Clinical Outcomes of a Collaborative, Home-Based Postdischarge Warfarin Management Service

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review

BACKGROUND

Measures to evaluate high-risk medication safety during transfers of care should span different safety dimensions across all components of these transfers and reflect outcomes and opportunities for proactive safety management.

OBJECTIVES

To scope measures currently used to evaluate safety interventions targeting insulin, anticoagulants and other high-risk medications during transfers of care and evaluate their comprehensiveness as a portfolio.

METHODS

Embase, Medline, Cochrane and CINAHL databases were searched using scoping methodology for studies evaluating the safety of insulin, anticoagulants and other high-risk medications during transfer of care. Measures identified were extracted into a spreadsheet, collated and mapped against three frameworks: (1) 'Key Components of an Ideal Transfer of Care', (2) work systems, processes and outcomes and (3) whether measures captured past harms, events in real time or areas of concern. The potential for digital health systems to support proactive measures was explored.

RESULTS

Thirty-five studies were reviewed with 162 measures in use. Once collated, 29 discrete categories of measures were identified. Most were outcome measures such as adverse events. Process measures included communication and issue identification and resolution. Clinic enrolment was the only work system measure. Twenty-four measures captured past harm (eg, adverse events) and six indicated future risk (eg, patient feedback for organisations). Two real-time measures alerted healthcare professionals to risks using digital systems. No measures were of advance care planning or enlisting support.

CONCLUSION

The measures identified are insufficient for a comprehensive portfolio to assess safety of key medications during transfer of care. Further measures are required to reflect all components of transfers of care and capture the work system factors contributing to outcomes in order to support proactive intervention to reduce unwanted variation and prevent adverse outcomes. Advances in digital technology and its employment within integrated care provide opportunities for the development of such measures.

A Qualitative Systematic Review of Facilitators of and Barriers to Community Pharmacists-Led Anticoagulation Management Service

Objective:

To identify the facilitators of and barriers to the implementation of Community Pharmacists–Led Anticoagulation Management Services (CPAMS).

Data Sources:

MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, and Cochrane CENTRAL Register of Controlled Trials were searched from inception until August 20, 2021.

Study Selection and Data Extraction:

All abstracts proceeded to full-text review, which was completed by 2 reviewers. Data extraction was completed by a single reviewer and verified. Analysis was completed using best-fit framework synthesis.

Data Synthesis:

A total of 17 articles reporting on CPAMS from 6 jurisdictions were included: 2 Canadian provincial programs (Nova Scotia, Alberta), a national program (New Zealand), and 3 cities in the United Kingdom (Whittington and Brighton and Hove) and Australia (Sydney). Facilitators of CPAMS included convenience for patients, accessibility for patients, professional satisfaction for pharmacists, increased efficiency in anticoagulation management, improved outcomes, enhanced collaboration, and scalability. Barriers included perceived poor quality of care by patients, resistance by general practitioners, organizational limits, capping of the number of eligible patients, and cost.

Relevance to Patient Care and Clinical Practice:

The barriers and facilitators identified in this review will inform health policy makers on the implementation and improvement of CPAMS for patients and health care practitioners.

Conclusion and Relevance:

CPAMS has been implemented in 6 jurisdictions across 4 countries, with reported benefits and challenges. The programs were structurally similar in most jurisdictions, with minor variations in implementation. New anticoagulation management programs should consider adapting existing frameworks to local needs.

Impact of pharmacist and physician collaborations in primary care on reducing readmission to hospital: A systematic review and meta-analysis

BACKGROUND

Readmissions to hospital due to medication-related problems are common and may be preventable. Pharmacists act to optimise use of medicines during care transitions from hospital to community.

OBJECTIVE

To assess the impact of pharmacist-led interventions, which include communication with a primary care physician (PCP) on reducing hospital readmissions.

METHODS

PubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL and Web of Science were searched for articles published from inception to March 2021 that described interventions involving a pharmacist interacting with a PCP in regards to medication management of patients recently discharged from hospital. The primary outcome was effect on all-cause readmission expressed as Mantel-Haenszel risk ratio (RR) derived from applying a random effects model to pooled data. Sensitivity analysis was also conducted to investigate differences between randomised controlled trials (RCTs) and non-RCTs. The GRADE system was applied in rating the quality of evidence and certainty in the estimates of effect.

RESULTS

In total, 37 studies were included (16 RCTs and 29 non-RCTs). Compared to control patients, the proportion of intervention patients readmitted at least once was significantly reduced by 13% (RR = 0.87, CI:0.79-0.97, p = 0.01; low to very low certainty of evidence) over follow-up periods of variable duration in all studies combined, and by 22% (RR = 0.78, CI:0.67-0.92; low certainty of evidence) at 30 day follow-up across studies reporting this time point. Analysis of data from RCTs only showed no significant reduction in readmissions (RR = 0.92, CI:0.80-1.06; low certainty of evidence).

CONCLUSIONS

The totality of evidence suggests pharmacist-led interventions with PCP communication are effective in reducing readmissions, especially at 30 days follow-up. Future studies need to adopt more rigorous study designs and apply well-defined patient eligibility criteria.

A realist synthesis of pharmacist-conducted medication reviews in primary care after leaving hospital: what works for whom and why?

BACKGROUND

Medication reviews for people transitioning from one healthcare setting to another potentially improve health outcomes, although evidence for outcome benefits varies. It is unclear when and why medication reviews performed by pharmacists in primary care for people who return from hospital to the community lead to beneficial outcomes.

OBJECTIVE

A realist synthesis was undertaken to develop a theory of what works, for whom, why and under which circumstances when pharmacists conduct medication reviews in primary care for people leaving hospital.

METHODS

The realist synthesis was performed in accordance with Realist And MEta-narrative Evidence Syntheses: Evolving Standards reporting standards. An initial programme theory informed a systematic literature search of databases (PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature, International Pharmaceutical Abstracts, OpenGrey, Trove), augmented by agency and government sources of information. Documents were synthesised by exploring interactions between contexts, intervention, outcomes and causal mechanisms.

RESULTS

The synthesis identified 9 contexts in which 10 mechanisms can be activated to influence outcomes of pharmacist medication reviews conducted in primary care postdischarge. For a medication review to take place these include trust patients have in healthcare professionals, their healthcare priorities postdischarge, capacity to participate, perceptions of benefit and effort, and awareness required by all involved. For the medication review process, mechanisms which issue an invitation to collaborate between healthcare professionals, enable pharmacists employing clinical skills and taking responsibility for medication review outcomes were linked to more positive outcomes for patients.

CONCLUSIONS

Medication reviews after hospital discharge seem to work successfully when conducted according to patient preferences, programmes promote coordination and collaboration between healthcare professionals and establish trust, and pharmacists take responsibility for outcomes. Findings of this realist synthesis can inform postdischarge medication review service models.

For which patient subgroups are there positive outcomes from a medication review? A systematic review

Background:

A medication review is a possibility to assess and optimise a patient’s medicine. A model that includes a medication review and a follow-up seem to provide the best results. However, it is not known whether specific subgroups of patients benefit more from a medication review than others.

Objective:

This literature review summarises the evidence that is available on which patient subgroups exist positive outcomes from a medication review carried out in a primary care setting.

Methods:

We performed a PICO analysis to identify keywords for setting, medication review and effect. We then conducted a search using the PubMed database (2004 to 2019) to identify studies relevant for our investigation. A screening process was carried out based on either title or abstract, and any study that matched the aim and inclusion criteria was included. All matching studies were obtained and read, and were included if they met predefined criteria such as study design, medication review and primary care. The studies were divided into subgroups. First, each subgroup was divided according to the studies’ own definition. Secondly, each subgroup was allocated as either risk patients if the subgroup described a specific patient subgroup or risk medication, if the subgroup was defined as using a specific type of medication. This was done after discussion in the author group.

Results:

28 studies from a total of 935 studies were included. Identified studies were divided into either risk patients; frail, recently discharged or multimorbid patients, or risk medication; heart medication, antithrombotic medication, blood pressure lowering medication, antidiabetic medication, anti-Parkinson medication or medication increasing the risk of falls. The subgroups identified from a medication review in primary care were defined as being frail, recently discharged from hospital or multimorbid (risk patients), or defined as patients using anticoagulant or blood pressure lowering medication (risk medication). Most of the medication reviews in the studies that showed an economic effect included at least one follow-up and were delivered by a pharmacist.

Conclusions:

The literature review demonstrates that medication reviews delivered by pharmacists to specific subgroups of patients are a way of optimising the economic effect of medication reviews in primary care. This is obtained by reducing health-related costs or the number of contacts with primary or secondary health care services.

Evaluation of patients' knowledge about oral anticoagulant medicines and use of alert cards by community pharmacists

Background Anticoagulants continue to pose high risk of harm to patients despite the discovery of novel direct-acting oral anticoagulant agents that require less monitoring than warfarin. Objective To evaluate patients’ knowledge about their oral anticoagulants and the potential role for community pharmacists in optimising safety. Setting Community pharmacies in England. Methods An online survey-based evaluation conducted over a 5-month period to ascertain patients’ knowledge, use of anticoagulant alert cards, compliance with national monitoring requirements for warfarin, and frequency and nature of community pharmacist involvement in optimisation. Differences between patients on direct-acting oral anticoagulant agents and warfarin were assessed using Chi squared tests. Main outcome measure Patients’ knowledge and use of anticoagulant alert cards. Results A total of 1515 pharmacies participated. Of 22,624 patients, 97% knew that they were taking anticoagulants; 20% had alert cards with them at time of dispensing; 17% had no card and 10% refuted their usefulness. Patients on warfarin were more aware of interactions with over-the-counter or herbal medicines than those on direct-acting oral anticoagulant agents. Of the patients on warfarin, 82% confirmed monitoring in the previous 12 weeks in accordance with national standards, with the international normalised ratio value known for 76%. Pharmacists intervened in a fifth of the patients to issue an alert card, contact the general practitioner for a change in the prescription or due to interacting medicines. Conclusion Patients had reasonable knowledge of their anticoagulation therapy, but areas for improvement were identified. Community pharmacists are well placed to optimise the safe use of anticoagulants.

High-risk medication in community care: a scoping review

PURPOSE

To review the international literature related to high-risk medication (HRM) in community care, in order to (1) define a definition of HRM and (2) list the medication that is considered HRM in community care.

METHODS

Scoping review: Five databases were systematically searched (MEDLINE, Scopus, CINAHL, Web Of Science, and Cochrane) and extended with a hand search of cited references. Two researchers reviewed the papers independently. All extracted definitions and lists of HRM were subjected to a self-developed quality appraisal. Data were extracted, analysed and summarised in tables. Critical attributes were extracted in order to analyse the definitions.

RESULTS

Of the 109 papers retrieved, 36 met the inclusion criteria and were included in this review. Definitions for HRM in community care were used inconsistently among the papers, and various recurrent attributes of the concept HRM were used. Taking the recurrent attributes and the quality score of the definitions into account, the following definition could be derived: "High-risk medication are medications with an increased risk of significant harm to the patient. The consequences of this harm can be more serious than those with other medications". A total of 66 specific medications or categories were extracted from the papers. Opioids, insulin, warfarin, heparin, hypnotics and sedatives, chemotherapeutic agents (excluding hormonal agents), methotrexate and hypoglycaemic agents were the most common reported HRM in community care.

CONCLUSION

The existing literature pertaining to HRM in community care was examined. The definitions and medicines reported as HRM in the literature are used inconsistently. We suggested a definition for more consistent use in future research and policy. Future research is needed to determine more precisely which definitions should be considered for HRM in community care.

The Need to Strengthen the Role of the Pharmacist in Sri Lanka: Perspectives

The role of the pharmacist in healthcare has evolved greatly over the last half-century, from dispensing to providing direct patient-oriented activities not associated with dispensing. However, pharmacist-led healthcare services in Sri Lanka must undergo reform to fully take advantage of their expertise and training in medicine management and related outcomes in Sri Lankan patients. As befits a profession's role development and value, professional and educational standards for pharmacists need ongoing development and growth. Currently, university curricula and continuing professional education in Sri Lanka require further development and optimisation to provide the theoretical and practical knowledge and skills regarding quality use of medicines and patient-oriented care. Furthermore, pharmacists' roles in Sri Lankan hospital and community pharmacist settings need to be recognised and should include the pharmacist as an integral part of the multidisciplinary healthcare team in Sri Lanka. Studies from developed countries and some developing countries have demonstrated that expanded pharmacists' roles have had a significant positive cost-effective impact on the population's health. Therefore, the availability of qualified Sri Lankan pharmacists trained to deliver expanded professional services accompanied by greater pharmacist integration into healthcare delivery is crucially important to ensure quality use of medicines within the Sri Lankan healthcare system and optimise the medication-related needs of Sri Lankans.

Patient-focused interventions to support vulnerable people using oral anticoagulants: a narrative review

The aim of this review was to identify patient-focused interventions that have been trialed to support vulnerable patient populations taking oral anticoagulants (warfarin and the direct-acting oral anticoagulants (DOACs)) such as older persons (65 years and over), those with limited health literacy, and those from culturally and linguistically diverse (CALD) backgrounds. This review also aimed to report on the effects of these interventions on outcomes relevant to the use of anticoagulant therapy. Original articles published between 1 January 1995 and 30 June 2017 were identified using several electronic databases such as Medline, Ovid, Embase, Scopus, Cochrane, and Google Scholar. The following terms were used for the three-tiered search: Tier 1, elderly, aged, older adult, geriatrics; Tier 2, health literacy, literacy, low health literacy, low English proficiency, patient literacy; and Tier 3, ethnicity, ethnic, ethnic groups, CALD, culturally and linguistically diverse, NESB, non-English speaking background, race, racial groups, religion, religious groups, and minority groups. The terms for each tier were combined with the following terms: anticoagulants, anticoagulation, warfarin, apixaban, dabigatran, rivaroxaban, DOACS, new oral anticoagulants, novel oral anticoagulants, patient care, patient knowledge, comprehension, patient education, patient participation, and communication. A total of 41 studies were identified. Most of the interventions identified included older persons taking warfarin who were monitored using the international normalized ratio (INR) and who received patient education. Many interventions reported a significant positive impact on patients' knowledge, reduction in the number of adverse events caused by hemorrhage, and better INR control. More research on patient-focused interventions is needed that includes patients with limited health literacy, those from CALD backgrounds, and family members and caregivers of patients taking oral anticoagulants.

A comparative study regarding antibiotic consumption and knowledge of antimicrobial resistance among pharmacy students in Australia and Sri Lanka

INTRODUCTION

Antimicrobial resistance (AMR) is a major global health challenge. Pharmacists play a key role in the health care setting to support the quality use of medicines. The education and training of pharmacy students have the potential to impact on patterns of antibiotic use in community and hospital settings. The aim of this study was to investigate and compare antibiotic use and knowledge of antibiotics and AMR among undergraduate pharmacy students in Australian and Sri Lankan universities.

METHODS

A cross-sectional survey was conducted in Australian and Sri Lankan universities that offer a pharmacy degree. A paper-based survey was utilised in Sri Lanka and an identical survey distributed online among pharmacy students in Australia. Descriptive and comparative data analyses were performed.

RESULTS

476 pharmacy students from 14 universities in Australia and 466 students from 6 universities in SL completed the survey. Participants commonly reported previous antibiotic use [Australia (88%) and Sri Lanka (86%)]. The majority of students [Australia (89%) and Sri Lanka (77%)] reported they obtained antibiotics with a prescription. Australian pharmacy students correctly reported regarding optimal antibiotic use for certain disease conditions when compared to Sri Lankan students (P<0.05). A greater antibiotic knowledge level regarding AMR was found among Australian students compared to Sri Lankan students (p<0.05).

CONCLUSION

This study provides an understanding about antibiotic consumption and knowledge on AMR among pharmacy students in a developed country, Australia and a developing country, Sri Lanka. These findings identify possible misconceptions about antibiotics and a lower level of knowledge of AMR amongst Sri Lankan undergraduate pharmacy students. Future research should focus on implementation of a strategic education plan for undergraduate pharmacy students in Sri Lankan universities. The curricula of pharmacy courses in Australian universities may inform such a plan.

American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy

BACKGROUND

Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat venous thromboembolism (VTE).

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. These guidelines assume the choice of anticoagulant has already been made.

METHODS

ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel agreed on 25 recommendations and 2 good practice statements to optimize management of patients receiving anticoagulants.

CONCLUSIONS

Strong recommendations included using patient self-management of international normalized ratio (INR) with home point-of-care INR monitoring for vitamin K antagonist therapy and against using periprocedural low-molecular-weight heparin (LMWH) bridging therapy. Conditional recommendations included basing treatment dosing of LMWH on actual body weight, not using anti-factor Xa monitoring to guide LMWH dosing, using specialized anticoagulation management services, and resuming anticoagulation after episodes of life-threatening bleeding.

Current perspectives on pharmacist home visits: do we keep reinventing the wheel?

The scope of clinical pharmacy services available in outpatient settings, including home care, continues to expand. This review sought to identify the evidence to support pharmacist provision of clinical pharmacy services in a home care setting. Seventy-five reports were identified in the literature that provided evaluation and description of clinical pharmacy home visit services available around the world. Based on results from randomized controlled trials, pharmacist home visit interventions can improve patient medication adherence and knowledge, but have little impact on health care resource utilization. Other literature reported benefits of a pharmacist home visit service such as patient satisfaction, improved medication appropriateness, increased persistence with warfarin therapy, and increased medication discrepancy resolution. Current perspectives to consider in establishing or evaluating clinical pharmacy services offered in a home care setting include: staff competency, ideal target patient population, staff safety, use of technology, collaborative relationships with other health care providers, activities performed during a home visit, and pharmacist autonomy.

Reducing adverse medication events in mental health: Australian National Survey

AIM

To determine the extent to which evidence-based medication safety practices have been implemented in public and private mental health inpatient units across Australia.

METHODS

The Reducing Adverse Medication Events in Mental Health survey was piloted in Victoria, Australia, in 2015, and rolled out nationally in 2016. In total, 235 mental health inpatient units from all States and Territories in Australia were invited to participate. The survey included questions about the demographics of the mental health unit, evidence-based strategies to improve prescription writing, the administration and dispensing of medicines and pharmacy-led interventions, and also questions relating to consumer engagement in medication management and shared decision-making.

RESULTS

The response rate was 45% (N = 106 units). Overall, the survey found that 57% of the mental health units had fully or partially implemented evidence-based medication safety practices. High levels of implementation (80%) were reported for the use of standardized medication charts such as the National Inpatient Medication Chart as a way to improve medication prescription writing. Most (71%) of the units were using standardized forms for recording medication histories, and 56% were using designated forms for Medication Management Plans. However, less than one-fifth of the units had implemented electronic medication management systems, and the majority of units still relied on paper-based documentation systems.Interventions to improve medicine administration and dispensing were not highly utilized. Individual patient-based medication distribution systems were fully implemented in only 9% of the units, with a high reliance (81%) on ward stock or imprest systems. Tall Man lettering for labelling was implemented in only one-third of the units.Pharmacy services were well represented in mental health units, with 80% having access to onsite pharmacist services providing assessments of current medications and clinical review services, adverse drug reaction reporting and management services, patient and carer education and counselling, and medicines information services. However, pharmacists were involved in only half of medical reconciliations. Their involvement in post-discharge follow-up was limited to 4% of units.

CONCLUSIONS

Gaps in medication safety practices included limited use of individual patient supply systems for medication distribution, a high reliance on ward stock systems and high reliance on paper-based systems for medication prescribing and administration. With regards to service provision, clinical pharmacist involvement in medical reconciliation services, therapeutic drug monitoring and interdisciplinary ward rounds should be increased. Discharge and post-discharge services were major gaps in service provision.

Health literacy and knowledge in a cohort of Australian patients taking warfarin

OBJECTIVES

To 1) characterise older patients taking warfarin, 2) assess these patients' level of warfarin knowledge, and 3) describe their strengths and limitations in health literacy, and 4) explore relationships between participants' characteristics, warfarin knowledge and health literacy.

METHODS

A warfarin knowledge questionnaire and Health Literacy Questionnaire (HLQ) were administered to older patients (aged >65 years, N=34) taking warfarin in an Australian general practice setting.

RESULTS

Key gaps in participant knowledge pertained to the consequences of an international normalized ratio (INR) being below the target INR range and safety issues such as when to seek medical attention. A limitation for participants with a lower level of health literacy was the ability to appraise health information. Patients who needed assistance in completing the HLQs had significantly lower warfarin knowledge scores (p=0.03). Overseas-born participants and those taking 5 or more long-term medications had lower HLQ scores for specific scales (p<0.05).

CONCLUSION

In this study warfarin knowledge gaps and a limitation of health literacy amongst a small sample of older patients were identified. The findings suggest that education and resources may need to be tailored to the needs of older patients taking warfarin and their carers to address these knowledge gaps and limitations in health literacy. Patients who may need greater support include those that need assistance in completing the HLQ, are overseas-born, or are taking 5 or more long-term medications.

Selecting antithrombotic therapy for stroke prevention in atrial fibrillation: Health professionals' feedback on a decision support tool

A Computerised Antithrombotic Risk Assessment Tool was developed for assisting the selection of antithrombotic therapy based on the risk versus benefit assessment. In view of the recent availability of the novel oral anticoagulants, this tool has been updated to CARATV2.0. To explore health professionals' perspectives on the tool, semi-structured interviews were conducted in seven pharmacists, seven specialists, six general practitioners and six nurses, who were involved in management of antithrombotic therapy for atrial fibrillation. Three overarching themes emerged: (1) CARATV2.0 provides comprehensive structured assessment of patients and could assist with the prescription and review of antithrombotic therapy, (2) subjective issues such as health professionals' and patients' preferences for a particular antithrombotic therapy may affect the usefulness of CARATV2.0 and (3) CARATV2.0 requires integration into existing systems and processes. The majority of health professionals surveyed would like to use CARATV2.0 in practice, believing it would improve antithrombotic use and might reduce stroke incidence.

Optimizing Stroke Prevention in Patients With Atrial Fibrillation: A Cluster-Randomized Controlled Trial of a Computerized Antithrombotic Risk Assessment Tool in Australian General Practice, 2012-2013

INTRODUCTION

Clinicians have expressed a need for tools to assist in selecting treatments for stroke prevention in patients with atrial fibrillation. The objective of this study was to evaluate the impact of a computerized antithrombotic risk assessment tool (CARAT) on general practitioners' prescribing of antithrombotics for patients with atrial fibrillation.

METHODS

A prospective, cluster-randomized controlled trial was conducted in 4 regions (in rural and urban settings) of general practice in New South Wales, Australia (January 2012-June 2013). General practitioner practices were assigned to an intervention arm (CARAT) or control arm (usual care). Antithrombotic therapy prescribing was assessed before and after application of CARAT.

RESULTS

Overall, the antithrombotic therapies for 393 patients were reviewed by 48 general practitioners; we found no significant baseline differences in use of antithrombotics between the control arm and intervention arm. Compared with control patients, intervention patients (n = 206) were 3.1 times more likely to be recommended warfarin therapy (over any other treatment option; P < .001) and 2.8 times more likely to be recommended any anticoagulant (in preference to antiplatelet; P = .02). General practitioners agreed with most (75.2%) CARAT recommendations; CARAT recommended that 75 (36.4%) patients change therapy. After application of CARAT, the proportion of patients receiving any antithrombotic therapy was unchanged from baseline (99.0%); however, anticoagulant use increased slightly (from 89.3% to 92.2%), and antiplatelet use decreased (from 9.7% to 6.8%).

CONCLUSION

Tools such as CARAT can assist clinicians in selecting antithrombotic therapies, particularly in upgrading patients from antiplatelets to anticoagulants. However, the introduction of novel oral anticoagulants has complicated the decision-making process, and tools must evolve to weigh the risks and benefits of these new therapy options.

A web-based training program to support chronic kidney disease screening by community pharmacists

Background Community pharmacists' role in screening of several chronic diseases has been widely explored. The global health burden of chronic kidney disease is high; however, the progression and adverse outcomes can be prevented or delayed by detecting and treating the disease in its initial stages 1-3. Therefore, a web-based training program was developed to enhance pharmacists' knowledge and skills required to perform a chronic kidney disease screening service in a community setting. Objective The aim of this study was to evaluate the impact of a web-based training program on community pharmacists' knowledge and skills associated with chronic kidney disease screening. As secondary aim, pharmacists' satisfaction with the training program was assessed. Setting Community pharmacy practice. Method A web-based training program was developed by four pharmacists and a nephrologist. Quantitative data was collected by employing a self-administered, web-based questionnaire, which comprised a set of five multiple-choice knowledge questions and one clinical vignette to assess skills. A nine-item Likert scale was used to determine pharmacists' satisfaction with the training program. Main outcome measure Pharmacists' knowledge and skills scores at pre and post-training, reliability of the Likert scale, and the proportion of responses to the individual nine items of the satisfaction survey. Results Fifty pharmacists participated in the pre-questionnaire and 38 pharmacists completed the web-based training and post-questionnaire. Significant differences were observed in the knowledge scores (p < 0.001) and skills scores (p < 0.001) at pre- and post-training. Cronbach's alpha for the nine-item satisfaction scale was 0.73 and the majority pharmacists (92.1-100 %) were satisfied with the various aspects of the training program. Conclusion The web-based training program positively enhanced pharmacists' knowledge and skills associated with chronic kidney disease screening. These findings support further development and widespread implementation of the training program to facilitate health promotion and early identification of chronic kidney disease in a community setting.

Contemporary approaches to managing atrial fibrillation: A survey of Australian general practitioners

BACKGROUND

Recent attention to the management of atrial fibrillation (AF) and stroke prevention has emphasised the need to support the use of existing pharmacotherapy through available services and resources, in preference to using the new, more expensive, novel oral anticoagulants. In this regard, general practitioners (GPs) are at the core of care.

AIMS

To survey Australian GPs regarding their approach to managing AF, particularly in relation to stroke prevention therapy, and to identify the range of services to support patient care.

METHODS

A structured questionnaire, comprising quantitative and qualitative responses, was administered to participating GPs within four geographical regions of NSW (metropolitan, regional, rural areas).

RESULTS

Fifty GPs (mean age 53.74±9.94 years) participated. Most (98 per cent) GPs regarded themselves as primarily responsible for the management of AF, only referring patients to specialists when needed. However, only 10 per cent of GPs specialised in "heart/vascular health". Most (76 per cent) GPs offered point-of-care international normalised ratio (INR) testing, with 90 per cent also offering patient support via practice nurses and home visits. Overall, key determinants influencing GPs' initiation of antithrombotic therapy were: "stroke risk"/"CHADS2 score", followed by "patients' adherence/compliance". GPs focused more on medication safety considerations and the day-to-day management of therapy than on the risk of bleeding.

CONCLUSION

Australian GPs are actively engaged in managing AF, and appear to be well resourced. Importantly, there is a greater focus on the benefits of therapy during decision-making, rather than on the risks. However, medication safety considerations affecting routine management of therapy remain key concerns, with patients' adherence to therapy a major determinant in decision-making.

A systematic review of the role of community pharmacies in improving the transition from secondary to primary care

AIM

We set out to determine the potential contribution of community pharmacists to improve the transfer of care of patients from secondary to primary care settings.

METHOD

We systematically reviewed the literature on interventions that involved community pharmacy post-discharge. We considered all relevant studies, including both randomized and non-randomized controlled trials, irrespective of patient population. Our primary outcome was any impact on patient and medication outcomes, while the secondary outcome was to identify intervention characteristics that influenced all reported outcomes.

RESULTS

We retrieved 14 studies that met our inclusion criteria. There were four studies reporting outcomes relating to the identification and rectification of medication errors that were significantly improved with community pharmacy involvement. Other patient outcomes such as medication adherence and clinical control were not unanimously positively or negatively influenced via the inclusion of community pharmacy in a transfer of care post-discharge intervention. Some inconsistencies in implementation and process evaluation of interventions were found across the reviewed studies. This limited the accuracy with which true impact could be considered.

CONCLUSIONS

There is evidence that interventions including a community pharmacist can improve drug related problems after discharge. However, impact on other outcomes is not consistent. Further studies are required which include process evaluations to describe fully the context of the intervention so as to determine better any influencing factors. Also applying more stringent controls and closer adherence to protocols in both intervention and control groups would allow clearer correlations to be made between the intervention and the outcomes.

Pharmacy Technicians and Point of Care Testing

Objective: As the practice of pharmacy continues to advance and involve nondispensing pharmacy services, point-of-care testing (POCT) has continued to demonstrate its usefulness as a tool and service in pharmacy. Of particular significance is the ability of POCT to assist clinical practice related to diabetes, cholesterol management, and anticoagulation. POCT can allow for certain laboratory results to be obtained within seconds to minutes, which can help direct care. Many components of POCT programs can involve pharmacy technicians to help enhance practice efficiency. The purpose of this review is to provide an overview of POCT devices commonly used in nondispensing pharmacy services and to describe the roles that pharmacy technicians may have in the POCT process. Data Sources: PubMed (1946-2014) was reviewed for relevant literature using terms such as "pharmacy technician" and "point of care testing." Additionally, manufacturer information/websites of POCT products were reviewed for approval information and instructions for use. Study Selection and Data Extraction: Articles describing POCT completed in a pharmacy setting and/or roles of pharmacy technicians and related support staff in the POCT process were considered for inclusion. Data Synthesis: Several types of POCT devices for different uses common to the practice of pharmacy are reviewed. Additionally, strategies for collaboration between pharmacy technicians and pharmacists in the execution of a POCT program are described. Conclusion: Pharmacy technicians are well suited to participate in portions of the POCT process, and the involvement of pharmacy technicians may improve POCT efficiency.

Pharmacist consultations in general practice clinics: the Pharmacists in Practice Study (PIPS)

BACKGROUND

Medication-related problems (MRPs) are a concern in primary care settings. Pharmacists based in the community or community pharmacies are able to identify, resolve and prevent MRPs; however, the lack of a formal partnership with physicians and poor access to patients' medical records are limitations. In Australia, delivery of pharmacist services within general practice clinics is rare.

OBJECTIVES

To evaluate the effectiveness of consultations by pharmacists based within primary care medical practices.

METHODS

A prospective, before-after intervention study was conducted at two primary health care (general practice) clinics in Melbourne, Australia. Participants were clinic patients who had risk-factors for MRPs (e.g. polypharmacy). Patients received a consultation with the pharmacist in a private consulting room at the clinic or in their home. The pharmacist reviewed the patient's medication regimen and adherence, with full access to their medical record, provided patient education, and produced a report for the general practitioner. The primary outcome was the number of MRPs identified by the pharmacist, and the number that remained unresolved 6 months after the pharmacist consultation. Secondary outcomes included medication adherence, health service use, and patient satisfaction.

RESULTS

Eighty-two patients were recruited and 62 (75.6%) completed the study. The median number of MRPs per patient identified by the practice pharmacist was 2 (interquartile range [IQR] 1, 4). Six months after review, this fell to 0 (IQR 0, 1), P < 0.001. The proportion of patients who were adherent to their medications improved significantly, according to both the Morisky (44.1% versus 62.7%, P = 0.023) and the Tool for Adherence Behaviour Screening (TABS) (35.6% versus 57.6%, P = 0.019) scales. There was no significant effect on health service use. Patients were highly satisfied with the pharmacist consultations.

CONCLUSIONS

Consultations undertaken by pharmacists located within primary health care clinics were effective in identifying and resolving MRPs. The consultations were well received by patients and were associated with improvements in medication adherence.

Medication review and reconciliation with cooperation between pharmacist and general practitioner and the benefit for the patient: a systematic review

This article systematically reviews the literature on the impact of collaboration between pharmacists and general practitioners and describes its effect on patients' health. A systematic literature search provided 1041 articles. After first review of title and abstract, 152 articles remained. After review of the full text, 83 articles were included. All included articles are presented according to the following variables: (i) reference; (ii) design and setting of the study; (iii) inclusion criteria for patients; (iv) description of the intervention; (v) whether a patient interview was performed to involve patients' experiences with their medicine-taking behaviour; (vi) outcome; (vii) whether healthcare professionals received additional training; and (viii) whether healthcare professionals received financial reimbursement. Many different interventions are described where pharmacists and general practitioners work together to improve patients' health. Only nine studies reported hard outcomes, such as hospital (re)admissions; however, these studies had different results, not all of which were statistically significant. Randomized controlled trials should be able to describe hard outcomes, but large patient groups will be needed to perform such studies. Patient involvement is important for long-term success.

Medication reviews

Recent years have seen a formalization of medication review by pharmacists in all settings of care. This article describes the different types of medication review provided in primary care in the UK National Health Service (NHS), summarizes the evidence of effectiveness and considers how such reviews might develop in the future. Medication review is, at heart, a diagnostic intervention which aims to identify problems for action by the prescriber, the clinician conducting the review, the patient or all three but can also be regarded as an educational intervention to support patient knowledge and adherence. There is good evidence that medication review improves process outcomes of prescribing including reduced polypharmacy, use of more appropriate medicines formulation and more appropriate choice of medicine. When 'harder' outcome measures have been included, such as hospitalizations or mortality in elderly patients, available evidence indicates that whilst interventions could improve knowledge and adherence they did not reduce mortality or hospital admissions with one study showing an increase in hospital admissions. Robust health economic studies of medication reviews remain rare. However a review of cost-effectiveness analyses of medication reviews found no studies in which the cost of the intervention was greater than the benefit. The value of medication reviews is now generally accepted despite lack of robust research evidence consistently demonstrating cost or clinical effectiveness compared with traditional care. Medication reviews can be more effectively deployed in the future by targeting, multi-professional involvement and paying greater attention to medicines which could be safely stopped.

The benefits of pharmacist-delivered warfarin education in the home

Objectives

Good warfarin knowledge is important for optimal patient outcomes, but barriers exist to effective education and warfarin knowledge is often poor. This study aimed to explore the educational outcomes of home-based warfarin education provided by trained pharmacists.

Methods

In a prospective, non-randomised, controlled cohort trial, patients received either usual community-based post-discharge care or a post-discharge warfarin management service, including warfarin education by trained pharmacists during two or three home visits. Patients’ warfarin knowledge was assessed at 8 and 90 days post-discharge using the Oral Anticoagulation Knowledge test.

Key findings

One hundred and thirty-nine patients were recruited into the usual care group between November 2008 and August 2009, and 129 into the intervention group between May and December 2009. Pharmacist-delivered warfarin education was associated with a significant difference between the intervention patients’ baseline and day 8 mean warfarin knowledge scores of 64.5% (95% confidence interval (CI) 61.0–68.5%) and 78.0% (95% CI 74.5–81.5%; P &lt; 0.001), respectively. The intervention patients also scored significantly higher than the usual care patients at day 8 (65.0%, 95% CI 61.5–68.0%; P &lt; 0.001), but not at day 90.

Conclusions

Use of an existing healthcare framework overcame several systemic barriers by facilitating warfarin education in patients’ homes. While the intervention was associated with better short-term warfarin knowledge, follow-up may be required to optimise its benefits. Widespread implementation of home-based warfarin education by pharmacists has the potential to contribute significantly to improved outcomes from warfarin therapy.

Home medicines reviews following acute coronary syndrome: study protocol for a randomized controlled trial

BACKGROUND

Despite continual improvements in the management of acute coronary syndromes, adherence to guideline-based medications remains suboptimal. We aim to improve adherence with guideline-based therapy following acute coronary syndrome using an existing service that is provided by specifically trained pharmacists, called a Home Medicines Review. We have made two minor adjustments to target the focus of the existing service including an acute coronary syndrome specific referral letter and a training package for the pharmacists providing the service.

METHODS/DESIGN

We will be conducting a randomized controlled trial to compare the directed home medicines review service to usual care following acute coronary syndromes. All patients aged 18 to 80 years and with a working diagnosis of acute coronary syndrome, who are admitted to two public, acute care hospitals, will be screened for enrolment into the trial. Exclusion criteria will include: not being discharged home, documented cognitive decline, non-Medicare eligibility, and presence of a terminal malignancy. Randomization concealment and sequence generation will occur through a centrally-monitored computer program. Patients randomized to the control group will receive usual post-discharge care. Patients randomized to receive the intervention will be offered usual post-discharge care and a directed home medicines review at two months post-discharge. The study endpoints will be six and twelve months post-discharge. The primary outcome will be the proportion of patients who are adherent to a complete, guideline-based medication regimen. Secondary outcomes will include hospital readmission rates, length of hospital stays, changes in quality of life, smoking cessation rates, cardiac rehabilitation completion rates, and mortality.

DISCUSSION

As the trial is closely based on an existing service, any improvements observed should be highly translatable into regular practice. Possible limitations to the success of the trial intervention include general practitioner approval of the intervention, general practitioner acceptance of pharmacists' recommendations, and pharmacists' ability to make appropriate recommendations. A detailed monitoring process will detect any barriers to the success of the trial. Given that poor medication persistence following acute coronary syndrome is a worldwide problem, the findings of our study may have international implications for the care of this patient group.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12611000452998.

Application of a prescribing indicators tool to assist in identifying drug-related problems in a cohort of older Australians

Objective

Drug-related problems (DRPs) are common in older people, resulting in a disproportionate number of serious medication adverse events. Pharmacist-led interventions have been shown to be effective in identifying and reducing DRPs such as medication interactions, omission of recommended medications and use of ineffective medications. In 2008 we proposed a prescribing indicators tool to assist in identifying DRPs as part of the Australian medication review process. The objective was to apply the proposed prescribing indicators tool to a cohort of older Australians, to assess its use in detecting potential DRPs.

Methods

The prescribing indicators tool was applied in a cross-sectional observational study to 126 older (aged ≥65 years) English-speaking Australians taking five or more medications, as they were being discharged from a small private hospital into the community. Indicators were unmet when prescribing did not adhere to indicator tool guidelines.

Key findings

We found a high incidence of under-treatment, and use of inappropriate medications. There were on average 18 applicable indicators per patient, with each patient having on average seven unmet indicators.

Conclusion

The use of a prescribing indicators tool for commonly used medications and common medical conditions in older Australians may contribute to the efficient identification of DRPs.