Novel opportunities for clinical pharmacy research: development of a machine learning model to identify medication related causes of delirium in different patient groups

The advent of artificial intelligence (AI) technologies has taken the world of science by storm in 2023. The opportunities of this easy to access technology for clinical pharmacy research are yet to be fully understood. The development of a custom-made large language model (LLM) (DELSTAR) trained on a wide range of internationally recognised scientific publication databases, pharmacovigilance sites and international product characteristics to help identify and summarise medication related information on delirium, as a proof-of-concept model, identified new facilitators and barriers for robust clinical pharmacy practice research. This technology holds great promise for the development of much more comprehensive prescribing guidelines, practice support applications for clinical pharmacy, increased patient and prescribing safety and resultant implications for healthcare costs. The challenge will be to ensure its methodologically robust use and the detailed and transparent verification of its information accuracy.

Artificial intelligence in academic writing and clinical pharmacy education: consequences and opportunities

The current academic debate on the use of artificial intelligence (AI) in research and teaching has been ongoing since the launch of ChatGPT in November 2022. It mainly focuses on ethical considerations, academic integrity, authorship and the need for new legal frameworks. Time efficiencies may allow for more critical thinking, while ease of pattern recognition across large amounts of data may promote drug discovery, better clinical decision making and guideline development with resultant consequences for patient safety. AI is also prompting a re-evaluation of the nature of learning and the purpose of education worldwide. It challenges traditional pedagogies, forcing a shift from rote learning to more critical, analytical, and creative thinking skills. Despite this opportunity to re-think education concepts for pharmacy curricula several universities around the world have banned its use. This commentary summarizes the existing debate and identifies the consequences and opportunities for clinical pharmacy research and education.

Development of hospital pharmacy services at transition of care points: a scoping review

BACKGROUND

Several hospital pharmacy services exist, which take place at different interfaces of patient care. Although they are an important tool for improving medication safety, they are not yet sufficiently implemented in hospitals around the world.

OBJECTIVE

This scoping review aims to summarise different hospital pharmacy services at transition of care (TOC) points in order to identify development trends and practice patterns in high-income countries over the past decade.

METHODS

A literature search of four databases (PubMed, PubPharm, Cochrane Library (Ovid) and ScienceDirect) since 2011 was conducted. A detailed search strategy was developed and refined with the help of a research librarian. Title, abstract and full-text selection was carried out by two researchers independently. The study was reported in accordance with the PRISMA-ScR items to ensure quality standard reporting. Only studies originating from developed countries and published in the English language were included. The data obtained were extracted and summarised using a data extraction form developed to meet the research aims of the study.

RESULTS

Of the 5456 search results, 65 studies met the inclusion criteria. These originated from Europe (n=29), North America/Canada (n=28), Australia (n=7) and Asia (n=1). Individual TOC services such as medication reconciliation and medication review on admission and at discharge were the main focus of published literature practice patterns between 2011 and 2016, after which a more holistic TOC service started to emerge that follows patients across all TOC points during their hospital stay. Facilitators and barriers were consistently dependent on resources and infrastructure. Clinical and economic outcomes show a mixed picture.

CONCLUSION

During the past decade pharmaceutical services have developed more holistic TOC services. Large-scale high-quality studies are needed to reliably determine clinical and economic benefit.

Effect of patient education videos on modifying medication-related health behaviours: A systematic review using the behaviour intervention functions

OBJECTIVE

This systematic review appraises, synthesises, and presents the published evidence on the effect of patient education videos in modifying medication-related health behaviours.

METHODS

A systematic literature review was conducted across 12 databases. Title, abstract and full-text screening was done independently using PICOS. Data extraction results were mapped directly to the Behaviour Change Intervention Functions. Results are reported in accordance with PRISMA 2020.

RESULTS

Out of 583 studies 12 articles from 4 countries were included. Interventions focus on improving patient's knowledge. Modelling, Enablement, Persuasion, and Training are used in video education development. PASS analysis showed very few well designed studies that allow the reliable determination of behaviour changes.

CONCLUSIONS

A reliable or sustained effect of patient education videos in modifying medication-related health behaviours could not be reported due to a lack of robust study design. Modelling, Enablement, Persuasion, and Training are all intervention designs used to target behaviour change often resulting either in a narrative (real people acting) or practice (demonstrating) presentation format.

PRACTICE IMPLICATIONS

With the increased use of health education technology, robust, theoretically underpinned studies are urgently needed to evaluate the effectiveness of these interventions in the context of their impact on patient medication-related behaviour change.

“They were waiting for me and welcomed me with great love and escorted me to my room”: a qualitative approach exploring patients’ experiences of cancer healthcare services

Introduction

Cancer is a complex illness whereby patients require access to various healthcare services provided by the multidisciplinary team over a prolonged period of time.

Aim

To explore patients’ experiences of cancer healthcare services whilst undergoing treatment with antineoplastic medicines.

Methods

This qualitative study involved in-depth semi-structured interviews with 16 patients diagnosed with colorectal cancer at the only national oncology centre available in Malta. Interviews allowed a detailed exploration of the patients’ lived experience with antineoplastic treatment on aspects relating to medicine-related beliefs, practice and burden (1). Interviews were held between December 2018 and November 2019, when patients were receiving their fourth or sixth cycle of treatment with XELOX or FOLFOX respectively. They were audio-recorded and transcribed verbatim in the native language, with a sample of 10% checked for transcription accuracy. Data saturation was established using a stopping criterion of three (2). Data were analysed thematically by two independent researchers with disagreements resolved through discussion.

Results

A total of 16 patients with colorectal cancer, aged between 38 and 78 years, were interviewed. Four themes emerged:1) experiences of patients of the cancer services, 2) healthcare professionals’ communication with patients, 3) patient’s perception of the role of the healthcare professional in the management of the illness, and 4) recommendations for the service.

Patients were appreciative of the fast-track route for hospital appointments upon a diagnosis of cancer and the accessibility of a cancer-specific nurse navigator to address their challenges. Problems were mainly encountered in-between cycles while patients were at home, with difficulty in assessing the severity of adverse effects. This led to struggles with decision making and whether to self-refer to the emergency department or alternatively whether to seek verbal advice from the nurse navigator. Despite the generalised information provision during the nurse-led group information session at initiation of treatment, patients recommended an additional follow-up session for reinforcement of knowledge tailored to their own needs. Although most patients preferred to receive parenteral treatment under the surveillance of trained healthcare professionals in a hospital setting, they proposed activities such as individual or group counselling and educational treatment-specific sessions or peer-led discussion during treatment administration. ‘Initially I had no symptoms however these cropped up around 4th cycle. Having meetings with healthcare professionals whilst receiving chemo allows sharing of information about this specific treatment.’[P004] Recommendations made by patients included medicine review taking into account their chronic medicines and provision of knowledge to assess the severity of their adverse effects experienced at home ‘Due to my heart problems, I wonder whether another ‘safe’ medicine may be used…prefer to discuss this with healthcare professional whilst having a review of all my medicines.’[P003]

Conclusion

This study highlighted that timeliness and accessibility of healthcare services are crucial in cancer care and are greatly appreciated by the patients. The limitation of the study was that views were only captured from those participants who consented to be interviewed. The introduction of interventions along the treatment journey to address their current needs was recommended.

References

(1) Brincat A, Bonanno PV, Stewart D, Weidmann AE. Patients’ lived experiences with antineoplastic medicines for the management of malignant solid tumours: A systematic review. Research in Social and Administrative Pharmacy. 2020; 16(4):450-463.

(2) Francis JJ, Johnston M, Robertson C, Glidewell L, Entwistle V, Eccles MP et al. What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol Health. 2010; 25(10):1229–1245.

Self-reported clinical pharmacy service provision in Austria: an analysis of both the community and hospital pharmacy sector-a national study

Background With expansion of more advanced clinical roles for pharmacists we need to be mindful that the extent to which clinical pharmacy services are implemented varies from one country to another. To date no comprehensive assessment of number and types of services provided by either community or hospital pharmacies in Austria exists. Objective To analyse and describe the number and types of clinical pharmacy services provided in both community and hospital pharmacies, as well as the level of clinical pharmacy education of pharmacists across Austria. Setting Austrian community and hospital pharmacies. Method An electronic questionnaire to determine number and types of clinical pharmacy services provided was send to all chief pharmacists at all community (n = 1365) and hospital pharmacies (n = 40) across Austria. Besides current and future services provision, education and training provision were also assessed. Main outcome measure Extent of and attitude towards CPS in Austria. Results Response rates to the surveys were 19.1% (n = 261/1365) in community and 92.5% (n = 37/40) in hospital pharmacies. 59.0% and 89.2% of community and hospital pharmacies, respectively, indicated that the provision of clinical pharmacy services in Austria has increased substantially over the past 10 years. Fifty-one percent of community pharmacies reported to provide a medication review service, while 97.3% of hospitals provide a range of services. Only 18.0% of community pharmacies offer services other than medication review services at dispensing. Binary regressions show that provision of already established medication management is a predictor for the willingness of community pharmacists to extend the range of CPS (p < 0.01), while completed training in the area of clinical pharmacy is not (p > 0.05). More hospital than community pharmacists have postgraduate education in clinical pharmacy (17.4% vs 6.5%). A desire to complete postgraduate education was shown by 28.3% of community and 14.7% of hospital pharmacists. Lack of time, inadequate remuneration, lack of resources and poor relationship between pharmacists and physicians were highlighted as barriers. Conclusion Both community and hospital pharmacists show strong willingness to expand their service provision and will need continued support, such as improved legislative structures, more supportive resources and practice focused training opportunities, to further these services.

Hospital staff views of prescribing and discharge communication before and after electronic prescribing system implementation

Background Electronic prescribing system implementation is recommended to improve patient safety and general practitioner's discharge information communication. There is a paucity of information about hospital staff perspectives before and after system implementation. Objective To explore hospital staff views regarding prescribing and discharge communication systems before and after hospital electronic prescribing and medicines administration (HEPMA) system implementation. Setting A 560 bed United Kingdom district general hospital. Methods Semi-structured face-to-face qualitative interviews with a purposive sample of hospital staff involved in the prescribing and discharge communication process. Interviews transcribed verbatim and coded using the Framework Approach. Behavioural aspects mapped to Theoretical Domains Framework (TDF) to highlight associated behavioural change determinants. Main outcome measure Staff perceptions before and after implementation. Results Nineteen hospital staff (consultant doctors, junior doctors, pharmacists and advanced nurse practitioners) participated before and after implementation. Pre-implementation main themes were inpatient chart and discharge letter design and discharge communication process with issues of illegible and inaccurate information. Improved safety was anticipated after implementation. Post-implementation themes were improved inpatient chart clarity and discharge letter quality. TDF domains relevant to staff behavioural determinants preimplementation were knowledge (task or environment); skills (competence); social/professional roles and identity; beliefs about capabilities; environmental context and resources (including incidents). An additional two were relevant post-implementation: social influences and behavioural regulation (including self-monitoring). Participants described challenges and patient safety concerns pre-implementation which were mostly resolved post-implementation. Conclusion HEPMA implementation produced perceptions of patient safety improvement. TDF use enabled behaviour change analysis due to implementation, for example, staff adoption of behaviours to ensure general practitioners receive good quality discharge information.

Hospital electronic prescribing system implementation impact on discharge information communication and prescribing errors: a before and after study

PURPOSE

The study aimed to test the hypothesis that hospital electronic prescribing and medicine administration system (HEPMA) implementation impacted patient discharge letter quality, nature and frequency of prescribing errors.

METHOD

A quasi experimental before and after retrospective case note review was conducted in one United Kingdom district general hospital. The total sample size was 318 (random samples of 159 before and after implementation), calculated to achieve a 10% error reduction with a power of 80% and p < 0.05. Adult patients discharged after ≥24-h inpatient stay were assessed for discharge information documentation quality using a modified validated discharge document template. Prescribing errors were classified as medicine omissions, commissions, incorrect dose/frequency/duration, drug interactions, therapeutic duplications or missing/inaccurate allergy information. Post-implementation assessments were undertaken 4 months following HEPMA implementation. Error severity was determined by a multidisciplinary panel consensus using the Medications at Transitions and Clinical Handoffs (MATCH) study validated scoring system.

RESULTS

There were no statistically significant differences in patient demographics between the pre- and post-implementation groups. Discharge information documentation quality improved; allergy documentation increased from 11 to 159/159 (p < 0.0001). The number of patients with prescribing errors reduced significantly from 158 to 37/159 (p < 0.001). Prescribing error category incidence identified in pre-implementation patients was reduced (e.g. omission incidence from 66 to 18/159 (p < 0.001)), although a new error type (sociotechnical [errors caused by the system]) was identified post-implementation (n = 8 patients). Post-implementation prescribing errors severity rating identified 8/37 as likely to cause potential patient harm.

CONCLUSION

HEPMA implementation was associated with improved discharge documentation quality, statistically significant prescribing error reduction and prescribing error type alteration. There remains a need to be alert for potential prescribing errors.

A qualitative study of determinants of patient behaviour leading to an infection related hospital admission

Objectives To describe and understand the determinants of patients' behaviours surrounding admission to hospital for an acute infective episode Method Patients admitted to the infection or acute medicine admission units of a major Scottish teaching hospital and commenced on antibiotic therapy after admission were included. Semi-structured face-to-face interviews were conducted using a pre-piloted interview schedule guide that focused on gathering information about patient behaviours and experiences prior to admission to hospital with an acute infection. Interviews were audio-recorded, transcribed verbatim and analysed using the Framework Approach. Emerging themes were matched to the Theoretical Domains Framework of behavioural determinants. Results Twenty-one patients consented to participate and 18 transcripts were suitable for analysis. The most common infections were those of the skin, soft tissue and respiratory tract. From the patients' perspectives, behavioural determinants that appeared to impact their admission to hospital were principally their knowledge, beliefs of consequences, the environmental context and resources (mainly out-of-hours services), social influences and their own emotions. Determinants such as knowledge of the signs and symptoms, beliefs of consequences and environmental context were facilitators of health seeking behaviours. The main barriers were a lack of awareness of consequences of infection potentially leading to delayed admission impacting infection severity, stay in secondary care and resource utilisation. Conclusions This study has shown that any initial patient-centred intervention that is proposed to change patient behaviour needs to be based on behavioural determinants emerging in this research. The intervention may include aspects such as patient education on resources available out-of-hours and ways to access the healthcare system, education on recognising signs of infection leading to prompter treatment and positive reinforcement for patients who present with recurrences of infection.

Hospital discharge information communication and prescribing errors: a narrative literature overview

Objectives

To provide a narrative overview of the literature on discharge information communication and medicines discharge prescribing error rate in the UK and other similar healthcare systems.

Methods

A narrative review of the peer reviewed literature (2000-2014) on communication of discharge information from hospitals to general practitioners. Databases included were MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Applied Social Sciences Index and Abstracts, and International Pharmacy Abstracts database.

Results

The search yielded 673 results with 15 papers satisfying all inclusion criteria. Direct comparison of studies was not feasible due to differences in study populations and outcome measures. No studies reported post Hospital Electronic Prescribing and Medicine Administration (HEPMA) implementation. Studies (n=6) investigating handwritten discharge communication systems demonstrated medicine information inaccuracy ranging from 0.81 errors per patient to 17.5% medicines with errors and 67% letters missing medicines change information; with 77% assessed as legible. Studies (n=4) comparing interim electronic solutions with traditional showed variable results: improved, unchanged or decreased medicine information accuracy. Studies researching solely interim electronic solutions (n=5) with one including prescribing error rate assessment at 8.4% of prescribed items and identification of a new electronic system-related error type.

Conclusion

Implementation of interim electronic discharge solutions resulted in complete legibility but did not eradicate information and prescribing errors. A paucity of information is available about HEPMA implementation impact on discharge information communication and prescribing error rates. There is urgent need for formal evaluation in this area.

Dihydroquercetin: More than just an impurity?

Dihydroquercetin (taxifolin) is a potent flavonoid found in onions, French maritime bark, milk thistle, tamarind seeds and commercially available semi-synthetic monoHER marketed as Venoruton. This review focuses on the therapeutic promise of dihydroquercetin in major disease states such as cancer, cardiovascular disease and liver disease by reviewing the proposed mechanism(s) of action, including the activation of the antioxidant response element (ARE) and detoxifying phase II enzymes, inhibition of cytochrome P(450) and fatty acid synthase in carcinogenesis. TNF-alpha and NF-ĸB dependent transcription in hepatitis C infections, the scavenging effect of myeloperoxidase (MPO) derived reactive nitrogen species and subsequent effects on cholesterol biosynthesis as well as the effects on apob/apoA-I, HMG-CoA reductase and apoptosis are reviewed. The stereochemistry and pro-oxidant effect of dihydroquercetin are also considered. Although the majority of research on dihydroquercetin to date has focused on the identification of molecular targets in vitro, this review will bring together evidence of the potency and mode of action of dihydroquercetin and will propose a role for the therapeutic potential of flavonoid antioxidants.

Over-the-counter orlistat: early experiences, views and attitudes of community pharmacists in Great Britain

OBJECTIVES OF THE STUDY

To describe community pharmacists' early experiences, views and attitudes with over-the-counter orlistat, 9 months post legal re-classification from November 2009 to January 2010.

SETTING

13,200 (81%) randomly selected registered community pharmacies across Great Britain out of a potential 16,200.

METHODS

A cross-sectional postal questionnaire survey of the main pharmacist with greatest responsibility for over-the-counter (OTC) supply.

MAIN OUTCOME MEASURES

Pharmacists' early experiences, views and attitudes of orlistat supply, demographic data of respondents and personal opinions with the supply of orlistat.

RESULTS

Questionnaires were returned by 32.4% (n = 4,026) of pharmacists surveyed. Just over half (51.9%, n = 2,091) reported no sales of orlistat in the previous 4 weeks with only 5.1% (n = 203) reporting frequent (5.1%) or very frequent supply in the same time frame. Two thirds (66.5%, n = 2,676) agreed or strongly agreed that the sale of orlistat was a good opportunity to extend their role as a healthcare professional and 92% (n = 3,712) felt confident in their ability to supply this product. Over half (57.9%, n = 2,334) admitted that customers frequently complained about the cost of the product and 47.8% (n = 1,926) agreed that customers could misuse the product.

CONCLUSION

Despite community pharmacists welcoming orlistat re-classification to increase medicines availability as an opportunity to extend their healthcare professional role there were concerns about poor public uptake, high cost and the potential for misuse. Exploratory studies collecting the views and experiences of the general public about the access and provision of weight management services through community pharmacies are warranted.