Repeat prescribing: scale, problems and quality management in ambulatory care patients

Knowledge, attitudes, and practices of primary healthcare practitioners regarding pharmacist clinics: a cross-sectional study in Shanghai

BACKGROUND

Pharmacist clinics offer professional pharmaceutical services that can improve public health outcomes. However, primary healthcare staff in China face various barriers and challenges in implementing such clinics. To identify existing problems and provide recommendations for the implementation of pharmacist clinics, this study aims to assess the knowledge, attitudes, and practices of pharmacist clinics among primary healthcare providers.

METHODS

A cross-sectional survey based on the Knowledge-Attitude-Practice (KAP) model, was conducted in community health centers (CHCs) and private hospitals in Shanghai, China in May, 2023. Descriptive analytics and the Pareto principle were used to multiple-answer questions. Chi-square test, Fisher's exact test, and binary logistic regression models were employed to identify factors associated with the knowledge, attitudes, and practices of pharmacist clinics.

RESULTS

A total of 223 primary practitioners participated in the survey. Our study revealed that most of them had limited knowledge (60.1%, n = 134) but a positive attitude (82.9%, n = 185) towards pharmacist clinics, with only 17.0% (n = 38) having implemented them. The primary goal of pharmacist clinics was to provide comprehensive medication guidance (31.5%, n = 200), with medication education (26.3%, n = 202) being the primary service, and special populations (24.5%, n = 153) identified as key recipients. Logistic regression analysis revealed that education, age, occupation, position, work seniority, and institution significantly influenced their perceptions. Practitioners with bachelor's degrees, for instance, were more likely than those with less education to recognize the importance of pharmacist clinics in medication guidance (aOR: 7.130, 95%CI: 1.809-28.099, p-value = 0.005) and prescription reviews (aOR: 4.675, 95% CI: 1.548-14.112, p-value = 0.006). Additionally, practitioners expressed positive attitudes but low confidence, with only 33.3% (n = 74) feeling confident in implementation. The confidence levels of male practitioners surpassed those of female practitioners (p-value = 0.037), and practitioners from community health centers (CHCs) exhibited higher confidence compared to their counterparts in private hospitals (p-value = 0.008). Joint physician-pharmacist clinics (36.8%, n = 82) through collaboration with medical institutions (52.0%, n = 116) emerged as the favored modality. Daily sessions were preferred (38.5%, n = 86), and both registration and pharmacy service fees were considered appropriate for payment (42.2%, n = 94). The primary challenge identified was high outpatient workload (30.9%, n = 69).

CONCLUSIONS

Although primary healthcare practitioners held positive attitudes towards pharmacist clinics, limited knowledge, low confidence, and high workload contributed to the scarcity of their implementation. Practitioners with diverse sociodemographic characteristics, such as education, age, and institution, showed varying perceptions and practices regarding pharmacist clinics.

GPs' awareness of pregnancy: trends and association with hazardous medication use

BACKGROUND

GPs have been shown to be important providers of medical care during pregnancy, however, little evidence exists on their awareness of pregnancy when prescribing medication to women.

AIM

To assess GPs' awareness of pregnancy and its association with prescribing medication with potential safety risks.

DESIGN AND SETTING

Population-based study using confirmed pregnancy records linked to GP records from the PHARMO Perinatal Research Network.

METHOD

GPs' awareness of pregnancy, defined as the presence of a pregnancy confirmation in the GP information system during pregnancy, was assessed from 2004 to 2020. GP prescriptions of medication with potential safety risks were selected during pregnancy and its association with GPs' awareness of pregnancy was assessed using multivariable logistic regression.

RESULTS

A pregnancy confirmation was present in the GP records for 48% (n = 67 496/140 976) of selected pregnancies, increasing from 28% (n = 34/121) in 2004 to 63% in 2020 (n = 5763/9124). During 3% (n = 4489/140 976) of all pregnancies, the GP prescribed highly hazardous medication with teratogenic effects that should have been (temporarily) avoided. Pregnancy was GP confirmed for only 13% (n = 585/4489) at the first occurrence of such a prescription. Comparative analyses showed that women without a pregnancy confirmation were 59% more likely to be prescribed this highly hazardous medication (odds ratio [OR] 1.59, 95% confidence interval [CI] = 1.49 to 1.70) compared with those with a confirmed pregnancy.

CONCLUSION

Results of this study indicate a potential issue with GP awareness about pregnancy status at the time medication with potential safety risks is prescribed. Although pregnancy registration by GPs improved over the years, inadequate use still seems to be made of the available information systems for appropriate drug surveillance.

Evaluation and pharmacists perspective of repeat prescribing process in refill clinics

Introduction

Repeat prescription refers to a re-prescribed medications list issued by a refill clinic, commonly for stable chronic illnesses. The issues regarding repeat prescriptions have garnered increasing important in recent years, as no general agreement about a standardized protocol exists between organizations. Due to the importance of pharmacists’ involvement and intervention in the process of repeat prescription and the lack of local studies discussing this topic, the aim of this study was to assess pharmacists’ perspectives toward the repeat prescription process and identify the issues related to repeat prescriptions in refill clinics at tertiary hospitals.

Methodology

A self-developed questionnaire was used to assess outpatient pharmacists’ perspectives toward the repeat prescription process. This was followed by a comprehensive review of the electronic health records (EHR) of patients who requested repeat prescriptions to identify related issues. The study was conducted at a tertiary teaching hospital from September 2019 to January 2020.

Results

Based on the questionnaire, 34 pharmacists reported receiving less than 10 repeat prescriptions per week (82.35%); nevertheless, around 88.24% of pharmacists have faced issues with the repeat prescription process, and only 15.65% of the issues got resolved. Most of the pharmacists (88.24%) showed a proactive attitude toward modifying the work process to reduce issues. Further, the review of the patients’ EHR identified 1766 prescriptions with related issues in 617 (14.02%) patients’ profiles. Most of these issues were seen in the elderly (46.7%). The most common issue encountered was “Patients came too early to request,” which accounted for 986 (55.8%) of the total issues, followed by the issue of “Refilling a restricted medication” reported at 247 (14%). Only 11% of these issues were completely resolved by pharmacists.

Conclusion

The repeat prescription service might be associated with issues that lead to preventable adverse effects, especially among the elderly who are prone to such effects. Comprehensive reviews of patients’ profiles are necessary to assess their needs and avoid such issues.

The evaluation of an e-learning prescribing course for general practice

Prescribed medication may lead to significant morbidity or mortality as a result of these medications causing adverse events, or because of a prescribing error. E-learning is a common tool used in supporting training in prescribing. This paper describes the development of an e-learning course and the subsequent evaluation undertaken by the users with the aim of obtaining an effective e-learning course for prescribing. The e-learning course was developed by general practitioners and pharmacists and focussed on the principles of good prescribing, examined the common reasons for prescribing errors, and was evaluated using self-reported quantitative and qualitative measures. Scores significantly increased on an assessment given before and after the course. The majority of respondents reported that the e-learning course had a positive impact on prescribing knowledge, skills and attitudes, with medication reviews the top area where a change in prescribing practice was reported. Over 90% of the respondents agreed that the e-learning course was easy to use and a useful part of their continuing professional education. This study shows that clinicians recognise the on-going need for training in prescribing, but the lack of training is one of the factors contributing to errors, which suggests that more education is needed, not just for GPs in training, but for qualified GPs as well.

Exploring Patient's Perspectives and Experiences After Start with Inhalation Maintenance Therapy: A Qualitative Theory-Based Study

BACKGROUND

Treatment of obstructive lung disease with inhalation therapy needs changes in patient behavior. Shortly after the start with inhaled corticosteroids (ICS) maintenance therapy, patients might be in need of additional pharmaceutical care, tailored to their individual needs. This study aimed to provide insight into patient behavior, goals and perceptions regarding their medical treatment at start with ICS therapy, by telephone interviews with ICS starters. Besides, this study investigated pharmacists' and patients' experiences with these interviews and opinions on the utility of this type of consultation for daily practice.

METHODS

Semi-structured telephone interviews were conducted by pharmacists with adult patients 2-3 weeks after starting ICS. The Theoretical Domain Framework (TDF) was used for data analysis and coding. Afterward, the patients and pharmacists were questioned about their experiences with the interview.

RESULTS

Five pharmacists conducted interviews with 23 ICS starters. Except the domains "environmental context and resources", "optimism", and "reinforcement", the remaining 11 domains in the TDF were addressed in the interviews. The majority of patients defined personal goals, which mainly addressed disease or symptom control (clinical goals). Some patients showed a lack of knowledge regarding the clinical indication or therapy duration. Views on beneficial medication effects differed between patients. Some patients specifically mentioned concerns or anxiety about side effects. The interviewees described different perceptions on the necessity of a personalized routine for regular medication use. Patients and pharmacists both felt positive about an added value of these interviews for daily practice.

CONCLUSION

Patient interviews shortly after start with ICS therapy revealed various perceptions and beliefs that might influence medication use and achievement of individual treatment goals. The patients appreciated the opportunity to ask questions and share their perspectives and needs with their pharmacist, and the pharmacists experienced that the interviews had added value.

Patient-centred improvement to repeat prescribing using the Always Event concept

Repeat prescriptions are prescriptions issued to a patient for a second or subsequent time without requiring a consultation with a doctor. Repeat prescribing is common and an efficient system is necessary to deliver a high-quality service. Always Events can be used to drive patient-centred improvements in healthcare delivery. Our aim was to use the Always Event concept to improve our repeat prescribing system. This quality improvement project was carried out in a deprived, inner-city general practice setting in Glasgow, UK. 51 patients taking repeat medications completed short questionnaires, and the Always Event ‘Repeat prescriptions should be ready and available to collect’ was generated. We used the Plan-Do-Study-Act cycles to elucidate how our system could be improved and check if our intervention was effective. Over a 3-day period in July 2016, 269 out of 292 prescriptions (92.1%) were ready. We mapped out the repeat prescribing process and discovered that sometimes reception staff graded a request as inappropriate, for example, requested too early, and these requests were therefore not processed. Patients would then attend to collect a prescription that was not there. This was both inconvenient for the patient and time-consuming for the reception staff to investigate the reason. Our system was changed so that any request that was not being processed was recorded and the patient informed. In September 260 out of 267 (97.4%) prescriptions were ready, in November 350 out of 364 (96.2%), and in February 2017 314 out of 323 (97.2%) were ready. In conclusion, the Always Event approach allowed us to elicit important feedback from patients to identify a weakness in our repeat prescribing system, which was simple to rectify and led to an improved, more efficient service.

Repeat prescribing of medications: A system-centred risk management model for primary care organisations

RATIONALE, AIMS AND OBJECTIVES

Reducing preventable harm from repeat medication prescriptions is a patient safety priority worldwide. In the United Kingdom, repeat prescriptions items issued has doubled in the last 20 years from 5.8 to 13.3 items per patient per annum. This has significant resource implications and consequences for avoidable patient harms. Consequently, we aimed to test a risk management model to identify, measure, and reduce repeat prescribing system risks in primary care.

METHODS

All 48 general medical practices in National Health Service (NHS) Lambeth Clinical Commissioning Group (an inner city area of south London in England) were recruited. Multiple interventions were implemented, including educational workshops, a web-based risk monitoring system, and external reviews of repeat prescribing system risks by clinicians. Data were collected via documentation reviews and interviews and subject to basic thematic and descriptive statistical analyses.

RESULTS

Across the 48 participating general practices, 62 unique repeat prescribing risks were identified on 505 occasions (eg, practices frequently experiencing difficulty interpreting medication changes on hospital discharge summaries), equating to a mean of 8.1 risks per practice (range: 1-33; SD = 7.13). Seven hundred sixty-seven system improvement actions were recommended across 96 categories (eg, alerting hospitals to illegible writing and delays with discharge summaries) with a mean of 15.6 actions per practice (range: 0-34; SD = 8.0).

CONCLUSIONS

The risk management model tested uncovered important safety concerns and facilitated the development and communication of related improvement recommendations. System-wide information on hazardous repeat prescribing and how this could be mitigated is very limited. The approach reported may have potential to close this gap and improve the reliability of general practice systems and patient safety, which should be of high interest to primary care organisations internationally.

Protocol for using mixed methods and process improvement methodologies to explore primary care receptionist work

INTRODUCTION

The need to cope with an increasingly ageing and multimorbid population has seen a shift towards preventive health and effective management of chronic disease. This places general practice at the forefront of health service provision with an increased demand that impacts on all members of the practice team. As these pressures grow, systems become more complex and tasks delegated across a broader range of staff groups. These include receptionists who play an essential role in the successful functioning of the surgery and are a major influence on patient satisfaction. However, they do so without formal recognition of the clinical implications of their work or with any requirements for training and qualifications.

METHODS AND ANALYSIS

Our work consists of three phases. The first will survey receptionists using the validated Work Design Questionnaire to help us understand more precisely the parameters of their role; the second involves the use of iterative focus groups to help define the systems and processes within which they work. The third and final phase will produce recommendations to increase the efficiency and safety of the key practice processes involving receptionists and identify the areas and where receptionists require targeted support. In doing so, we aim to increase job satisfaction of receptionists, improve practice efficiency and produce better outcomes for patients.

ETHICS AND DISSEMINATION

Our work will be disseminated using conferences, workshops, trade journals, electronic media and through a series of publications in the peer reviewed literature. At the very least, our work will serve to prompt discussion on the clinical role of receptionists and assess the advantages of using value streams in conjunction with related tools for process improvement.

Potentially inappropriate prescribing and adverse drug reactions in the elderly: a population-based study

Purpose

Potentially inappropriate prescriptions (PIPs) criteria are widely used for evaluating the quality of prescribing in elderly. However, there is limited evidence on their association with adverse drug reactions (ADRs) across healthcare settings. The study aimed to determine the prevalence of PIPs, defined by the Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) criteria, in the Swedish elderly general population and to investigate the association between PIPs and occurrence of ADRs.

Method

Persons ≥65 years old were identified from a random sample of 5025 adults drawn from the Swedish Total Population Register. A retrospective cohort study was conducted among 813 elderly with healthcare encounters in primary and specialised healthcare settings during a 3-month period in 2008. PIPs were identified from the Swedish Prescribed Drug Register, medical records and health administrative data. ADRs were independently identified by expert reviewers in a stepwise manner using the Howard criteria. Multivariable logistic regression examined the association between PIPs and ADRs.

Results

Overall, 374 (46.0 %) persons had ≥1 PIPs and 159 (19.5 %) experienced ≥1 ADRs during the study period. In total, 29.8 % of all ADRs was considered caused by PIPs. Persons prescribed with PIPs had more than twofold increased odds of experiencing ADRs (OR 2.47; 95 % CI 1.65–3.69). PIPs were considered the cause of 60 % of ADRs affecting the vascular system, 50 % of ADRs affecting the nervous system and 62.5 % of ADRs resulting in falls.

Conclusion

PIPs are common among the Swedish elderly and are associated with increased odds of experiencing ADRs. Thus, interventions to decrease PIPs may contribute to preventing ADRs, in particular ADRs associated with nervous and vascular disorders and falls.

Electronic supplementary material

The online version of this article (doi:10.1007/s00228-015-1950-8) contains supplementary material, which is available to authorized users.

Adherence to Antihypertensive Therapy and Elevated Blood Pressure: Should We Consider the Use of Multiple Medications?

Background

Although a majority of patients with hypertension require a multidrug therapy, this is rarely considered when measuring adherence from refill data. Moreover, investigating the association between refill non-adherence to antihypertensive therapy (AHT) and elevated blood pressure (BP) has been advocated.

Objective

Identify factors associated with non-adherence to AHT, considering the multidrug therapy, and investigate the association between non-adherence to AHT and elevated BP.

Methods

A retrospective cohort study including patients with hypertension, identified from a random sample of 5025 Swedish adults. Two measures of adherence were estimated by the proportion of days covered method (PDC≥80%): (1) Adherence to any antihypertensive medication and, (2) adherence to the full AHT regimen. Multiple logistic regressions were performed to investigate the association between sociodemographic factors (age, sex, education, income), clinical factors (user profile, number of antihypertensive medications, healthcare use, cardiovascular comorbidities) and non-adherence. Moreover, the association between non-adherence (long-term and a month prior to BP measurement) and elevated BP was investigated.

Results

Non-adherence to any antihypertensive medication was higher among persons < 65 years (Odds Ratio, OR 2.75 [95% CI, 1.18–6.43]) and with the lowest income (OR 2.05 [95% CI, 1.01–4.16]). Non-adherence to the full AHT regimen was higher among new users (OR 2.04 [95% CI, 1.32–3.15]), persons using specialized healthcare (OR 1.63, [95% CI, 1.14–2.32]), and having multiple antihypertensive medications (OR 1.85 [95% CI, 1.25–2.75] and OR 5.22 [95% CI, 3.48–7.83], for 2 and ≥3 antihypertensive medications, respectively). Non-adherence to any antihypertensive medication a month prior to healthcare visit was associated with elevated BP.

Conclusion

Sociodemographic factors were associated with non-adherence to any antihypertensive medication while clinical factors with non-adherence to the full AHT regimen. These differing findings support considering the use of multiple antihypertensive medications when measuring refill adherence. Monitoring patients' refill adherence prior to healthcare visit may facilitate interpreting elevated BP.

Patient and carer experience of obtaining regular prescribed medication for chronic disease in the English National Health Service: a qualitative study

BACKGROUND

The increasing burden of chronic disease is recognised globally. Within the English National Health Service, patients with chronic disease comprise of half of all consultations in primary care, and 70% of inpatient bed days. The cost of prescribing long-term medications for those with physical chronic diseases is rising and there is a drive to reduce medicine wastage and costs. While current policies in England are focused on the latter, there has been little previous research on patient experience of ordering and obtaining regular medication for their chronic disease. This paper presents findings from England of a qualitative study and survey of patients and their carers' experiences of community and primary care based services for physical chronic diseases. Although not the primary focus of the study, the results highlighted particular issues around service delivery of repeat prescriptions.

METHODS

We conducted 21 qualitative in-depth interviews with 30 patients and family carers' in two Primary Care Trusts in England. Participants were receiving community based care for diabetes, respiratory, neurological or complex co-morbidities, and ranged in age from 39-92 years old. We used a broadly inductive approach to enable themes around patient experience to emerge from the data.

RESULTS

While the study sought to gain an overview of patient experience, the findings suggested that the processes associated with ordering and obtaining regular medication - the repeat prescription, was most frequently described as a recurring hassle of managing a long-term condition. Issues for patients and carers included multiple journeys to the surgery and pharmacy, lack of synchrony and dissatisfaction with the length of prescriptions.

CONCLUSION

Much literature exists around medication waste and cost, which led to encouragement from the NHS in England to reduce dosage units to a 28-day supply. While there has been an acknowledgement that longer supplies may be suitable for people with stable chronic conditions, it appears that there is limited evidence on the impact of shorter length prescriptions on patient and carer experience, adherence and health outcomes. Recent policy documents within England also fail to address possible links between patient experience, adherence and flaws within repeat prescription service delivery.

Increased primary healthcare utilisation among women with a history of breast cancer

PURPOSE

Little is known about the current role of the general practitioner (GP) in breast cancer follow-up care. This study explores primary healthcare use in the period after completion of primary breast cancer treatment.

METHODS

A total of 336 women with a history of early-stage breast cancer treated with curative intent were identified in the primary care database of the Registration Network Groningen (RNG) (1998-2007) and matched with a reference population of 983 women without breast cancer on birth year and GP.

RESULTS

Over the entire follow-up period (starting 1 year post-diagnosis), the median numbers of face-to-face contacts, drug prescriptions, and referrals in the patient group were significantly higher than those in the reference group: 4.0 vs. 3.2/year, 12.3 vs. 8.4/year, and 0.4 vs. 0.3/year, Mann-Whitney (M-W) test p < 0.001 for all differences. At least one annual face-to-face contact was observed for 96.7 % of patients and 92.9 % of women from the reference population (Chi-square test p = 0.011). More patients than women from the reference population had face-to-face contacts for reasons related to breast cancer or were prescribed hormone antagonists and aromatase inhibitors to treat breast cancer. The main predictor of higher rates of face-to-face contacts and drug prescriptions was a higher age at diagnosis.

CONCLUSIONS

This study shows increased primary healthcare utilisation among women with a history of breast cancer, especially among the elderly. When follow-up is transferred to the primary care setting, new responsibilities of GPs might be incorporated into existing primary healthcare delivery.

The influence of drug use in university hospitals on the pharmaceutical consumption in their surrounding communities

AIM

To investigate the influence of hospital drug choices on pharmaceutical consumption for nine competitive classes in the surrounding community.

METHODS

Ecological study. Data from the national survey on drugs in hospitals were used to extract quantities purchased by 25 French university hospitals for three 'hospital classes' (EPOs, LMWHs and setrons) and six 'ambulatory classes' (PPIs, ACEIs and ARBs, statins, α-adrenoreceptor antagonists (AAAs) and selective serotonin re-uptake inhibitors SSRIs). Re-imbursed quantities for patients living in the hospital's catchment area were extracted from the national health insurance database. The relationship between the use of a brand in hospitals and their catchment areas was assessed using multivariate linear regressions with instrumental variables.

RESULTS

An increase of 1 day of treatment with one brand in the hospital was associated with a significant increase of 2.8 days of treatment with the same brand in the catchment area. However, results strongly varied according to classes. An increase of 1 day of treatment in the hospital was significantly associated with an increase of 0.21 day for 'hospital classes' and 21.8 days for 'ambulatory classes' in the catchment area. Strong variations were seen across 'ambulatory classes'. The effect was maximal for cardiovascular classes and not significant for AAAs and SSRIs. The size of the effect also varied with hospital characteristics: small and proximity university hospitals exerted the greatest influence.

CONCLUSIONS

Hospital consumption influences the use of drugs in the community. A significant effect was found, especially for competitive classes used on a long-term basis. The economic consequences of these findings need to be addressed.

Targeting outpatient drug safety: recommendations of the Dutch HARM-Wrestling Task Force

BACKGROUND

Two Dutch observational studies (HARM [Hospital Admissions Related to Medication] and IPCI [Integrated Primary Care Information]) have shown that approximately 5% of all unplanned hospital admissions are associated with adverse drug events (ADEs), of which 40-46% are potentially preventable. These studies prompted the initiation of a Dutch multidisciplinary task force, which was assigned to reduce the number of prescriber-related hospital admissions related to medications (HARMs) in a quick-win way.

OBJECTIVE

The aim of the study was to identify the most relevant ADEs and to develop a limited number of recommendations for concrete interventions, which should be feasible and relatively easy to convert into computerized drug safety alerts.

METHOD

To identify the major ADEs, crude data of HARM and IPCI were reanalysed and compared with different international studies, followed by structured literature searches for further characterization of the identified ADEs, their risk factors and potential risk-reduction strategies. Based on this information, the Task Force drew up general and drug-specific recommendations. As the recommendations of the Task Force are a mixture of evidence- and expert-based risk-reducing strategies, they have been graded in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology.

RESULTS

Seven pharmacologically predictable ADEs associated with ten drug classes were responsible for more than half of all potentially preventable hospital admissions in the IPCI and HARM studies, which was comparable to the results of international studies. Gastrointestinal and other bleedings were the most frequent ADE, followed by disturbances of diabetes mellitus control, electrolyte disturbances, fractures, renal insufficiency and heart failure. Nine general and 34 drug-specific recommendations were developed.

CONCLUSIONS

As HARMs constitute a significant public health problem, the Task Force underlines the need to implement its recommendations as soon as possible. They do not replace existing guidelines, but reinforce, complement and fine-tune existing Dutch and international guidelines. Further research is still required to assess the cost consequences and cost effectiveness of some recommendations, and to monitor the implementation of the recommendations and their effect on the incidence of potentially preventable HARMs.

Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study

OBJECTIVE

To describe, explore, and compare organisational routines for repeat prescribing in general practice to identify contributors and barriers to safety and quality.

DESIGN

Ethnographic case study.

SETTING

Four urban UK general practices with diverse organisational characteristics using electronic patient records that supported semi-automation of repeat prescribing.

PARTICIPANTS

395 hours of ethnographic observation of staff (25 doctors, 16 nurses, 4 healthcare assistants, 6 managers, and 56 reception or administrative staff), and 28 documents and other artefacts relating to repeat prescribing locally and nationally.

MAIN OUTCOME MEASURES

Potential threats to patient safety and characteristics of good practice.

METHODS

Observation of how doctors, receptionists, and other administrative staff contributed to, and collaborated on, the repeat prescribing routine. Analysis included mapping prescribing routines, building a rich description of organisational practices, and drawing these together through narrative synthesis. This was informed by a sociological model of how organisational routines shape and are shaped by information and communications technologies. Results Repeat prescribing was a complex, technology-supported social practice requiring collaboration between clinical and administrative staff, with important implications for patient safety. More than half of requests for repeat prescriptions were classed as "exceptions" by receptionists (most commonly because the drug, dose, or timing differed from what was on the electronic repeat list). They managed these exceptions by making situated judgments that enabled them (sometimes but not always) to bridge the gap between the idealised assumptions about tasks, roles, and interactions that were built into the electronic patient record and formal protocols, and the actual repeat prescribing routine as it played out in practice. This work was creative and demanded both explicit and tacit knowledge. Clinicians were often unaware of this input and it did not feature in policy documents or previous research. Yet it was sometimes critical to getting the job done and contributed in subtle ways to safeguarding patients. Conclusion Receptionists and administrative staff make important "hidden" contributions to quality and safety in repeat prescribing in general practice, regarding themselves accountable to patients for these contributions. Studying technology-supported work routines that seem mundane, standardised, and automated, but which in reality require a high degree of local tailoring and judgment from frontline staff, opens up a new agenda for the study of patient safety.

[Incidence rate of adverse drug effects in a hospital emergency unit and its associated factors]

INTRODUCTION

Adverse drug effects (ADEs) are the reason for 0.86% to 38.2% of hospital emergency admissions, and a large percentage of them are avoidable. Rational prescription and pharmacotherapy monitoring decrease the appearance of such health problems.

METHOD

Study performed in a tertiary hospital emergency unit with patients selected using a two-phase random sample. The information was obtained from a validated questionnaire and from the clinical history. The data were grouped according to the following cause-effect schema: 1-Potential risk factors for an ADE. 2-Effects likely to be caused by drugs. 3-Consequences of ADEs. 4-Potential confounding factors. The information obtained was evaluated by four independent evaluators using the Dader method.

RESULTS

840 patients were included in the study, and 33% of them came to the emergency unit due to an ADE. ADEs were more frequently observed in female patients, those with higher drug consumption, older patients, those with an underlying illness and in those from underprivileged backgrounds. The factors determining risk of an ADE are the quantity of drugs consumed, sex and the health practices index.

DISCUSSION

One third of hospital emergency admissions were due to ADEs, and these were associated with the same factors found in other studies (number of drugs consumed, female sex, age and social background). In addition, we observed that ADEs are predominant in patients with low values on the health practices index, and in those with underlying illnesses.

Computerised prescribing: assessing the impact on prescription repeats and on generic substitution of some commonly used antibiotics

OBJECTIVES

To assess the impact of two interventions on computer-generated prescriptions for antibiotics--(i) an educational intervention to reduce automatic computerised ordering of repeat antibiotic prescriptions, and (ii) a legislative change prohibiting the "no brand substitution" box being checked as a default setting in prescribing software--and to compare these findings with those of a similar survey we conducted in 2000.

DESIGN AND SETTING

Prospective audit of consecutive prescriptions for four antibiotics (amoxycillin, amoxycillin/clavulanate, roxithromycin, and cefaclor) commonly prescribed for upper respiratory tract infections in community pharmacies in New South Wales and Queensland between 1 November 2008 and 31 January 2009.

MAIN OUTCOME MEASURES

PRIMARY OUTCOME

rate of repeat prescription ordering on computer-generated versus handwritten prescriptions. Secondary outcome: rate of checking of the "no brand substitution" box on computer-generated versus handwritten prescriptions.

RESULTS

Data were collected on 2807 prescriptions presented to 51 pharmacies (50 in NSW, one in Queensland), of which 2354 were computer-generated. Repeats were ordered on 1633 computer-generated prescriptions (69%) compared with 183 handwritten prescriptions (40%). These proportions were identical to those found in 2000, although the rates of computer prescribing were much higher in this study (84% v 54%). This difference in repeat prescribing was statistically significant (odds ratio adjusted for clustering at pharmacy level, 2.87; 95% CI, 2.32-3.55). Twenty-three (1%) of the computer-generated prescriptions had the "no brand substitution" box checked compared with 3 (0.7%) of the handwritten prescriptions (27% and 1%, respectively, in our previous survey).

CONCLUSIONS

The legislative change which disallowed having the "no brand substitution" box checked as a default setting in prescribing software had a dramatic impact on the checking of the "no brand substitution" box. In contrast, there was no sustained effect of educating prescribers about software default settings relating to repeat prescribing of antibiotics. Other actions are required if unnecessary repeat prescriptions for some medicines, such as antibiotics, are to be reduced.

An intervention to develop repeat prescribing in community pharmacy

BACKGROUND

Lack of review of patients' medications in repeat prescribing is common. This and other problems in repeat prescribing need to be addressed. Community pharmacists could be more proactive in the review of chronic medications.

OBJECTIVE

The purpose of this study was to test the feasibility and effects of pharmacists' interventions in repeat prescribing.

METHODS

The normal repeat prescribing process used at Kuopio University Pharmacy and in Kuopio Health Services was developed by an intervention which included a pharmacist's interview and the annual medication data of the patient that were both transferred to the prescribing physician.

RESULTS

Physicians in the intervention group identified and solved patients' drug-related problems better than was the case in the comparison group with normal repeat prescribing. Over half the patients receiving repeat prescriptions had at least one drug-related problem. The physicians used more information sources to support repeat prescribing in the intervention system.

CONCLUSIONS

Community pharmacists are able to improve the quality of physician's repeat prescribing by providing vital information.

Comparison of two methods for performing treatment reviews by pharmacists and general practitioners for home-dwelling elderly people

RATIONALE, AIMS AND OBJECTIVES

There is room for improvement in pharmacotherapy for elderly outpatients. Studies have shown that collaborating health care professionals [e.g. pharmacists in cooperation with general practitioners (GPs)] are able to resolve prescription-related pharmaceutical care issues by means of treatment reviews. The aim of the study was to describe the feasibility of two methods for treatment review (results were given to the GP either in case conferences or in written feedback), and to determine if and how the process of treatment review can be improved.

SETTING

Local pharmacists and GPs cooperated in performing treatment reviews for outpatients aged 75 years or more who were using five or more medicines chronically.

METHOD

Written questionnaires, structured telephone interviews and analysis of various features of the treatment reviews that were recorded during the intervention study were used.

RESULTS

The pharmacists in the case conference group made more recommendations to the GPs (non-significant). Significantly more recommendations were identified by the pharmacists themselves in the case conference group. Health care professionals accepted an intervention with personal contact in case conferences better than an intervention with feedback in writing. They were more positive about the process of treatment review presented personally, although there were not always as many medication changes as they had hoped for. They also had concrete suggestions for improving the intervention, such as using a combination of written feedback and case conferences, and reserving the case conferences for the most complex cases.

CONCLUSIONS

Treatment reviews for the elderly in normal primary care are feasible. Health care professionals agree that the process for treatment review can be improved.

A composite screening tool for medication reviews of outpatients: general issues with specific examples

Regular performance of medication reviews is prominent among methods that have been advocated to reduce the extent and seriousness of drug-related problems, such as adverse drug reactions, drug-disease interactions, drug-drug interactions, drug ineffectiveness and cost ineffectiveness. Several screening tools have been developed to guide practising healthcare professionals and researchers in reviewing the medication patterns of elderly patients; however, each of these tools has its own limitations. This review discusses a wide range of general prescription-, treatment- and patient-related issues that should be taken into account when reviewing medication patterns by implicit screening. These include generic and therapeutic substitution; potentially superfluous or inappropriate medications; potentially inappropriate dosages or duration of treatment; drug-disease and drug-drug interactions; under-treatment; making use of laboratory test results; patient adherence, experiences and habits; appropriate dosage forms and packaging. A broad selection of specific examples and references that can be used as a basis for explicit screening of medication patterns in outpatients is also offered.

Frequency, nature and determinants of pharmaceutical consultations provided in private by Dutch community pharmacists

OBJECTIVE

According to a report published by the federation of Dutch patients' associations, patients would like to see a pharmacist, who acts more as a personal adviser. This raised the question, how often Dutch community pharmacists have personal consultations with their patients in daily practice, on which factors this depends, and what kind of topics are discussed during these meetings.

SETTING

Community pharmacies in the Netherlands.

METHOD

A questionnaire was distributed among 800 randomly selected pharmacies. Questions were restricted to consultations characterized by one-to-one contact, drug therapy related content, and adequate privacy. These consultations were labelled as pharmaceutical consultations in private to distinguish them from other contacts between pharmacists and patients.

MAIN OUTCOME MEASURE

Number, content, and character of consultations.

RESULTS

198 (24.8%) community pharmacies responded. The pharmacists provide an average of roughly 1.2 consultations in private per working day. The vast majority of respondents provided face-to-face and telephone consultations (94.4 and 91.9%, respectively), only a minority gave consultations by e-mail (30.8%). These consultations primarily dealt with topics related to medication safety. The mean overall time spent was 290 min per month. A relatively high frequency of personal consultations was significantly associated with the absolute number of full-time equivalent pharmacists in the pharmacy.

CONCLUSION

The frequency of pharmaceutical consultations in private is low, but may be improved by reorganisation of the pharmacist's activities. The possibility of personal consultations by e-mail is not yet well-developed. Further research is needed to assess the patient's view of pharmaceutical consultations in private.

Clinical medication review by a pharmacist of elderly people living in care homes--randomised controlled trial

OBJECTIVE

to measure the impact of pharmacist-conducted clinical medication review with elderly care home residents.

DESIGN

randomised controlled trial of clinical medication review by a pharmacist against usual care.

SETTING

sixty-five care homes for the elderly in Leeds, UK.

PARTICIPANTS

a total of 661 residents aged 65+ years on one or more medicines.

INTERVENTION

clinical medication review by a pharmacist with patient and clinical records. Recommendations to general practitioner for approval and implementation. Control patients received usual general practitioner care.

MAIN OUTCOME MEASURES

primary: number of changes in medication per participant. Secondary: number and cost of repeat medicines per participant; medication review rate; mortality, falls, hospital admissions, general practitioner consultations, Barthel index, Standardised Mini-Mental State Examination (SMMSE).

RESULTS

the pharmacist reviewed 315/331 (95.2%) patients in 6 months. A total of 62/330 (18.8%) control patients were reviewed by their general practitioner. The mean number of drug changes per patient were 3.1 for intervention and 2.4 for control group (P < 0.0001). There were respectively 0.8 and 1.3 falls per patient (P < 0.0001). There was no significant difference for GP consultations per patient (means 2.9 and 2.8 in 6 months, P = 0.5), hospitalisations (means 0.2 and 0.3, P = 0.11), deaths (51/331 and 48/330, P = 0.81), Barthel score (9.8 and 9.3, P = 0.06), SMMSE score (13.9 and 13.8, P = 0.62), number and cost of drugs per patient (6.7 and 6.9, P = 0.5) (pounds sterling 42.24 and pounds sterling 42.94 per 28 days). A total of 75.6% (565/747) of pharmacist recommendations were accepted by the general practitioner; and 76.6% (433/565) of accepted recommendations were implemented.

CONCLUSIONS

general practitioners do not review most care home patients' medication. A clinical pharmacist can review them and make recommendations that are usually accepted. This leads to substantial change in patients' medication regimens without change in drug costs. There is a reduction in the number of falls. There is no significant change in consultations, hospitalisation, mortality, SMMSE or Barthel scores.

Fatal long-term immunosuppressive therapy with uncontrolled repeat prescription

A case of nephrotic syndrome treated with associated cyclophosphamide and corticosteroids came to our attention after over 2 years of self-administered immunosuppressive therapy which remained unchanged and uncontrolled during this period. The self-administered therapy resulted in a severe cell-mediated immunodeficiency (as expressed by a nadir CD4 lymphocyte count of 2 cells/muL). This led to a rapid unfavorable progression of hepatitis B, which was recently acquired and subsequently evolved into a severe cholestatic and fibrosing chronic hepatitis, causing multiple end-organ failure, and ultimately, death. This process was not reversed by lamivudine therapy, hemodialysis, and the use of a Molecular Adsorbent Recirculating System. The role played by repeated drug prescriptions from general practitioners without appropriate clinical and laboratory controls, and that of our patient's depression are discussed. Current literature related to the presented case and the ongoing debate regarding repeated prescriptions are considered in this study.

Linking community pharmacy dispensing data to prescribing data of general practitioners

BACKGROUND

Databases are frequently used for pharmacoepidemiological research. However, most of these databases consist either of prescribing, dispensing or administrative data and therefore lack insight in the interaction between the several health professionals around the patient.

METHODS

To determine the success rate of linking records from the dispensing database of the Foundation for Pharmaceutical Statistics to the prescribing database of the second Dutch national survey of general practice, conducted by NIVEL (Netherlands Institute for Health Services Research), a deterministic record linkage approach was used with patient and prescription characteristics as matching variables between the two databases.

RESULTS

The catchment area included 123 community pharmacies, 90 GP practices and approximately 170,000 unique patients. Overall 110,102 (64.8%) unique patients were linked using the matching variables patient's gender, year of birth, the 4-digit part of the postal code, date of dispensing/prescribing and ATC-code. The final database contains of the 110,102 both prescribing data from 83 GP practices and dispensing data of 112 community pharmacies.

CONCLUSION

This study shows that linkage of dispensing to prescribing data is feasible with a combination of patient characteristics, such as gender, year of birth and postal code, and prescription characteristics like prescription date and ATC-code. We obtained a linkage proportion of 64.8% resulting in complete prescribing and dispensing history of 110,102 patients. This offers an opportunity to gain insight in the mechanisms and factors influencing drug utilisation in general practice.

Pharmaceutical care in community pharmacy: practice and research in the Netherlands

OBJECTIVE

To describe the pharmaceutical care activities and research in community pharmacy in the Netherlands.

FINDINGS

Pharmaceutical care is well advanced in Dutch pharmacy practice. This is largely due to the fact that clinical pharmacy was already an integrated part of community pharmacy practice by the end of the 1980s. Activities of the International Pharmaceutical Federation (FIP), some wholesale companies, and influential individuals in the Netherlands stimulated universities and the Royal Society for the Advancement of Pharmacy to advance the implementation of pharmaceutical care.

DISCUSSION

Not all pharmacies in the Netherlands provide pharmaceutical care at the same level, although medication surveillance (concurrent and prospective medication analysis) is part of everyday practice. Implementation of quality assurance systems in community pharmacy practice could be helpful in assuring high levels of care. Similar to those in other countries, Dutch pharmacists are torn between the wish to provide pharmaceutical care and economic considerations, although the financial status of most pharmacies is still (very) healthy. New entrants into the market, such as supermarket and pharmacy chains, seem to put little emphasis on care provision.

CONCLUSIONS

Pharmaceutical care has been implemented in many Dutch community pharmacies, but not everywhere to the same extent. Due to excellent automated medication surveillance; structured, high-quality medication counseling; and the fact that patients usually visit the same pharmacy, Dutch patients are well protected against many drug-related problems.