The status of the performance of medication reviews in German community pharmacies and assessment of the practical performance

A newly developed algorithm for switching outpatient medications to medications listed in the hospital formulary: a prospective real-word evaluation in patients admitted electively to hospital

PURPOSE

In many countries, outpatient and inpatient care are separated. During hospitalization, therefore, switching the outpatient medication to medication of the hospital formulary is required.

METHODS

We newly designed a switching algorithm in six switching steps (S0-S5) and conducted a study at Bundeswehr Hospital Hamburg (300 beds, 80% civilians). We performed (i) a medication reconciliation to obtain information on outpatient medications and (ii) a medication review to solve drug-related-problems, e.g., drug-drug interactions. We applied (iii) the algorithm to switch medications to the hospital formulary.

RESULTS

(i) We identified 475 outpatient medications (median per patient: 4; Q25/Q75 2/7) in 100 patients consecutively admitted to hospital (median age: 71; Q25/Q75: 64/80 years). Of 475 medications, the switching algorithm could not be used since product names were missing in 23.9% and strength in 1.7%. In 3.2%, switching was not required since medication was not prescribed during the hospital stay. (ii) Drug-drug interactions were identified in 31 of 79 patients with more than one medication. (iii) Of 475 medications, 18.5% were on the hospital formulary and therefore did not need to be  switched (S0), 0.2% were on a substitution-exclusion list not allowing switching (S1), 42.0% were switched to a generic medication of the hospital formulary (S2), 1.7% to a therapeutically equivalent medication (S3), 0.4% were patient-individually switched (S4), and for 8.2% a standardized/patient-individual switching was not possible (S5).

CONCLUSIONS

Despite comprehensive medication reconciliation, patient- and medication-related information for switching medications to the hospital formulary was often missing. Once all the necessary information was available, standardized switching could be easily carried out according to a newly developed switching algorithm.

Drug-related problems identified at a Japanese community pharmacy: a cross-sectional study

Objectives

This study aimed to identify drug-related problems (DRPs) using data regarding the communication of pharmacists with prescribers over the phone at a community pharmacy. Furthermore, we elucidated the frequency of the sources of information for detecting each DRP and evaluated the decisions made by the prescribers for each DRP.

Methods

This cross-sectional study was conducted at a community pharmacy in Fukuoka Prefecture, Japan. We anonymously collected data obtained by pharmacists through contacting prescribers over the phone relating to any problems or doubts found in prescriptions between April 2016 and March 2019. We classified the data and identified DRPs. We elucidated the frequency of sources of information for detecting each DRP using descriptive analyses and evaluated prescribers’ decisions regarding each DRP via multivariate Poisson regression analyses.

Key findings

Of the 95 023 prescriptions, 5073 DRPs were identified (5073/95 023 = 5.34%). The most frequent DRP was inappropriate dosage and administration (1349/5073 = 26.59%), followed by non-adherence (1272/5073 = 25.07%) and incorrect prescription periods (889/5073 = 17.52%). Patient interviews were the most frequent sources of information for detecting following DRPs: non-adherence (1057/1272 = 83.10%), untreated indication (590/631 = 93.50%) and adverse drug reactions (80/107 = 74.77%). Most of the DRPs were resolved by making changes to the prescriptions (4571/5073 = 90.10%).

Conclusions

Inappropriate dosage and administration and non-adherence issues were the most frequent DRPs in a Japanese community pharmacy. Patient interviews were an important source of information for detecting DRPs. Further research is warranted to address the impact of DRPs on patient safety.

Instruments to assess the role of the clinical pharmacist: a systematic review

BACKGROUND

The clinical pharmacist is an essential member of the healthcare team and plays an important role in health care in the primary care and the hospital setting. Knowledge regarding the instruments that evaluate the different activities of the clinical pharmacist, as well as the evaluation of the psychometric properties of these instruments, is necessary.

METHODS

A literature search was performed in the PubMed and Scopus electronic databases without time and language restrictions. For the search strategy, the "pharmaceutical services," "validity studies," and "professional performance" domains were used. To assess the quality of the instruments, the five sources of validity evidence of contemporary psychometry were used, and the Joanna Briggs Institute's standardized instrument was used to assess the methodological quality of the studies. After screening 4096 articles, 32 studies were selected.

RESULTS

A total of 32 studies were included, and 32 instruments were identified to be used by pharmacists acting in various pharmaceutical practice scenarios. It was found that the available instruments were developed or adapted from others, with variation in the methods, constructs, dimensions, and domains, as well as the psychometric properties. Most of the instruments addressed community pharmacies, and evidence of content validity and internal structure was found most frequently. A standardized and validated instrument that comprehensively assessed the performance of the clinical pharmacist, addressing clinical activities, was not identified for all practice environments.

CONCLUSIONS

Without standardized and validated instruments specifics to assess the performance of the clinical pharmacist, it is hard to establish the main clinical activities performed by pharmacists in their pharmaceutical practice environments and to propose training actions to improve professional practice. Despite the large number of instruments available and considered validated by the authors, it is questioned to what extent the validity indicators presented in the different studies really show the validation status.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD 42018099912.

The influence of intervention complexity on barriers and facilitators in the implementation of professional pharmacy services - A systematic review

BACKGROUND

Community pharmacies increasingly offer professional pharmacy services, whose implementation is often influenced by facilitating or obstructive implementation factors. The occurrence and composition of implementation factors vary among different services with discrete characteristics and complexity of the intervention, making it difficult to foresee potential barriers in implementation.

OBJECTIVE(S)

This paper investigates potential associations between intervention complexity and occurring implementation factors.

METHODS

A systematic literature search on the implementation factors and intervention complexity of professional pharmacy services in the community setting was carried out in electronic databases (PubMed, CINAHL, and PsycINFO) throughout December 2018. Implementation factors were extracted from semi-structured interviews, focus groups, and surveys with community pharmacists and categorized using the Consolidated Framework for Implementation Research (CFIR). The complexity of each service was assessed using the following complexity parameters: (I) number of involved healthcare professions, (II) number of service components such as recruiting of patients, screening intervention, and follow-up, (III) frequency of the service, (IV) expenditure of time per patient (encounter), and (V) workflow distortion, i.e. booking appointments for intervention with the patient. Finally, the association between implementation factors and intervention complexity was analyzed by quantifying implementation factors and by relating them to specific intervention characteristics using Fisher's exact test.

RESULTS

15 studies covering a broad spectrum of professional pharmacy services were included. There was a trend that in services with higher complexity more implementation factors occurred (p = 0.094). Single key complexity parameters can trigger specific implementation factors. For instance, general practitioner and pharmacy technician involvement were significantly associated with interprofessional communication and leadership engagement, respectively.

CONCLUSION

Key implementation factors and associated complexity parameters seem to be of similar or more importance than the total number of implementation factors with regard to successful implementation. By assessing various complexity parameters of an intervention, potential key barriers could be identified and subsequently addressed prior to implementation.

Evidence-based self-medication: development and evaluation of a professional newsletter concept for community pharmacies

Background Providing evidence-based care is recognized as a key competence for all healthcare professionals. In order to support community pharmacists in evidence-based self-medication counseling, the umbrella organization of German pharmacists initiated the development of a nationwide concept. The key element of the concept was a professional newsletter that should help pharmacists incorporate research findings into their daily counseling practice. Objective To develop, implement and evaluate the professional newsletter concept. Setting German community pharmacies. Method Clinical pharmacists from a German university compiled and synthesized clinical trial data in a professional newsletter that would supply community pharmacists with evidence-based information on common over-the-counter medicines as well as instructions for searching and appraising scientific literature. The electronic newsletter was offered to interested community pharmacists free of charge, once or twice a month, after they signed up for a subscription. About one year after the publication of the first newsletter issue, the subscribers were invited to take part in an anonymous cross-sectional online survey. In all, 21 newsletter issues were published through the end of the survey period. Main outcome measure Perceived value of the professional newsletter with 10 predefined objectives. Results A total of 1975 persons subscribed to the professional newsletter. Of those, 150 persons working in community pharmacies completed the survey. Most of them perceived the synthesized information as ‘useful’ (81–95%). They attributed positive changes in knowledge (89%), skills (87–91%), awareness (85%), and motivation (67–77%) to the newsletter. However, almost half of them (43%) found it difficult to incorporate reading the newsletter in their everyday working life. Free-text feedback suggested that further modifications should be considered to facilitate a better integration of the newsletter into everyday pharmacy practice. Conclusion A nationwide provided professional newsletter can play a vital part in supporting pharmacists in evidence-based self-medication counseling. However, the practicability of such a newsletter needs to be further improved and the newsletter should be accompanied by additional measures.

Prevalence and risk factors of drug-related problems identified in pharmacy-based medication reviews

Background Medication safety is a major health concern, especially for older patients, in whom drug-related problems occur frequently as a consequence of polypharmacy and frailty, increasing the risk of adverse drug events. Objective To investigate the prevalence and types of drug-related problems in community pharmacies and to identify associated risk factors in order to adjust the focus of care. Setting 300 German community pharmacies in Saxony-Anhalt (Germany). Method In April 2015, community pharmacists conducted brown bag medication reviews for primary care patients, in which they identified and solved drug-related problems with patients or their physicians. Data from these reviews were analyzed, including frequency and nature of problems and their respective resolutions. Potentially inappropriate medications according to the PRISCUS list were identified by post hoc analysis. Risk factors for drug-related problems were determined using bivariate and multivariate logistic regression analysis. Main outcome measure Prevalence and risk factors of drug-related problems. Results 1090 medication reviews were conducted. On average, patients were 72.0 ± 9.1 years old and had 10.6 ± 3.7 medications, 62.0% (n = 676) presented a medication plan. Knowledge gaps about medications were detected in almost a third of patients (n = 345). Drug-related problems were identified in 84.2% (n = 918) of patients (in 3836 medications). Frequent problems concerned drug–drug-interactions (53.7%, n = 585) as well as drug use and adherence (46.7%, n = 509). Most problems (72.2%, n = 2769) were resolved between pharmacist and patient. Knowledge gaps and the number of drugs were independently associated with a higher risk of drug-related problems. For older patients, potentially inappropriate medications were a risk factor in bivariate, but not in multivariate analysis. Conclusion Pharmacists identified and resolved considerable rates of drug-related problems, suggesting that they are capable and well-positioned to conduct medication reviews. Knowledge gaps, the number of drugs, patient age and, in older patients, potentially inappropriate medications may indicate an increased risk for drug-related problems.

Pharmacist-led medication reviews for geriatric residents in German long-term care facilities

BACKGROUND

The benefit of medication reviews for long-term care (LTC) residents has been generally recognized throughout health care systems. Whereas many studies showed the impact of comprehensive medication reviews performed by specialized clinical pharmacists, little is known about the impact of medication reviews performed by community pharmacists. Involving them in the provision of medication reviews may help satisfy the increasing demand for ensuring medication safety.

METHODS

Community pharmacists supplying drugs to the LTC facilities performed a medication review for German LTC residents aged at least 65 years and taking five or more drugs per day based on the patients' medication only. Documented potential drug-related problems (DRPs) and the implementation rate of pharmaceutical interventions were evaluated descriptively. To assess the quality of the medication reviews, we developed a corresponding reference system based on the analysis of two experienced clinical pharmacists.

RESULTS

Twelve pharmacies performed medication reviews for 94 LTC residents. Overall, the pharmacists documented 154 potential DRPs (mean 1.6 per patient, SD 1.5) of which the most common were drug-drug interactions (40%) followed by potentially inappropriate medication (PIM) (16%) and inappropriate dosages (14%). 33% of the pharmacists' interventions to solve DRPs were successfully implemented, mostly dosage adjustments. The identification of potentially severe drug-drug interactions and PIM showed the highest agreement (88 and 73%) with the reference system.

CONCLUSIONS

The medication review program of community pharmacists for LTC residents led to the identification of relevant DRPs. The reference system assessing the quality of the service can contribute to its transparency and reveals the potential for its improvement. The community pharmacists' knowledge of the LTC residents and their relation to the prescribers is crucial for providing successful medication reviews.

Knowledge of and readiness for medication therapy management among community pharmacists in Lebanon

Background To follow international standards, the Lebanese Order of Pharmacists would like to start to implement the medication therapy management in community pharmacies. Objective The objective of this study is to evaluate community pharmacists' knowledge of and readiness for medication therapy management. Setting Community pharmacists from all Lebanese regions. Method A cross-sectional observational descriptive study was conducted. Pharmacists at their workplace completed self-administered anonymous standardized questionnaires between June and December 2016, with no compensation in return. Statistical analysis was conducted using bi-variate and multi-variable methods. Main outcome measure The major dependent variable of interest was the willingness to engage in medication therapy management activities. Results While only 376 (46%) of the interviewed pharmacists declared to be familiar with this concept, the majority of interviewed pharmacists 646 (78.8%) agreed on the importance of patient-centered care. Although this service will not be remunerated at this stage, 529 (64.5%) were willing to attend advanced training sessions to become actively engaged in medication therapy management, particularly those who had adequate workflow, staff and time at their workplace (aOR = 1.51; p = 0.045) and those agreeing to review a patient's medication profile and provide interventions as part of their role (aOR = 6.10; p < 0.001). Conclusion Lebanese pharmacists have adequate knowledge and a positive attitude towards medication therapy management services implementation; however, barriers could arise such as inadequate time, workflow and physical space. Efforts should be exerted by the Lebanese Order of Pharmacist to extend the role of the pharmacist and its positive effect on patient outcome.