Therapeutic monitoring of antiepileptic drugs: Recommendations to improve care of patients with epilepsy in the Palestinian practice

A community-based awareness program improves knowledge and attitudes toward epilepsy: An interventional study

OBJECTIVE

Little interventional studies were conducted to improve knowledge, improve attitude, and eliminate stigma against patients with epilepsy. This study was conducted to investigate the effect of a community-based epilepsy awareness program (CBEAP) on knowledge, attitude, and stigma against patients with epilepsy among the Palestinian general public.

METHODS

This interventional study used a pre-post design. Knowledge and attitudes were assessed using a reliable and internally consistent questionnaire before and 1 month after receiving a CBEAP. Knowledge was assessed using a 16-item and attitudes were assessed using 13 items.

RESULTS

A total of 150 participants completed the questionnaire before the CBEAP. Of those, 136 (90.7 %) completed the CBEAP, and 129 (86.0 %) completed the questionnaire 1 month after receiving the CBEAP. The CBEAP significantly (p-value < 0.05) increased knowledge about the nature of epilepsy and seizures, triggers and treatment options, and patients with epilepsy. Similarly, the CBEAP significantly (p-value < 0.001) improved the attitudes of the participants toward epilepsy or having epilepsy, patients with epilepsy, relationships with patients with epilepsy, and working or staying with patients with epilepsy. Greater changes in knowledge and attitude scores were predicted by younger age and having a close friend or family member with epilepsy.

CONCLUSION

The CBEAP developed and implemented in this interventional study significantly increased the knowledge of the participants about epilepsy and improved their attitudes toward epilepsy and patients with epilepsy. Large-scale implementation of such interventional programs is still needed to increase knowledge and improve attitudes toward epilepsy and patients with epilepsy.

Status and Quality of Guidelines for Therapeutic Drug Monitoring Based on AGREE II Instrument

BACKGROUND

With the progress of therapeutic drug monitoring (TDM) technology and the development of evidence-based medicine, many guidelines were developed and implemented in recent decades.

OBJECTIVE

The aim was to evaluate the current status of TDM guidelines and provide suggestions for their development and updates based on Appraisal of Guidelines for Research and Evaluation (AGREE) II.

METHODS

The TDM guidelines were systematically searched for among databases including PubMed, Embase, China National Knowledge Infrastructure, Wanfang Data, and the Chinese biomedical literature service system and the official websites of TDM-related associations. The search period was from inception to 6 April 2023. Four researchers independently screened the literature and extracted data. Any disagreement was discussed and reconciled by another researcher. The quality of guidelines was assessed using the AGREE II instrument.

RESULTS

A total of 92 guidelines were included, including 57 technical guidelines, three management guidelines, and 32 comprehensive guidelines. The number of TDM guidelines has gradually increased since 1979. The United States published the most guidelines (20 guidelines), followed by China (15 guidelines) and the United Kingdom (ten guidelines), and 23 guidelines were developed by international organizations. Most guidelines are aimed at adult patients only, while 28 guidelines include special populations. With respect to formulation methods, there are 23 evidence-based guidelines. As for quality evaluation results based on AGREE II, comprehensive guidelines scored higher (58.16%) than technical guidelines (51.36%) and administrative guidelines (50.00%).

CONCLUSION

The number of TDM guidelines, especially technical and comprehensive ones, has significantly increased in recent years. Most guidelines are confronted with the problems of unclear methodology and low quality of evidence according to AGREE II. More evidence-based research on TDM and high-quality guideline development is recommended to promote individualized therapy.

Development of Consensus-Based Recommendations to Prevent/Minimize Medication Errors in the Perioperative Care of Patients with Epilepsy: A Mixed-Method

BACKGROUND

This study explored medication errors in the perioperative care of patients with epilepsy and developed consensus-based recommendations to prevent/minimize these errors.

METHODS

A mixed method was used in this study. Medication error situations were explored in semi-structured in-depth interviews with nurses (n = 12), anesthesiologists (n = 5), anesthesia technicians (n = 5), surgeons (n = 4), neurologists (n = 4), and patients with epilepsy (n = 10). The qualitative data were analyzed using the qualitative interpretive description approach. A two-round Delphi technique was used among nurses (n = 22), anesthesiologists (n = 9), anesthesia technicians (n = 7), surgeons (n = 7), and neurologists (n = 5).

RESULTS

A total of 1400 minutes of interview time was analyzed in this study. Of the panelists, 39 (78.0%) agreed that patients with epilepsy present unique challenges to providers of perioperative care that make them prone to medication errors. The interviewees in this study described 32 different medication error situations that occurred while providing perioperative care services to patients with epilepsy. In this study, 35 consensus-based recommendations to prevent/minimize medication errors in the perioperative care of patients with epilepsy were developed.

CONCLUSIONS

The findings of this study are informative to decision-makers in health care facilities and other stakeholders in health regulatory authorities who need to design measures to prevent/minimize medication errors and improve perioperative outcomes of patients with epilepsy. Studies are needed to investigate if these recommendations can be effective in preventing/reducing medication errors in the perioperative care of patients with epilepsy.

Development of the Practice of Pharmaceutical Care for Cancer Pain Management in Outpatient Clinics Using the Delphi Method

Background: There exists no broad agreement of experts on the practice of pharmaceutical care for cancer pain management in outpatient clinics. Objectives: This study aimed to use the Delphi consensus process to provide expert recommendations on the practice of cancer pain management in outpatient clinics from the point of view of pharmaceutical care in clinical practice and future clinical trials. Methods: A comprehensive literature review was conducted to draft the initial practice. In this process, 30-40 senior experts from various provinces in China were invited to rank the items of practice during the two Delphi consultations. The definitions of consensus included a combination with an average score of ≥4, the percentage of experts rating the scores at >4 points, and the coefficient of variation of the scores. Results: The expert panel comprised 18 pharmacists, 3 anesthesiologists, 6 oncologists, and 9 nurses. As a result of a comprehensive review, 33 items were initially formed. Among them, the consensus was reached for 27 items after the first Delphi round. The other six items and a total of five items for supplementation entered the second round, among which consensus was reached for eight items and three items were excluded. Expert consensus was achieved on 35 items after two rounds of consultation, which involved the collection of patient basic information, comprehensive pain assessment, breakthrough or neuropathic pain assessment, analgesic treatment evaluation, out-of-hospital follow-up, medical records, and evidence-based documents for reference. Conclusion: The final list of 35 items could be used to develop the practice of pharmaceutical care for cancer pain management in outpatient clinics in China. The practice may aid in the standardization of pharmaceutical care for pain, relieve pain to the greatest extent possible, and enhance the level of pain management in China.

Caring for women with epilepsy: Qualitative exploration of key challenges and future directions in a resource poor healthcare system

OBJECTIVE

This qualitative explorative study was conducted to explore the key challenges and future directions of caring for women with epilepsy (WWE) from the perspectives of healthcare professionals who provide care for WWE in Palestine.

METHODS

A qualitative explorative design was used in this study in adherence to the consolidated criteria for reporting qualitative research. The study participants were interviewed in semi-structured in-depth interviews using a pre-validated and pilot-tested interview schedule. The interpretative description approach was used to qualitatively analyze the contents of the interviews.

RESULTS

Interviews were conducted with 6 neurologists, 5 gynecologists, 3 psychiatrists, 5 clinical pharmacists, and 1 internal medicine specialist. The current challenges and future directions in caring for WWE were grouped under healthcare system-, healthcare provider-, patient-, and society-related. Lack of adequate availability, accessibility, and affordability of neurology services and safe antiepileptic drugs (AEDs) were the main challenges. Increasing access of WWE to specialized neurology services and improving acceptance in the society were the main future directions.

CONCLUSION

Findings of this study highlighted the key challenges and future directions of caring for WWE in a resource-poor healthcare system. Decision makers in health authorities, professional bodies, and patient advocacy groups should consider improving availability, accessibility, and affordability of neurology services and safe AEDs for WWE. Future studies are still needed to investigate if addressing these challenges can improve the care of WWE in Palestine.

Views, knowledge, and practices of hospital pharmacists about using clinical pharmacokinetics to optimize pharmaceutical care services: a cross-sectional study

Background

Pharmacokinetics (PK) is often used to optimize individualized dosing regimens of some drugs. This study was conducted to determine views, knowledge, and practices of hospital pharmacists in Palestine about using clinical PK to optimize pharmaceutical care services.

Method

This study was conducted in a cross-sectional design using a questionnaire. The questionnaire collected information about the nature of PK courses taught to hospital pharmacists, importance, relevance, effectiveness, adequacy, and depth of these courses, adequacy of PK skills, implementing PK knowledge/skills in current practice, and barriers limiting the implementation of PK to optimize pharmaceutical care services for hospitalized patients. The hospital pharmacists were visited in their places of work and were asked to complete the questionnaire in privacy. Categorical data were compared using Kruskal-Wallis test or Mann-Whitney U tests.

Results

The questionnaire was completed by 145 hospital pharmacists. Of the pharmacists, 84 (57.9%) received basic PK courses, 79 (54.5%) were taught integrated PK courses, and 94 (64.8%) agreed that the PK courses were important to their current practice. Similarly, 85 (57.9%) of the pharmacists were not satisfied with the teaching methods and contents of the PK courses. Pharmacists who obtained their degrees from Palestine were less satisfied with the methods of teaching compared to those who obtained their degrees from foreign countries (p-value = 0.006). Only 25 (17.2%) pharmacists reported frequent use of PK knowledge in their current practice. Lack of practical knowledge and continuing education, poor understanding of PK by pharmacists and other healthcare professionals were identified as barriers limiting the implementation of PK in optimizing pharmaceutical care services to hospitalized patients.

Conclusion

The hospital pharmacists were generally not satisfied with the way PK courses were taught and expressed difficulty in implementing PK knowledge and skills to improve pharmaceutical care services to hospitalized patients. Integrating PK topics within other relevant courses and adopting more clinically oriented learning methods could improve understanding and implementing PK knowledge and skills in optimizing pharmaceutical services to hospitalized patients. Further studies are still needed to determine the optimal teaching/learning methods that can improve knowledge and skill acquisitions of pharmacists in the area of PK.

Polypharmacy composition and patient- and provider-related variation in patients with epilepsy

OBJECTIVE

To describe polypharmacy composition, and the degree to which patients versus providers contribute to variation in medication fills, in people with epilepsy.

METHODS

We performed a retrospective study of Medicare beneficiaries with epilepsy (antiseizure medication plus diagnostic codes) in 2014 (N = 78,048). We described total number of medications and prescribers, and specific medications. Multilevel models evaluated the percentage of variation in two outcomes (1. number of medications per patient-provider dyad, and 2. whether a medication was filled within thirty days of a visit) due to patient-to-patient differences versus provider-to-provider differences.

RESULTS

Patients filled a median of 12 (interquartile range [IQR] 8-17) medications, from median of 5 (IQR 3-7) prescribers. Twenty-two percent filled an opioid, and 61% filled at least three central nervous system medications. Levetiracetam was the most common medication (40%), followed by hydrocodone/acetaminophen (27%). The strongest predictor of medications per patient was Charlson comorbidity index (7.5 [95% confidence interval (CI) 7.2-7.8] additional medications for index 8+ versus 0). Provider-to-provider variation explained 36% of variation in number of medications per patient, whereas patient-to-patient variation explained only 2% of variation. Provider-to-provider variation explained 57% of variation in whether a patient filled a medication within 30 days of a visit, whereas patient-to-patient variation explained only 30% of variation.

CONCLUSION

Patients with epilepsy fill a large number of medications from a large number of providers, including high-risk medications. Variation in medication fills was substantially more related to provider-to-provider rather than patient-to-patient variation. The better understanding of drivers of high-prescribing practices may reduce avoidable medication-related harms.