Impact of clinical pharmacist interventions on inappropriate prophylactic acid suppressant use in hepatobiliary surgical patients undergoing elective operations

Overuse of medications in low- and middle-income countries: a scoping review

Objective

To identify and summarize the evidence about the extent of overuse of medications in low- and middle-income countries, its drivers, consequences and potential solutions.

Methods

We conducted a scoping review by searching the databases PubMed®, Embase®, APA PsycINFO® and Global Index Medicus using a combination of MeSH terms and free text words around overuse of medications and overtreatment. We included studies in any language published before 25 October 2021 that reported on the extent of overuse, its drivers, consequences and solutions.

Findings

We screened 3489 unique records and included 367 studies reporting on over 5.1 million prescriptions across 80 low- and middle-income countries - with studies from 58.6% (17/29) of all low-, 62.0% (31/50) of all lower-middle- and 60.0% (33/55) of all upper-middle-income countries. Of the included studies, 307 (83.7%) reported on the extent of overuse of medications, with estimates ranging from 7.3% to 98.2% (interquartile range: 30.2-64.5). Commonly overused classes included antimicrobials, psychotropic drugs, proton pump inhibitors and antihypertensive drugs. Drivers included limited knowledge of harms of overuse, polypharmacy, poor regulation and financial influences. Consequences were patient harm and cost. Only 11.4% (42/367) of studies evaluated solutions, which included regulatory reforms, educational, deprescribing and audit-feedback initiatives.

Conclusion

Growing evidence suggests overuse of medications is widespread within low- and middle-income countries, across multiple drug classes, with few data of solutions from randomized trials. Opportunities exist to build collaborations to rigorously develop and evaluate potential solutions to reduce overuse of medications.

Evaluation of the effect of pharmaceutical care during inpatient treatment in a department of neurology: A retrospective study

Common drug-related problems during neurology inpatient treatment can affect expected health results. Some interventions need to be implemented to reduce DRPs. To explore the effect of care from clinical pharmacists during inpatient treatment. Inpatients treated in the department of neurology in the Second Hospital of Shanxi Medical University between January 1 to December 31, 2019, were retrospectively included. Those who received care from the clinical pharmacist service were assigned to the pharma-care group while the other patients were assigned to the control group. From the perspective of drugs, the two groups were compared in terms of types, antimicrobial use, and key monitoring of drug use. From the perspective of patients, the two groups were compared in terms of length of stay, hospital cost, drug cost and proportion. Propensity score matching was used to balance the baseline characteristics. A total of 2684 patients were included 554 in the pharma-care group and 2130 in the control group with a median of 9 days (range, 3-30 days) hospital stay. The groups showed no significant difference in age or gender. Length of stay, the proportion of drug cost, number of adverse events, cost of antibacterial agents, use of a single antibacterial agent, and use of three or more different antibacterial agents were similar between the groups. Medicine expenses cost more in the pharma-care group. The cost and types of intensive monitoring drugs were similar, but Defined Daily Doses were lower in the control group. While clinical pharmacists may play a positive role in the pharmaceutical care of inpatients, in this study the benefits were not obvious. This may be because of the small number of clinical pharmacists in the department of neurology with narrow coverage.

Efficacy of administrative intervention for neurosurgical patients with off-label use of alprostadil lipid microsphere

As an adjuvant drug, alprostadil lipid microsphere injection (Lipo-PGE₁) is one of the best-selling drugs in China in recent years. However, the off-label use of Lipo-PGE₁ is very common. This study aimed to investigate the use of Lipo-PGE₁ and evaluate the clinical effects and economic benefits after administrative intervention on inappropriate use of Lipo-PGE₁ in neurosurgical patients in a Chinese tertiary hospital. Administrative interventions were implemented from January to December 2018 by reducing the procurement volume of Lipo-PGE₁, judging the rationality of medical records, and establishing reward and punishment mechanisms. Administrative interventions significantly decreased prescription rate (49.98% vs 22.49%), utilization (22,311 DDDs vs 8334 DDDs), drug use density (43.52 DDDs/TID vs 15.84 DDDs/TID), total expenditure (3.58 million RMB vs 1.30 million RMB), and average expenditure (2025.04 RMB vs 1466.49 RMB) of Lipo-PGE₁. To our delight, these intervention effects were maintained or even better in the 1-year post-intervention period. Moreover, in the intervention and post-intervention phases, the Lipo-PGE₁ use for no indications as well as inappropriate drug dose, frequency, menstruum type, combination, and contraindication were markedly reduced. Besides, the mean costs (P < 0.001), and mean duration (P < 0.001) of Lipo-PGE₁ were also obviously decreased. The administrative intervention obviously reduced the off-label use of Lipo-PGE₁. However, there still remains a number of inappropriate uses of Lipo-PGE₁. To further improve the rational use of Lipo-PGE₁, combination of administrative intervention and real-time clinical pharmacists intervention should be implemented.

Impact of a clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy in older hospitalized patients: a non-randomized controlled study

BACKGROUND

The potentially inappropriate use of the proton pump inhibitors is prevalent in older adults.

AIM

To evaluate the impact of a clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy in older hospitalized patients.

METHOD

This parallel nonrandomized controlled study was conducted at an internal medicine service of a tertiary training and research hospital between September 2019 and August 2021. Older patients (≥ 65 years old and received proton pump inhibitors within 48 h of admission) were allocated to two groups according to their number of medical file records, whether odd or even, two groups: control and clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy (including medication reconciliation and medication review) during the hospital stay. Primary outcome measures were the rate of appropriate use of proton pump inhibitors during hospitalization and potentially inappropriate proton pump inhibitor use at discharge.

RESULTS

The rate of appropriate proton pump inhibitor use during hospitalization was significantly higher in the clinical pharmacist-led program (n = 100) than in the control group (n = 97) (46.4% vs. 79.0%; P < 0.001). The rate of potentially inappropriate proton pump inhibitor use at discharge was significantly lower (61.7% vs. 35.1%; P < 0.05) in the clinical pharmacist-led program among the older patients discharged with a proton pump inhibitor prescription.

CONCLUSION

A clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy improved the rate of appropriate proton pump inhibitor use and reduced the potentially inappropriate proton pump inhibitor use during the hospital stay.

TRIAL REGISTRATION

NCT05113667 (17 October 2021-registered retrospectively).

Impact of proton pump inhibitor management committee's multifaceted interventions on acid suppressant prescribing patterns in outpatient and emergency departments

Background

A nationwide campaign for rational proton pump inhibitor (PPI) use launched in 2015 had a positive impact for hospitalized patients PPI use. But there were few studies focusing on the rational use of PPIs in outpatients. In 2018, the PPI management committee conducted a year-long intervention on the appropriate use of PPIs in outpatient and emergency departments, including clinical pharmacist interventions and stewardship interventions. The purpose of this study was to examine the impact of the PPI management committee’s multifaceted interventions by comparing the real-world acid suppressant prescribing patterns for outpatients before (2017) and after intervention (2019) at a Chinese tertiary teaching hospital.

Methods

Prescriptions containing any acid suppressant in outpatient and emergency departments in baseline (2017) and postintervention (2019) periods were extracted from the hospital information system and the prescription automatic screening system. Acid suppressant prescribing patterns were evaluated based on primary diagnoses and patient demographics. The prescribed acid suppressants stratified using age groups (< 7, 7–17, 18–45, 46–65, 66–85 and > 85 years) were also examined.

Result

The utilization rate of acid suppressant in 2017 and 2019 was 2.5% (41,165/1,619,366) and 2.2% (49,550/2,236,471), respectively (P < 0.0001). 60,135 acid suppressant prescriptions were obtained in 2017 and 73,275 in 2019. The rate of acid suppressant prescriptions for the approved indications significantly increased from 62.6% (2017) to 65.4% (2019) (P < 0.0001). Prescriptions diagnosed as abnormal symptoms, signs and clinical manifestations, decreased in 2019 (13.0% vs. 16.5%, P < 0.0001). The most frequently prescribed PPIs differed between 2017 and 2019 (rabeprazole 2017 vs. esomeprazole 2019). Omeprazole was the most common PPI and cimetidine was the most common H₂RA prescribed to patients aged < 18 years in 2017 and 2019. A total of CNY11.83 million was spent on acid suppressants in 2019, accounting for about 48.7% of total medication cost, increased by 11.3% from 2017 (37.4%).

Conclusion

The proportion of acid suppressant prescriptions for approved indications was enhanced after the PPI management committee’s multifaceted interventions, but there were still some problems in the selection of acid suppressants.

Use of proton pump inhibitors: An exploration of awareness, attitude and behavior of health care professionals of Riyadh, Saudi Arabia

Background & Objectives

One of the broadly talked about class of medications for their extravagantly expanded abuse is proton pump inhibitors (PPIs). In spite of the fact that, they are known to be profoundly useful, it is accounted for several adverse manifestations. Health care professionals can assume an essential part in controlling its irrational use. The purpose of this study was to explore the knowledge, attitude and behavior of health care professionals of Riyadh region of Saudi Arabia on the use of PPIs by a cross-sectional study design.

Methods

The study data was obtained through a validated self-administered questionnaire covering knowledge (20 items), attitude (8 items) and behavior (6 items). Furthermore, demographic questions were placed to decide their effect on the intended three domains. The results were analysed by descriptive analysis and affirmed by multinomial regression method using SPSS-IBM 25.

Results

Of 414 surveyors, 121 (31%), 182 (44%) and 103 (25%) were doctors, pharmacist and nurses, respectively. Average age of participants' was 33.96 ± 8.37 years. Both doctors and pharmacist showed better degree of information (13.17/20 and 13.25/20) and good attitude (6.66/8 and 6.9/8) towards PPI use compared to nurses. Altogether higher extent of knowledge score showed by highly educated individuals, middle age groups and those with more practicing experience. The reliance on the utilization of PPI is less among pharmacist and nurses when compared to doctors. The outcome of the regression analysis exhibited that the odds of having low knowledge is more in young and bachelor degree holders.

Interpretation & Conclusion

Healthcare professionals in the Riyadh area are generally positive about the use of PPIs. However, increasing their level of knowledge and reducing their reliance on PPIs must be strengthened. Frequent professional development programs and trainings for healthcare professionals are needed to minimize widespread PPI overuse.

Impact of pharmacy-supported interventions on proportion of patients receiving non-indicated acid suppressive therapy upon discharge: A systematic review and meta-analysis

Objective

Conduct a systematic review and meta-analysis to estimate the impact of pharmacy-supported interventions on the proportion of patients discharged from the hospital on inappropriate acid suppressive therapy (AST).

Methods

To identify studies, the following databases were systematically searched on October 14^th, 2018 and repeated on September 12^th, 2019: Ovid MEDLINE(R) and In-Process & Other Non-Indexed Citations and Daily, Embase.com, CINAHL, Web of Science, Cochrane CENTRAL (EBSCO), and ClinicalTrials.gov. Eligible studies consisted of adults, intervention and historical/usual care groups, description of active pharmacy-supported intervention, and proportion of patients discharged on inappropriate AST. Qualitative assessments and quantitative analyses were performed. Modified funnel plot analysis assessed heterogeneity. Preferred reporting items of systematic reviews and meta-analyses (PRISMA) methodology was used to evaluate studies in this review.

Results

Seventeen publications resulting in 16 studies were included in the review. Using random effects model, meta-analysis showed a significant reduction in the odds of being discharged on inappropriate AST from the hospital in the pharmacist-supported intervention arm versus comparator (Odds Ratio 0.33 [95%CI 0.20 to 0.53]), with significant heterogeneity (I² = 86%). Eleven studies favored pharmacy-supported interventions, four were inconclusive and one favored usual care. Using modified funnel plot analysis, our final evaluation was distilled to 11 studies and revealed a similar outcome (OR 0.36 [95%CI 0.27 to 0.48]), but with less heterogeneity (I² = 36%).

Conclusion

This systematic review and meta-analysis showed that pharmacy-supported interventions were associated with a significantly reduced probability of patients discharged on inappropriate AST. However, heterogeneity was high and may affect interpretation of results. Using funnel plot optimization method, three positive and two negative studies were objectively removed from analyses, resulting in a similar effect size, but with less heterogeneity. To improve study quality, future researchers should consider utilizing a pre-post, multi-arm, prospective design with sampling randomization, training of data extractors (preferably two extractors), re-evaluating a small dataset to check for agreement and providing a comprehensive methodology in subsequent publications.

Impact of interventions targeting the inappropriate use of proton-pump inhibitors by clinical pharmacists in a hepatobiliary surgery department

WHAT IS KNOWN AND OBJECTIVE

At present, studies on the usage of proton-pump inhibitors (PPIs) have universal significance. In clinical practice, PPIs are widely used to treat a variety of acid-related diseases, but they can be inappropriately prescribed, leading to increased medical costs and patient harm. The study comprehensively evaluated the clinical effects of a clinical pharmacist intervention on inappropriate PPI prescriptions in a tertiary general hospital hepatobiliary surgery ward.

METHODS

A retrospective, single-centre intervention study covering the periods of July-December 2018 and July-December 2019 was conducted. In the intervention group, clinical pharmaceutical care was initiated by a clinical pharmacist in the hepatobiliary surgery ward. Outcomes, including the clinical pattern of PPI utilization, the rate of inappropriate PPI use and safety outcomes, were compared between the two periods.

RESULTS AND DISCUSSION

In total, 1150 patients were admitted to the hepatobiliary surgery ward in our hospital in the study periods. Of these, 717 patients met the inclusion criteria for this study, and 420 and 297 patients were included in the preintervention and post-intervention groups, respectively. The PPI utilization rates before and after the intervention were 82.0% and 55.0%, respectively. The rates of inappropriate PPI use before and after the intervention were 48.9 and 22.7 per 100 patient-days, respectively. Clinical safety outcomes were nearly identical between before and after the intervention, but patients treated with PPIs were more likely to experience nosocomial pneumonia (2.4% vs. 0.6%).

WHAT IS NEW AND CONCLUSION

The implementation of a clinical pharmacist intervention for PPI use decreased inappropriate PPI use during hospitalization without sacrificing clinical safety outcomes.

Drug Therapy Problems and the Role of Clinical Pharmacist in Surgery Ward: Prospective Observational and Interventional Study

BACKGROUND

Drug therapy problems (DTPs) are of major concern in health care because of the associated increased cost of treatment, morbidity, and mortality. Thus, clinical practice should constitute the mainstream practice of clinical pharmacy in every ward. However, nothing is known about DTPs and the role of clinical pharmacist in the surgical ward of Ethiopia (the neglected ward).

OBJECTIVE

To assess the prevalence of DTP among patients hospitalized at the surgical ward and the role of clinical pharmacists in their identification and resolution.

METHODS

Hospital-based prospective observational and interventional study design was used with daily patients' chart review using a semi-structured questionnaire among hospitalized adult patients at the surgical ward. After identification of DTP, verbal communication was used as a means of intervention with the treating physician. Acceptance of clinical pharmacist's intervention was considered only if a change was made to the patients' medication order. To identify determinants of DTPs, multiple stepwise forward logistic regression analysis was done by SPSS version 20.0. Statistical significance was considered at p-value < 0.05. Written informed consent was sought and the data were secured.

RESULTS

The response rate was 97.1% (300) for the final analysis. The mean (±SD = standard deviation) age of the participants was 42.62 ±18.29 with male (67%) predominance. DTP was identified in 76% of study participants. A total of 449 DTPs were identified, which equates with an average of 1.97 per patient. Dose too low 124/449 (27.6%) and dose too high 81/449 (18.0%) were found to be the most common types of DTPs. The intervention rate was 86.0% (196/228 per patients) and 86.2% (387/449 DTPs), with the acceptance rate of 85.2% (167/196 per patients) and 78% (302/387 per DTP) which mean (67.3%) 302/449 of the problems were fully resolved by the clinical pharmacist. Poly-pharmacy [AOR, 7.23; 95% CI, 2.29-22.13: P-value < 0.001] and hospital stay > 20 days [AOR, 5.42; 95% CI, 2.74-10.70; p < 0.001] were the only independent predictors for DTPs.

CONCLUSION AND RECOMMENDATION

This study identified a high prevalence of DTP which was independently predicted by the presence of poly-pharmacy and >20 days of hospital stay. The rate of intervention provided and acceptance from the physician was high, which is one indicator that the role of clinical pharmacists in the identification and resolution of DTP was paramount in the surgery ward and should be implemented as a must not as optional.

Awareness, attitude and behavior regarding proton pump inhibitor among medical staff in the Southwest of China

BACKGROUND

Proton pump inhibitors (PPIs) are one of the most frequently prescribed classes of drug in the world and there is a growing number of publications on correct versus incorrect use of PPIs worldwide. The knowledge of PPIs among the medical staff is essential for improving the rationality of PPI application. The present study aimed to investigate awareness, attitude and behavior toward PPI use among medical staff in the Southwest of China.

METHODS

The present descriptive-analytical study was conducted on 900 medical staff from three professional groups (300 doctors, 300 nurses and 300 pharmacists) in China. The study data were collected through a self-designed questionnaire which included demographics, awareness, attitude and behavior toward PPI use. The study was carried out in 22 hospitals in Luzhou between February and June 2018.

RESULTS

Of 900 surveys issued, 851valid questionnaires (295doctors, 268 nurses and 288 pharmacists) were returned. Of all respondents, 33.25% were men and 66.75% were women. The score related to PPI awareness score of medical staff was low (59.47 ± 15.75). The level of awareness of pharmacist was significantly higher than that of doctors and nurses (P < 0.01), which was related to gender, age, occupation, educational level, professional title, hospital nature and hospital grade. Similarly, on the attitude towards PPI use, the pharmacists scored also significantly higher than doctors and the nurses (P < 0.01). Three hundred eighty-one of 851 medical staff had used PPI in the past 1 year, of which omeprazole was the most widely used. Among doctors, nurses and pharmacists, the usage rate of PPI was 50.85, 42.16, 40.97%, respectively. The use frequency was related to occupation and professional title. The score about the behavior toward PPIs of the nurses was also significantly lower than that of doctors and pharmacists (P < 0.01).

CONCLUSIONS

The study indicated that the medical staff lack of awareness concerning rational use of PPI in China, especially nurse. Thus, it is necessary to call for action on the improvement of PPI awareness and medication-taking behaviors to reduce PPI overuse and to promote the rationality of PPI application.

Changes in proton pump inhibitor prescribing trend over the past decade and pharmacists' effect on prescribing practice at a tertiary hospital

BACKGROUND

Proton pump inhibitors (PPIs) remain one of the world's most frequently prescribed medications and there is a growing number of publications on correct versus incorrect use of PPIs worldwide. The objective of this observational retrospective study was to assess changes in PPI prescribing trends over the past decade and pharmacists' effect on optimizing PPI prescribing practice at a tertiary hospital in China.

METHODS

We collected the prescriptions of PPIs in our hospital from January 2007 to December 2016. Then the rate of PPI prescribing, the defined daily doses (DDDs) and expenditures were calculated and plotted to show the change in utilization of and expenditure on PPIs. Reasons behind this change and effect of pharmacists' intervention were evaluated by investigating the rationality of PPI use through sample surveys of patients of pre-intervention (Jul.-Dec. 2015) and post-intervention (Jul.-Dec. 2016).

RESULTS

In outpatient settings, the rate of PPI prescribing remained almost constant, utilization (from 135,808 DDDs to 722,943 DDDs) and expenditure (from 1.85 million CNY to 7.96 million CNY) increased for the past ten years, dominated by oral formulations and rabeprazole. In contrast, in inpatient settings, the rate of PPI prescribing (from 20.41 to 37.21%), utilization (from 132,329 DDDs to 827,747 DDDs) and expenditure (from 3.15 million CNY to 25.29 million CNY) increased from 2007 to 2015 and then decreased, dominated by injection formulations and omeprazole. Pharmacist interventions could significantly promote the rational use of PPIs (44.00% versus 26.67%), decrease PPI use and reduce patients' charges (P < 0.05).

CONCLUSIONS

The utilization of and expenditure on PPIs grew due to the increase of patients and irrational use of PPI. Pharmacist interventions help to reduce PPI utilization and expenditure and enhance rationality for inpatients, but much work should be done to regulate injection and originator formulas, and improve the rationality in the future.