Tools for Assessing Potential Significance of Pharmacist Interventions: A Systematic Review

Enhancing pharmaceutical decision support system: evaluating antithrombotic-focused algorithms for addressing drug-related problems

OBJECTIVES

To evaluate the efficacy of integrating antithrombotic-focused pharmaceutical algorithms (PAs) into a pharmaceutical decision support system (PDSS) for detecting drug-related problems (DRPs) and facilitating pharmaceutical interventions.

METHODS

A set of 26 PAs (12.4%) out of a total of 210 were created to model patient situations involving antithrombotics, and their contributions were compared with the entire PDSS system.The observational prospective study was conducted between November 2019 and June 2023 in two health facilities with 1700 beds. Pharmacists, who followed a DRP resolution strategy to support human supervision, analysed alerts generated by these encoded PAs. They registered their interventions and the acceptance by physicians.

RESULTS

From 3290 alerts analysed targeting antithrombotics, the pharmacists issued 1170 interventions of which 676 (57.8%) were accepted by physicians. With the 184 other PAs, from 9484 alerts the pharmacists issued 3341 interventions of which 1785 were accepted (53.4%).Results indicate that the detection of DRPs related to antithrombotics usage represents a high proportion of those detected by the PDSS, highlighting the importance of incorporating tailored PA elements at the modelling stage.

CONCLUSIONS

The system evolves alongside the physiological changes associated to the patient situations, adapts the alerts and complements the current care. Therefore, we recommend that all PDSS should integrate specific algorithms targeting DRPs associated with antithrombotics to enhance pharmaceutical interventions and improve patient safety.

Improving the impact of pharmacy interventions in hospitals

The clinical and pharmaceutical interventions of pharmacy professionals are considered impactful inputs towards optimised patient care and safety, by rationalising prescriptions, enhancing therapeutic choices and reducing and preventing medication errors and adverse effects. Pharmacy interventions (PIs), related to the identification, prevention and resolution of drug-related problems, should be recorded for optimal clinical governance and potential health outcomes.Between October 2020 and October 2021, the community hospitals at Powys Teaching Health Board recorded 158 PIs, corresponding to 0.4 interventions per staff per week. Only two members of the team were recording these PIs. Poor indicative PIs can result in lost opportunities for medication optimisation and prescribing rationalisation, increased costs and unidentified training potential.The aims of this project were (1) to record 180 interventions between 22 November 2021 and 8 April 2022 (20 weeks), corresponding to an average threefold increase, compared to the interventions recorded between October 2020 and October 2021 (52 weeks); (2) to have all hospital pharmacy staff recording at least one intervention during the same period.The number of interventions recorded and the number of pharmacy staff recording each intervention were two process measures. The project was completed through two Plan-Do-Study-Act cycles and applied theory on managing change in healthcare.The most successful intervention influencing positively the process measures was the implementation of a new Pharmacy Intervention Record Tool (xPIRT) toolkit that included an online recording tool (xPIRT) and an interactive panel with up-to-date results from all interventions recorded (xPIRT Dashboard). Motivating change was proven to be one of the best determinants of user satisfaction and engagement that contributed to meet the project's targets. xPIRT Dashboard provided staff the capacity to act on possible personal motivators and the possibility to improving care with medicines on their wards. The implementation of xPIRT toolkit was able to increase the representativity and significance of PIs recorded by the hospital pharmacy team, and it is expected to be used for personal professional development, demonstrating team activity and impact, service planning, prescribing practice optimisation and to identify education/training needs. This toolkit can be easily applied and adapted to other health organisations, settings and services.

Pharmacist tracking and correction of medication errors: An improvement project in the observation ward of the emergency department

OBJECTIVE

The risk of medication errors is high in emergency departments. Implementation of medication reconciliation activity complemented by pharmaceutical analysis of prescription is an effective way to reduce drug related problems. This study aimed to assess the potential clinical impact of these activities to prevent medication errors for the observation ward patients. The secondary objective was to assess these activities' cost-avoidance and benefit-to-cost ratio.

MATERIAL AND METHODS

This study was conducted in a 16-bed unit, over a 5-month period. The patients' demographic and treatment details, and data from pharmaceutical activities were collected and analyzed by a pharmacist. Two pharmacists and an emergency physician assessed the potential clinical impact of medication errors.

RESULTS

Medication reconciliation for 250 patients (15.7% of 1589 admitted patients) and pharmaceutical analysis of prescription for 302 patients (19%) were performed by the pharmacist. Medication reconciliation detected 752 errors in 197 patients; 19% were related to high-risk medications and 14% had a potential clinical impact assessed as major, critical or fatal. Pharmaceutical analysis of prescription revealed 159 drug related problems in 118 patients; of which 26% involved high-risk medications and 24% had a potential clinical impact assessed "at least major". In total, 16% of pharmacist interventions had a potential clinical impact assessed "at least major" in 33% of patients: this represents 1.8 pharmacist interventions formulated per day.

CONCLUSION

The presence of a pharmacist in the observation ward of the emergency department is useful in detecting iatrogenic drug related problems and reducing their medical impact. The benefit-to-cost ratio is favorable for the hospital.

Evaluating the potential outcomes of pharmacist-led activities in the Australian general practice setting: a prospective observational study

BACKGROUND

Pharmacists have been co-located in general practice teams to support the quality use of medicines and optimise patient health outcomes. Evidence of the impact of pharmacist-led activities in Australian general practices is sparse.

AIM

This study aimed to evaluate the potential outcomes of pharmacist-led activities in Australian general practices.

METHOD

A prospective observational study was conducted in eight general practices in the Australian Capital Territory, where each general practice employed a pharmacist on a part-time basis for 18 months. A recommended, but flexible, list of activities was provided for pharmacists. Descriptive information on general practice pharmacist-led activities, collected with an online diary, was analysed. The potential clinical, economic, and organisational impact of pharmacist-led clinical activities was evaluated using the CLinical Economic Organisational (CLEO) tool, with a modified economic dimension.

RESULTS

Nine pharmacists reported 4290 activities over 3918.5 work hours in general practice. Medication management services were the primary clinical activity of pharmacists. In medication reviews, 75% of the pharmacists' recommendations were fully accepted by general practitioners. Conducting clinical audits, updating patients' medical records, and providing information to patients and staff were other major activities of pharmacists. Of 2419 clinical activities, around 50% had the potential for a moderate or major positive clinical impact on patients. Sixty-three per cent of activities had the potential to decrease healthcare costs. Almost all the pharmacist-led clinical activities had a positive organisational impact.

CONCLUSION

Most pharmacist-led clinical activities in general practice had the potential for a positive impact on patients and reduction in healthcare costs, supporting the expansion of this model in Australia.

Pharmacist Role in Hypertension Management in the Community Setting: Questionnaire Development, Validation, and Application

BACKGROUND

Hypertension is a leading cause of mortality and morbidity globally. Pharmacists can play a substantial role in decreasing the burden of the disease.

PURPOSE

The primary aim of this study was to develop and validate a scale assessing the pharmacist role in hypertension management in the community pharmacy setting. The secondary aims were to assess the services/interventions in hypertension management that were performed in the real-life setting, as well as the patient satisfaction from these services/interventions.

METHODS

This cross-sectional study was conducted in Egypt. The data were collected using a survey composed of three sections: a general section, the pharmacist role questionnaire section, and the patient satisfaction from the provided interventions/services section. The pharmacist role questionnaire was developed based on the pharmaceutical care practice conceptual model and included 23 questions. The face validity, content validity, reliability testing using Cronbach alpha, and construct validity using exploratory factor analysis were determined. The percentage of the frequency by which each role was reported to be performed was determined. Patient satisfaction from the provided interventions/services was determined by means of an overall rating. The correlation between practiced roles and patient satisfaction with received interventions/services was determined.

RESULTS

The questionnaire was valid with a 4-factor structure and a Cronbach alpha >0.75, reiterating the main pharmaceutical care practice domains: medication management, disease-state education, disease-state management, and care plan monitoring. Roles falling in the domains of disease state management and disease state education were significantly more practiced than roles falling in the other domains.

CONCLUSION

Pharmacist practice in hypertension management in the community setting was inclined towards contemporary roles, such as disease state education and management. Patients seem to be satisfied with these roles.

Using xPIRT to Record Pharmacy Interventions: An Observational, Cross-Sectional and Retrospective Study

Medication errors and omissions can potentially cause harm, prolong a hospital stay, lead to co-morbidities and even death. Pharmacy interventions (PI) ensure that these errors are identified and addressed, leading to improved patient safety and prescriber practice. Particularly in community hospitals, many only having general practitioners and not specialist doctors in their medical teams, PIs assume a strategic role. The PIs recorded throughout 8 months (between November 2021 and June 2022) in the community hospital wards in Powys, Wales, UK, using xPIRT (Pharmacy Intervention Recording Tool), a new pharmacy intervention record toolkit, were subjected to a retrospective analysis. The data were organised by location, drug, severity, acceptance, cost avoidance and intervention type. Significant prescribing errors were identified, which can potentially be different from those recorded in acute settings. Our results also informed on the need for integrated electronic prescribing systems paired with a PI recording tool to address effectively prescribing inaccuracies. Overall, this study was able to identify pharmacy teams as key to improve patient safety and care while contributing to significant cost-savings, through the recording of PI using xPIRT.

Development and implementation of a pharmacist-led telehealth medication management program for veterans receiving oral antineoplastic therapies through the MISSION Act

DISCLAIMER

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Veterans prescribed oral antineoplastic therapies (OATs) by community providers outside the Veterans Health Administration (VA) may lack access to comprehensive medication management. To address this, our multidisciplinary team developed and implemented a pharmacist-led telehealth medication management program for veterans prescribed OATs by community providers.

SUMMARY

The program exclusively uses telehealth to connect veterans with a dedicated board-certified clinical oncology pharmacist who provides comprehensive medication management. The program is based on established pharmacy models found in the research literature. We developed a standard operating procedure, communication templates, patient education materials, and a suite of health information technology tools to help streamline pharmacy processes. The Consolidated Framework for Implementation Research was used to design implementation strategies to promote the adoption of the program. In the first year, 64 veterans from 3 VA medical centers were enrolled in the program. The oncology clinical pharmacist performed 342 encounters and 101 interventions. The program saved an estimated $200,724 in medication-related costs. The veterans we surveyed reported high levels of satisfaction with the pharmacy services provided by the program.

CONCLUSION

The delivery of comprehensive medication management through telehealth is feasible from a healthcare system perspective and beneficial for patients. The board-certified oncology clinical pharmacist provided remote pharmacy services to Veterans across three sites in a large and rural service area for the VA. The program realized several benefits, including positive clinical outcomes, high levels of patient satisfaction, and cost savings on medication-related costs.

A pilot study to identify elderly patients with cognitive impairment for clinical pharmacist polypharmacy review in General Practice

Background

Polypharmacy in elderly patients is common with potential for harm. Cognitive impairment is postulated as the biggest contributor to poor medication management with increased risk of hospital admission. There is limited information about approaches to identify high risk patients for polypharmacy review.

Objective

Pilot study to determine if a new patient prioritisation tool would identify appropriate patients for pharmacist polypharmacy review.

Method

Prioritisation tool developed to rank community-dwelling elderly patients prescribed 10 or more medications with cognitive impairment for pharmacist polypharmacy review. Tool used General Practice (GP) appointments, Emergency Department attendances, repeat medications and cognitive impairment to create a score to prioritise review invitations. Reviews were completed by GP clinical pharmacists who recorded interventions and measured outcome assessments using the adapted RiO scoring tool.

Results

Polypharmacy reviews completed for 34 patients from three GP practices. Demographic results were 62% female (n = 21), median 78 years [IQR 72–80], median 3 comorbidities [IQR 2–4] with most reviews conducted face-to-face (n = 29; 85%). Pharmaceutical care interventions were hospital admission possible or likely prevention for the majority of patients (85%, n = 29) which contrasts with the historical level of 33% (n = 228) patients with traditional processes.

Conclusion

Pilot study demonstrated that the new tool identified appropriate patients for review prioritisation as patients had complex pharmaceutical care needs.

Surviving the surge: Evaluation of early impact of COVID-19 on inpatient pharmacy services at a community teaching hospital

Purpose

The coronavirus disease 2019 (COVID-19) pandemic has presented novel challenges to healthcare systems; however, an analysis of the impact of the pandemic on inpatient pharmacy services has not yet been conducted.

Methods

Results of an observational assessment of operational and clinical pharmacy services at a community teaching hospital during the first weeks of the COVID-19 pandemic are presented. Service outcomes of the inpatient pharmacy were evaluated from February 1 to April 8, 2020. Outcomes during the weeks preceding the first COVID-19 admission (February 1 to March 11, 2020) and during the pandemic period (March 12 to April 8, 2020) were compared. Evaluated outcomes included daily order verifications, clinical interventions, and usage of relevant medications. An exploratory statistical analysis was conducted using Student’s t test.

Results

During the pandemic period, the number of new order verifications decreased from approximately 5,000 orders per day to 3,300 orders per day (P < 0.01), a reduction of 30% during the first 4 weeks of the pandemic compared to the weeks prior. Average daily pharmacokinetic dosing consults were reduced in the pandemic period (from 82 to 67; P < 0.01) compared to the prepandemic period; however, total daily pharmacist interventions did not differ significantly (473 vs 456; P = 0.68). Dispensing of hydroxychloroquine, azithromycin, enoxaparin, and sedative medications increased substantially during the pandemic period (P < 0.01 for all comparisons).

Conclusion

The operational and clinical requirements of an inpatient pharmacy department shifted considerably during the first weeks of the COVID-19 pandemic. Pharmacy departments must be adaptable in order to continue to provide effective pharmaceutical care during the pandemic.

A pharmacist's unique opportunity within a multidisciplinary team to reduce drug-related problems for older adults in an intermediate care setting

BACKGROUND

There is a paucity of research describing the pharmacist's role in the multidisciplinary care of older adults in the intermediate care setting.

OBJECTIVE

To determine the types of drug-related problems (DRPs) in older patients in this setting, to evaluate the implementation rate of pharmacist recommendations and the factors affecting implementation, and to assess the clinical significance of these recommendations.

METHODS

Data were collected over a 12-week period on one pharmacist's recommendations to reduce clinically relevant DRPs identified during medication reconciliation and review for all patients ≥65 years admitted to an intermediate care unit. The clinical significance of the recommendations was judged by four independent assessors using a validated tool. Statistical significance was predetermined as p < 0.05.

RESULTS

Of 494 clinically relevant DRPs identified in 91 patients (mean age: 82 years), 406 recommendations were communicated to the medical team, and 89.2% were implemented. Overall, 48.5% were communicated verbally, but no difference was found between the implementation rates of verbal and written recommendations (87.8% versus 90.4%; p = 0.4). Medication reconciliation recommendations were implemented more commonly than those regarding medication review (96.5% versus 79.5%; p < 0.0001). Recommendations judged to be of 'moderate significance' (66.8% of total) were implemented more often than those of 'minor significance' (93.2% versus 81.6%; p < 0.001). The consultant was provided with a significantly higher proportion of recommendations of 'moderate significance' when compared to the junior doctor (79.6% versus 63.3%; p = 0.02), but implemented significantly fewer recommendations (69.4% versus 91.9%; p < 0.0001).

CONCLUSION

The high implementation rate in this study shows the importance of pharmacist involvement to reduce DRPs in the multidisciplinary care of older adults in an intermediate care unit. Future research should focus on investigating the impact of pharmacist interventions on older patient outcomes and the associated cost-effectiveness in this setting.

CLEO: a multidimensional tool to assess clinical, economic and organisational impacts of pharmacists' interventions

OBJECTIVES

Clinical pharmacists' interventions (PIs) are an important element in ensuring good pharmaceutical care. We aimed to develop and validate a comprehensive multidimensional tool for assessing the potential impact of PIs for daily practice of medication review.

METHODS

Experts of the French Society of Clinical Pharmacy (SFPC) developed the CLinical, Economic and Organisational (CLEO) tool, consisting of three independent dimensions concerning clinical, economic and organisational impact. They were asked to analyse 30 scenarios of PIs, and re-rated 10 PIs with a washout of 1 month (internal validation). Then, seven external experts not involved in the development of the tool rated 60 scenarios collected when using the CLEO in daily practice. Inter- and intra-rater reliabilities were determined by calculation of the intra-class correlation (ICC_A,1). Users' satisfaction and acceptability of the tool were assessed on a 7-level Likert scale with a 17-item questionnaire.

RESULTS

For internal reliability, the inter-rater reliability for the CLEO tool was good for clinical dimensions (ICC_A,1=0.693), excellent for economic dimensions (ICC_A,1=0.815) and fair for organisational dimensions (ICC_A,1=0.421); and the intra-rater reliability was good for clinical dimensions (ICC_A,1=0.822), excellent for economic dimensions (ICC_A,1=0.918) and good for organisational dimensions (ICC_A,1=0.738). For external reliability, the inter-rater reliability was good for clinical dimensions (ICC_A,1=0.649), excellent for economic dimensions (ICC_A,1=0.814) and fair for organisational dimensions (ICC_A,1=0.500). CLEO was viewed as relevant (mean±SD 4.93±1.27), acceptable (4.81±1.78), practicable (5.56±1.45) and precise (5.38±1.47).

CONCLUSIONS

CLEO is a comprehensive tool assessing clinical, economic and organisational impacts of PIs which has been developed, validated and was reliable and feasible for use in routine clinical practice.

Clinical evaluation of pharmacists' interventions on multidisciplinary lung transplant outpatients' management: results of a 7-year observational study

OBJECTIVES

Lung transplant (LT) recipients require multidisciplinary care because of the complexity of therapeutic management. Pharmacists are able to detect drug-related problems and provide recommendations to physicians through pharmacists' interventions (PIs). We aimed at assessing the clinical impact of PIs on therapeutic management in LT outpatients.

DESIGN

Data were collected prospectively from an LT recipients cohort during 7 years. A multidisciplinary committee assessed retrospectively the clinical impact of accepted PIs.

SETTING

French University Hospital.

PARTICIPANTS

LT outpatients followed from 2009 to 2015.

PRIMARY OUTCOME MEASURES

Clinical impact of PIs performed by pharmacists using the CLEO tool and the Pareto chart.

RESULTS

1449 PIs led to a change in patient therapeutic management and were mainly related to wrong dosage (39.6%) and untreated indication (19.6%). The clinical impact of PIs was 'avoids fatality', 'major' and 'moderate', in 0.1%, 7.0% and 57.9%, respectively. Immunosuppressants, antimycotics for systemic use and antithrombotic agents had the greatest clinical impact according to the Pareto chart. PIs related to drug-drug interactions (10%) mainly had a moderate and major clinical impact (82.3%, p<0.0001).

CONCLUSION

Clinical pharmacists play a key role for detecting drug-related problems mostly leading to a change in therapeutic management among LT outpatients. Our study provides a new insight to analyse the clinical impact of PIs in order to target PIs which have most value and contribute to patient care through interdisciplinary approach.

Clinical, economic, and organizational impact of pharmacists' interventions in a cognitive-behavioral unit in France

Objective Evaluate the clinical, economic, and organizational impact of pharmaceutical interventions performed during medication review in a cognitive-behavioral unit. Setting Study conducted in a cognitive-behavioral unit with retrospective data from January 2011 to june 2017. Methods This study was conducted from retrospective data of medication review in a cognitive-behavioral unit. During medication review, pharmacists identified relevant drug related problems lead to a pharmaceutical intervention which is submitted to the physician. All pharmaceutical interventions carried out from January 2011 to june 2017 were retrospectively analyzed to evaluate their clinical, economic and organizational impact using a multidimensional tool. Main outcome measure CLinical, Economic and Organizational impact using the CLEO tool. Results During the study period, 543 drug related problems and pharmaceutical interventions were recorded for patients hospitalized in the cognitive-behavioral unit (79.0 ± 9.5 years, 59% female). The most common types of drug related problems identified were 'non conformity to guidelines / contra-indication' (28.7%), 'drug without indication' (21.7%), and 'improper administration' (15.1%). The majority of pharmaceutical interventions were considered to have at least a clinical significant impact from the pharmacist's perspective (74%). Regarding the economic and organizational dimensions, 55.2% of pharmaceutical interventions would decrease the costs of care and 35.9% of pharmaceutical interventions would be favorable on the quality of care process. Conclusions The present study shows that the pharmacist may detect a high number of drug related problems with significant clinical relevance during medication review in a cognitive-behavioral unit. Describing and identifying significant pharmaceutical interventions in cognitive-behavioral unit patients allow us to better understand and improve clinical practice in this population.

Nature and frequency of prescription modifications in community pharmacies: A nationwide study in the Netherlands

AIMS

To investigate the nature and frequency of prescription modifications in Dutch community pharmacies.

METHODS

In this cross-sectional study, Dutch community pharmacists documented prescription modifications in their pharmacy during 1 predetermined day. Pharmacists from all Dutch community pharmacies were invited to participate. A prescription modification was defined as any modification in a prescription for a medicine or other healthcare product because of an administrative problem, logistic issue or potential drug-related problem (DRP). All documented modifications were assessed to establish the nature and frequency of prescription modifications.

RESULTS

Pharmacists in 275 pharmacies completed the study. A modification was performed in 5.5% of all prescriptions. 1.3% of the prescriptions contained an administrative problem, of which insufficient specification of the dosing regimen was most common (63.1%). A modification was performed due to a logistic issue in 2.4% of the prescriptions. The most frequently recorded issues were unavailability of medication (40.9%) and obligatory product substitutions due to reimbursement policies (33.2%). A modification was performed in 1.8% of the prescriptions to solve or prevent potential DRPs. Of these, 69.2% was potentially clinically relevant according to the pharmacist concerned. The most frequently prevented potential DRP was an incorrect strength or dose (31.9%).

CONCLUSION

Dutch community pharmacists modified almost 1 in 20 prescriptions per pharmacy. The nature of the modifications reflects current community pharmacy practice, in which pharmacists frequently deal with logistic issues and intervene to solve or prevent for DRPs several times a day. The majority of the DRPs were considered to be potentially clinically relevant.

Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in The Netherlands

Background Medication errors occur frequently in intensive care units (ICU). Voluntarily reported medication errors form an easily available source of information. Objective This study aimed to characterize prescribing, monitoring and medication transfer errors that were voluntarily reported in the ICU, in order to reveal medication safety issues. Setting This retrospective data analysis study included reports of medication errors from eleven Dutch ICU's from January 2016 to December 2017. Method We used data extractions from the incident reporting systems of the participating ICU's. The reports were transferred into one database and categorized into type of error, cause, medication (groups), and patient harm. Descriptive statistics were used to calculate the proportion of medication errors and the distribution of subcategories. Based on the analysis, ICU medication safety issues were revealed. Main outcome measure The main outcome measure was the proportion of prescribing, monitoring and medication transfer error reports. Results Prescribing errors were reported most frequently (n = 233, 33%), followed by medication transfer errors (n = 85, 12%) and monitoring errors (n = 27, 4%). Other findings were: medication transfer errors frequently caused serious harm, especially the omission of home medication involving the central nervous system and proton pump inhibitors; omissions and dosing errors occurred most frequently; protocol problems caused a quarter of the medication errors; and medications needing blood level monitoring (e.g. tacrolimus, vancomycin, heparin and insulin) were frequently involved. Conclusion This analysis of voluntarily reported prescribing, monitoring and medication transfer errors warrants several improvement measures in these processes, which may help to increase medication safety in the ICU.

Usability and sensitivity of the risk of bias assessment tool for randomized controlled trials of pharmacist interventions

Background The Cochrane collaboration risk of bias assessment (RoB) tool is used in several fields to evaluate the methodological quality of studies. Its strengths and challenges are discussed. Objective To assess the sensitivity of the RoB tool in studies of pharmacist interventions. Setting DEPICT database was used to pool randomized controlled trials (RCTs) of complex interventions. Method A Guide for RoB Judgment in Pharmacy Services was created to help in the interpretation and judgment of bias criteria. The evaluation of bias (low, unclear, high risk) was performed by RCT. Sensitivity analyses were performed to assess the influence of different interpretations of eight elements of judgment in the RoB tool. Paired analysis and estimations of the effect size (95% confidence interval) of the criteria modifications compared to the original analyses were calculated. Main outcome measure Changes in the interpretations of judgment in the RoB tool. Results Overall, 8.3, 45.4, and 46.3% of the studies were determined to have low, unclear, and high risk of bias, respectively. High risk of bias was caused by attrition and detection domains. The number of studies classified with high risk of bias significantly increased for five of the eight interpretations, while unclear risk of bias increased for three interpretations (with a negligible effect size in all of them). Lack of blinding, loss of participants, and the use of subjective and self-reported outcomes were the main elements resulting in high risk of bias. Conclusion The RoB tool is useful for evaluating RCTs of pharmacist interventions if adapted criteria for judgment are used. Ignoring these adjustments produces a floor-effect with studies classified with high risk of bias.

Impact of pharmacist care provision in value-based care settings: How are we measuring value-added services?

OBJECTIVES

To discuss the current state of measuring value-added services in emerging value-based payment practice models and their impact on the pharmacy profession.

SUMMARY

Value-based care models require a focus on population health. In value-based care settings, providers are held accountable for risk that goes beyond the clinic encounter, and payment is tied to quality measures that reflect clinical and humanistic outcomes across the health care spectrum. This creates opportunities for pharmacist integration into value-based care settings through addressing gaps in care, optimizing medication use, and developing physician-pharmacist team-based care practice models.

CONCLUSION

Scalable and sustainable pharmacist integration into value-based care settings should involve expansion of preventive care into the community. The need for measurement of the value added by pharmacy services is a priority.

Translation and validation of a tool to assess the impact of clinical pharmacists' interventions

Background The tool CLEO in French language is designed for estimating the potential relevance of pharmacists' interventions (PIs) in three independent dimensions with regard to process-related, clinical, economic, and humanistic impact. Objective We aimed to translate CLEO into German (CLEO_de), to demonstrate its feasibility in daily practice, and to validate the German version. Setting Convenience sample of three Swiss hospitals with established clinical pharmacy services. Method We translated CLEO according to the ISPOR Principles of Good Practice. The potential relevance of PIs performed within a 13-day period of routine clinical pharmacy services was then estimated with CLEO_de. Ten clinical pharmacists experienced with CLEO_de subsequently completed a 19-item questionnaire to assess user's agreement on appropriateness, acceptability, feasibility, and precision of the tool. Additionally, each pharmacist evaluated 10 model cases with CLEO_de. Main outcome measure User satisfaction; interrater reliability and test-retest reliability. Results CLEO_de was used to estimate the potential relevance of 324 PIs. The reported time needed to complete a single estimation was less than 1 min. The use of CLEO_de was seen as appropriate, acceptable, feasible, and precise. Interrater reliability was good for the clinical and economic dimensions and was poor for the organisational dimension; test-retest correlation was strong for all three dimensions with excellent to fair reliability. Conclusion We present CLEO_de as a validated tool in German language suitable to estimate the potential relevance of PIs. After further refinement of the organisational dimension, CLEO_de could provide a qualitative value to quantitative information on PIs.

Investigating the Relative Significance of Drug-Related Problem Categories

The aim of the review was to investigate whether an assessment of clinical significance can be related to specific drug-related problems (DRPs) and hence may assist in prioritizing individual categories of DRP categorization systems. The literature search using Google Scholar was performed for the period 1990 to 2013 and comprised primary research studies of clinical pharmacy interventions including DRP and clinical significance assessments. Two reviewers assessed the titles, abstracts, and full-text papers individually, and inclusion was determined by consensus. A total of 27 unique publications were included in the review. They had been conducted in 14 different countries and reported a large range of DRPs (71-5948). Five existing DRP categorisation systems were frequently used, and two methods employed to assess clinical significance were frequently reported. The present review could not establish a consistent relation between the DRP categories and the level of clinical significance. However, the categories "ADR" and possibly "Drug interaction" were often associated with an assessed high clinical significance, albeit they were infrequently identified in the studies. Hence, clinical significance assessments do not seem to be useful in prioritizing individual DRPs in the DRP categorization systems. Consequently, it may be necessary to reconsider our current approach for evaluating DRPs.