Cost of Prescription Drug-Related Morbidity and Mortality

Exploration of Features of Mobile Applications for Medication Adherence in Asia: Narrative Review

BACKGROUND

Medication is crucial for managing chronic diseases, yet adherence rates are often suboptimal. With advanced integration of IT and mobile internet into health care, mobile apps present a substantial opportunity for improving adherence by incorporating personalized educational, behavioral, and organizational strategies. However, determining the most effective features and functionalities for these apps within the specific health care context in Asia remains a challenge.

OBJECTIVE

We aimed to review the existing literature, focusing on Asian countries, to identify the optimal features of mobile apps that can effectively enhance medication adherence within the unique context of Asian societies.

METHODS

We conducted a narrative review with the SPIDER (sample, phenomenon of interest, design, evaluation, research type) tool. We identified studies on mobile apps for medication adherence from January 2019 to August 2024 on PubMed and Scopus. Key search terms included "Asia," "chronic disease," "app," "application," "survey," "experiment," "questionnaire," "group," "medical adherence," "medication adherence," "case-control," "cohort study," "randomized controlled trial," "clinical trial," "observational study," "qualitative research," "mixed methods," and "analysis," combined using logical operators "OR" and "AND." The features of mobile apps identified in the studies were evaluated, compared, and summarized based on their disease focuses, developers, target users, features, usability, and use.

RESULTS

The study identified 14 mobile apps designed to enhance medication adherence. Of these, 11 were developed by research teams, while 3 were created by commercial companies or hospitals. All the apps incorporated multiple features to support adherence, with reminders being the most common, present in 11 apps. Patient community forums were the least common, appearing in only 1 app. In total, 6 apps provided lifestyle modification functions, offering dietary and exercise recommendations, generating individualized plans, and monitoring progress. In addition, 6 apps featured health data recording and monitoring functions, with 4 allowing users to export and share records with researchers or health care professionals. Many apps included communication features, with 10 enabling feedback from researchers or health care professionals and 7 offering web-based consultation services. Educational content was available in 8 apps, and 7 used motivation strategies to encourage adherence. Six studies showed that mobile apps improved clinical outcomes, such as blood glucose, lipid, and pressure, while reducing adverse events and boosting physical activities. Twelve studies noted positive humanistic effects, including better medication adherence, quality of life, and user satisfaction.

CONCLUSIONS

This review has identified key components integrated into mobile apps to support medication adherence. However, the lack of government and corporate involvement in their development limits the generalizability of any individual app. Beyond basic reminder functions, features such as multiuser support, feedback mechanisms, web-based consultations, motivational tools, and socialization features hold significant promise for improving medication adherence. Further pragmatic research is necessary to validate the effectiveness of these selected apps in enhancing adherence.

Exploring the impact of a digital health tool on patients' interaction with community pharmacists: A pilot randomized controlled study

BACKGROUND

The use of digital Patient- Reported Outcomes (PRO) tools has been shown to enhance the exchange of information and shared decision-making in medical encounters. However, their influence on patient-pharmacist interactions has not yet been explored.

OBJECTIVES

This study aimed to examine the impact of RxTalk™, a digital PRO tool, in supporting the communication between patients and pharmacists compared to usual care.

METHODS

Intervention: RxTalk™ was developed to collect information about medication adherence and beliefs, using a tablet computer.

STUDY DESIGN

A pilot randomized controlled study was conducted at a community pharmacy in Wisconsin, USA. Sixty patients were randomized to either the intervention group who used RxTalk™ during medication pick-up or the control group who did not use the tool. Patients who used RxTalk™ received paper copies of their responses which were also shared with pharmacists. The consultation was audio-recorded for both groups and coded using the Active Patient Participation Coding scale. Follow-up phone interviews were conducted with both groups within one week of enrollment.

RESULTS

Patient tapes were analyzed. In the unadjusted model, patients in the intervention group had a higher active participation rate (p = 0.004) and raised significantly more concerns during consultations (p < 0.001) compared to the control group. Pharmacists asked twice as many questions while counseling patients in the intervention group compared to the control group (p < 0.001). After controlling for patients' demographics and pharmacists' questions, there was a statistical difference between the two patient groups in their odds of expressing at least one concern utterance.

CONCLUSION

This pilot study suggests that collecting PRO from patients with chronic illnesses and providing results to pharmacists and patients can help patients express their health and medication concerns. RxTalk™ would be useful for pharmacists who wish to improve the recognition and management of medication-related problems.

The approach of Norm Balance in predicting pharmacists' intention to collaborate with physicians to improve medication therapy

Objective

Norm Balance is an approach under the Theory of Planned Behavior (TPB) where subjective norm is weighted by the relative importance of others and self-identity is weighted by the relative importance of self. The relative importance was measured previously by a trade-off measure. In this study, we developed separate measures for the relative importance. The study objectives were to: 1) assess the construct validity of the separate measures; 2) examine the approach of Norm Balance in predicting pharmacists' intention to collaborate with physicians to improve medication therapy; and 3) establish a modified TPB.

Methods

We selected a random sample of 750 Iowa pharmacists and conducted two surveys. The first survey was to examine intention prediction, and the second survey was to examine behavior prediction by measuring behavior among respondents to the first survey. The relative importance was measured by both the trade-off measure and the separate measures. Exploratory factor analyses were performed for the relative importance of others (separate measures) and subjective norm, and for the relative importance of self (separate measures) and self-identity. Regressions for intention prediction were conducted for TPB with self-identity and the approach of Norm Balance. The same regressions were also conducted for three subgroups according to the median of the relative importance of others (trade-off measure). Moreover, another regression was conducted for behavior prediction.

Results

239 practicing pharmacists responded to the first survey, and 188 responded to the second survey. The separate measures had cross factor loadings, whereas the trade-off measure had low correlations with other constructs. Both regressions for intention prediction explained 75% of the variance, with self-efficacy and attitude being strong predictors. Self-identity was not a predictor in the TPB with self-identify, but self-identity weighted by the relative importance of self was a significant predictor in the approach of Norm Balance. Regression coefficients of subjective norm and self-identify varied across subgroups. The regression for behavior prediction explained 30% of the variance, with intention and self-efficacy being two predictors.

Conclusion

The trade-off measure was better than separate measures. The approach of Norm Balance appears to be a better model than the TPB with self-identity to examine pharmacist-physician collaboration.

Frequency and preventability of adverse drug events in the outpatient setting

BACKGROUND

Limited data exist regarding adverse drug events (ADEs) in the outpatient setting. The objective of this study was to determine the incidence, severity, and preventability of ADEs in the outpatient setting and identify potential prevention strategies.

METHODS

We conducted an analysis of ADEs identified in a retrospective electronic health records review of outpatient encounters in 2018 at 13 outpatient sites in Massachusetts that included 13 416 outpatient encounters in 3323 patients. Triggers were identified in the medical record including medications, consultations, laboratory results, and others. If a trigger was detected, a further in-depth review was conducted by nurses and adjudicated by physicians to examine the relevant information in the medical record. Patients were included in the study if they were at least 18 years of age with at least one outpatient encounter with a physician, nurse practitioner or physician's assistant in that calendar year. Patients were excluded from the study if the outpatient encounter occurred in outpatient surgery, psychiatry, rehabilitation, and paediatrics.

RESULTS

In all, 5% of patients experienced an ADE over the 1-year period. We identified 198 ADEs among 170 patients, who had a mean age of 60. Most patients experienced one ADE (87%), 10% experienced two ADEs and 3% experienced three or more ADEs. The most frequent drug classes resulting in ADEs were cardiovascular (25%), central nervous system (14%), and anti-infective agents (14%). Severity was ranked as significant in 85%, 14% were serious, 1% were life-threatening, and there were no fatal ADEs. Of the ADEs, 22% were classified as preventable and 78% were not preventable. We identified 246 potential prevention strategies, and 23% of ADEs had more than one prevention strategy possibility.

CONCLUSIONS

Despite efforts to prioritise patient safety, medication-related harms are still frequent. These results underscore the need for further patient safety improvement in the outpatient setting.

Validation of a novel Artificial Pharmacology Intelligence (API) system for the management of patients with polypharmacy

OBJECTIVE

Medication management of patients with polypharmacy is highly complex. We aimed to validate a novel Artificial Pharmacology Intelligence (API) algorithm to optimize the medication review process in a comprehensive, personalized, and scalable way.

MATERIALS AND METHODS

The study was conducted on anonymized retrospective electronic health records (EHR) of 49 patients. Each patient's file was reviewed by the API system, a clinical pharmacist, and a judging committee. Validation was assessed by comparing the overall agreement of the judging committee (as the gold standard, blinded to the identity of the analyzer) to both the API system and clinical pharmacists' conclusions. Five medication-related problem (MRP) categories were assessed: duplication of therapy, age-related issues, incorrect dose, current side effects and future side effects' risk. For each category the overall validity parameters, agreement, positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity were analyzed.

RESULTS

The agreement between the API system and the judging committee was 93.5 % (95 % CI 92.7-94.4), while the agreement between the clinical pharmacists and the judging committee was 73.9 % (95 % CI 72.5-75.3). The PPV was 92.2 % (90.9-93.5) and NPV was 94.2 % (93.1-95.2) for the API system and 76.3 % (69.8-82.8) and 73.5 % (72.3-74.8) respectively for the clinical pharmacists.

DISCUSSION

AI systems can equip clinicians with sophisticated tools and scale manual processes such as comprehensive medication reviews, thus reducing MRPs and drug-related hospitalizations related to multidrug treatments. The API system validated in this study provided comprehensive, multidrug, multilayered analysis intended to bridge the innate complexity of personalized polypharmacy treatment.

CONCLUSIONS

The API system was validated as a tool for providing actionable clinical insights non-inferior to a manual clinical review of a clinical pharmacist. The API system showed promising results in reducing MRPs.

Barriers and Unmet Educational Needs Regarding Implementation of Medication Adherence Management Across Europe: Insights from COST Action ENABLE

BACKGROUND

Medication adherence is essential for the achievement of therapeutic goals. Yet, the World Health Organization estimates that 50% of patients are nonadherent to medication and this has been associated with 125 billion euros and 200,000 deaths in Europe annually.

OBJECTIVE

This study aimed to unravel barriers and unmet training needs regarding medication adherence management across Europe.

DESIGN

A cross-sectional study was conducted through an online survey. The final survey contained 19 close-ended questions.

PARTICIPANTS

The survey content was informed by 140 global medication adherence experts from clinical, academic, governmental, and patient associations. The final survey targeted healthcare professionals (HCPs) across 39 European countries.

MAIN MEASURES

Our measures were barriers and unmet training needs for the management of medication adherence across Europe.

KEY RESULTS

In total, 2875 HCPs (pharmacists, 40%; physicians, 37%; nurses, 17%) from 37 countries participated. The largest barriers to adequate medication adherence management were lack of patient awareness (66%), lack of HCP time (44%), lack of electronic solutions (e.g., access to integrated databases and uniformity of data available) (42%), and lack of collaboration and communication between HCPs (41%). Almost all HCPs pointed out the need for educational training on medication adherence management.

CONCLUSIONS

These findings highlight the importance of addressing medication adherence barriers at different levels, from patient awareness to health system technology and to fostering collaboration between HCPs. To optimize patient and economic outcomes from prescribed medication, prerequisites include adequate HCP training as well as further development of digital solutions and shared health data infrastructures across Europe.

The Bibliometric and Visualized Analysis of Research for Hospital Medication Management Based on the Web of Science Database

Objective

Identify the collaborations between authors, countries, and institutions, respectively, and explore the hot issues and prospects for research on hospital medication management.

Materials and Methods

Publications on hospital medication management were retrieved from the Web of Science Core Collection. Bibliometric analyses were performed using CiteSpace 6.1.R3, HistCite 2.1, and VOSviewer 1.6.16. The network maps were created between authors, countries institutions, and keywords.

Results

A total of 18,723 articles related to hospital medication management studies were identified. Rapid growth in the number of publications since 2017. The high papers were published in AM J HEALTH-SYST PH, while JAMA-J AM MED ASSOC was the most co-cited journal. Manias E and WHO ranked first in the author and cited author. There were active collaborations among the top authors. Bates DW was the key author in this field. The authors have active collaborations in adverse drug events, acute coronary syndrome, in-hospital major bleeding, and so on. The US was the leading contributor in this field. The UK, Australia, and China are also very active. Active cooperation between countries and between institutions was observed. The main hot topics included matters related to outcome indicators, hospital pharmacy service behaviors, and medication use in pain management. More recent keywords focus on chronic disease medication management and clinical medication management.

Conclusion

Hospital medication management studies have significantly increased after 2017. There was active cooperation between authors, countries, and institutions. The application of hospital medication management in the emergency department and the relationship between medication management and medication adherence are current research hotspots. In addition, with the continuous progress of society, chronic diseases have become an important factor affecting people's health, and medication management is becoming more and more subdivided, so the direction of chronic disease medication management as well as precise medication may become the development direction of future research.

Assessment of Potentially Inappropriate Prescribing for People With Type 2 Diabetes Mellitus Using IMPACT2DM, a New Explicit Tool

Background: People with type 2 diabetes mellitus (T2DM) are at greater risk of potentially inappropriate prescribing (PIP) due to multiple comorbidities and polypharmacy. IMPACT2DM (Inappropriate Medication Prescribing Assessment Criteria for Type 2 Diabetes Mellitus) is a tool designed to identify PIP for adults with T2DM. Objectives: To assess PIP for adults with T2DM in Ethiopia using the IMPACT2DM and to test the face validity and clinical validity of the tool. Methods: A cross-sectional study was undertaken using data extracted retrospectively from the medical records of adults being managed for T2DM at Debretabore Hospital. PIP was assessed using IMPACT2DM. Some items/item components of IMPACT2DM were modified to increase the tool's applicability for the outpatient setting, to clarify content or to use the terms most common in this particular setting. Multivariant logistic regression analyses were conducted to identify factors associated with PIP. Results: More than 90% of medical records had at least 1 PIP. Prescribing omission (80.9%) was the most commonly identified type of PIP. Adults with prescribing omissions are more likely to be ≥40 years old or to be prescribed with <5 medications. Adults with dosing problems were more likely ≥50 years old, or have had a fasting blood sugar (FBS) level out of the target range (80-130 mg/dL). Conclusions: IMPACT2DM is a clinically valid PIP identification tool for application in an Ethiopian outpatient setting. Health professionals should be alert to check for potential prescribing omissions for adults ≥40 years old and dosing problems for adults with an FBS level out of the target range or >50 years.

N-of-1 health optimization: Digital monitoring of biomarker dynamics to gamify adherence to metabolic switching

The digital health field is experiencing substantial growth due to its potential for sustained and longitudinal deployment. In turn, this may drive improved monitoring and intervention as catalysts for behavioral change compared to traditional point-of-care practices. In particular, the increase in incidence of population health challenges such as diabetes, heart disease, fatty liver disease, and other disorders coupled with rising healthcare costs have emphasized the importance of exploring technical, economics, and implementation considerations, among others in the decentralization of health and healthcare innovations. Both healthy individuals and patients stand to benefit from continued technical advances and studies in these domains. To address these points, this study reports a N-of-1 study comprised of sustained regimens of intermittent fasting, fitness (strength and cardiovascular training), and high protein, low carbohydrate diet and parallel monitoring. These regimens were paired with serial blood ketone, blood glucose (wearable and finger stick) and blood pressure readings, as well as body weight measurements using a collection of devices. Collectively this suite of platforms and approaches were used to monitor metabolic switching from glucose to ketones as energy sources-a process associated with potential cardio- and neuroprotective functions. In addition to longitudinal biomarker dynamics, this work discusses user perspectives on the potential role of harnessing digital devices to these dynamics as potential gamification factors, as well as considerations for the role of biomarker monitoring in health regimen development, user stratification, and potentially informing downstream population-scale studies to address metabolic disease, healthy aging and longevity, among other indications.

The Need for Competency-Based Education

OBJECTIVES

While pharmacy education updates learning as new information arises, changes to learning experiences can trail behind current practices and technology. There have been multiple calls for radical changes in how health professions education is delivered to ensure patients are receiving high-quality care. Competency-based education has been one way discussed in the literature for how to handle this need to develop students who have a willingness to learn and can problem-solve. The goal of this review is to examine whether competency-based education is needed to drive the profession of pharmacy forward.

FINDINGS

To address, we collaboratively identified stakeholder perspectives to evaluate the need. The following stakeholders achieved consensus among the committee members: patients/society, learners, workplace/profession, and academic institutions.

SUMMARY

Based on those perspectives, needs, and gaps to address those needs were identified and are presented in this review.

Community Pharmacist and Family Medicine Collaboration for Pre-Visit Planning for Shared Patients Receiving Chronic Care Management Services

Background: Pre-visit planning entails completing necessary tasks prior to clinic appointments. Community pharmacists (CPs) have unique knowledge about patients' medication use but do not routinely provide drug therapy reviews before clinic visits. Objectives: (1) Create and implement a business partnership between a CP and family medicine clinic (FMC) for CP provision of pre-visit medication reviews, and (2) describe the billing experience for shared patients in the FMC chronic care management (CCM) program. Methods: A prospective 8-month study in one community pharmacy and FMC in Iowa. Eligible patients were enrolled in the clinic CCM program and received their prescriptions at the CP. CPs were granted access to the clinic electronic health record (EHR), performed medication reviews, and recorded drug therapy recommendations (DTRs) in the clinic EHR. FMC physicians reviewed CP DTRs before the patient encounter. Time tracking software in the EHR recorded CP and FMC time performing CCM services. CCM revenue was prorated between parties. FMC physicians completed a survey about their experience. Results: Overall, there were 129 CP reviews performed for 95 patients. These reviews resulted in 169 DTRs and 76% were accepted by the physician. There were 71 CCM claims billed and CCM revenue was $3596 ($1796 FMC, $1800 CP). More than 90% of physicians (N = 11) indicated they reviewed CP DTRs before the patient encounter and agreed they were helpful to their practice. Conclusion: CPs completed pre-visit medication reviews and made accepted medication therapy recommendations. CCM billing provided a mechanism for CPs to receive revenue for their services.

Cost-benefit analysis with return on investment of clinical pharmacists in the Military Health System

BACKGROUND

The Defense Health Agency comprises more than 700 military medical, dental, and veterinary facilities and provides care to more than 9.6 million beneficiaries. As medication experts, pharmacists identify opportunities to optimize medication therapy, reduce cost, and increase readiness to support the Defense Health Agency's mission. The Tripler Pilot Project and the Army Polypharmacy Program were used to establish a staffing model of 1 clinical pharmacist for every 6,500 enrolled beneficiaries. No large-scale cost-benefit study within the military health care system has been done, which documents the number of clinical interventions and uses established cost-avoidance (CA) data, to determine the cost-benefit and return on investment (ROI) for clinical pharmacists working in the medical treatment facilities.

OBJECTIVE

To validate the patient-centered medical home staffing model across the military health care system using the Tripler Pilot Project results to provide a cost-benefit analysis with an ROI. The secondary goal is to describe the interventions, staffing levels, and US Department of Defense-specific requirements impacting the provision of clinical pharmacy.

METHODS

A retrospective analysis of 3 years of encounters by clinical pharmacists in which an intervention was documented in the Tri-Service Workflow (TSWF) form as part of the electronic health record was completed. The analysis used 6 steps to assign CA intervention types and to prevent duplication and overestimation of the ROI. The absolute number of clinical pharmacists was determined using workload criteria defined as at least 20 encounters per month for at least 3 months of each calendar year. The number of clinical pharmacist full-time employees (FTEs) was determined by dividing the number of total active months by 12 months. Attrition was calculated comparing the presence of a unique provider identification between calendar years. The ROI range was calculated by dividing the CA by the total cost of clinical pharmacists using the variables' raw and extrapolated CA based on percentage of documentation template usage and the active clinical pharmacist calculation (absolute and FTE-based).

RESULTS

Between January 1, 2017, and December 31, 2019, a total of 1,069,846 encounters by clinical pharmacists were documented in the electronic health record. The TSWF Alternative Input Method form was used by pharmacists to document 616,942 encounters. Forty-three percent of TSWF documented encounters had at least 1 CA intervention. The absolute number of clinical pharmacists associated with a documented encounter in any medical treatment facility ranged from 404 in 2017 to 374 in 2018 and the clinical pharmacist FTEs ranged from 324 in 2017 to 314 in 2019. Annual attrition rates for clinical pharmacists ranged from 15% to 20% (58 to 81 clinical pharmacists) annually. The total CA range was $329,166,543-$534,014,494. The ROI range was between $2 and $4 per dollar spent.

CONCLUSIONS

This analysis demonstrated that ambulatory care clinical pharmacists in the Military Health System bring value through a positive ROI. Our study also identified a potential shortage of clinical pharmacists within the Air Force and Navy branches impacting medication management. This can have a negative impact on the readiness of service members, one of the leading priorities of the US Department of Defense.

Specific Medication Literacy in Older Adults with Asthma

Purpose

To explore specific medication literacy (SML) of older adults and associations of SML strength.

Methods

This was an observational study. Participants were at least 60 years old, with an asthma diagnosis and in good health. Data were collected by a registered nurse researcher. The SML data collection instrument gathered information about each medication a participant used: name, purpose, how taken, special instructions, adverse effects, and drug-drug or drug-disease interactions. An SML scoring rubric was developed.

Results

All could provide name, and most provided purpose, how taken. The lowest SML domains were side effects and interactions. Age at time of asthma diagnosis correlated with stronger SML scores and living in a disadvantaged neighborhood correlated with lower SML scores.

Discussion

Gaps in medication literacy may create less ability to self-monitor. Patients want medication literacy but struggle with appropriate, individualized, information.

Conclusion

The study provides insights on gaps and opportunities for SML.

Individual and Community-Level Characteristics and Adherence to Specialty Medications

Background: Understanding risk factors for nonadherence can help specialty pharmacies optimize resources to prevent nonadherence and inform risk-stratification processes. Objective: To determine which individual and community-level characteristics are associated with nonadherence to specialty medications. Methods: We analyzed a cohort of patients enrolled in a prospective randomized controlled trial having filled a specialty medication at least 4 times in the previous 12 months with a proportion of days (PDC) covered < 0.90. We collected patient age, gender, race, medication administration type, therapy start date, home address, insurance type, and online patient portal status from the electronic health record. An ordinal logistic regression model was used to assess the association of nonadherence with individual and community-level patient characteristics. Results: Most patients were female (68%), white (82%), and held commercial insurance (58%) with a median age of 53 (interquartile range [IQR] 40, 64) years. Patients were mostly from the adult rheumatology (35%), multiple sclerosis (20%) and lipid (17%) clinics. Given a 10-year increase in age, patients had lower odds of having lower PDC (odds ratio [OR] = 0.82, 95% confidence interval [CI] = 0.71-0.94, P = 0.005). Patients on therapy greater than or equal to 1 year had half the odds of having lower PDC relative to patients on therapy less than 1 year (OR = 0.52, CI = 0.35 - 0.75, P < 0.001). No statistically significant associations were found between PDC and gender, race, insurance type, route of administration, clinic type, patient portal status, median income, percent receiving government assistance, or percent with no health insurance. Conclusion: Patients with younger age and shorter duration on treatment may be at-risk for lower adherence. Specialty pharmacies may benefit from targeting adherence interventions to these groups.

Comparison of the sensitivities of pharmacotherapy-related and disease-specific quality of life measures in response to pharmacist-led pharmaceutical care for cancer outpatients: a randomised controlled trial

BACKGROUND

No data were previously available regarding the sensitivities of pharmacotherapy-related and disease-specific quality of life measures to pharmacist-led pharmaceutical care (PC).

AIM

The aim was to compare the sensitivities of two health-related quality of life (HRQoL) measures, i.e. the Patient-Reported Outcomes Measure of Pharmaceutical Therapy for Quality of Life (PROMPT-QoL) versus the Functional Assessment of Cancer Therapy-General (FACT-G), in response to pharmacist-led PC for cancer outpatients.

METHOD

A randomised controlled trial was conducted on cancer outpatients of a tertiary Thai hospital. Eligible patients were randomly allocated to a PC group receiving PC interventions or a usual care (UC) group receiving pharmacist's standard care. The HRQoL of both groups was assessed using the PROMPT-QoL and the FACT-G before and after intervention. The sensitivities of the two measures were determined using standardised mean differences (SMDs).

RESULTS

A total of 237 patients in two arms (120 PC vs. 117 UC patients) completed the trial. With PC interventions, all eight PROMPT-QoL domains and 3 out of 4 FACT-G domains were significantly improved. The PROMPT-QoL yielded SMDs ranging from 0.24 to 1.68 that were considered moderate-to-high sensitivity, while the FACT-G provided moderate sensitivity with SMDs of 0.31-0.64. The average SMDs of four FACT-G domains was 0.50 and SMD of the total score was 0.80. Eight PROMPT-QoL domains had the average SMD of 0.60 and the total score SMD was 1.40.

CONCLUSION

The PROMPT-QoL is more sensitive to detect HRQoL when delivering pharmacist-led pharmaceutical care to cancer outpatients.

TRIAL REGISTRATION

TCTR20210809008.

Estimated Costs of Drug-Related Problems Prevented by Pharmacist Prescription Reviews Among Hospitalized Internal Medicine Patients

BACKGROUND AND OBJECTIVES

Data are lacking on the estimated costs of pharmacist prescription reviews (PPRs) for hospitalized internal medicine patients. This study investigates the estimated costs of drug-related problems (DRPs) prevented by PPRs among hospitalized internal medicine patients.

METHODS

We reviewed all medication orders for patients at an academic teaching hospital in China for 2 years. DRPs were categorized using the Pharmaceutical Care Network Europe classification. The severity of the potential harm of DRPs was assessed by the Harm Associated with Medication Error Classification (HAMEC) tool. The estimated cost of PPRs was calculated.

RESULTS

A total of 162426 medication orders for 4314 patients were reviewed, and 1338 DRPs were identified by pharmacists who spent 2230 hours performing PPRs. Among the 1080 DRPs that were prospectively intervened upon, 703 were resolved. The HAMEC tool showed that 47.1% of DRPs were assessed as level 2, 30.4% as level 3, 20.6% as level 1, and 0.6% carried a life-threatening risk. Pharmacist interventions contributed to the prevention of DRP errors and a reduction of $339 139.44. This resulted in a mean cost saving of $482.42 per patient at an input cost of $21 495.06 over the 2 years. The benefit-cost ratio was 15.8.

CONCLUSION

PPRs are beneficial for detecting potential DRPs and creating potential cost savings among hospitalized internal medicine patients.

Economic impact of a clinical pharmacist in the orthopaedic sector: a review of the literature

OBJECTIVES

This review of the literature aimed to evaluate the economic impact of a clinical pharmacist in the orthopaedic sector.

METHODS

The review followed the PRISMA recommendations. A bibliographic search was conducted on 23 June 2023 using PubMed, Cochrane Library and Web of Science. All articles in French or English with economic data on clinical pharmacy activities in orthopaedics were included. Articles not mentioning the term 'orthopaedics' and those published prior to 1990 were excluded. Data from the studies were compiled in an Excel table. A bias analysis using the ROBINS-I Cochrane tool was performed. The methodology of the studies was compared and weighted using the CHEERS and STROBE checklists.

RESULTS

Among 529 articles initially identified, 10 were included in the review. The cost-benefit ratio of a clinical pharmacist in orthopaedics ranged from 0.47:1 to 28:1. The maximum savings reached US$73 410 /year in the American study and €1 42 356 /year in the French study. For three studies, the cost of a clinical pharmacist was not evaluated. Eight studies showed a positive economic impact. The Dutch study showed a balance and the Danish study showed a negative economic impact of €3442/month.

CONCLUSIONS

This literature review has shown an economic benefit of a clinical pharmacist in the orthopaedic sector despite several biases and methodological limitations. The two studies that did not confirm this benefit only evaluated a limited number of expected benefits. Nevertheless, the economic impact of the clinical pharmacist in the orthopaedic sector seems positive and undervalued.

Evaluation of a pharmacist-led intervention to reduce drug-related problems in patients included in a home healthcare program: study protocol for a pragmatic randomized clinical trial

BACKGROUND

ATDOM is the Catalan home healthcare program at primary care level. Patients in the home care program are usually frail, elderly people with multiple comorbidities. They are often polymedicated, leading to a high risk of drug-related problems (DRPs). Our hypothesis is that the pharmacist-led individualized review of the pharmacotherapeutic plans of ATDOM patients will be effective in improving the quality of treatments by reducing DRPs in terms of indication, adequacy, effectiveness, and safety.

METHODS

Aim: To compare the effectiveness of a standardized pharmaceutical intervention for the review and optimization of pharmacological treatments in ATDOM patients with usual management practice.

DESIGN

Pragmatic randomized clinical trial with a comparable control group, with prospective follow-up regarding the intervention on the adequacy of the pharmacological treatment of patients in the ATDOM program.

SETTING

Primary care teams in the Camp de Tarragona Primary Care Area, Tarragona, Spain.

PARTICIPANTS

Four hundred and thirty-two ATDOM patients will be recruited, those who are over 65 years old and who are currently undergoing pharmacological treatment.

MEASURES

Effectiveness of a six-month long intervention in reducing DRPs per patient and polypharmacy. Additionally, in the intervention group we will evaluate the implementation of the proposals for change or improvement made by the responsible physician.

ANALYSIS

The outcomes will be analyzed on an intent-to-treat basis and the analysis units will be the individual patients. Logistic regression and linear regression models will be used to evaluate the effects of the intervention on dichotomous and continuous variables versus the control arm.

ETHICS

The protocol was approved by the Research Ethics Committee of the Jordi Gol Primary Care Research Institute (IDIAPJGol), Barcelona, (19/141-P).

DISCUSSION

If the results of the pharmaceutical intervention are favorable, widespread implementation of the program could be possible. It could be extended to all ATDOM patients or outpatients in general. Interdisciplinary teamwork could be strengthened as a result, which would improve the healthcare continuum.

TRIAL REGISTRATION

Retrospectively registered.

CLINICALTRIALS

gov Identifier NCT05820945; Registered 21 March, 2023.

Medication use in a cohort of adults with chronic intestinal failure: A prospective cross-sectional study

BACKGROUND

Oral drug therapy may be compromised in chronic intestinal failure (IF) because of alterations in absorption and transit. Only scarce literature is available on which medication patients with chronic IF take in daily life. The aim was to describe the medication use in these patients.

METHODS

A medication history was obtained from adults with chronic IF treated in our tertiary care IF center. Degree of polypharmacy, drug classes, Biopharmaceutics Classification System classes, route of administration, and formulation of drugs were analyzed.

RESULTS

From October 2019 until December 2020, 72 patients (35 patients with short bowel syndrome [SBS] and 37 patients without SBS) were included. Polypharmacy was seen in 85.7% of patients with SBS and 75.7% of patients without SBS. The top three drug classes were proton-pump inhibitors, vitamin D or acetaminophen, and antimotility medication or laxatives/benzodiazepines. Approximately 25% of the drugs were classified as Biopharmaceutics Classification System class I drugs. In patients with SBS (78%) and patients without SBS (74.9%), most medication was taken orally, requiring gastrointestinal absorption of the active substance to be pharmacologically active. Most of these medications (77% in patients with SBS and 80.8% in patients without SBS) were formulated as a capsule or tablet, requiring disintegration and dissolution in the gastrointestinal tract before absorption can take place.

CONCLUSION

Polypharmacy was observed in most patients with chronic IF. Most medication was taken orally in formulations requiring disintegration, dissolution, and gastrointestinal absorption, which could be compromised in chronic IF.

Pharmacists Colocated With Primary Care Physicians: Understanding Delivery of Interprofessional Primary Care

BACKGROUND

While evidence supports interprofessional primary care models that include pharmacists, the extent to which pharmacists are working in primary care and the factors associated with colocation is unknown.

OBJECTIVES

This study aimed to analyze the physical colocation of pharmacists with primary care providers (PCPs) and examine predictors associated with colocation.

RESEARCH DESIGN

This is a retrospective cross-sectional study of pharmacists and PCPs with individual National Provider Identifiers in the National Plan and Provider Enumeration System's database. Pharmacist and PCP practice addresses of the health care professionals were geocoded, and distances less than 0.1 miles were considered physically colocated.

SUBJECTS

In all, 502,373 physicians and 221,534 pharmacists were included.

RESULTS

When excluding hospital-based pharmacists, 1 in 10 (11%) pharmacists were colocated with a PCP. Pharmacists in urban settings were more likely to be colocated than those in rural areas (OR=1.32, CI: 1.26-1.38). Counties with the highest proportion of licensed pharmacists per 100,000 people in the county had higher colocation (OR=1.38, CI: 1.32-1.45). Colocation was significantly higher in states with an expanded scope of practice (OR 1.37, CI: 1.32-1.42) and those that have expanded Medicaid (OR 1.07, CI: 1.03-1.11). Colocated pharmacists more commonly worked in larger physician practices.

CONCLUSION

Although including pharmacists on primary care teams improves clinical outcomes, reduces health care costs, and enhances patient and provider experience, colocation appears to be unevenly dispersed across the United States, with lower rates in rural areas. As the integration of pharmacists in primary care continues to expand, knowing the prevalence and facilitators of growth will be helpful to policymakers, researchers, and clinical administrators.

Digital Therapeutics for Improving Effectiveness of Pharmaceutical Drugs and Biological Products: Preclinical and Clinical Studies Supporting Development of Drug + Digital Combination Therapies for Chronic Diseases

Limitations of pharmaceutical drugs and biologics for chronic diseases (e.g., medication non-adherence, adverse effects, toxicity, or inadequate efficacy) can be mitigated by mobile medical apps, known as digital therapeutics (DTx). Authorization of adjunct DTx by the US Food and Drug Administration and draft guidelines on "prescription drug use-related software" illustrate opportunities to create drug + digital combination therapies, ultimately leading towards drug-device combination products (DTx has a status of medical devices). Digital interventions (mobile, web-based, virtual reality, and video game applications) demonstrate clinically meaningful benefits for people living with Alzheimer's disease, dementia, rheumatoid arthritis, cancer, chronic pain, epilepsy, depression, and anxiety. In the respective animal disease models, preclinical studies on environmental enrichment and other non-pharmacological modalities (physical activity, social interactions, learning, and music) as surrogates for DTx "active ingredients" also show improved outcomes. In this narrative review, we discuss how drug + digital combination therapies can impact translational research, drug discovery and development, generic drug repurposing, and gene therapies. Market-driven incentives to create drug-device combination products are illustrated by Humira® (adalimumab) facing a "patent-cliff" competition with cheaper and more effective biosimilars seamlessly integrated with DTx. In conclusion, pharma and biotech companies, patients, and healthcare professionals will benefit from accelerating integration of digital interventions with pharmacotherapies.

An Awareness of Pharmacovigilance Among Healthcare Professionals Due to an Underreporting of Adverse Drug Reactions Issue: A Systematic Review of the Current State, Obstacles, and Strategy

BACKGROUND

Healthcare professionals play an essential role in reporting adverse drug reactions as part of pharmacovigilance activities. However, adverse drug reactions reported by healthcare professionals remain low.

OBJECTIVE

The aim of this systematic review was to investigate healthcare professionals' knowledge, awareness, attitude, and practice on pharmacovigilance and adverse drug reaction reporting, explore the causes of the underreporting issue, and provide improvement strategies.

METHODS

This systematic review was conducted using four electronic databases for original papers, including PubMed, Scopus, Google Scholar, and Scholar ID. Recent publications from 1st January 2012 to 31st December 2022 were selected. The following terms were used in the search: "awareness", "knowledge", "adverse drug reaction", "pharmacovigilance", "healthcare professional", and "underreporting factor". Articles were chosen, extracted, and reviewed by the two authors.

RESULTS

Twenty-five studies were selected for systematic review. This review found that 24.8%-73.33% of healthcare professionals were unaware of the National Pharmacovigilance Center. Around 20%-95.7% of healthcare professionals have a positive attitude toward pharmacovigilance and adverse drug reaction reporting, while 12%-60.8% of healthcare professionals have experience reporting any adverse drug reaction in their practice. The most frequently highlighted barriers to pharmacovigilance were a lack of awareness and knowledge regarding what, when, and to whom to report.

CONCLUSION

Underreporting issues require immediate attention among healthcare professionals due to a lack of awareness and knowledge of pharmacovigilance and adverse drug reaction reporting. Educational and training program interventions have been suggested by most studies to address these issues.

Social Determinants of Health: An Overview for the Primary Care Provider

Social determinants of health (SDoH) are reflected in how people live (access to health care, economic stability, built environment, food security, climate), learn (the educational environment), work (occupational environment), and play/socialize (social context and digital domain). All of these day-to-day conditions play a vital role in a patient's overall health, and a primary care provider should be prepared to understand their role to screen, assess, and address SDoH in clinical practice.

Building health plan-pharmacist provider partnerships to optimize medication outcomes

Over the years, the practice of medication management has taken on various terms and definitions. As a result, health plans have developed different approaches to identifying beneficiaries for medication therapy management (MTM), engaging pharmacists to provide MTM, and adopting standards for documentation and quality assurance. This variation leads to inconsistent delivery of MTM and potential quality concerns. Therefore, an environment needs to be created that allows for health plans to discuss and share approaches, challenges, and best practices. To achieve this, the University of Minnesota College of Pharmacy has served as an organizer and facilitator of an ongoing series of Minnesota Health Plan Summits to drive sustainable and mutually beneficial MTM programs and payment models across the state. In less than 2 years, the University of Minnesota College of Pharmacy has hosted and organized 4 Health Plan Summits with the objective of sharing ideas and identifying mutual goals (short- and long-term) across health plans and pharmacy providers of MTM services to optimize medication outcomes for the citizens of Minnesota and beyond. These meetings have led to several productive discussions and takeaways, including: (1) having a convener is essential for these types of connections and discussions, (2) health plans and pharmacists find value in these summits, (3) there is a range of experience in MTM program development across health plans, and (4) there are important opportunities to enhance understanding between health plans and pharmacist providers. In addition, 3 workgroups have been established in the following areas: (1) improve consistency in the design of MTM benefits across health plans for service and delivery, including provider credentialing, (2) increase transparency and education between plans and providers on the "fixed points" (such as CMS requirements) vs modifiable portions of plan design, and (3) create agreement on a single quality metric to target, collect data, and demonstrate value of MTM. For change to occur, it often must start locally, suggesting that the formal, facilitated convening of local health plan leaders and pharmacist providers to discuss building consistent and high-quality MTM programs is an essential strategy for MTM program adoption and growth. Including both groups of stakeholders should not only focus on payment, but also the mechanisms necessary to support implementation and create a win-win for both groups. In sharing our experience in Minnesota, we aim to inspire others to form regional initiatives that create structured, facilitated conversations that can produce new partnerships. Strategies that have supported our success are described and can be adopted once a regional entity, such as a school of pharmacy or other trusted entity, chooses to convene a group of invested stakeholders.

Prescribers' approval rate of pharmacist-initiated interventions to optimise patients' clinical status of hypertension in the ambulatory care setting

This perspective, pre- and post-intervention study with a one-year follow-up primarily aimed to ascertain prescribers' approval rate of pharmacists' interventions and clinical status of hypertension following comprehensive medication management (CMM) intervention in the ambulatory care clinic. Between January 2018 and January 2022 overall 100 patients with hypertension and other comorbidities were referred to the CMM services at the Health Centre Zagreb - Centar (HCZC). Out of 275 interventions directed to prescribers, 73.1 % of interventions were approved, 12.4 % were rejected and 14.5 % were not reviewed. The percentage of patients with a blood pressure goal increased from 45 % at the initial consultation to 82.5 % at the patients' latest encounter (p < 0.001). The average number of drug therapy problems (DTPs) per patient totaled 3.53 ± 1.80, where 98 % of patients had one or more DTPs, 48 % had 4 or more DTPs, whereas 26 % had 5 or more DTPs. Sub-therapeutic dosage (32.6 %) and the need for additional drug therapy (30.9 %) were the two most commonly identified DTPs. These results reinforce the need to integrate pharmacy-led services in the primary care setting with the aim of improving patients' health outcomes.

Perceptions of conflicting information about long-term medications: a qualitative in-depth interview study of patients with chronic diseases in the Swiss ambulatory care system

OBJECTIVE

Patients with multiple long-term conditions visit various healthcare professionals and are exposed to medication information from various sources causing an increased risk of patients perceiving contradictory medication information. The aims of this study are to: (1) characterise conflicting medication information perceived by patients with long-term conditions, (2) better understand the related impact on patients' medication self-management and healthcare system navigation and (3) explore ways in which such events could be prevented.

DESIGN

This study was conducted through qualitative semistructured interviews. Data were analysed using thematic analysis.

SETTING

Community pharmacies and medical centres in Geneva, Switzerland.

PARTICIPANTS

This study included outpatients from April 2019 to February 2020. Patients were included after participating in a quantitative survey of perceived conflicting information about medications for long-term diseases.

METHODS

Semistructured audiotaped interviews of 20 to 60 min following a pre-established interview guide to explore participants' perceptions of conflicting information. Interviews were transcribed verbatim, and a thematic analysis was conducted with inductive and deductive coding using MAXQDA (2018, Release 18.2.3).

RESULTS

Twenty-two patients were interviewed, until data saturation, mentioning indication or need for a medication as the main topic of conflicting information between two healthcare professionals. Perceived conflicting information often resulted from insufficient information provided and poor communication leading to confusion, doubts and medication non-adherence. Patients expected more information and more interprofessional communication on their medications. As a result of conflicting information, most participants learnt or were learning to take an active role and become partners of the healthcare providers.

CONCLUSION

The need to strengthen and improve communication and interprofessional collaborative practice among healthcare professionals and with the patient is emerging to increase the quality and consistency of information about medications, and consequently, to ensure better use and experience of medications.

Costs of Prescription Drugs for Children and Parental Adherence to Long-Term Medications

Importance

The adverse effects of prescription drug costs on medication adherence and health have been well described for individuals. Because many families share financial resources, high medication costs for one could lead to cost-related nonadherence in another; however, these family-level spillover effects have not been explored.

Objective

To evaluate whether the cost of a child's newly initiated medication was associated with changes in their parent's adherence to their own medications and whether that differed by likely duration of treatment.

Design, Setting, and Participants

This cohort study used interrupted time-series analysis with a propensity score-matched control group from a large national US health insurer database (2010-2020) and included children initiating medication and their linked presumed parents using long-term medications.

Exposure

The cost of the child's initiated medication. Child medication cost was classified based on highest (≥90th) or lowest (<10th) decile from out-of-pocket medication spending, stratified by whether the medication was intended for short- or long-term use. Children initiating high-cost medications (based on the highest decile) were propensity-score matched with children initiating low-cost medications.

Main Outcome and Measures

The child's parent's adherence to long-term medication assessed by the widely used proportion of days covered metric in 30-day increments before and after the child's first fill date. Parent demographic characteristics, baseline adherence, and length of treatment, and family unit size and out-of-pocket medication spending were key subgroups.

Results

Across 47 154 included pairs, the parents' mean (SD) age was 42.8 (7.7) years. Compared with a low-cost medication, initiating a high-cost, long-term medication was associated with an immediate 1.9% (95% CI, -3.8% to -0.9%) reduction in parental adherence sustained over time (0.2%; 95% CI, -0.1% to 0.4%). Similar results were observed for short-term medications (0.6% immediate change; 95% CI, -1.3% to -0.01%). Previously adherent parents, parents using treatment for longer periods, and families who spent more out-of-pocket on medications were more sensitive to high costs, with immediate adherence reductions of 2.8% (95% CI, -4.9% to -0.6%), 2.7% (95% CI, -4.7% to -0.7%), and -3.8% (95% CI, -7.2% to -0.5%), respectively, after long-term medication initiation.

Conclusions and Relevance

In this cohort study small reductions in adherence across parents with higher child drug costs were observed. Health care systems should consider child-level or even household-level spending in adherence interventions or prescription policy design.

Communication Protocols Integrating Wearables, Ingestibles, and Implantables for Closed-Loop Therapies

Body-conformal sensors and tissue interfacing robotic therapeutics enable the real-time monitoring and treatment of diabetes, wound healing, and other critical conditions. By integrating sensors and drug delivery devices, scientists and engineers have developed closed-loop drug delivery systems with on-demand therapeutic capabilities to provide just-in-time treatments that correspond to chemical, electrical, and physical signals of a target morbidity. To enable closed-loop functionality in vivo, engineers utilize various low-power means of communication that reduce the size of implants by orders of magnitude, increase device lifetime from hours to months, and ensure the secure high-speed transfer of data. In this review, we highlight how communication protocols used to integrate sensors and drug delivery devices, such as radio frequency communication (e.g., Bluetooth, near-field communication), in-body communication, and ultrasound, enable improved treatment outcomes.

Assessing feasibility of a novel approach to effective medication self-management for older persons

The fact that nearly one-half of patients take medications differently than as prescribed, combined with the predisposition of older persons to adverse events, suggests a need for new strategies supporting medication self-management for older persons. This pilot study describes the development, acceptability and feasibility of a novel toolkit approach focusing on a systematic 4-step process for ensuring medication appropriateness. A preliminary qualitative assessment of the toolkit's acceptability and feasibility was carried out using a convenience sample of 39 residents aged 62-97 years in two senior living facilities convened in focus groups. A facilitator guided participants through discussions of the 4-step process. All participants indicated they perceive that the toolkit's systematic 4-step process can help older persons successfully self-manage medications. The most common medication use challenges cited by participants were related to effectiveness (35%), followed by intended medical use (27%), safety (23%), and ability to take medications (15%). This preliminary investigation suggests that older adults resonate with use of this 4-step process to confidently self-manage medications and find it feasible and acceptable to use in assessing the appropriateness of their medications. More research is needed to establish the reliability and validity of this toolkit with more diverse populations of older adults.

Determination of drug-related problems among type 2 diabetes outpatients in a hospital in Vietnam: A cross-sectional study

INTRODUCTION

Drug-related problems (DRPs) are common in clinical practice and occur at all stages of the medication process. The major factor contributing to DRPs is prescription, although patients' poor adherence to treatment is also a significant factor. This study evaluated type 2 diabetes outpatients in a hospital in Vietnam for drug-related problems (DRPs) and related variables.

METHODS

A cross-sectional descriptive study was conducted on 495 outpatients who met the criteria and 157 people agreed to participate in the interview. Medication order review and medication adherence review were used to identify DRPs. The types of DRP were based on the Pharmaceutical Care Network Europe (PCNE) categories version 9.0. The identification and assessment DRPs were carried out by clinical pharmacists and get agreed upon by physicians who had not directly prescribed patients who participated in the study.

RESULTS

A total of 762 DRPs were identified via prescribing review process, the average number of DRP on each prescription was 1.54±1.07, while 412 DRPs were determined through patient interviewing. The most frequent DRPs were "ADR (Adverse Drug Reaction) occurring" (68.8%). The main causes were "patient is unable to understand instructions properly" or "patient is not properly instructed", "patient stores insulin inappropriately", "patient decides to use unnecessary drugs" and "patient intentionally uses/takes less drug than prescribed or does not take the drug at all for whatever reason" which accounted for 65.0%, 41.4%, 38.2%, and 28.7%, respectively. From the prescribing review, the most observed DRPs were "Inappropriate drug according to guidelines/formulary" and "No or incomplete drug treatment in spite of existing indication", accounting for 45.0% and 42.9%, respectively. There was a significant association between age (OR 3.38, 95% CI: 1.01-11.30), duration of diabetes (OR 3.61, 95%CI: 1.11-11.74), presence of comorbidity (OR 5.31, 95%CI: 1.97-14.30), polypharmacy (OR: 2.95, 95%CI: 1.01-8.72) and DRPs. In patients, poor knowledge of antidiabetic agents was the main reason to lack adherence and occurring ADR (OR 2.73, 95%CI: 1.32-5.66, p = 0.007 and OR 2.49, 95%CI: 1.54-4.03, p = 0.001 respectively).

CONCLUSION

DRPs occurred in the prescribing stage and relating to patient's behavior of drug administration was high. Clear identification of DRPs and the associated factors are essential for building the intervention process to improve effectiveness and safety in the treatment of type 2 diabetes mellitus patients.

Generalizability of machine learning methods in detecting adverse drug events from clinical narratives in electronic medical records

We assessed the generalizability of machine learning methods using natural language processing (NLP) techniques to detect adverse drug events (ADEs) from clinical narratives in electronic medical records (EMRs). We constructed a new corpus correlating drugs with adverse drug events using 1,394 clinical notes of 47 randomly selected patients who received immune checkpoint inhibitors (ICIs) from 2011 to 2018 at The Ohio State University James Cancer Hospital, annotating 189 drug-ADE relations in single sentences within the medical records. We also used data from Harvard's publicly available 2018 National Clinical Challenge (n2c2), which includes 505 discharge summaries with annotations of 1,355 single-sentence drug-ADE relations. We applied classical machine learning (support vector machine (SVM)), deep learning (convolutional neural network (CNN) and bidirectional long short-term memory (BiLSTM)), and state-of-the-art transformer-based (bidirectional encoder representations from transformers (BERT) and ClinicalBERT) methods trained and tested in the two different corpora and compared performance among them to detect drug-ADE relationships. ClinicalBERT detected drug-ADE relationships better than the other methods when trained using our dataset and tested in n2c2 (ClinicalBERT F-score, 0.78; other methods, F-scores, 0.61-0.73) and when trained using the n2c2 dataset and tested in ours (ClinicalBERT F-score, 0.74; other methods, F-scores, 0.55-0.72). Comparison among several machine learning methods demonstrated the superior performance and, therefore, the greatest generalizability of findings of ClinicalBERT for the detection of drug-ADE relations from clinical narratives in electronic medical records.

Small patients, big challenges: navigating pediatric drug manipulations to prevent medication errors - a comprehensive review

INTRODUCTION

Medication errors during drug manipulations in pediatric care pose significant challenges to patient safety and optimal medication management. Epidemiological studies have revealed a high prevalenceof medication errors throughout the medication process. Due to the lack of age-appropriate dosage forms, medication manipulation is common in pediatric drug administration. The consequences of these manipulations on drug efficacy and safety could be devastating, highlighting the need for evidence-based guidelines and standardized compounding practices.

AREAS COVERED

This review focuses on examining medication errors in pediatric care and delving into the manipulation of medicinal products.

EXPERT OPINION

The observed prevalence of medication errors and manipulations underscores the importance of addressing these issues to enhance patient safety and improve medication outcomes in pediatric care. Overall, the development of age-appropriate formulations and the dissemination of comprehensive clinical guidelines are essential steps toward improving medication safety and minimizing manipulations in pediatric healthcare settings.

Pattern, frequency and factors associated with inappropriate high dosing in chronic kidney disease patients at a tertiary care hospital in Pakistan

BACKGROUND

Patients with chronic kidney diseases (CKD) are susceptible to the toxic drug effects if given unadjusted doses. Although Pakistan harbors a high burden of CKD patients, there is limited information available on the frequency, pattern and factors associated with unadjusted drug doses among CKD patients.

METHODS

This cross-sectional study conducted at Sandeman Provincial Hospital, Quetta included 303 non-dialysis ambulatory CKD patients (glomerular filtration rate < 60 ml/min/1.73m²). The patients' data were collected through a purpose designed data collection form. The appropriateness of doses was checked against the renal drug handbook-2018, Kidney Disease Improving Global Outcomes guidelines, British National Formulary-2022, and manufacturer leaflets. Data were analysed by SPSS 23 and multiple binary logistic regression analysis was used to assess the factors associated with receiving inappropriate high doses. A p-value < 0.05 was considered statistically significant.

RESULTS

The patients received a total of 2265 prescription lines, with a median of eight different drugs per patient (interquartile range: 6-9 drugs). A total of 34.5% (783/2265) drugs required dose adjustment. Of these, doses were not adjusted for 56.1% (440) drugs in 162 (53.4%) patients. The most common pharmacological class of drugs requiring dose adjustment were antibiotics (79.1%), followed by antidiabetics (59.2%), diuretics (57.0%), angiotensin converting enzyme inhibitors (56.9%), beta blockers (56.9%), analgesics (56.0%), angiotensin receptor blockers (55.2%), domperidone (53.9%) and antihyperlipidmics (46.1%). Patient's age of 41-60 (OR = 5.76) and > 60 years (OR = 9.49), hypertension (OR = 2.68), diabetes mellitus (OR = 3.47) and cardiovascular diseases (OR = 2.82) had statistically significant association (p-value < 0.05) with inappropriate high doses.

CONCLUSION

The high frequency of inappropriate high doses suggests an important quality gap in medication dosing for patients with ND-CKD at the study site. Special attention should be paid to the drugs and patients with identified risk factors for receiving inappropriate high doses.

Beyond Antiretroviral Treatment: Patterns and Factors Associated With Composite Medication Adherence Before and During the COVID-19 Pandemic in Patients With HIV With Multiple Chronic Conditions

BACKGROUND

Polypharmacy for multiple chronic conditions (MCCs) poses an increasing challenge in people with HIV (PWH). This research explores medication adherence in PWH with MCCs before and during COVID-19.

SETTING

Kaiser Permanente Mid-Atlantic States.

METHODS

Medical and pharmacy records of a continuously enrolled cohort (September 2018-September 2021) of adult PWH were used. To estimate medication adherence, monthly proportion of days covered (PDC) was measured individually for antiretrovirals (ARVs), diabetes medications (DMs), renin-angiotensin antagonists (RASMs), and statins (SMs) and combined into composite measures (CMs) with and without ARVs. Descriptive statistics, time-series models, and multivariable population-averaged panel general estimating equations were used to profile trends, effects, and factors associated with adherence.

RESULTS

The cohort (n = 543) was predominantly 51-64 years old (59.3%), Black (73.1%), male (69.2%), and commercially insured (65.4%). Two-thirds (63.7%) of patients were taking medications in 2 medication groups (ie, ARVs and either DMs, RASMs, or SMs), 28.9% were taking medications in 3 medication groups, and 7.4% were taking medications in all 4 medication groups. Overall, PDC for CMs without ARVs was 77.2% and 70.2% with ARVs. After March 2020, negative monthly trends in PDC were observed for CMs without ARVs (β = -0.1%, P = 0.003) and with ARVs (β = -0.3%, P = 0.001). For CMs with ARVs, Black race (aOR = 0.5; P < 0.001; ref: White) and taking medications for 3 medication groups (aOR = 0.8; P < 0.02; ref: 2) were associated with lower adherence.

CONCLUSION

Decreasing medication adherence trends were observed during the COVID-19 pandemic with variations among population subgroups. Opportunity exists to improve medication adherence for non-White populations and those taking medications for MCCs beyond ARVs.

Telehealth medication management and health care spending in a Medicare Accountable Care Organization

BACKGROUND: Value-based care is an opportunity for medication optimization services to improve medication management and reduce health care spending. The reach of these services may be extended through telehealth. However, as health care systems and payers grapple with the long-term financing of telehealth, real-world assessments are needed to evaluate the potential economic impact of pharmacy-driven telehealth services. OBJECTIVE: To evaluate the impact of a scalable pharmacist-driven telehealth intervention to improve medication management on health care spending for clinically complex patients who were enrolled in a Medicare Next Generation Accountable Care Organization. METHODS: Data for this pretest-posttest nonequivalent group design study came from Medicare claims from 2015 to 2020 and linked pharmacist care activity data derived from the electronic medical record. Patients in the intervention group were identified as those who received the telehealth medication management service. Patients in the control group were offered the service and refused or could not be contacted. The primary outcome was total medical spending over a 6-month period, and impact was assessed using a covariate-adjusted difference-in-difference model. RESULTS: There were 581 patients who received the intervention and 1,765 who served as controls. The telehealth intervention reduced total medical spending by $2,331.85 per patient over the first 6 months of the service ($388.50 per month; P = 0.0261). Across a range of estimates for the cost of service delivery, we find a return on investment of 3.6:1 to 5.2:1. CONCLUSIONS: The $388.50 monthly savings found in this study represent a substantial reduction in health care spending and emphasize the opportunity for telehealth delivery of medication management services to improve value as a part of alternative payment models. DISCLOSURES: This study was funded by the UNC Health Care Department of Pharmacy. Dr Urick has received personal fees from Pharmacy Quality Solutions and Cardinal Health. Drs Peters, Vest, Colmenares, Foushee, and DeFalco are employees of UNC Health Care Department of Pharmacy. Mr Easter received a Co-PI grant from NACDS Foundation to implement Community-based Value Care Initiative (CVCI) in a community pharmacy setting. He also received a grant to Eshelman School of Pharmacy. He has an individual consulting agreement with digital health company Truentity Health to provide go to market strategy for medication management services. He also has stock options from Truentity Health as a component of the consulting agreement. Dr Foushee has a leadership or fiduciary role at Member-At-Large and the Ambulatory Care Academy of the North Carolina Association of Pharmacists. At the time this work was conducted, Dr Urick, Dr Pathak, and Dr Blanchard were all employees of the UNC Eshelman School of Pharmacy.

Racial and ethnic disparities in Medicare Part D medication therapy management services utilization

Background

The Medicare Part D medication therapy management (MTM) program has positive effects on medication and health service utilization. However, little is known about its utilization, much less so about the use among racial and ethnic minorities.

Objective

To examine MTM service utilization among older Medicare beneficiaries and to identify any racial and ethnic disparity patterns.

Methods

A retrospective cross-sectional analysis of 2017 Medicare administrative data, linked to the Area Health Resources Files. Fourteen outcomes related to MTM service nature, initiation, quantity, and delivery were examined using logistic, negative binomial, and Cox proportional hazards regression models.

Results

Racial and ethnic disparities were found with varying patterns across outcomes. For example, compared with White patients, the odds of opting out of MTM were 8% higher for Black patients (odds ratio [OR] = 1.08, 95% confidence interval [CI] = 1.03-1.14), 57% higher for Hispanic patients (OR = 1.57, 95% CI = 1.42-1.72), and 57% higher for Asian patients (OR = 1.57, 95% CI = 1.33-1.85). The odds of continuing MTM from the previous years were 12% lower for Black patients (OR = 0.88, 95% CI = 0.86-0.90) and 3% lower for other patients (OR = 0.97, 95% CI = 0.95-0.99). In addition, the probability of being offered a comprehensive medication review (CMR) after MTM enrollment was 9% lower for Hispanic patients (hazard ratio [HR] = 0.91, 95% CI = 0.85-0.97), 9% lower for Asian patients (HR = 0.91, 95% CI = 0.87-0.94), and 3% lower for other patients (HR = 0.97, 95% CI = 0.95-0.99). Hispanic and Asian patients were more likely to have someone other than themselves receive a CMR.

Conclusions

Racial and ethnic disparities in MTM service utilization were identified. Although the disparities in specific utilization outcomes vary across racial/ethnic groups, it is evident that these disparities exist and may result in vulnerable communities not fully benefiting from the MTM services. Causes of the disparities should be explored to inform future reform of the Medicare Part D MTM program.

Au/SiNCA-based SERS analysis coupled with machine learning for the early-stage diagnosis of cisplatin-induced liver injury

Cisplatin has been widely applied in the clinical treatment of various cancers, whereas liver injury induced by its hepatotoxicity is still a severe issue. Reliable identification of early-stage cisplatin-induced liver injury (CILI) can improve clinical care and help to streamline drug development. Traditional methods, however, cannot achieve enough information at the subcellular level due to the requirement of the labeling process and low sensitivity. To overcome these, we designed an Au-coated Si nanocone array (Au/SiNCA) to fabricate the microporous chip as the surface-enhanced Raman scattering (SERS) analysis platform for the early diagnosis of CILI. A CILI rat model was established, and the exosome spectra were obtained. The principal component analysis (PCA)-representation coefficient-based k-nearest centroid neighbor (RCKNCN) classification algorithm was proposed as the multivariate analysis method to build the diagnosis and staging model. The PCA-RCKNCN model has been validated to achieve a satisfactory result, with accuracy and AUC of over 97.5%, and sensitivity and specificity of over 95%, indicating that SERS combined with the PCA-RCKNCN analysis platform can be a promising tool for clinical applications.

A Methodological Review of Drug-Related Toxicological Studies in Saudi Arabia

This study aimed to conduct a methodological review of drug-related toxicological studies in Saudi Arabia. A systematic review and a methodological analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Medline and Embase were searched for all types of studies reporting toxicological studies in the English language published until January 10, 2022. The search was conducted using both keywords and Medical Subject Headings (MeSH) terms. The methodological analysis of included studies was assessed using the Newcastle-Ottawa Scale. A total of 3,750 studies were extracted and screened. Of these, 30 observational studies (seven cohort studies and 23 cross-sectional studies) met the inclusion criteria. The methodological scores ranged from five to seven out of 10 possible points. Twelve studies had high quality, and 18 studies had moderate quality. Eight studies focused on adverse drug reactions, eight explored poisoning, four explored drug-related hospitalizations, nine explored drug-induced toxicity, and one explored drug overdose. This research project revealed that most of the drug-related toxicological studies conducted in Saudi Arabia were observational studies of moderate quality. Future studies should focus on the quality of the design and reporting.

Predictors of Receipt of Comprehensive Medication Reviews in Older Adults

BACKGROUND

Polypharmacy is highly prevalent among older adults. This study's purpose was to provide nationally representative estimates of self-reported comprehensive medication review (CMR) receipt among older adults and describe factors associated with their receipt, as CMRs are available through the Medicare Part D program.

METHODS

This cross-sectional study used data from the National Poll on Healthy Aging (NPHA), a nationally representative online survey of community-dwelling adults aged 50-80, administered in December 2019. Participants included older adults aged 65-80 with any health insurance (n = 960). Outcomes were self-reported CMR receipt, awareness of CMR insurance coverage, and interest in a future CMR with a pharmacist. Sociodemographic and health-related variables were included. Descriptive statistics and multivariable logistic regression with NPHA population sampling weights were used.

RESULTS

Among older adults on 2 or more prescription medications, only 20.8% had received a CMR while 34.3% were interested in a future CMR. Among individuals who had not received a CMR, most (83.4%) were unaware their insurance might cover a CMR. Factors associated with higher odds of receiving a CMR included taking 5 or more prescription medications (adjusted odds ratio [AOR] = 2.6, 95% CI: 1.59-4.38) and reporting food insecurity (AOR = 2.9, 95% CI: 1.07-7.93). Having fair or poor self-reported physical health was associated with lower odds of receiving a CMR (AOR = 0.49, 95% CI: 0.25-0.97).

CONCLUSIONS

Most older adults on 2 or more prescription medications with health insurance had not received a CMR and many were interested in one. Targeted strategies to increase older adults' awareness and receipt of CMRs are warranted.

Multidrug Interactions: Why Do They Occur and How to Handle?

A nonoptimized medication therapy (NOMT) event is an iatrogenic hazard or incident associated with medications and is a leading cause of death, serious injury, and illness. NOMT events are often related to multidrug interactions in patients with polypharmacy. In these patients, NOMT events can be avoided by using advanced clinical decision support systems and clinical interventions such as separating the time of administration of certain drugs during the day. At the individual level, medication reconciliation is a first logical step for reducing adverse side effects. Then, intersubject variability in drug response should be considered to optimize patient drug regimens. Furthermore, patient pharmacogenomic status information can help ensure appropriateness of drug therapy. However, in patients with polypharmacy, such information is most valuable when combined with phenoconversion probability. At a population level, the virtual addition of drugs to various drug regimens and the use of a medication risk score can help predict the risk of NOMT events. This review outlines some of the mechanisms behind multidrug interactions and their association with drug safety and NOMTs, polypharmacy and its impact on patient outcomes, the value of pharmacogenomics, and an assessment of simulation studies and the virtual addition of drugs to a drug regimen using real-world data. (Clin Ther. 2023;45:XXX-XXX) © 2023 Elsevier HS Journals, Inc.

Implementing pharmacists' medication safety recommendations is associated with reduced health care resource utilization and mortality in high-risk older Americans

BACKGROUND

A medication safety review (MSR) is a novel, pharmacist-driven, technology-supported intervention that prioritizes adverse drug event risk mitigation. Previous research has shown that Medicare Part D beneficiaries who received MSRs in an enhanced medication therapy management (EMTM) model realized improvements in total Medicare spending, hospitalizations, emergency department (ED) visits, and mortality compared to control. However, it is unknown whether beneficiaries implemented pharmacists' MSR recommendations.

OBJECTIVE

The objective of the study was to evaluate whether MSR recommendation implementation is associated with improvements in these same outcomes for Part D beneficiaries enrolled in EMTM compared to a control group.

METHODS

This retrospective, pre-post, cohort study evaluated outcomes for beneficiaries who were targeted for MSR services in 2018 and 2019. The "validated implementation MSR (viMSR)" cohort included those who received their first-ever MSR in 2018, received another MSR in 2019, and validated implementation of ≥1 recommendation in their 2018 MSR. The "failed to engage" (FTE) cohort included beneficiaries who were targeted for MSR services in both 2018 and 2019 but did not engage in an MSR at any point through the end of 2019. For both cohorts, we calculated the 2018-to-2019 change for each outcome and then determined whether year-over-year changes differed significantly between cohorts. For mortality, we relaxed the requirement for continuous enrollment in 2019, permitting us to compare the proportion of beneficiaries that died in each group in 2019. Analyses were adjusted for baseline multimorbidity.

RESULTS

Of 4384 beneficiaries who completed MSRs, 602 (13.7%) implemented ≥1 recommendation. The viMSR cohort (N = 602) outperformed the FTE cohort (N = 7052) in total Medicare costs ($2162/y lower; P = 0.020), Part A Medicare costs ($1855/y; P = 0.024), hospitalizations (9.1 fewer admissions/100 beneficiaries/y, P = 0.020), ED visits (10.8 fewer visits/100 beneficiaries/y, P = 0.014), and mortality (3.8% fewer died in 2019; P < 0.001).

CONCLUSION

Implementing pharmacists' recommendations in MSRs was associated with improved health care resource utilization and mortality for MSR-eligible beneficiaries.

A systematic review on sex differences in adverse drug reactions related to psychotropic, cardiovascular, and analgesic medications

Background and objective: Adverse drug reactions (ADRs) are the main safety concerns of clinically used medications. Accumulating evidence has shown that ADRs can affect men and women differently, which suggests sex as a biological predictor in the risk of ADRs. This review aims to summarize the current state of knowledge on sex differences in ADRs with the focus on the commonly used psychotropic, cardiovascular, and analgesic medications, and to aid clinical decision making and future mechanistic investigations on this topic. Methods: PubMed search was performed with combinations of the following terms: over 1,800 drugs of interests, sex difference (and its related terms), and side effects (and its related terms), which yielded over 400 unique articles. Articles related to psychotropic, cardiovascular, and analgesic medications were included in the subsequent full-text review. Characteristics and the main findings (male-biased, female-biased, or not sex biased ADRs) of each included article were collected, and the results were summarized by drug class and/or individual drug. Results: Twenty-six articles studying sex differences in ADRs of six psychotropic medications, ten cardiovascular medications, and one analgesic medication were included in this review. The main findings of these articles suggested that more than half of the ADRs being evaluated showed sex difference pattern in occurrence rate. For instance, lithium was found to cause more thyroid dysfunction in women, and amisulpride induced prolactin increase was more pronounced in women than in men. Some serious ADRs were also found to exert sex difference pattern, such as clozapine induced neutropenia was more prevalent in women whereas simvastatin/atorvastatin-related abnormal liver functions were more pronounced in men.

Real price of health-experiences of out-of-pocket costs in Australia: protocol for a systematic review

INTRODUCTION

Australians have substantial out-of-pocket (OOP) health costs compared with other developed nations, even with universal health insurance coverage. This can significantly affect access to care and subsequent well-being, especially for priority populations including those on lower incomes or with multimorbidity and chronic illness. While it is known that high OOP healthcare costs may contribute to poorer health outcomes, it is not clear exactly how these expenses are experienced by people with chronic illnesses. Understanding this may provide critical insights into the burden of OOP costs among this population group and may highlight policy gaps.

METHOD AND ANALYSIS

A systematic review of qualitative studies will be conducted using Pubmed, CINAHL Complete (EBSCO), Cochrane Library, PsycINFO (Ovid) and EconLit from date of inception to June 2022. Primary outcomes will include people's experiences of OOP costs such as their preferences, priorities, trade-offs and other decision-making considerations. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and methodological appraisal of included studies will be assessed using the Critical Appraisal Skills Programme. A narrative synthesis will be conducted for all included studies.

ETHICS AND DISSEMINATION

Ethics approval was not required given this is a systematic review that does not include human recruitment or participation. The study's findings will be disseminated through conferences and symposia and shared with consumers, policymakers and service providers, and published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022337538.