followed by that the patient doesn't want a laxative; both were patient-related factors.

CONCLUSION

There was room for improvement in following the guideline on laxative prescribing in opioid use. A main reason seemed to be that the patient refuses a laxative. Improvement measures should therefore focus on communication between GPs and patients on the relevance of co-using a laxative with opioids. Future studies need to establish the effect of such improvement measures, and determine whether reasons for non-adherence to the guideline changed over time.

Development and consensus testing of quality indicators for geriatric pharmacotherapy in primary care using a modified Delphi study

Background Polypharmacy is associated with an increased risk of adverse drug events in older people. Although national guidance on geriatric pharmacotherapy exists in Japan, tools to routinely monitor the quality of care provided by community pharmacists are lacking. Aim To develop a set of quality indicators (QIs) to measure the quality of care provided by community pharmacists in improving geriatric pharmacotherapy in primary care in Japan, using a modified Delphi study. Method The development of QIs for the Japanese community pharmacy context followed a two-step process: national guidance review and consensus testing using a modified Delphi study. The latter involved two rounds of rating with a face-to-face meeting between the rounds. Ten experts in geriatric pharmacotherapy in primary care were recruited for the panel discussion. QIs were mapped to three key taxonomies and frameworks: the Anatomical Therapeutic Chemical (ATC) classification system, problems and causes of drug-related problems (DRPs) taxonomy and Donabedian's framework. Results A total of 134 QIs for geriatric pharmacotherapy were developed. This QI set included 111 medicine specific indicators, covering medicines in 243 third-level ATC classifications. QIs were classified into the problem of treatment safety (80%) and causes of drug selection (38%) based on validated classification for DRPs. In Donabedian's framework, most QIs (82%) were process indicators. There were no structure indicators. Conclusion A set of 134 QIs for geriatric pharmacotherapy was rigorously developed. Measurement properties of these QIs will be evaluated for feasibility, applicability, room for improvement, sensitivity to change, predictive validity, acceptability and implementation issues in a subsequent study.

Prescriptions as quality indicators of pharmaceutical services in Polish community pharmacies

Background

Assessment of community pharmacies’ quality of service is a very difficult task, resulting from the multiplicity and variety of provided services as well as patient-related factors (i.e. their health condition, expectations, education level or cultural and social background). Although proceedings of pharmaceutical professionals are to a great extend legally determined and described in various acts and regulations, work diligence should be one of the most characteristic traits of a professional pharmacy employee. Many publications addressing the quality of services provided by pharmaceutical employees focus on patient satisfaction, here the authors focused on more objective methods i.e. prescription analysis.

Objective

The main aim of the study was to assess whether post-inspection National Health Fund reports would constitute a reliable source of quality assessment of pharmaceutical services provided by community pharmacies.

Methods

The study is an in-depth quality and quantity analysis of 28 post-inspection quarterly reports conducted by the National Health Fund between 2013 and 2019.

Results

Vast majority of inspections ended in stating a variety of irregularities.

Conclusions

The analysis of irregularities contained in the National Health Fund’s post-inspection reports does not seem an appropriate indicator of assessing the quality of pharmaceutical services provided in community pharmacies, because of its targeted character. Inappropriate performance of professional duties by staff members is the main source of irregularities in the implementation of prescriptions for reimbursable medications. There is a need to improve staffs’ professional competence and ultimately the quality of pharmaceutical services.

Deprescribing in the Older Patient: A Narrative Review of Challenges and Solutions

Polypharmacy is a major challenge in healthcare for older people, and is associated with increased risks of adverse outcomes, such as delirium, falls, frailty, cognitive impairment and hospitalization. There is significant public and professional interest in the role of deprescribing in reducing medication-related harms in older people. We aim to provide a narrative review of 1) the safety and efficacy of deprescribing interventions, 2) the challenges and solutions of deprescribing research and implementation in clinical practice, and 3) the benefits of using Computerized Clinical Decision Support Systems (CCDSS) and Quality Indicators (QIs) in deprescribing research and practice. Deprescribing is an established management strategy to minimize polypharmacy and potentially inappropriate medications. There is limited clinical evidence for its efficacy on global and geriatric outcomes. Various challenges at patient, healthcare professional and healthcare system levels may impact on the success of deprescribing interventions in research and practice. Management strategies that target all levels of the healthcare system are required to overcome these challenges. Future studies may consider large multicenter prospective designs to establish the effects and sustainability of deprescribing interventions on clinical outcomes.

Defining clinical pharmacy and support activities indicators for hospital practice using a combined nominal and focus group technique

Background Although clinical pharmacy is a crucial part of hospital pharmacist’s day-to-day activity, its performance is not usually subject to a holistic assessment. Objective To define a set of relevant and measurable clinical pharmacy and support activities key performance indicators (cpKPI and saKPI, respectively). Setting Portuguese Hospital Pharmacies. Method After a comprehensive literature review focusing on the metrics already in use in other countries, several meetings with directors of hospital pharmacies were conducted to obtain their perspectives on hospital pharmacy practices and existing metrics. Finally, five rounds with a panel of 8 experts were performed to define the final set of KPIs, where experts were asked to score each indicator’ relevance and measurability, and encouraged to suggest new metrics. Main outcome measure The first Portuguese list of KPIs to assess pharmacists’ clinical and support activities performance and quality in hospital pharmacies. Results A total of 136 KPIs were assessed during this study, of which 57 were included in the original list and 79 were later added by the expert panel. By the end of the study, a total of 85 indicators were included in the final list, of which 40 are considered to be saKPI, 39 cpKPI and 6 neither. Conclusion A set of measurable KPIs was established to allow for benchmarking within and between Portuguese hospital Pharmacies and to elevate professional accountability and transparency. Future perspectives include the use of both cpKPIs and saKPIs on a national scale to identify the most efficient performances and areas of possible improvement.

Design and validation of quality indicators for drug dispensing in a pediatric hospital

OBJECTIVES

This article presents a methodological strategy to design and validate quality indicators for drug dispensing in a pediatric hospital.

SETTING

The literature evaluation, design, and validation of indicators by experts were carried out from September 2017 to March 2018 in the pharmaceutical services of a pediatric hospital at the Autonomous University of the State of Hidalgo, Mexico.

PRACTICE DESCRIPTION

The design and validation of quality indicators for dispensing allow the evaluation, planning, and follow-up of this activity.

PRACTICE INNOVATION

The development of the indicators follows a holistic vision considering the relationship between the structure on which the pediatric dispensation is based, the involved processes, and the outcomes and provide a simple tool to improve the quality of the dispensing service.

EVALUATION

A methodological investigation for the development of systems and health services in drug dispensing was performed. For the indicator's design, the Mexican standards for establishments dedicated to the sale and supply of drugs, the Good Dispensation Practices, and the Donabedian model were considered. The validation of such indicators was carried out using the Delphi method and the Torgerson mathematical model.

RESULTS

Indicators of structure, process, and results were designed; of the 16 indicators designed, 15 reached the average score of greater than 3.5, and the percentage of experts who qualified each indicator in the highest categories was greater than 50%.

CONCLUSION

The design of indicators guarantees the quality of the dispensing service and can be extrapolated to the pharmaceutical services of any pediatric hospital.

Community and hospital pharmacists in Europe: encroaching on medicine?

Pharmacy has been historically regarded as a discipline between health and chemistry devoted to drug development, production, and compounding. These tasks have been almost lost with the industrial manufacturing, and dispensing remains the main activity of pharmacists. Hospital pharmacists are usually employees in their workplace, while the professional framework of community pharmacists is very different, being pharmacies predominantly private shops in almost all European countries. In the last years pharmacists have strongly advocated that the focus of their services should switch from 'product' to 'patient'. Clinical pharmacy and pharmaceutical care are the two most cited concepts to support this shift. Clinical pharmacy was originally defined as the area of pharmacy concerned with the science and practice of rational medication use, pharmaceutical care as the responsible provision of drug therapies to achieve definite outcomes. The practice of clinical pharmacy should embrace the philosophy of pharmaceutical care. The new wave of pharmacists' patient-centered care in Europe still seems to be a reaction against the loss of their traditional professional role after the drug manufacturing revolution. To depict a realistic scenario for progress, it is worth differentiating between hospital and community. Hospital pharmacists should strengthen their pivotal role of medication gatekeepers to improve among clinicians the appropriateness of drug prescriptions and generate savings in expenditures. Any proposal for clinical services provided by community pharmacists is inevitably affected by the issue of their potential remuneration, especially in countries where the remuneration for reimbursable drugs is still a proportion of the retail price.

Evaluating Pharmacist's Patient Care Process in Shiraz, using a newly-validated questionnaire: The First Report from Iran

Background:

The Pharmacists’ Patient Care Process (PPCP) as one of many inter-related foundations for the delivery of evidence-based and outcomes-focused patient care has a positive trend in academic literatures in the world. Unfortunately, PPCP has not been establish well in community pharmacies in Iran, yet. This study was performed to explore the current status of the provision and perception toward patient care services and finally evaluate professional competency of pharmacists about PPCP implementation, in both patients and pharmacist’s perspectives.

Methods:

A cross-sectional study was conducted using two self-administrated Likert-based questionnaires_ one for pharmacists and another one for patients. In total, 121 pharmacists and 479 patients participated to the study. Questionnaires were distributed and collected in the Shiraz during the Oct 2017 till Jun 2018. Obtained data were analyzed through the statistical package for social sciences (SPSS) version 25. In addition, the competency to PPCP implementation was classified to three groups _good, moderate, and weak _ based on achieving ≥75%, 50%-75%, and <50% of the dimensions’ total score, respectively.

Results:

The pharmacist’s age range was 23-76 years (mean age: 40.61±12.85 years). Their Competency to PPCP implementation was good (43.8%), moderate (52%), and just 4% weak. Patient’s response to PPCP was 11.2% good, 50.7% moderate and 35.6% weak.

Conclusion:

Besides promotion of public awareness about PPCP, improvement of pharmacists’ motivation toward these services seems necessary. In addition, the introduced instrument may be useful for practice of pharmacists, but it should be used cautiously until it is tested among clients of pharmacies known to provide all levels of pharmacy care within pharmacy stores. (www.actabiomedica.com)

Non-dispensing pharmacist integrated in the primary care team: effect on the quality of physician's prescribing, a non-randomised comparative study

Background Especially in elderly with polypharmacy, medication can do harm. Clinical pharmacists integrated in primary care teams might improve quality of pharmaceutical care. Objective To assess the effect of non-dispensing clinical pharmacists integrated in primary care teams on general practitioners’ prescribing quality. Setting This study was conducted in 25 primary care practices in the Netherlands. Methods Non-randomised, controlled, multi-centre, complex intervention study with pre-post comparison. First, we identified potential prescribing quality indicators from the literature and assessed their feasibility, validity, acceptability, reliability and sensitivity to change. Also, an expert panel assessed the indicators’ health impact. Next, using the final set of indicators, we measured the quality of prescribing in practices where non-dispensing pharmacists were integrated in the team (intervention group) compared to usual care (two control groups). Data were extracted anonymously from the healthcare records. Comparisons were made using mixed models correcting for potential confounders. Main outcome measure Quality of prescribing, measured with prescribing quality indicators. Results Of 388 eligible indicators reported in the literature we selected 8. In addition, two more indicators relevant for Dutch general practice were formulated by an expert panel. Scores on all 10 indicators improved in the intervention group after introduction of the non-dispensing pharmacist. However, when compared to control groups, prescribing quality improved solely on the indicator measuring monitoring of the renal function in patients using antihypertensive medication: relative risk of a monitored renal function in the intervention group compared to usual care: 1.03 (95% CI 1.01–1.05, p-value 0.010) and compared to usual care plus: 1.04 (1.01–1.06, p-value 0.004). Conclusion This study did not demonstrate a consistent effect of the introduction of non-dispensing clinical pharmacists in the primary care team on the quality of physician’s prescribing.

This study is part of the POINT-study, which was registered at The Netherlands National Trial Register with trial registration number NTR‐4389.

[Quality indicators for medication reviews in community pharmacies]

BACKGROUND

Medication reviews conducted in community pharmacies are a measure to reduce drug-related problems and to increase medication safety. Since 2014, a guideline for medication reviews has been available in Germany. However, the sole existence of a guideline does not guarantee a high quality of this novel service. Quality indicators can contribute to ensure appropriate quality standards. So far, no such indicators have been available in Germany. This project therefore aims at developing suitable indicators to assess the quality of medication reviews type 2a in community pharmacies.

METHODS

Based on a literature review, potential quality indicators were generated. Using a two-step Delphi method applying the RUMBA criteria, a set of structure, process, and outcome indicators was developed.

RESULTS

The literature review identified 23 potential indicators. Nine further indicators derived from the guideline for medication reviews and expert opinion were amended. After discussion in a focus group, the 32 indicators were reduced to a preliminary set of twelve indicators used for the Delphi survey. Following two Delphi rounds, a final indicator set consisting of three structure indicators, one process indicator and two outcome indicators, was generated.

DISCUSSION

The set of quality indicators is potentially suitable for measuring the quality of medication reviews in German community pharmacies. In the next step, these indicators need to be evaluated with regard to their validity and applicability in daily routine.

Cost-Utility and Budget Impact Analysis for Stopping the Inappropriate Use of Proton Pump Inhibitors After Cessation of NSAID or Low-Dose Acetylsalicylic Acid Treatment

BACKGROUND

In accordance with current guidelines, proton pump inhibitors (PPIs) are now generally prescribed as a protective co-medication in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or low-dose acetylsalicylic acid (LDASA). However, less attention is paid to the corresponding discontinuation of a PPI after cessation of NSAID or LDASA treatment.

OBJECTIVE

The aim of this study was to assess the extent of inappropriate PPI use, as the proportion of patients who started a PPI as a protective co-medication but continued using these drugs after cessation of NSAID and LDASA treatment. We also sought to estimate the potential cost savings and effect gains of discontinuing inappropriate PPI use and the resulting decrease in adverse effects and their detrimental consequences.

METHODS

Pharmacy dispensing data were used to map inappropriate PPI use in 2014 for community-dwelling patients. Strategies with or without PPI continuation were compared in the cost-utility analysis for a time horizon of 5 years from a healthcare perspective. Subsequently, incremental costs and effects (quality-adjusted life-years) were estimated with a Markov model.

RESULTS

Related to NSAID and LDASA treatment, 11.0% and 5%, respectively, of the PPI users were found to inappropriately continue PPI co-treatment. Discontinuation in 71- to 80-year-old patients suggested cost savings of €170.46 (95% confidence interval 75-282) at a 0.003 (95% confidence interval 0.001-0.005) quality-adjusted life-year increase. The total budget impact of stopping inappropriate PPI use related to NSAID/LDASA treatment in the Netherlands would amount to almost €1,050,000 after 1 year. Correspondingly, successful interventions to stop a patient's inappropriate use would cost up to €29 and probably would pay for themselves in the following years.

CONCLUSIONS

A substantial number of patients inappropriately continue to use a PPI after cessation of NSAID or LDASA treatment. Because adverse effects and their detrimental consequences are avoided, interventions to stop inappropriate PPI use, particularly in older patients, are likely to pay for themselves.

Quality indicators and community pharmacy services: a scoping review

BACKGROUND

Quality indicators are a commonly used improvement tool in health care. There is growing interest and activity in the use of quality indicators to improve community pharmacy practice.

OBJECTIVES

To conduct a scoping review of the use of quality indicators for community pharmacy practice, including their methods of development and evaluation.

METHODS

Electronic databases (EMBASE and PubMed) were searched to identify papers published between January 2008 and April 2018. No limits were applied for language of publication or country of origin. Studies were included if they reported empirical data regarding the development or evaluation of quality indicators. All study designs were eligible for inclusion. Duplicate independent screening was undertaken of the search results. Data extraction was performed by one reviewer.

RESULTS

Of the 988 records identified from the database search, 15 articles were included. The studies were conducted in 12 countries from six continents. Eleven studies described the development of quality indicators, eight of which included the evaluation of the psychometric properties of the indicators developed. Four studies examined the impact of quality indicators on practice all of which reported improvements in some aspects of quality, mainly with structure indicators rather than those relating to process and outcome.

CONCLUSIONS

Whilst there is a growing emphasis on promoting improvement in community pharmacy services, evidence is lacking of the effect of indicators on improving quality. Measurable process and outcome indicators are needed. The future development of quality indicators would also benefit from a multi-stakeholder approach.

Cost-effectiveness of a clinical medication review in vulnerable older patients at hospital discharge, a randomized controlled trial

Background Drug-related problems (DRP) following hospital discharge may cause morbidity, mortality and hospital re-admissions. It is unclear whether a clinical medication review (CMR) and counseling at discharge is a cost-effective method to reduce DRP. Objective To assess the effect of a CMR on health care utilization and to investigate whether CMR is a cost-effective method to reduce DRP in older polypharmacy patients discharged from hospital. Setting 24 community pharmacies in the Netherlands. Method A cluster-randomized controlled trial with an economic evaluation. Community pharmacies were randomized to those providing a CMR, counseling and follow-up at discharge and those providing usual care. Main outcome measures Change in the number of DRP after 1 year of follow-up and costs of health care utilization during follow-up. In 216 patients the use of health care was prospectively assessed. Missing data on effects and costs were imputed using multiple imputation techniques. Bootstrapping techniques were used to estimate the uncertainty around the differences in costs and incremental cost-effectiveness ratios. Results CMR resulted in a small reduction of DRP. The proportion of patients readmitted to the hospital during 6 months of follow-up was significantly higher in the intervention group than in the control group (46.4 vs. 20.9%; p < 0.05). Health care costs were higher in the intervention group, although not statistically significant. The costs of reducing one DRP by a CMR amounted to €8270. Conclusion A CMR in vulnerable older patients at hospital discharge led to a small reduction in DRP. Because of a significantly higher use of health care and higher number of re-hospitalisations post CMR, the present study data indicate that performing the intervention in this patient population is not cost-effective.

Feasibility, acceptability and potential effectiveness of an information technology-based, pharmacist-led intervention to prevent an increase in anticholinergic and sedative load among older community-dwelling individuals

Background:

Anticholinergic/sedative medications are frequently used by older people, despite their negative impacts on cognitive and physical function. We explore the feasibility, acceptability and potential effectiveness of an innovative information technology (IT)-based intervention to prevent an increase in anticholinergic/sedative load in older people.

Methods:

This was a prospective study in 51 Dutch community pharmacies. Pharmacists used an IT-based tool to identify patients aged ⩾65 years, with existing high anticholinergic/sedative loads (drug burden index ⩾2) and a newly initiated anticholinergic/sedative medication. We determined the following. Feasibility: number of eligible patients identified. Acceptability: pharmacists’ satisfaction with the intervention, pharmacists’ time investment and patients’ willingness to reduce medication use. Potential effectiveness: number of recommendations, rate of agreement of general practitioners (GPs) with proposed recommendations and factors associated with agreement. To evaluate the latter, pharmacists conducted medication reviews and proposed recommendations to GPs for 5–10 patients selected by the IT-based tool.

Results:

We included 305 patients from 47 pharmacies. Feasibility: a mean of 17.0 (standard deviation, 8.8) patients were identified per pharmacy. Acceptability: 43 pharmacists (91.5%) were satisfied with the intervention. The median time investment per patient was 33 min (range 6.5–210). Of 35 patients, 30 (85.7%) were willing to reduce medication use. Potential effectiveness: pharmacists proposed 351 recommendations for 212 patients (69.5%). GPs agreed with recommendations for 108 patients (35.4%). Agreement to stop a medication was reached in 19.8% of recommendations for newly initiated medications (37 of 187) and for 15.2% of recommendations for existing medications (25 of 164). Agreement was more likely for recommendations on codeine [odds ratio (OR) 3.30; 95% confidence interval (CI) 1.14–9.57] or medications initiated by a specialist (OR 2.85; 95% CI 1.19–6.84) and less likely for pharmacies with lower level of collaboration with GPs (OR 0.15; 95% CI 0.02–0.97).

Conclusion:

This innovative IT-based intervention was feasible, acceptable and potentially effective. In one-third of patients an increase in anticholinergic/sedative load was prevented within reasonable time investment.

Laxative co-medication and changes in defecation patterns during opioid use

Introduction

Opioid-induced constipation is a clinically relevant side effect and a cause of potentially avoidable drug-related hospital admissions.

Objectives

To describe the presence of laxative co-medication, the reasons for not starting laxatives and to evaluate changes in stool patterns of opioid initiators.

Methods

In this observational study community pharmacists evaluated the availability of laxative co-medication in starting opioid users and registered reasons for non-use. Two opioid initiators per pharmacy were invited to complete questionnaires (‘Bristol stool form scale’ and ‘Rome III Diagnostic Questionnaire for the Adult Functional Gastrointestinal Disorders’) on their defecation prior to and during opioid use. Descriptive statistics and Chi square tests were used to analyse reasons for non-use of laxatives and changes in defecation patterns.

Results

Eighty-one pharmacists collected data from 460 opioid initiators. Of those, 344 (74.8%) used laxatives concomitantly. Main reason not to use laxatives was that either prescribers or patients did not consider them necessary. Sixty-seven (89.3%) of the 75 opioid starters with two questionnaires completed were not constipated at opioid start. Eleven of them (16%) developed constipation during opioid use (Chi square p=0.003). At follow-up within laxative users 10.6% were constipated compared to 20.7% in subjects without laxatives.

Conclusion

One in four opioid starters did not dispose of laxative co-medication, mainly because they were not considered necessary by either the prescriber or the patient. The prevalence of constipation doubled during opioid use. A watchful waiting strategy for the use of laxative co-medication might include a monitoring of defecation patterns with validated questionnaires.

Jugglers and tightrope walkers: The challenge of delivering quality community pharmacy services

INTRODUCTION

This is the first exploration of service providers' attitudes and beliefs of quality and quality improvement in the community pharmacy setting in the UK.

MATERIALS AND METHODS

A series of interviews and focus groups was conducted with stakeholders from the pharmacy profession in the UK. Interviews were semi-structured and conducted face-to-face or by telephone. Focus groups were conducted with naturally-occurring groups i.e. at pharmacy conferences. Interviews and focus groups were audio-recorded, transcribed and analysed systematically using an interpretive approach.

RESULTS

Forty-two individuals participated across four focus groups and four interviews. A maximum variation sample was achieved in terms of pharmacist and pharmacy characteristics. Participants were generally positive about the need for quality and quality improvement and provided multifaceted and interlinked interpretations of quality and acknowledged its dynamic nature "quality moves forward". The challenge of standardising practice whilst providing person-centred care emerged: "you don't want to lose the personal touch, but you can't have people having a variable experience and one day it's fantastic and the next day it isn't". A variety of quality measurement methods were identified including direct observation (by internal and external agents) and feedback (mystery shoppers, colleagues, regulatory inspectors, service users), suggesting that standardisation was also needed in terms of future quality measurement. There was a tendency to report negative events as triggers for improvement. Future initiatives could adopt more positive approaches including positive deviants "There's nothing more powerful than people who've come up with something really good sharing it with their other colleagues".

DISCUSSION

The results are being used to develop and evaluate future quality improvement initiatives in this sector. These are likely to be targeted at organisational, team and individual levels.

Reducing the anticholinergic and sedative load in older patients on polypharmacy by pharmacist-led medication review: a randomised controlled trial

OBJECTIVE

To evaluate if a pharmacist-led medication review is effective at reducing the anticholinergic/sedative load, as measured by the Drug Burden Index (DBI).

DESIGN

Randomised controlled single blind trial.

SETTING

15 community pharmacies in the Northern Netherlands.

PARTICIPANTS

157 community-dwelling patients aged ≥65 years who used ≥5 medicines for ≥3 months, including at least one psycholeptic/psychoanaleptic medication and who had a DBI≥1.

INTERVENTION

A medication review by the community pharmacist in collaboration with the patient's general practitioner and patient.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The primary outcome was the proportion of patients whose DBI decreased by at least 0.5. Secondary outcomes were the presence of anticholinergic/sedative side effects, falls, cognitive function, activities of daily living, quality of life, hospital admission and mortality. Data were collected at baseline and 3 months follow-up.

RESULTS

Mean participant age was 75.7 (SD, 6.9) years in the intervention arm and 76.6 (SD, 6.7) years in the control arm, the majority were female (respectively 69.3% and 72.0%). Logistic regression analysis showed no difference in the proportion of patients with a≥0.5 decrease in DBI between intervention arm (17.3%) and control arm (15.9%), (OR 1.04, CI 0.47 to 2.64, p=0.927). Intervention patients scored higher on the Digit Symbol Substitution Test, measure of cognitive function (OR 2.02, CI 1.11 to 3.67, p=0.021) and reported fewer sedative side effects (OR 0.61, CI 0.40 to 0.94, p=0.024) at follow-up. No significant difference was found for other secondary outcomes.

CONCLUSIONS

Pharmacist-led medication review as currently performed in the Netherlands was not effective in reducing the anticholinergic/sedative load, measured with the DBI, within the time frame of 3 months. Preventive strategies, signalling a rising load and taking action before chronic use of anticholinergic/sedative medication is established may be more successful.

TRIAL REGISTRATION NUMBER

NCT02317666.

Quality indicators for responsible use of medicines: a systematic review

OBJECTIVE

All healthcare systems require valid ways to evaluate service delivery. The objective of this study was to identify existing content validated quality indicators (QIs) for responsible use of medicines (RUM) and classify them using multiple frameworks to identify gaps in current quality measurements.

DESIGN

Systematic review without meta-analysis.

SETTING

All care settings.

SEARCH STRATEGY

CINAHL, Embase, Global Health, International Pharmaceutical Abstract, MEDLINE, PubMed and Web of Science databases were searched up to April 2018. An internet search was also conducted. Articles were included if they described medication-related QIs developed using consensus methods. Government agency websites listing QIs for RUM were also included.

ANALYSIS

Several multidimensional frameworks were selected to assess the scope of QI coverage. These included Donabedian's framework (structure, process and outcome), the Anatomical Therapeutic Chemical (ATC) classification system and a validated classification for causes of drug-related problems (c-DRPs; drug selection, drug form, dose selection, treatment duration, drug use process, logistics, monitoring, adverse drug reactions and others).

RESULTS

2431 content validated QIs were identified from 131 articles and 5 websites. Using Donabedian's framework, the majority of QIs were process indicators. Based on the ATC code, the largest number of QIs pertained to medicines for nervous system (ATC code: N), followed by anti-infectives for systemic use (J) and cardiovascular system (C). The most common c-DRPs pertained to 'drug selection', followed by 'monitoring' and 'drug use process'.

CONCLUSIONS

This study was the first systematic review classifying QIs for RUM using multiple frameworks. The list of the identified QIs can be used as a database for evaluating the achievement of RUM. Although many QIs were identified, this approach allowed for the identification of gaps in quality measurement of RUM. In order to more effectively evaluate the extent to which RUM has been achieved, further development of QIs may be required.

Development of Quality Indicators to Assess Oral Anticoagulant Management in Community Pharmacies for Patients with Atrial Fibrillation

BACKGROUND

Few studies have evaluated the quality of oral anticoagulant management by community pharmacists. There is no complete set of quality indicators available for this purpose.

OBJECTIVE

To develop a set of specific quality indicators to assess oral anticoagulant management by community pharmacists for patients with atrial fibrillation (AF).

METHODS

Quality indicators were developed in 3 phases. In phase 1, potential quality indicators were generated based on clinical guidelines and a literature review. In phase 2, a modified RAND appropriateness method involving 2 rounds was implemented with 9 experts, who judged the appropriateness of quality indicators generated in phase 1 based on the extent to which they were accurate, based on evidence, relevant, representative of best practices, and measurable in community pharmacies. Phase 3 consisted of a feasibility assessment in 5 community pharmacies on 2 patients each.

RESULTS

The final set included 38 quality indicators grouped into 6 categories: documentation (n = 29), risk assessment (n = 3), clinical control (n = 1), clinical follow-up (n = 15), choice of therapy (n = 11), and interaction management (n = 8). The quality indicators referred to process of care (n = 34), clinical outcomes (n = 2), or structure of care (n = 2). There were 24 quality indicators related to vitamin K antagonists (VKAs), and 17 were related to direct oral anticoagulants (DOACs). To assess quality indicators, a questionnaire was developed for completion by community pharmacists for each patient, which included 17 questions about VKA patients and 12 questions about DOAC patients.

CONCLUSIONS

A first set of quality indicators is now available to assess the quality of oral anticoagulant management by community pharmacists for patients with AF.

DISCLOSURES

This research was supported by the Réseau Québécois de recherche sur le médicament (RQRM); the Blueprint for Pharmacy in collaboration with Pfizer Canada; and the Cercle du Doyen of the Faculty of Pharmacy, University of Montreal. The study sponsors were not involved in the study design, data collection, data interpretation, the writing of the article, or the decision to submit the report for publication. Chartrand received a scholarship from the Fonds de Recherche du Québec en Santé (FRQ-S), the Réseau Québécois de recherche sur l'usage des médicaments with Pfizer, and the Faculty of Pharmacy, University of Montreal. Guénette holds a Junior-1 Clinician Researcher Award from the FRQ-S in partnership with the Société québécoise d'hypertension artérielle. Williamson holds a Junior-1 Career Award from the FRQ-S. Côté reported being a medical speaker for Bayer, Boehringer Ingelheim Canada, and Pfizer Canada. The other authors reported no conflicts of interest. Study concept and design were contributed by Lalonde, Chartrand, and Martin. Chartrand, Martin, and Lalonde collected the data, along with Brouillette, Côté, Huot, Landry, Martineau, Perreault, Williamson, and White-Guay. Data interpretation was performed by Chartrand, Gagnon, and Lalonde, along with Guénette and Martin. The manuscript was primarily written by Chartrand, along with Guénette and Lalonde, and revised by Chartrand, Guénette, and Lalonde, along with the other authors. A portion of this study's results was presented at the 4th RQRM Annual Meeting on September 22-23, 2014, in Orford, Quebec, Canada, in the form of an abstract, which was published in the Journal of Population Therapeutics and Clinical Pharmacology, 2014;21(2):e312.

Patient-reported common symptoms as an assessment of interventions in medication reviews: a randomised, controlled trial

Background A 'Patient-Reported Outcome Measure, Inquiry into Side Effects' (PROMISE) instrument was developed for patients to report common symptoms in clinical medication reviews. Objective To determine changes in patient-reported drug-associated symptoms collected by PROMISE before and after community pharmacist-led clinical medication reviews compared with usual care. Setting Community pharmacies in the Netherlands. Methods Patients were randomised into an intervention group (IG) and a control group (CG). PROMISE was used to collect symptoms experienced during the previous month, and any suspected drug-associated symptoms from both groups at baseline and at follow-up after 3 months. IG patients received a one-time clinical medication review, while CG patients received usual care. Main outcome measure Mean number of drug-associated symptoms at follow-up. Results Measurements were completed by 78 IG and 67 CG patients from 15 community pharmacies. Mean numbers of drug-associated symptoms per patient at follow-up were 4.0 in the IG and 5.0 in the CG, with an incident rate ratio between the groups of 0.90 (95% CI 0.62-1.33). Mean numbers of drug-associated symptoms per patient reported at follow-up and persisting since baseline were 2.1 in the IG and 2.6 in the CG, with an incident rate ratio of 0.85 (95% CI 0.43-1.42). The lowest percentages of persisting drug-associated symptoms detected in the IG were 'palpitations' and 'stomach pain, dyspepsia' while in the CG they were 'stomach pain, dyspepsia' and 'trembling, shivering'. Conclusion PROMISE provided meaningful information on drug-associated symptoms in clinical medication reviews, however the number of drug-associated symptoms was not reduced by performing clinical medication reviews compared with usual care.