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Kelleci Cakir B, Aydın A, Yılmaz M, Bayraktar-Ekincioglu A. Drug-related problems at the heart of cardiac surgery. Eur J Hosp Pharm 2024; 31:332-338. [PMID: 36788008 PMCID: PMC11265555 DOI: 10.1136/ejhpharm-2022-003669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/05/2023] [Indexed: 02/16/2023] Open
Abstract
OBJECTIVES Optimal perioperative success in cardiac surgery requires precise management of drug treatment. This study aimed to determine the prevalence, types and associated factors of drug-related problems (DRPs) during the entire hospital stay. METHODS A prospective observational study was conducted at the department of cardiovascular surgery in a university hospital between November 2019 and March 2020. Patients with planned elective cardiac surgery, aged ≥18 years, were included. A clinical pharmacist collaboratively reviewed medications on a daily basis and identified DRPs. RESULTS A total of 100 patients (60 male) were included; median (range) age was 62 (19-86) years, and median (IQR) length of stay in hospital was 15 (9) days. A total of 275 DRPs were identified (median (IQR) 3 (2-4)). The number of patients who had at least one DRP was 47 preoperatively, 55 in the postoperative intensive care unit, 100 in the postoperative ward, and 16 at discharge. In order to reduce bias because of the small sample size, Firth's logistic regression analysis was conducted. Statistically significant variables according to univariate analysis were included into a logistic regression model. Therefore the length of hospital stay (OR 1.14, 95% CI 1.03 to 1.26, p=0.008), living arrangements (living alone) (OR 4.24, 95% CI 1.41 to 12.73, p=0.009), number of medications at admission (OR 1.32, 95% CI 1.09 to 1.59, p=0.002), and having coronary artery bypass graft surgery (OR 2.87, 95% CI 1.07 to 7.70, p=0.03) were associated with an increased risk for DRPs in the final model. CONCLUSION Hospital stay carries an increased risk for DRPs, especially at the postoperative stage. Modifiable risk factors for DRPs can be managed by required interventions performed by a multidisciplinary healthcare team.
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Affiliation(s)
- Burcu Kelleci Cakir
- Department of Clinical Pharmacy, Hacettepe University Faculty of Pharmacy, Ankara, Turkey
| | - Ahmet Aydın
- Department of Cardiovascular Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Mustafa Yılmaz
- Department of Cardiovascular Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Saldanha V, de Araújo IB, Lima SIVC, Martins RR, Oliveira AG. Correction: Risk factors for drug-related problems in a general hospital: A large prospective cohort. PLoS One 2024; 19:e0303708. [PMID: 38718009 PMCID: PMC11078350 DOI: 10.1371/journal.pone.0303708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pone.0230215.].
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Han N, Oh OH, Oh J, Kim Y, Lee Y, Cha WC, Yu YM. The Application of Knowledge-Based Clinical Decision Support Systems to Detect Antibiotic Allergy. Antibiotics (Basel) 2024; 13:244. [PMID: 38534679 DOI: 10.3390/antibiotics13030244] [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: 02/06/2024] [Revised: 02/29/2024] [Accepted: 03/05/2024] [Indexed: 03/28/2024] Open
Abstract
Prevention of drug allergies is important for patient safety. The objective of this study was to evaluate the outcomes of antibiotic allergy-checking clinical decision support system (CDSS), K-CDSTM. A retrospective chart review study was performed in 29 hospitals and antibiotic allergy alerts data were collected from May to August 2022. A total of 15,535 allergy alert cases from 1586 patients were reviewed. The most frequently prescribed antibiotics were cephalosporins (48.5%), and there were more alerts of potential cross-reactivity between beta-lactam antibiotics than between antibiotics with the same ingredients or of the same class. Regarding allergy symptoms, dermatological disorders were the most common (38.8%), followed by gastrointestinal disorders (28.4%). The 714 cases (4.5%) of immune system disorders included 222 cases of anaphylaxis and 61 cases of severe cutaneous adverse reactions. Alerts for severe symptoms were reported in 6.4% of all cases. This study confirmed that K-CDS can effectively detect antibiotic allergies and prevent the prescription of potentially allergy-causing antibiotics among patients with a history of antibiotic allergies. If K-CDS is expanded to medical institutions nationwide in the future, it can prevent an increase in allergy recurrence related to drug prescriptions through cloud-based allergy detection CDSSs.
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Affiliation(s)
- Nayoung Han
- Jeju Research Institute of Pharmaceutical Sciences, College of Pharmacy, Jeju National University, Jeju 63243, Republic of Korea
| | - Ock Hee Oh
- FirstDIS Ltd., Seoul 07343, Republic of Korea
| | - John Oh
- Kakao Healthcare Corp., Seongnam 13529, Republic of Korea
| | - Yoomi Kim
- Korea Health Information Service, Seoul 04512, Republic of Korea
| | - Younghee Lee
- Department of Pharmacy, Ajou University Hospital, Suwon 16499, Republic of Korea
| | - Won Chul Cha
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, Seoul 06355, Republic of Korea
| | - Yun Mi Yu
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon 21983, Republic of Korea
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Tobiano G, Manias E, Thalib L, Dornan G, Teasdale T, Wellwood J, Chaboyer W. Older patient participation in discharge medication communication: an observational study. BMJ Open 2023; 13:e064750. [PMID: 36958781 PMCID: PMC10040044 DOI: 10.1136/bmjopen-2022-064750] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
OBJECTIVE To describe the extent to which older patients participate in discharge medication communication, and identify factors that predict patient participation in discharge medication communication. DESIGN Observational study. SETTING An Australian metropolitan tertiary hospital. PARTICIPANTS 173 older patients were observed undertaking one medication communication encounter prior to hospital discharge. OUTCOME Patient participation measured with MEDICODE, a valid and reliable coding framework used to analyse medication communication. MEDICODE provides two measures for patient participation: (1) Preponderance of Initiative and (2) Dialogue Ratio. RESULTS The median for Preponderance of Initiative was 0.7 (IQR=0.5-1.0) and Dialogue Ratio was 0.3 (IQR=0.2-0.4), indicating healthcare professionals took more initiative and medication encounters were mostly monologue rather than a dialogue or dyad. Logistic regression revealed that patients had 30% less chance of having dialogue or dyads with every increase in one medication discussed (OR 0.7, 95% CI 0.5 to 0.9, p=0.01). Additionally, the higher the patient's risk of a medication-related problem, the more initiative the healthcare professionals took in the conversation (OR 1.5, 95% CI 1.0 to 2.1, p=0.04). CONCLUSION Older patients are passive during hospital discharge medication conversations. Discussing less medications over several medication conversations spread throughout patient hospitalisation and targeting patients at high risk of medication-related problems may promote more active patient participation, and in turn medication safety outcomes.
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Affiliation(s)
- Georgia Tobiano
- NHMRC CRE in Wiser Wound Care, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Elizabeth Manias
- School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
- School of Nursing and Midwifery, Deakin University, Burwood, Victoria, Australia
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Burwood, Victoria, Australia
| | - Lukman Thalib
- Department of Biostatistics, Istanbul Aydin University, Istanbul, Turkey
| | - Gemma Dornan
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Trudy Teasdale
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Jeremy Wellwood
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Wendy Chaboyer
- NHMRC CRE in Wiser Wound Care, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
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Chen W, Zhang H, Jiang J, Zhang X, Ding J, Liu Y, Dang H. Application of comprehensive pharmaceutical care program in identifying and addressing drug-related problems in hospitalized patients with osteoporosis. BMC Health Serv Res 2022; 22:1438. [PMID: 36443812 PMCID: PMC9706996 DOI: 10.1186/s12913-022-08862-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 11/21/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND More information about the impacts of comprehensive pharmaceutical care program (CPCP) on the identification and resolution of drug-related problems (DRPs) is needed. This study aimed at researching the characteristics of DRPs in osteoporosis patients and evaluating the effect of CPCP in identifying and addressing DRPs. METHODS We performed a prospective interventional study in a teaching hospital. CPCP was established and conducted to identify and resolve DRPs by a multidisciplinary team (MDT) based on the Pharmaceutical Care Network Europe (PCNE) classification V9.0. Six pharmacists and one doctor worked directly in the study. All data was obtained from electronic medical records, direct observation and visits. The statistical analyses were performed using the SPSS Statistics software version 26.0. RESULTS Two hundred nineteen patients with osteoporosis were included in the final analysis. A total of 343 DRPs were identified, with an average of 1.57 DRPs per patient. The most common DRPs identified were "treatment safety P2" (66.8%; 229/343), followed by "other P3" (21.0%; 72/343) and "treatment effectiveness, P1" (12.2%; 42/343). The primary causes of DRPs were "dose selection C3" (35.9%; 211/588), followed by "drug use process C6" (28.9%; 170/588) and "drug selection C1" (12.6%; 74/588). Seven hundred eleven interventions were proposed to address the 343 DRPs, with an average of 2.1 interventions per DRP. The acceptance rate reached 95.9, and 91.0% of these accepted interventions were fully implemented. As a result, only 30 DRPs were unsolved before discharge. Additionally, the number of drugs was found to be associated with the number of DRPs significantly (p = 0.023). CONCLUSION DRPs frequently occurred in hospitalized osteoporosis patients. CPCP could be an effect option to solve and reduce DRPs for osteoporosis patients and should be implemented widely to increase patient safety.
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Affiliation(s)
- Wenwen Chen
- Department of Pharmacy, the Second Affiliated Hospital of Shandong First Medical University, 366 Taishan Street, Tai'an, 271000, Shandong, China
| | - Houli Zhang
- Department of Pharmacy, the Second Affiliated Hospital of Shandong First Medical University, 366 Taishan Street, Tai'an, 271000, Shandong, China
| | - Juan Jiang
- Department of Stomatology, the Second Affiliated Hospital of Shandong First Medical University, 366 Taishan Street, Tai'an, 271000, Shandong, China
| | - Xu Zhang
- Department of Pharmacy, the Second Affiliated Hospital of Shandong First Medical University, 366 Taishan Street, Tai'an, 271000, Shandong, China
| | - Jing Ding
- Department of Pharmacy, the Second Affiliated Hospital of Shandong First Medical University, 366 Taishan Street, Tai'an, 271000, Shandong, China
| | - Yanlin Liu
- Department of Pharmacy, the Second Affiliated Hospital of Shandong First Medical University, 366 Taishan Street, Tai'an, 271000, Shandong, China.
| | - Heqin Dang
- Department of Pharmacy, the Second Affiliated Hospital of Shandong First Medical University, 366 Taishan Street, Tai'an, 271000, Shandong, China.
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T. Nguyen K, T. Pham S, P.M. Vo T, X. Duong C, A. Perwitasari D, H.K. Truong N, T.H. Quach D, N.P. Nguyen T, T.T. Duong V, M. Nguyen P, H. Nguyen T, Taxis K, Nguyen T. Pneumonia: Drug-Related Problems and Hospital Readmissions. Infect Dis (Lond) 2022. [DOI: 10.5772/intechopen.100127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Pneumonia is one of the most common infectious diseases and the fourth leading cause of death globally. According to US statistics in 2019, pneumonia is the most common cause of sepsis and septic shock. In the US, inpatient pneumonia hospitalizations account for the top 10 highest medical costs, totaling $9.5 billion for 960,000 hospital stays. The emergence of antibiotic resistance in the treatment of infectious diseases, including the treatment of pneumonia, is a globally alarming problem. Antibiotic resistance increases the risk of death and re-hospitalization, prolongs hospital stays, and increases treatment costs, and is one of the greatest threats in modern medicine. Drug-related problems (DRPs) in pneumonia - such as suboptimal antibiotic indications, prolonged treatment duration, and drug interactions - increase the rate of antibiotic resistance and adverse effects, thereby leading to an increased burden in treatment. In a context in which novel and effective antibiotics are scarce, mitigating DRPs in order to reduce antibiotic resistance is currently a prime concern. A variety of interventions proven useful in reducing DRPs are antibiotic stewardship programs, the use of biomarkers, computerized physician order entries and clinical decision support systems, and community-acquired pneumonia scores.
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Sah SK, Ramaswamy S, Ramesh M. Frequency and risk factors for the development of drug related problems among rheumatoid arthritis patients. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2022. [DOI: 10.1016/j.cegh.2022.100969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Bekele F, Bereda G, Tamirat L, Geleta BA, Jabessa D. "Childrens are not just "little adults". The rate of medication related problems and its predictors among patients admitted to pediatric ward of southwestern Ethiopian hospital: A prospective observational study. Ann Med Surg (Lond) 2021; 70:102827. [PMID: 34540216 PMCID: PMC8435910 DOI: 10.1016/j.amsu.2021.102827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/03/2021] [Accepted: 09/05/2021] [Indexed: 01/18/2023] Open
Abstract
Background The rate of medication related problems is high in developing countries due to the complexity of pediatrics medication management. Pediatric population should have their own dosage regimens. The pediatric dosage regimens were derived from the adult dose that might lead to sudden reach of sub or supra-therapeutic doses. As the result, the medication therapy management is difficult in this populations. Despite this, a scanty of studies were conducted on medication related problems among pediatric populations. Therefore, this study examined the prevalence and risk factors for the occurrence of the medication related problems among patients admitted to pediatric ward of Mettu karl referral hospital. Patients and methods The pediatric population who were received the pharmacotherapy for their disease was observed and followed for the occurrences of medication related problems at pediatric wards of Mettu karl referral hospital from February 12, 2020 to February 24, 2021. Patients whose age was less than or equal to 18 years and who were on drug therapy or who needs drug therapy during study period were included. The possibility of adverse drug reactions developed from the drug was assessed by using the Naranjo scale. Multivariable logistic regression analysis was used to determine the predictors of medication related problems. Result Over the study period, a total of 189 pediatric populations were included. Among these, 115 (60.8%) were males, and the mean age of the patients was 1.4339 ± 0.864 years. The mediciation related problems was found among 121(64.01%) of pediatric patients. Among seven types of drug therapy problems unnecessary drug therapy, need additional drug therapy, ineffective drug therapy and dose too high were the most predominantly occured DRP that accounted 74 (27.72%), 67 (25.09%), 43 (16.10%), 36 (13.48%), respectively. The mean number of hospital stay was 4.29 days with minimum and maximum stay of 2 and 9 days and antibiotics 364(51.3%) were the most common class of drugs that was associated with drug related problems. Being a neonate (AOR = 1.48, 95CI%: 1.69–7.42, P = <0.001), hospital stay greater than or equal to seven days (AOR = 1.98, 95CI%: 2.471–12.644, P = 0.016), and the presence of co-morbidity(AOR = 2.507, 95CI%: 3.270–4.949, P = 0.080) were the predictors of the medication related problems. Conclusion The prevalence of medication-related problems in pediatrics patient was found to be high. Being neonatal, prolonged hospital stay and the presence of a multiple disease were the predictors of medication-related problems in pediatric patients. Therefore special attention should be given for newborns, prolonged hospital stay and patients having co-morbidity. Besides this, the drug information service and the patients round activity should be started by clinical pharmacist to decrease the occurences of any preventable medication related problems. DRP is the problem that interferes with a patient's pharmacotherapy that results in poor treatment outcomes. The rate of medication related problems in developing countries is high. “Children are not just “little adults” in which they should have their own pharmacokinetic and pharmacodynamics profile.
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Affiliation(s)
- Firomsa Bekele
- Department of Pharmacy, College of Health Science, Mettu University, Mettu, Ethiopia
| | - Gudisa Bereda
- Department of Pharmacy, College of Health Science, Mettu University, Mettu, Ethiopia
| | - Lalisa Tamirat
- Department of Pharmacy, College of Health Science, Mettu University, Mettu, Ethiopia
| | - Bonsa Amsalu Geleta
- Department of Nursing, College of Health Science, Mettu University, Mettu, Ethiopia
| | - Dabala Jabessa
- Department of Statistics, College of Natural and Computational Science, Mettu University, Mettu, Ethiopia
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Functional Status among Polymedicated Geriatric Inpatients at Discharge: A Population-Based Hospital Register Analysis. Geriatrics (Basel) 2021; 6:geriatrics6030086. [PMID: 34562987 PMCID: PMC8482227 DOI: 10.3390/geriatrics6030086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 12/22/2022] Open
Abstract
This study explored and compared the functional status of polymedicated and non-polymedicated geriatric inpatients at hospital discharge. We used a cross-sectional registry of geriatric patients' hospital records from a multi-site public hospital center in Switzerland. The analysis included all inpatients aged 65 years old or more admitted between 1 January 2015 and 31 December 2017 (n = 53,690), of whom 67.5% were polymedicated at hospital discharge, 52.1% were women (n = 18,909), and 42.7% were 75-84 years old (n = 15,485). On average, the polymedicated patients' hospital lengths of stay were six days longer, they presented with more than three comorbidities, and they were prescribed more than nine medications at hospital discharge (p < 0.001). They showed more frequent general mobility decline (43.2% vs. 41.9%), gait disorders (46.2% vs. 43%), fatigue (48.6% vs. 43.4%) and dependence on lower-body care (49.7% vs. 47.6%), and presented a higher malnutrition risk (OR = 1.411; 95%CI 1.263-1.577; p < 0.001). However, the non-polymedicated inpatients had proportionally more physical and cognitive impairments. The comparison of the functional status of polymedicated and non-polymedicated geriatric inpatients at hospital discharge is important for clinicians trying to identify and monitor those who are most vulnerable to functional decline, and to design targeted strategies for the prevention of functional impairment and related adverse health outcomes.
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Awoke M, Melaku T, Beshir M. Drug-related problems and its determinant among hospitalized neonates with sepsis at Jimma University Medical Center, Ethiopia: a prospective observational study. J Pharm Health Care Sci 2021; 7:20. [PMID: 34059150 PMCID: PMC8168002 DOI: 10.1186/s40780-021-00203-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/16/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Neonatal populations are quite susceptible to drug-related problems (DRPs) because of clinical heterogeneity and clinical practice trends. However, studies reporting DRPs in the neonatal population are quite limited. OBJECTIVE This study aimed to assess the magnitude and types of DRPs and determinant factors among neonates admitted with neonatal sepsis at the Neonatal Intensive Care Unit (NICU) of the Jimma University Medical Center (JUMC), Ethiopia. METHODS A hospital-based prospective observational study was conducted involving 201 neonates with sepsis admitted to the NICU from May to August 30, 2018. DRPs were classified using Cipolle's classification method. Statistical Package for Social Science Version 22 was employed for data analysis. Logistical regression was carried out to determine the determinants of DRPs. A p-value < 0.05 was considered to be statistically significant. RESULTS Of 201 neonates with sepsis included in this study, 125 (62.2%) were males and the median age of the neonate was 5 days. The mean (±standard deviation) number of medications taking during their hospital stay was 2.6 ± 0.7. DRPs were identified in 98 neonates, at a rate of 48.8% (95% CI, 41.7-55.9). Dose too high (42, 35.8%) and need additional drug therapy (40, 34.1%) were the commonly identified DRPs. Taking antibiotics plus other medications (Adjusted Odds Ratio (AOR) =5.2, 95%CI [1.2-22.0], p = 0.02) was a determinant factor for the occurrence of DRPs. CONCLUSION The burdens of DRPs occurrence were high in hospitalized neonates with sepsis. The most common DRPs identified were dose too high and need additional drug therapy. Combined use of other medicines with antibiotics was a predictor of DRP occurrence. The innovative way to tackle the occurrence of DRPs, such as the incorporation of clinical pharmacy service provider into the neonatal care team, which will prevent, detect and/or minimize the occurrence of DRPs, is highly recommended.
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Affiliation(s)
- Mengist Awoke
- Department of Clinical Pharmacy, School of Pharmacy, Institute of Health, Jimma University, PO. Box 378, Jimma, Ethiopia.
| | - Tsegaye Melaku
- Department of Clinical Pharmacy, School of Pharmacy, Institute of Health, Jimma University, PO. Box 378, Jimma, Ethiopia
| | - Mohammed Beshir
- Department of Pediatrics, Jimma University Medical Center, PO. Box 378, Jimma, Ethiopia
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Effectiveness of Clinical Pharmacist Service on Drug-Related Problems and Patient Outcomes for Hospitalized Patients with Chronic Kidney Disease: A Randomized Controlled Trial. J Clin Med 2021; 10:jcm10081788. [PMID: 33924036 PMCID: PMC8072770 DOI: 10.3390/jcm10081788] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: The study aimed to analyze the effectiveness of clinical pharmacist services on drug-related problems (DRPs) and patient outcomes in inpatients with chronic kidney disease (CKD). (2) Methods: In a randomized controlled trial, the participants in the intervention group received pharmacist services, including medication reconciliation, medication evaluation and management, and discharge pharmaceutical care transition services. Participants in the control group received usual care. The primary outcome was the number of DRPs per patient at discharge. (3) Results: The baseline characteristics of 100 participants included the following: mean age, 52.5 years; median eGFR, 9.2 mL/min/1.73 m2. The number of DRPs in the intervention group during hospitalization increased significantly with decreasing eGFR (PR, 0.970; 95% CI, 0.951–0.989) and an increasing number of unintentional medication discrepancies at admission (PR, 1.294; 95% CI, 1.034–1.620). At discharge, the number of DRPs per patient was 0.94 ± 1.03 and 1.96 ± 1.25 in the intervention and control groups, respectively (p < 0.001). The service had a significant effect on the reduction of the unintentional discrepancies at discharge (p < 0.001). (4) Conclusion: Hospital pharmacists play an important role in the prevention of DRPs at discharge and unintentional medication discrepancies in inpatients with CKD.
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