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Gasi E, Gustafsson M, Kindstedt J. Psychotropic Drug Use and Associated Factors Among Acutely Admitted Older People: A Cross-Sectional Study of a Clinical Sample. Drugs Real World Outcomes 2024:10.1007/s40801-024-00455-w. [PMID: 39316319 DOI: 10.1007/s40801-024-00455-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2024] [Indexed: 09/25/2024] Open
Abstract
INTRODUCTION Older people are on average more susceptible to the adverse effects of psychotropic drugs, but addressing older people as a homogenous group based on age alone can be misleading when exploring psychotropic drug use. This study aimed to describe psychotropic drug use and associated factors among community-dwelling older people who had been acutely admitted to hospital. METHODS This cross-sectional study was based on a sample of 300 community-dwelling people 75 years or older who had been admitted to the acute medical ward at Umeå University Hospital at any time from September 2018 to October 2021. Data on medication use were obtained from electronic medical charts, and psychotropic drug use was presented as user proportions, both in terms of individual substances and drug classes. Associations between psychotropic drug use and factors comprising sex, age, cohabitation, comorbidities and multi-dose dispensing (MDD) of medicines were analysed through logistic regression. RESULTS Approximately 50% of the individuals used at least one psychotropic drug, and 18% used two or more such medicines. Zopiclone displayed the highest user proportion of all psychotropics (18.3%), followed by mirtazapine (11.3%) and zolpidem (9.7%). Of note, zolpidem was more prevalent among the females than among the males (p = 0.006). Regarding other sex differences, 55 and 38% of the females and males, respectively, used at least one psychotropic drug (p = 0.004). A similar pattern was observed regarding sedatives and hypnotic drugs exclusively (p = 0.048). In the regression analysis, female sex (adjusted odds ratio [OR] 2.05 [95% confidence interval {CI} 1.22-3.42]) and MDD (adjusted OR 2.20 [95% CI 1.23-3.93]) were positively associated with psychotropic drug use. CONCLUSION The most common psychotropic drugs used by community-dwelling older people admitted to the acute medical ward were hypnotic drugs and antidepressants. Regarding patient factors, female sex and MDD system were positively associated with psychotropic drug use. Further studies concerning those two factors in relation to potential overprescribing could provide a better picture on how to optimize psychotropic drug use among acutely admitted vulnerable older people.
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Affiliation(s)
- Ema Gasi
- Region Västerbotten, Umeå University Hospital, Umeå, Sweden
| | - Maria Gustafsson
- Department of Medical and Translational Biology, Umeå University, 901 87, Umeå, Sweden
| | - Jonas Kindstedt
- Department of Medical and Translational Biology, Umeå University, 901 87, Umeå, Sweden.
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Robinson EG, Gyllensten H, Johansen JS, Havnes K, Granas AG, Bergmo TS, Småbrekke L, Garcia BH, Halvorsen KH. A Trial-Based Cost-Utility Analysis of a Medication Optimization Intervention Versus Standard Care in Older Adults. Drugs Aging 2023; 40:1143-1155. [PMID: 37991657 PMCID: PMC10682290 DOI: 10.1007/s40266-023-01077-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Older adults are at greater risk of medication-related harm than younger adults. The Integrated Medication Management model is an interdisciplinary method aiming to optimize medication therapy and improve patient outcomes. OBJECTIVE We aimed to investigate the cost effectiveness of a medication optimization intervention compared to standard care in acutely hospitalized older adults. METHODS A cost-utility analysis including 285 adults aged ≥ 70 years was carried out alongside the IMMENSE study. Quality-adjusted life years (QALYs) were derived using the EuroQol 5-Dimension 3-Level Health State Questionnaire (EQ-5D-3L). Patient-level data for healthcare use and costs were obtained from administrative registers, taking a healthcare perspective. The incremental cost-effectiveness ratio was estimated for a 12-month follow-up and compared to a societal willingness-to-pay range of €/QALY 27,067-81,200 (NOK 275,000-825,000). Because of a capacity issue in a primary care resulting in extended hospital stays, a subgroup analysis was carried out for non-long and long stayers with hospitalizations < 14 days or ≥ 14 days. RESULTS Mean QALYs were 0.023 [95% confidence interval [CI] 0.022-0.025] higher and mean healthcare costs were €4429 [95% CI - 1101 to 11,926] higher for the intervention group in a full population analysis. This produced an incremental cost-effectiveness ratio of €192,565/QALY. For the subgroup analysis, mean QALYs were 0.067 [95% CI 0.066-0.070, n = 222] and - 0.101 [95% CI - 0.035 to 0.048, n = 63] for the intervention group in the non-long stayers and long stayers, respectively. Corresponding mean costs were €- 824 [95% CI - 3869 to 2066] and €1992 [95% CI - 17,964 to 18,811], respectively. The intervention dominated standard care for the non-long stayers with a probability of cost effectiveness of 93.1-99.2% for the whole willingness-to-pay range and 67.8% at a zero willingness to pay. Hospitalizations were the main cost driver, and readmissions contributed the most to the cost difference between the groups. CONCLUSIONS According to societal willingness-to-pay thresholds, the medication optimization intervention was not cost effective compared to standard care for the full population. The intervention dominated standard care for the non-long stayers, with a high probability of cost effectiveness. CLINICAL TRIAL REGISTRATION The IMMENSE trial was registered in ClinicalTrials.gov on 28 June, 2016 before enrolment started (NCT02816086).
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Affiliation(s)
| | - Hanna Gyllensten
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jeanette Schultz Johansen
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Kjerstin Havnes
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Anne Gerd Granas
- Department of Pharmacy, University of Oslo, 1068 Blindern, 0316 Oslo, Norway
| | - Trine Strand Bergmo
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
- Norwegian Centre for E-Health Research, University Hospital of North Norway, Tromsø, Norway
| | - Lars Småbrekke
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Beate Hennie Garcia
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
- Hospital Pharmacy of North Norway Trust, Tromsø, Norway
| | - Kjell H Halvorsen
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
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Jónsdóttir F, Blöndal AB, Guðmundsson A, Bates I, Stevenson JM, Sigurðsson MI. Epidemiology and association with outcomes of polypharmacy in patients undergoing surgery: retrospective, population-based cohort study. BJS Open 2023; 7:7166807. [PMID: 37194458 DOI: 10.1093/bjsopen/zrad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/10/2023] [Accepted: 03/16/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND The aim of this study was to determine the prevalence of preoperative polypharmacy and the incidence of postoperative polypharmacy/hyper-polypharmacy in surgical patients and their association with adverse outcomes. METHODS This was a retrospective, population-based cohort study among patients older than or equal to 18 years undergoing surgery at a university hospital between 2005 and 2018. Patients were categorized based on the number of medications: non-polypharmacy (fewer than 5); polypharmacy (5-9); and hyper-polypharmacy (greater than or equal to 10). The 30-day mortality, prolonged hospitalization (greater than or equal to 10 days), and incidence of readmission were compared between medication-use categories. RESULTS Among 55 997 patients, the prevalence of preoperative polypharmacy was 32.3 per cent (95 per cent c.i. 33.5 to 34.3) and the prevalence of hyper-polypharmacy was 25.5 per cent (95 per cent c.i. 25.2 to 25.9). Thirty-day mortality was higher for patients exposed to preoperative hyper-polypharmacy (2.3 per cent) and preoperative polypharmacy (0.8 per cent) compared with those exposed to non-polypharmacy (0.6 per cent) (P < 0.001). The hazards ratio (HR) of long-term mortality was higher for patients exposed to hyper-polypharmacy (HR 1.32 (95 per cent c.i. 1.25 to 1.40)) and polypharmacy (HR 1.07 (95 per cent c.i. 1.01 to 1.14)) after adjustment for patient and procedural variables. The incidence of longer hospitalization (greater than or equal to 10 days) was higher for hyper-polypharmacy (11.3 per cent) and polypharmacy (6.3 per cent) compared with non-polypharmacy (4.1 per cent) (P < 0.001). The 30-day incidence of readmission was higher for patients exposed to hyper-polypharmacy (10.2 per cent) compared with polypharmacy (6.1 per cent) and non-polypharmacy (4.8 per cent) (P < 0.001). Among patients not exposed to polypharmacy, the incidence of new postoperative polypharmacy/hyper-polypharmacy was 33.4 per cent (95 per cent c.i. 32.8 to 34.1), and, for patients exposed to preoperative polypharmacy, the incidence of postoperative hyper-polypharmacy was 16.3 per cent (95 per cent c.i. 16.0 to 16.7). CONCLUSION Preoperative polypharmacy and new postoperative polypharmacy/hyper-polypharmacy are common and associated with adverse outcomes. This highlights the need for increased emphasis on optimizing medication usage throughout the perioperative interval. REGISTRATION NUMBER NCT04805151 (http://clinicaltrials.gov).
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Affiliation(s)
- Freyja Jónsdóttir
- Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
- Pharmacy Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Anna B Blöndal
- Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
- Development Centre for Primary Healthcare in Iceland, Primary Health Care of the Capital Area, Reykjavik, Iceland
| | - Aðalsteinn Guðmundsson
- Division of Geriatrics, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Ian Bates
- School of Pharmacy, University College London, London, UK
| | - Jennifer M Stevenson
- Institute of Pharmaceutical Science, King's College, London, UK
- Pharmacy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Martin I Sigurðsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Division of Anaesthesia and Intensive Care Medicine, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
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Rahman Jabin MS, Hammar T. Issues with the Swedish e-prescribing system - An analysis of health information technology-related incident reports using an existing classification system. Digit Health 2022; 8:20552076221131139. [PMID: 36249479 PMCID: PMC9554230 DOI: 10.1177/20552076221131139] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022] Open
Abstract
Objective To identify issues with the Swedish e-prescribing system and devise a set of recommendations to overcome the identified challenges. Methods A number of health information technology-related incidents were collected retrospectively from various sources using purposive and snowball sampling. A search term containing five keywords was used to identify the electronic prescription-related incidents. The identified incidents (n = 24) were subjected to an existing framework, i.e., the Health Information Technology Classification System. Special attention was paid to the software-related issues, which were analysed using thematic analysis. Results Several types of software-related issues (n = 22) were identified: system configuration, interface with other software systems or components, software functionality, data storage and backup, record migration, software not accessible, and network/server down or slow. Both human and technical factors contributed to these incidents, including prescriptions not cancelled actively, drug handling errors, software programming errors, and system updates/upgrades. These software problems led to various consequences, such as incidents affecting multiple patients’ care management, delays in patient care, and risks of serious deterioration of health. Several temporary initiatives or administrative adjustments, for instance, cover letters to patients and local strategies, were used to overcome some of these challenges. Conclusions This study provides insights into the challenges related to the e-prescribing system, contributing factors, consequences, and actions taken to mitigate those risks. Therefore, healthcare organisations using the e-prescribing system should adopt the provided recommendations to minimise the risks of design and developmental challenges, implementation and use-related issues, and the problems related to monitoring, evaluation, and optimisation.
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Affiliation(s)
- Md Shafiqur Rahman Jabin
- Md Shafiqur Rahman Jabin, Department of Medicine and Optometry, eHealth Institute, Linnaeus University, Hus Vita (level 3), Kalmar 392 31, Sweden.
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Rangfast I, Sönnerstam E, Gustafsson M. Prevalence of potentially inappropriate medications among old people with major neurocognitive disorder in 2012 and 2017. BMC Geriatr 2022; 22:544. [PMID: 35773643 PMCID: PMC9245287 DOI: 10.1186/s12877-022-03240-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background The increased risk of adverse drug reactions due to age-related altered pharmacokinetics and pharmacodynamics is a challenge when prescribing medications to older people, and especially among older people with major neurocognitive disorder who are particularly sensitive to drug effects. The aim of this study was to investigate the use of potential inappropriate medications (PIMs) in 2012 and 2017 among old people with major neurocognitive disorder. A secondary aim was to investigate factors associated with PIM use. Methods This register-study was based on the Swedish registry for cognitive/dementia disorders and the Swedish prescribed drug register. Criteria from the National Board of Health and Welfare were used to identify PIMs between 1 July–31 December 2012 and 1 July-–31 December 2017 among people ≥ 65 years. Drug use was defined as one or more filled prescriptions during each timeframe. Results The total use of PIMs declined significantly between 2012 (28.7%) and 2017 (21.7%). All PIMs and PIM groups declined between these years, except for antipsychotic drugs, which increased from 11.6% to 12.3%. The results from the multiple regression model found that PIM use was associated with younger age (OR: 0.97 CI: 0.96–0.97), a lower Mini Mental State Examination score (OR: 0.99 CI: 0.99–1.00), the use of multi-dispensed drugs (OR: 2.05 CI: 1.93–2.18), and compared to Alzheimer’s disease, with the subtypes dementia with Lewy bodies and Parkinson’s disease dementia (OR: 1.57 CI: 1.40–1.75), frontotemporal dementia (OR: 1.29 CI: 1.08–1.54) and vascular dementia (OR: 1.10 CI: 1.03–1.16). Conclusions Overall, the use of PIMs decreased between the years 2012 and 2017. The increase of antipsychotic drugs and the association between PIM use and multi-dispensed drugs warrant concern. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03240-y.
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Affiliation(s)
- Iris Rangfast
- Department of Integrative Medical Biology, Umeå University, 901 87, Umeå, Sweden
| | - Eva Sönnerstam
- Department of Integrative Medical Biology, Umeå University, 901 87, Umeå, Sweden
| | - Maria Gustafsson
- Department of Integrative Medical Biology, Umeå University, 901 87, Umeå, Sweden.
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Tukukino C, Parodi López N, Svensson SA, Wallerstedt SM. Drug interaction alerts in older primary care patients, and related medically justified actions. Eur J Clin Pharmacol 2022; 78:1115-1126. [PMID: 35355082 PMCID: PMC9184366 DOI: 10.1007/s00228-022-03292-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 02/10/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To describe presented interaction alerts in older patients, and the extent to which these require further medical action for the specific patient or are already being addressed. METHODS Interaction alerts presented at a physician consultation, for 274 consecutive primary care patients treated with two or more drugs (median age: 75 years; 59% female), were extracted. These alerts are based on Janusmed, a decision support integrated in the medical records that provides recommendations for managing the interactions. One general practitioner (GP) and one GP/clinical pharmacologist determined in retrospect, first independently and then in consensus, whether the alerts justified further medical action, considering each patient's health condition. RESULTS In all, 405 drug interaction alerts in 151 (55%) patients were triggered. Medical action in response was deemed medically justified for 35 (9%) alerts in 26 (17%) patients. These actions most often involved a switch to a less interacting drug from the same drug class (n = 10), a separate intake (n = 9), or the ordering of a laboratory test (n = 8). Out of 531 actions suggested by the alert system, only 38 (7%) were applicable to the specific patient, as, for instance, laboratory parameters were already being satisfactorily monitored or a separate intake implemented. CONCLUSIONS More than every other older patient receives drug treatment that triggers drug interaction alerts. Nine in ten alerts were already being addressed or were not relevant in the clinical setting, whereas, for the remaining tenth, some medical action, that for unknown reasons had not been taken, was reasonable. These findings show that interaction alerts are questionable as indicators of problematic prescribing.
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Affiliation(s)
- Carina Tukukino
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 430, 405 30, Gothenburg, Sweden.,Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Naldy Parodi López
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 430, 405 30, Gothenburg, Sweden.,Närhälsan Kungshöjd Health Centre, Gothenburg, Sweden
| | - Staffan A Svensson
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 430, 405 30, Gothenburg, Sweden.,Närhälsan Hjällbo Health Centre, Gothenburg, Sweden
| | - Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 430, 405 30, Gothenburg, Sweden. .,HTA-Centrum, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Gullslett MK, Strand Bergmo T. Implementation of E-prescription for Multidose Dispensed Drugs: Qualitative Study of General Practitioners' Experiences. JMIR Hum Factors 2022; 9:e27431. [PMID: 35037881 PMCID: PMC8804951 DOI: 10.2196/27431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/21/2021] [Accepted: 11/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Increased use of pharmaceuticals challenges both capacity and safety related to medication management for patients and changes in how general practitioners (GPs) and other health personnel interact with and follow up with patients. E-prescribing of multidose drug dispensing (eMDD) is 1 of the national measures being tested in Norway. Objective The objective of this study is to explore GPs’ experiences with the challenges and benefits of implementing eMDD in Norway. Methods Qualitative in-depth and group interviews were conducted with a total of 25 GPs between 2018 and 2020. Transcribed files were saved in NVivo to conduct a step-by-step content analysis. NVivo is a software tool for organizing, managing, and analyzing qualitative data. Results The study revealed that eMDD offers many benefits. At the same time, there are several challenges related to information, training, and initiation, as well as to the responsibility for the medication, interactions, and the risk of incorrect medication. An important activity in the start-up phase was an information meeting with pharmacies and technology suppliers, as well as exchanging information and instructions with pharmacies on how to get started. Four analytic themes emerged through the extraction of data: (1) start-up with eMDD (“Be patient”); (2) the need for training; (3) interaction, safety, and efficiency; and (4) the working day with eMDD. Conclusions There is a variation in different GPs’ needs regarding training and information, and considerable variation in competence and motivation related to the use of digital tools. There are also different degrees of understanding the everyday work of the other actors in the medication chain. In particular, the harmonization of medication lists related to the use of time, expenditures, and challenges with technological solutions in the introduction phase was emphasized as a challenge. Overall, GPs who have started using the system report great benefits; these are largely related to an increased overview of patients’ total medication lists, less time spent on prescribing prescriptions, and increased collaboration with pharmacies and nurses, both in service from providers in homes and in nursing homes.
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Affiliation(s)
| | - Trine Strand Bergmo
- Norwegian Centre for E-Health Research, University Hospital of North Norway, Tromsø, Norway
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Josendal AV, Bergmo TS, Granas AG. The Practice Guidelines for Multidose Drug Dispensing Need Revision-An Investigation of Prescription Problems and Interventions. PHARMACY 2021; 9:pharmacy9010013. [PMID: 33418861 PMCID: PMC7838985 DOI: 10.3390/pharmacy9010013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/26/2020] [Accepted: 01/01/2021] [Indexed: 11/16/2022] Open
Abstract
Multidose drug dispensing (MDD) is an adherence aid used by one-third of patients receiving home care services in Norway. The system can increase patient safety by reducing dispensing errors and increase adherence, however it has also been criticised for unclear routines and distribution of responsibilities. We investigated prescription problems which pharmacists have detected, and the responsibilities they adopt regarding MDD. For two consecutive weeks, 11 pharmacies used a self-completion form to register prescription problems identified with MDD. Of the 4121 MDD prescriptions, problems were identified on 424 (11%). The most common issues were expired prescriptions (29%), drug shortages (19%), missing prescriber signatures (10%) and unclear/missing medication names or strengths (10%). Compared to ordinary prescriptions, the pharmacist took on additional responsibility for renewing MDD prescriptions. However, because these patients received their medications via the home care service, there was limited patient counselling during dispensing. To increase the efficiency and patient safety of the MDD system, the roles and responsibilities of the pharmacist, GP, and home care nurses in the MDD system should be clearly defined. This seems most urgent for the renewal of prescriptions and patient counselling, where the responsibilities and work practice seem to differ from ordinary prescriptions.
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Affiliation(s)
- Anette Vik Josendal
- Norwegian Centre for E-health Research, University Hospital of North Norway, 9038 Tromsø, Norway; (T.S.B.); (A.G.G.)
- Department of Pharmacy, Section for Pharmaceutics and Social Pharmacy, University of Oslo, 0316 Oslo, Norway
- Correspondence: ; Tel.: +47-9767-1938
| | - Trine S. Bergmo
- Norwegian Centre for E-health Research, University Hospital of North Norway, 9038 Tromsø, Norway; (T.S.B.); (A.G.G.)
- Department of Pharmacy, Faculty of Health Sciences, UiT The Artic University of Norway, 9037 Tromsø, Norway
| | - Anne Gerd Granas
- Norwegian Centre for E-health Research, University Hospital of North Norway, 9038 Tromsø, Norway; (T.S.B.); (A.G.G.)
- Department of Pharmacy, Section for Pharmaceutics and Social Pharmacy, University of Oslo, 0316 Oslo, Norway
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