Inappropriate prescribing in patients with kidney disease: A rapid review of prevalence, associated clinical outcomes and impact of interventions

BACKGROUND

The prevalence of patients with chronic kidney disease (CKD) and polypharmacy is increasing and has amplified the importance of examining inappropriate prescribing (IP) in CKD. This review focuses on the latest research regarding the prevalence of IP in CKD and the related adverse clinical effects and explores new interventions against IP.

METHOD

A literature search was performed using PubMed, EMBASE and the Cochrane Library searching articles published between June 2016 and March 2022.

RESULTS

Twenty-seven studies were included. An IP prevalence of 12.6% to 96% and 0.3% to 66% was reported in hospital and outpatient settings, respectively. In nonhospital settings, the prevalence of IP varied between 3.9% and 60%. IP was associated with higher risk of hospitalisation (HR 1.46, 95% CI 1.17-1.81), higher bleeding rate (HR 2.34, 95% CI 1.32 to 3.37) and higher risk of all-cause mortality (OR 1.07, 95% CI 1.02 to 1.13). Three studies reported the impact of interventions on IP.

CONCLUSION

This review highlights widespread IP in CKD patients across healthcare settings, with varying prevalence rates. IP is substantially linked to adverse outcomes in patients. While limited interventions show promise, urgent research is needed to develop effective strategies addressing IP and improving CKD patient care.

What Are the Drug-Related Problems Still Faced by Patients in Daily Life?-A Qualitative Analysis at the Pharmacy Counter

BACKGROUND

Drug-related problems (DRPs) affect many patients. Many activities in general practice, hospitals, and community pharmacies have been initiated to tackle DRPs. However, recent studies exploring what DRP patients are still facing in their daily lives are scarce.

METHODS

Danish pharmacy staff registered DRPs in prescription encounters to understand what DRPs patients are still experiencing in daily life. They noted short descriptions of what happened in the encounter that qualified the incident as a DRP. The descriptions were subjected to an inductive content analysis.

RESULTS

A wide range of DRPs that impacted patients' daily lives practically and healthwise were identified. In total, eighteen percent of patients with prescriptions had a DRP. Three overall stages of DRPs were identified: challenges in receiving the medications, not knowing how or why to take the medications, and not experiencing satisfactory effects. Patients were emotionally affected by these problems.

CONCLUSIONS

DRPs are still widespread in patients' daily lives and influence their well-being. The identified DRPs illustrated the complexity of obtaining medications to work as intended and demonstrate that health professionals must take even the basics of medication intake much more seriously.

The Danish Network for Community Pharmacy Practice Research and Development

The community pharmacy has a number of attributes that makes it an excellent setting for research and development projects, as it is a highly accessible part of the healthcare system and is staffed by highly trained health care professionals. The big turnover in patients in the community pharmacy makes it possible to reach a great number of patients and collect a lot of data in a relatively short time. However, conducting nation-wide research and development projects can be a rather time-consuming process for the individual community pharmacy, and can thus require collaboration with other community pharmacies and researchers. This will help ensure strong results and better implementation. Thus, the Danish Network for Community Pharmacy Practice for Research and Development (NUAP) was established in Denmark by a number of highly committed community pharmacies and researchers. NUAP consists of 102 member pharmacy owners in addition to a number of researchers. The aim of the network is to strengthen pharmacy practice and pharmacy practice research in Denmark by providing a forum where community pharmacy practitioners and researchers meet and work together. The network is led by a steering committee elected by the members in the network.

Integration of and visions for community pharmacy in primary health care in Denmark

In 2014, the Danish government launched a plan for health entitled: "Healthier lives for everyone - national goals for the health of Danes within the next 10 years". The overall objective is to prolong healthy years of life and to reduce inequality in health. In Denmark, the responsibility for health and social care is shared between the central government, the regions and the municipalities. National and local strategies seek to enhance public health through national and local initiatives initiated by different stakeholders. The Danish community pharmacies also contribute to promoting public health through distribution of and counselling on medication in the entire country and through offering several pharmacy services, six of which are fully or partly remunerated on a national level. Because of greater demands from patients, health care professionals and society and a lack of general practitioners, the Danish community pharmacies now have the opportunity to suggest several new functions and services or to extend existing services. The Danish pharmacy law changed in 2015 with the objective to maintain and develop community pharmacies and to achieve increased patient accessibility. The change in the law made it possible for every community pharmacy owner to open a maximum of seven pharmacy branches (apart from the main pharmacy) in a range of 75 km. This change also increased the competition between community pharmacies and consequently the pharmacies are now under financial pressure. On the other hand, each pharmacy may have been given an incentive to develop their specific pharmacy and become the best pharmacy for the patients. Community pharmacies are working to be seen as partners in the health care system. This role is in Denmark increasingly being supported by the government through the remunerated pharmacy services and through contract with municipalities. Concurrent with the extended tasks for the Danish community pharmacies and utilisation of their excellent competencies in medication the community pharmacies need to focus on their main tasks of supplying medicines and implementing services. This requires efficient management, an increased use of technology for distribution and communication and continuing education and training.

Effect of a medicines management model on medication-related readmissions in older patients admitted to a medical acute admission unit-A randomized controlled trial

RATIONALE, AIMS, AND OBJECTIVES

Medication-related problems are frequent and can lead to serious adverse events resulting in increased morbidity, mortality, and costs. Medication use in frail older patients is even more complex. The aim of this study was to investigate the effect of a pharmacist-led medicines management model among older patients at admission, during inpatient stay and at discharge on medication-related readmissions.

METHOD

A randomized controlled trial conducted at the acute admission unit in a Danish hospital with acutely admitted medical patients, randomized to either a control group or one of two intervention groups. The intervention consisted of pharmacist-led medication review and patient interview upon admission (intervention ED) or pharmacist-led medication review and patient interview upon admission, medication review during inpatient stay, and medication report and patient counselling at discharge (intervention STAY).

RESULTS

In total, 600 patients were included. The pharmacist identified 920 medication-related problems with 57% of the recommendations accepted by the physician. After 30 days, 25 patients had a medication-related readmission, with no statistical significant difference between the groups on either primary or secondary outcomes.

CONCLUSIONS

This study showed that a clinical pharmacist can be used to identify and solve medication-related problems, but this study did not find any effect on the selected outcomes. The frequency of medication-related readmissions was low, leaving little room for improvement. Future research should consider other study designs or outcome measures.

Improving Medication Adherence in Patients with Hypertension: A Randomized Trial

BACKGROUND AND PURPOSE

In patients with hypertension, medication adherence is often suboptimal, thereby increasing the risk of ischemic heart disease and stroke. In a randomized trial, we investigated the effectiveness of a multifaceted pharmacist intervention in a hospital setting to improve medication adherence in hypertensive patients. Motivational interviewing was a key element of the intervention.

METHODS

Patients (n = 532) were recruited from 3 hospital outpatient clinics and randomized to usual care or a 6-month pharmacist intervention comprising collaborative care, medication review, and tailored adherence counseling including motivational interviewing and telephone follow-ups. The primary outcome was composite medication possession ratio (MPR) to antihypertensive and lipid-lowering agents, at 1-year follow-up, assessed by analyzing pharmacy records. Secondary outcomes at 12 months included persistence to medications, blood pressure, hospital admission, and a combined clinical endpoint of cardiovascular death, stroke, or acute myocardial infarction.

RESULTS

At 12 months, 20.3% of the patients in the intervention group (n = 231) were nonadherent (MPR <0.80), compared with 30.2% in the control group (n = 285) (risk difference -9.8; 95% confidence interval [CI], -17.3, -2.4) and median MPR (interquartile range) was 0.93 (0.82-0.99) and 0.91 (0.76-0.98), respectively, P = .02. The combined clinical endpoint was reached by 1.3% in the intervention group and 3.1% in the control group (relative risk 0.41; 95% CI, 0.11-1.50). No significant differences were found for persistence, blood pressure, or hospital admission.

CONCLUSIONS

A multifaceted pharmacist intervention in a hospital setting led to a sustained improvement in medication adherence for patients with hypertension. The intervention had no significant impact on blood pressure and secondary clinical outcomes.

Multifaceted intervention including motivational interviewing to support medication adherence after stroke/transient ischemic attack: a randomized trial

Background and Purpose

Adherence to medication is often suboptimal after stroke and transient ischemic attack (TIA), which increases the risk of recurrent stroke and death. Complex interventions and motivational interviewing (MI) have been proven effective in other areas of medicine. The objective of this study was to investigate the effectiveness of a multifaceted intervention including MI in improving medication adherence for secondary stroke prevention.

Methods

In this randomized controlled trial, TIA and stroke patients receiving a pharmacist intervention in a hospital setting were compared with patients receiving usual care. The intervention consisted of a focused medication review, an MI-approached consultation and 3 follow-up telephone calls and lasted for 6 months. The primary outcome was a composite medication possession ratio (MPR) for antiplatelets, anticoagulants and statins in the year after hospitalization, assessed by analyzing pharmacy records and reported as both a continuous rate and a binary outcome. Secondary outcomes included composite MPRs at 3, 6 and 9 months as well as adherence and persistence to specific thrombopreventive medications at 12 months. Clinical outcomes included a combined end point of cardiovascular death, stroke or acute myocardial infarction. Patient satisfaction with the service was assessed for the intervention patients.

Results

The analyses included 102 intervention patients and 101 controls. At 12 months, the median MPRs (IQR) were 0.95 (0.77-1) in the intervention group and 0.91 (0.83-0.99) in the control group, and 28 and 21% of the patients, respectively, were nonadherent (MPR <0.80; risk difference: 7%; 95% CI: −5 to 19%). In both groups, the median MPR decreased over time. From 3 to 12 months, the MPR fell by 5% (p < 0.05) in the intervention group and by 9% (p < 0.05) in the control group, but between the groups, comparisons showed no statistically significant difference. No significant differences were found for adherence and persistence to specific thrombopreventive agents or for the clinical outcome. The intervention patients were satisfied with the service; about half of them reported increased knowledge about medication, and one third reported increased confidence with medication use. Pharmacists identified drug-related problems in one third of the patients.

Conclusions

A multifaceted pharmacist intervention including MI did not improve adherence or persistence to secondary stroke prevention therapy and had no impact on clinical outcomes. However, due to the high adherence rates, only little room for improvement existed. Future studies should focus on patients at high risk of nonadherence and include outcomes more sensitive to the impact of behavioral interventions.

[Activation of psoriasis in patients undergoing treatment with interferon-beta]

Psoriasis is a chronic, inflammatory skin disorder that is induced and aggravated by a number of endogenous and exogenous factors. Traditionally lithium, beta blockers, NSAIDs, ACE inhibitors and antimalarials have been associated with psoriasis, but interferon can also be a triggering factor. We present two patients with multiple sclerosis who suffered from activation of psoriasis in relation to interferon-beta treatment. In one of the patients, psoriasiform injection site lesions persisted six years after termination of the interferon treatment.