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Snijders BMG, Kempen TGH, Aubert CE, Koek HL, Dalleur O, Donzé J, Rodondi N, O'Mahony D, Gillespie U, Knol W. Drug-related readmissions in older hospitalized adults: External validation and updating of OPERAM DRA prediction tool. J Am Geriatr Soc 2023; 71:3848-3856. [PMID: 37615214 DOI: 10.1111/jgs.18575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/28/2023] [Accepted: 08/09/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Drug-related readmissions (DRAs) are defined as rehospitalizations with an adverse drug event as their main or significant contributory cause. DRAs represent a major adverse health burden for older patients. A prediction model which identified older hospitalized patients at high risk of a DRA <1 year was previously developed using the OPERAM trial cohort, a European cluster randomized controlled trial including older hospitalized patients with multimorbidity and polypharmacy. This study has performed external validation and updated the prediction model consequently. METHODS The MedBridge trial cohort (a multicenter cluster randomized crossover trial performed in Sweden) was used as a validation cohort. It consisted of 2516 hospitalized patients aged ≥65 years. Model performance was assessed by: (1) discriminative power, assessed by the C-statistic with a 95% confidence interval (CI); (2) calibration, assessed by visual examination of the calibration plot and use of the Hosmer-Lemeshow goodness-of-fit test; and (3) overall accuracy, assessed by the scaled Brier score. Several updating methods were carried out to improve model performance. RESULTS In total, 2516 older patients were included in the validation cohort, of whom 582 (23.1%) experienced a DRA <1 year. In the validation cohort, the original model showed a good overall accuracy (scaled Brier score 0.03), but discrimination was moderate (C-statistic 0.62 [95% CI 0.59-0.64]), and calibration showed underestimation of risks. In the final updated model, the predictor "cirrhosis with portal hypertension" was removed and "polypharmacy" was added. This improved the model's discriminative capability to a C-statistic of 0.64 (95% CI 0.59-0.70) and enhanced calibration plots. Overall accuracy remained good. CONCLUSIONS The updated OPERAM DRA prediction model may be a useful tool in clinical practice to estimate the risk of DRAs in older hospitalized patients subsequent to discharge. Our efforts lay the groundwork for the future development of models with even better performance.
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Affiliation(s)
- Birgitta M G Snijders
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Thomas G H Kempen
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Carole E Aubert
- Department of General Internal Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Huiberdina L Koek
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Olivia Dalleur
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
- Pharmacy Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Jacques Donzé
- Department of General Internal Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
- Department of Internal Medicine, Neuchatel Hospital Network, Neuchâtel, Switzerland
- Division of internal medicine, Lausanne University Hospital, CHUV, Lausanne, Switzerland
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicolas Rodondi
- Department of General Internal Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Denis O'Mahony
- Department of Medicine (Geriatrics), University College Cork, Cork, Ireland
- Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland
| | - Ulrika Gillespie
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
- Hospital Pharmacy Department, Uppsala University, Uppsala, Sweden
| | - Wilma Knol
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Cam H, Wennlöf B, Gillespie U, Franzon K, Nielsen EI, Ling M, Lindner KJ, Kempen TGH, Kälvemark Sporrong S. The complexities of communication at hospital discharge of older patients: a qualitative study of healthcare professionals' views. BMC Health Serv Res 2023; 23:1211. [PMID: 37932683 PMCID: PMC10626684 DOI: 10.1186/s12913-023-10192-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 10/20/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Hospital discharge of older patients is a high-risk situation in terms of patient safety. Due to the fragmentation of the healthcare system, communication and coordination between stakeholders are required at discharge. The aim of this study was to explore communication in general and medication information transfer in particular at hospital discharge of older patients from the perspective of healthcare professionals (HCPs) across different organisations within the healthcare system. METHODS We conducted a qualitative study using focus group and individual or group interviews with HCPs (physicians, nurses and pharmacists) across different healthcare organisations in Sweden. Data were collected from September to October 2021. A semi-structured interview guide including questions on current medication communication practices, possible improvements and feedback on suggestions for alternative processes was used. The data were analysed thematically, guided by the systematic text condensation method. RESULTS In total, four focus group and three semi-structured interviews were conducted with 23 HCPs. Three main themes were identified: 1) Support systems that help and hinder describes the use of support systems in the discharge process to compensate for the fragmentation of the healthcare system and the impact of these systems on HCPs' communication; 2) Communication between two separate worlds depicts the difficulties in communication experienced by HCPs in different healthcare organisations and how they cope with them; and 3) The large number of medically complex patients disrupts the communication reveals how the highly pressurised healthcare system impacts on HCPs' communication at hospital discharge. CONCLUSIONS Communication at hospital discharge is hindered by the fragmented, highly pressurised healthcare system. HCPs are at risk of moral distress when coping with communication difficulties. Improved communication methods at hospital discharge are needed for the benefit of both patients and HCPs.
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Affiliation(s)
- Henrik Cam
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden.
- Department of Pharmacy, Uppsala University, Uppsala, Sweden.
| | - Björn Wennlöf
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
- Centre for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden
- Närvården Viksäng-Irsta, Region Västmanland, Västerås, Sweden
| | - Ulrika Gillespie
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Kristin Franzon
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | | | - Mia Ling
- Department of Pharmacy, Region Västmanland, Västerås, Sweden
| | | | - Thomas Gerardus Hendrik Kempen
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Sofia Kälvemark Sporrong
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
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Kempen TGH, Hedman AN, Hadziosmanovic N, Lindner K, Melhus H, Nielsen EI, Sulku J, Gillespie U. Risk factors for and preventability of drug‐related hospital revisits in older patients: a post‐hoc analysis of a randomised clinical trial. Br J Clin Pharmacol 2022; 89:1575-1587. [PMID: 36454520 DOI: 10.1111/bcp.15621] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022] Open
Abstract
AIM The aims of this study were (1) to identify older patients' risk factors for drug-related readmissions and (2) to assess the preventability of older patients' drug-related revisits. METHODS Post hoc analysis of a randomized clinical trial with patients aged ≥65 years at eight wards within four hospitals in Sweden. (1) The primary outcome was risk factors for drug-related readmission within 12 months post-discharge. A Cox proportional hazards model was made with sociodemographic and clinical baseline characteristics. (2) Four hundred trial participants were randomly selected and their revisits (admissions and emergency department visits) were assessed to identify potentially preventable drug-related revisits, related diseases and causes. RESULTS (1) Among 2637 patients (median age 81 years), 582 (22%) experienced a drug-related readmission within 12 months. Sixteen risk factors (hazard ratio >1, P < 0.05) related to age, previous hospital visits, medication use, multimorbidity and cardiovascular, liver, lung and peptic ulcer disease were identified. (2) The 400 patients experienced a total of 522 hospital revisits, of which 85 (16%) were potentially preventable drug-related revisits. The two most prevalent related diseases were heart failure (n = 24, 28%) and chronic obstructive pulmonary disease (n = 13, 15%). The two most prevalent causes were inadequate treatment (n = 23, 27%) and insufficient or no follow-up (n = 22, 26%). CONCLUSION (1) Risk factors for drug-related readmissions in older hospitalized patients were age, previous hospital visits, medication use and multiple diseases. (2) Potentially preventable drug-related hospital revisits are common and might be prevented through adequate pharmacotherapy and continuity of care in older patients with cardiovascular or lung disease.
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Affiliation(s)
- Thomas G. H. Kempen
- Department of Pharmacy Uppsala University Uppsala Sweden
- Hospital Pharmacy Department Uppsala University Hospital Uppsala Sweden
| | - Anton N. Hedman
- Hospital Pharmacy Department Uppsala University Hospital Uppsala Sweden
| | | | | | - Håkan Melhus
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | | | | | - Ulrika Gillespie
- Department of Pharmacy Uppsala University Uppsala Sweden
- Hospital Pharmacy Department Uppsala University Hospital Uppsala Sweden
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Kempen TGH, Hedman A, Gillespie U. Drug-related emergency department visits in older patients: an applicability and reliability study of an existing assessment tool. Int J Clin Pharm 2022; 44:1078-1082. [PMID: 35840865 PMCID: PMC9393129 DOI: 10.1007/s11096-022-01456-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/10/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AT-HARM10 is a research tool to identify possible drug-related hospital admissions. It is unclear whether the tool can be applied to emergency department visits as well. AIM The aim of this study was to investigate the applicability and reliability to identify drug-related emergency department visits in older patients with AT-HARM10. METHOD A random sample of 400 patients aged 65 years or older from a clinical trial in four Swedish hospitals was selected. All patients' emergency department visits within 12 months after discharge were assessed with AT-HARM10. The main outcome measures were the percentage of successfully assessed visits for applicability and the interrater reliability (Cohen's kappa). RESULTS Of the initial sample (n = 400), 113 patients [median age (interquartile range): 81 (76-88) years] had at least one emergency department visit within 12 months. The patients had in total 184 visits, of which 179 (97%) were successfully assessed. Fifty-three visits (29%) were possibly drug-related. The Cohen's kappa value was 0.70 (substantial). CONCLUSION It seems applicable and reliable to identify possible drug-related emergency department visits in addition to hospital admissions in older patients with AT-HARM10. As a consequence, the tool has been updated to support its novel use in clinical research.
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Affiliation(s)
- Thomas Gerardus Hendrik Kempen
- Department of Pharmacy, Uppsala University, Uppsala, Sweden. .,Primary Care and Health, Uppsala County Council, Uppsala, Sweden. .,Nivel, Netherlands Institute for Health Services Research, Utrecht, the Netherlands.
| | - Anton Hedman
- grid.412354.50000 0001 2351 3333Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
| | - Ulrika Gillespie
- grid.8993.b0000 0004 1936 9457Department of Pharmacy, Uppsala University, Uppsala, Sweden ,grid.412354.50000 0001 2351 3333Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
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Cam H, Kempen TGH, Eriksson H, Abdulreda K, Franzon K, Gillespie U. Assessment of requests for medication-related follow-up after hospital discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective chart review. BMC Geriatr 2021; 21:618. [PMID: 34724895 PMCID: PMC8561898 DOI: 10.1186/s12877-021-02564-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The discharge of older hospitalised patients is critical in terms of patient safety. Inadequate transfer of information about medications to the next healthcare provider is a known problem, but there is a lack of understanding of this problem in settings where shared electronic health records are used. The aims of this study were to evaluate the prevalence of patients for whom hospitals sent adequate requests for medication-related follow-up at discharge, the proportion of patients with unplanned hospital revisits because of inadequate follow-up requests, and the association between medication reviews performed during hospitalisation and adequate or inadequate follow-up requests. METHODS We conducted a retrospective chart review. The study population was randomly selected from a cluster-randomised crossover trial which included patients 65 years or older who had been admitted to three hospitals in Sweden with shared electronic health records between hospital and primary care. Each patient was assessed with respect to the adequacy of the request for follow-up. For patients where the hospitals sent inadequate requests, data about any unplanned hospital revisits were collected, and we assessed whether the inadequate requests had contributed to the revisits. The association between medication reviews and adequate or inadequate requests was analysed with a Chi-square test. RESULTS A total of 699 patients were included. The patients' mean age was 80 years; an average of 10 medications each were prescribed on hospital admission. The hospitals sent an adequate request for 418 (60%) patients. Thirty-eight patients (14%) had a hospital revisit within six months of discharge which was related to an inadequate request. The proportion of adequate or inadequate requests did not differ between patients who had received a medication review during hospitalisation and those who had not (p = 0.83). CONCLUSIONS The prevalence of patients for whom the hospitals sent adequate follow-up requests on discharge was low. More than one in every ten who had an inadequate request revisited hospital within six months of discharge for reasons related to the request. Medication reviews conducted during hospitalisation did not affect the proportion of adequate or inadequate requests sent. A communication gap still exists despite the usage of a shared electronic health record between primary and secondary care levels.
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Affiliation(s)
- Henrik Cam
- Hospital Pharmacy Department, Uppsala University Hospital, SE-751 85, Uppsala, Sweden. .,Department of Pharmacy, Uppsala University, Uppsala, Sweden.
| | - Thomas Gerardus Hendrik Kempen
- Department of Pharmacy, Uppsala University, Uppsala, Sweden.,Academic Primary Health Care Centre, Region Uppsala, Uppsala, Sweden
| | | | | | - Kristin Franzon
- Geriatric Department, Uppsala University Hospital, Uppsala, Sweden.,Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Ulrika Gillespie
- Hospital Pharmacy Department, Uppsala University Hospital, SE-751 85, Uppsala, Sweden.,Department of Pharmacy, Uppsala University, Uppsala, Sweden
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Kempen TGH, Bertilsson M, Hadziosmanovic N, Lindner KJ, Melhus H, Nielsen EI, Sulku J, Gillespie U. Effects of Hospital-Based Comprehensive Medication Reviews Including Postdischarge Follow-up on Older Patients' Use of Health Care: A Cluster Randomized Clinical Trial. JAMA Netw Open 2021; 4:e216303. [PMID: 33929523 PMCID: PMC8087955 DOI: 10.1001/jamanetworkopen.2021.6303] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/23/2021] [Indexed: 12/27/2022] Open
Abstract
Importance Suboptimal use of medications is a leading cause of health care-related harm. Medication reviews improve medication use, but evidence of the possible benefit of inpatient medication review for hard clinical outcomes after discharge is scarce. Objective To study the effects of hospital-based comprehensive medication reviews (CMRs), including postdischarge follow-up of older patients' use of health care resources, compared with only hospital-based reviews and usual care. Design, Setting, and Participants The Medication Reviews Bridging Healthcare trial is a cluster randomized crossover trial that was conducted in 8 wards with multiprofessional teams at 4 hospitals in Sweden from February 6, 2017, to October 19, 2018, with 12 months of follow-up completed December 6, 2019. The study was prespecified in the trial protocol. Outcome assessors were blinded to treatment allocation. In total, 2644 patients aged 65 years or older who had been admitted to 1 of the study wards for at least 1 day were included. Data from the modified intention-to-treat population were analyzed from December 10, 2019, to September 9, 2020. Interventions Each ward participated in the trial for 6 consecutive 8-week periods. The wards were randomized to provide 1 of 3 treatments during each period: CMR, CMR plus postdischarge follow-up, and usual care without a clinical pharmacist. Main Outcomes and Measures The primary outcome measure was the incidence of unplanned hospital visits (admissions plus emergency department visits) within 12 months. Secondary outcomes included medication-related admissions, visits with primary care clinicians, time to first unplanned hospital visit, mortality, and costs of hospital-based care. Results Of the 2644 participants, 7 withdrew after inclusion, leaving 2637 for analysis (1357 female [51.5%]; median age, 81 [interquartile range, 74-87] years; median number of medications, 9 [interquartile range, 5-13]). In the modified intention-to-treat analysis, 922 patients received CMR, 823 received CMR plus postdischarge follow-up, and 892 received usual care. The crude incidence rate of unplanned hospital visits was 1.77 per patient-year in the total study population. The primary outcome did not differ between the intervention groups and usual care (adjusted rate ratio, 1.04 [95% CI, 0.89-1.22] for CMR and 1.15 [95% CI, 0.98-1.34] for CMR plus postdischarge follow-up). However, CMR plus postdischarge follow-up was associated with an increased incidence of emergency department visits within 12 months (adjusted rate ratio, 1.29; 95% CI, 1.05-1.59) compared with usual care. There were no differences between treatment groups regarding other secondary outcomes. Conclusions and Relevance In this study of older hospitalized patients, CMR plus postdischarge follow-up did not decrease the incidence of unplanned hospital visits. The findings do not support the performance of hospital-based CMRs as conducted in this trial. Alternative forms of medication reviews that aim to improve older patients' health outcomes should be considered and subjected to randomized clinical trials. Trial Registration ClinicalTrials.gov Identifier: NCT02986425.
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Affiliation(s)
- Thomas G. H. Kempen
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | | | | | - Håkan Melhus
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Johanna Sulku
- Pharmacy Department, Region Gävleborg, Gävle, Sweden
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Ulrika Gillespie
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
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Kempen TGH, Kälvemark A, Sawires M, Stewart D, Gillespie U. Facilitators and barriers for performing comprehensive medication reviews and follow-up by multiprofessional teams in older hospitalised patients. Eur J Clin Pharmacol 2020; 76:775-784. [PMID: 32076745 PMCID: PMC7239809 DOI: 10.1007/s00228-020-02846-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 02/07/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE There is a lack of knowledge about factors that influence the performance of comprehensive medication reviews (CMRs) by multiprofessional teams in hospital practice. This study aimed to explore the facilitators and barriers for performing CMRs and post-discharge follow-up in older hospitalised patients from the healthcare professional perspective. METHODS Physicians and ward-based pharmacists were recruited from an ongoing trial at four hospitals in Sweden. Semi-structured interviews were conducted with 16 physicians and 7 pharmacists. Interview topics were working processes, resources, competences, medication-related problems, intervention effects and collaboration. The interviews were audio-recorded, transcribed verbatim and thematically analysed using the Consolidated Framework for Implementation Research (CFIR). Identified subthemes were categorised as facilitators or barriers and grouped into overarching main themes. RESULTS In total, 21 facilitators and 25 barriers were identified across all CFIR domains and grouped in 6 main themes: (a) CMRs and follow-up are needed, but not in all patients; (b) there is a general belief in positive effects; (c) lack of resources is an issue, although the performance of CMRs may save time; (d) pharmacists' knowledge and skills are valuable, but they need more clinical competence; (e) compatibility with hospital practice is challenging, and roles and responsibilities are unclear and (f) personal contact at the ward is essential for physician-pharmacist collaboration. CONCLUSION Multiple facilitators and barriers for performing CMRs and post-discharge follow-up in older hospitalised patients exist. These factors should be addressed in future initiatives with similar interventions by multiprofessional teams to ensure successful implementation and performance in hospital practice.
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Affiliation(s)
- Thomas Gerardus Hendrik Kempen
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden.
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
| | - Amanda Kälvemark
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
| | - Maria Sawires
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Derek Stewart
- College of Pharmacy, Qatar University Health, Qatar University, Doha, Qatar
| | - Ulrika Gillespie
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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Kempen TGH, Cam H, Kälvemark A, Lindner KJ, Melhus H, Nielsen EI, Sulku J, Gillespie U. Intervention fidelity and process outcomes of medication reviews including post-discharge follow-up in older hospitalized patients: Process evaluation of the MedBridge trial. J Clin Pharm Ther 2020; 45:1021-1029. [PMID: 32171028 DOI: 10.1111/jcpt.13128] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/13/2020] [Indexed: 12/14/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Drug-related problems (DRPs) are a growing healthcare burden worldwide. In an ongoing cluster-randomized controlled trial in Sweden (MedBridge), comprehensive medication reviews (CMRs) including post-discharge follow-up have been conducted in older hospitalized patients to prevent and solve DRPs. As part of a process evaluation of the MedBridge trial, this study aimed to assess the intervention fidelity and process outcomes of the trial's interventions. METHODS For intervention delivery, the percentage of patients that received intervention components was calculated per study group. Process outcomes, measured in about one-third of all intervention patients, included the following: the number of identified medication discrepancies, DRPs and recommendations to solve DRPs, correction rate of discrepancies, and implementation rate of recommendations. RESULTS AND DISCUSSION The MedBridge trial included 2637 patients (mean age: 81 years). The percentage of intervention patients (n = 1745) that received the intended intervention components was 94%-98% during admission, and 40%-81% upon and after discharge. The percentage of control patients (n = 892) that received at least one unintended intervention component was 15%. On average, 1.1 discrepancies and 2.0 DRPs were identified in 652 intervention patients. The correction and implementation rates were 79% and 73%, respectively. Stop medication was the most frequently implemented recommendation (n = 293) and 77% of the patients had at least one corrected discrepancy or implemented recommendation. WHAT IS NEW AND CONCLUSION The intervention fidelity within the MedBridge trial was high for CMRs during hospital stay and lower for intervention components upon and after discharge. The high prevalence of corrected discrepancies and implemented recommendations may explain potential effects of CMRs in the MedBridge trial.
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Affiliation(s)
- Thomas G H Kempen
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden.,Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Henrik Cam
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Amanda Kälvemark
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
| | | | - Håkan Melhus
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Elisabet I Nielsen
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Johanna Sulku
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden.,Pharmacy Department, Region Gävleborg, Gävle, Sweden
| | - Ulrika Gillespie
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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Kempen TGH, Kälvemark A, Gillespie U, Stewart D. Comprehensive medication reviews by ward-based pharmacists in Swedish hospitals: What does the patient have to say? J Eval Clin Pract 2020; 26:149-157. [PMID: 30834647 DOI: 10.1111/jep.13121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/07/2019] [Accepted: 02/09/2019] [Indexed: 12/26/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Inappropriate medication prescribing and use amongst older patients is a major patient safety and health care problem. To promote appropriate medication prescribing and use, comprehensive medication reviews (CMRs) by ward-based pharmacists, including follow-up telephone calls after hospital discharge, have been conducted in older patients in the context of a randomized controlled trial (RCT). One of the key actors in a CMR is the patient. To support the understanding of the effects of CMRs on patients' health outcomes and improve clinical practice, knowledge about the patient perspective is needed. We therefore aimed to explore older patients' experiences with, and views on, hospital-initiated CMRs and follow-up telephone calls by ward-based clinical pharmacists within an RCT. METHODS We conducted in-depth semi-structured interviews with 15 patients (66-94 years) and carers from four hospitals in Sweden. Discussion topics included communication, information, decision-making, and effects on the patient. Interviews took place after discharge, were audio-recorded, transcribed verbatim, and thematically analysed using a framework approach. RESULTS In general, patients' experiences and views were positive. Seven key themes were identified: (a) feeling of being taken care of and heterogenous health effects; (b) the pharmacist is competent; (c) despite the unclear role of pharmacists, their involvement is appreciated; (d) patients rely on health care professionals for decision-making; (e) importance of being informed, but receiving and retaining information is problematic; (f) time, location, and other factors influencing the effectiveness of CMRs; and (g) generic substitution is a problem. CONCLUSIONS Older patients generally have positive experiences with and views on CMRs and follow-up telephone calls. However, some factors, like the unclear role of the ward-based pharmacist and problems with receiving and retaining information, may negatively impact the effectiveness of these interventions. Future initiatives on hospital-initiated CMRs by clinical pharmacists should address these negative factors and utilize the positive views.
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Affiliation(s)
- Thomas G H Kempen
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
| | - Amanda Kälvemark
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Ulrika Gillespie
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Derek Stewart
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK.,College of Pharmacy, Qatar University, Doha, Qatar
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Kempen TG, Gillespie U, Färdborg M, McIntosh J, Mair A, Stewart D. A case study of the implementation and sustainability of medication reviews in older patients by clinical pharmacists. Res Social Adm Pharm 2019; 15:1309-1316. [DOI: 10.1016/j.sapharm.2018.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/18/2018] [Accepted: 12/18/2018] [Indexed: 11/30/2022]
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McIntosh J, Alonso A, MacLure K, Stewart D, Kempen T, Mair A, Castel-Branco M, Codina C, Fernandez-Llimos F, Fleming G, Gennimata D, Gillespie U, Harrison C, Illario M, Junius-Walker U, Kampolis CF, Kardas P, Lewek P, Malva J, Menditto E, Scullin C, Wiese B. A case study of polypharmacy management in nine European countries: Implications for change management and implementation. PLoS One 2018; 13:e0195232. [PMID: 29668763 PMCID: PMC5905890 DOI: 10.1371/journal.pone.0195232] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 03/08/2018] [Indexed: 12/21/2022] Open
Abstract
Background Multimorbidity and its associated polypharmacy contribute to an increase in adverse drug events, hospitalizations, and healthcare spending. This study aimed to address: what exists regarding polypharmacy management in the European Union (EU); why programs were, or were not, developed; and, how identified initiatives were developed, implemented, and sustained. Methods Change management principles (Kotter) and normalization process theory (NPT) informed data collection and analysis. Nine case studies were conducted in eight EU countries: Germany (Lower Saxony), Greece, Italy (Campania), Poland, Portugal, Spain (Catalonia), Sweden (Uppsala), and the United Kingdom (Northern Ireland and Scotland). The workflow included a review of country/region specific polypharmacy policies, key informant interviews with stakeholders involved in policy development and implementation and, focus groups of clinicians and managers. Data were analyzed using thematic analysis of individual cases and framework analysis across cases. Results Polypharmacy initiatives were identified in five regions (Catalonia, Lower Saxony, Northern Ireland, Scotland, and Uppsala) and included all care settings. There was agreement, even in cases without initiatives, that polypharmacy is a significant issue to address. Common themes regarding the development and implementation of polypharmacy management initiatives were: locally adapted solutions, organizational culture supporting innovation and teamwork, adequate workforce training, multidisciplinary teams, changes in workflow, redefinition of roles and responsibilities of professionals, policies and legislation supporting the initiative, and data management and information and communication systems to assist development and implementation. Depending on the setting, these were considered either facilitators or barriers to implementation. Conclusion Within the studied EU countries, polypharmacy management was not widely addressed. These results highlight the importance of change management and theory-based implementation strategies, and provide examples of polypharmacy management initiatives that can assist managers and policymakers in developing new programs or scaling up existing ones, particularly in places currently lacking such initiatives.
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Affiliation(s)
- Jennifer McIntosh
- Departament de Recerca i Innovació, Fundació Clínic per a la Recerca Biomèdica, Barcelona, Spain
- * E-mail:
| | - Albert Alonso
- Departament de Recerca i Innovació, Fundació Clínic per a la Recerca Biomèdica, Barcelona, Spain
| | - Katie MacLure
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, Scotland
| | - Derek Stewart
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, Scotland
| | - Thomas Kempen
- Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
| | - Alpana Mair
- Effective prescribing and therapeutics, Health and social care directorate, Scottish Government, Edinburgh, Scotland
| | - Margarida Castel-Branco
- Laboratory of Pharmacology and Pharmaceutical Care, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
| | - Carles Codina
- Servei de Farmàcia, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Fernando Fernandez-Llimos
- Institute for Medicines Research, Department of Social Pharmacy, Faculty of Pharmacy, University of Lisbon, Lisboa, Portugal
| | - Glenda Fleming
- Pharmacy Department and Regional Medicines Optimisation Innovation Centre(MOIC) Northern Health and Social Care Trust, Antrim, Northern Ireland
| | - Dimitra Gennimata
- Department of Social and Education Policy, University of Peloponnese, Korinthos, Greece
- eHealth Innovation Unit, 1 Regional Health Authority of Attica, Athens, Greece
| | - Ulrika Gillespie
- Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
| | | | | | | | - Christos F. Kampolis
- Department of Social and Education Policy, University of Peloponnese, Korinthos, Greece
- eHealth Innovation Unit, 1 Regional Health Authority of Attica, Athens, Greece
| | - Przemyslaw Kardas
- Department of Family Medicine, Medical University of Lodz, Lodz, Poland
| | - Pawel Lewek
- Department of Family Medicine, Medical University of Lodz, Lodz, Poland
| | - João Malva
- Institute of Biomedical Imaging and Life Sciences (IBILI) and Institute of Pharmacology and Experimental Therapeutics, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Enrica Menditto
- CIRFF, Center of Pharmacoeconomics, University of Naples Federico II, Naples, Italy
| | - Claire Scullin
- Clinical & Practice Research Group, School of Pharmacy, Queen’s University, Belfast, Northern Ireland
| | - Birgitt Wiese
- Institute of General Practice, Hannover Medical School, Hannover, Germany
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Gillespie U, Eriksson T. Medication reconciliation activities among pharmacists in Europe. Eur J Hosp Pharm 2018; 25:100-102. [DOI: 10.1136/ejhpharm-2016-000901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/24/2016] [Accepted: 06/21/2016] [Indexed: 11/04/2022] Open
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Hedström M, Carlsson M, Ekman A, Gillespie U, Mörk C, Åsberg KH. Development of the PHASE-Proxy scale for rating drug-related signs and symptoms in severe cognitive impairment. Aging Ment Health 2018; 22:53-60. [PMID: 27657536 DOI: 10.1080/13607863.2016.1232364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The need for assessment of possible drug-related signs and symptoms in older people with severe cognitive impairment has increased. In 2009, the PHASE-20 rating scale for identifying symptoms possibly related to medication was the first such scale to be found valid and reliable for use with elderly people. In this project, the aim was to develop and examine the psychometric properties and clinical utility of PHASE-Proxy, a similar scale for proxy use in assessing elderly people with cognitive impairment. METHODS Three expert groups revised PHASE-20 into a preliminary proxy version, which was then tested for inter-rater reliability, internal consistency, and content validity. Its clinical usefulness was investigated by pharmacist-led medication reviews. Group interviews and a study-specific questionnaire with nursing home staff were used to investigate the feasibility of use. RESULTS The PHASE-Proxy scale had satisfactory levels of inter-rater reliability (Spearman's rank correlation coefficient; rs = 0.8), and acceptable internal consistency (Cronbach's alpha coefficient; α = 0.73). The factor analysis resulted in a logical solution with seven factors, grouped into two dimensions: signs of emotional distress and signs of physical discomfort. The medication reviews, interviews, and questionnaires also found the proxy scale to be clinically useful, and feasible to use. CONCLUSION The PHASE-Proxy scale appears to be a valid instrument that enables proxies to reliably assess nursing home residents who cannot participate in the assessment, to identify possible drug-related signs and symptoms. It also appears to be clinically useful and feasible for use in this population.
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Affiliation(s)
- Mariann Hedström
- a Department of Public Health and Caring Sciences, Section of Caring Sciences , Uppsala University , Uppsala , Sweden
| | - Marianne Carlsson
- a Department of Public Health and Caring Sciences, Section of Caring Sciences , Uppsala University , Uppsala , Sweden.,b Department of Health and Caring Sciences, Faculty of Health and Occupational Studies , University of Gävle , Gävle , Sweden
| | - Anna Ekman
- c Department of medication and patient safety , Uppsala University Hospital , Uppsala , Sweden
| | - Ulrika Gillespie
- c Department of medication and patient safety , Uppsala University Hospital , Uppsala , Sweden
| | - Christina Mörk
- d Pharmaceutical Committee , Uppsala County Council , Uppsala , Sweden
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Stewart D, Gibson-Smith K, MacLure K, Mair A, Alonso A, Codina C, Cittadini A, Fernandez-Llimos F, Fleming G, Gennimata D, Gillespie U, Harrison C, Junius-Walker U, Kardas P, Kempen T, Kinnear M, Lewek P, Malva J, McIntosh J, Scullin C, Wiese B. A modified Delphi study to determine the level of consensus across the European Union on the structures, processes and desired outcomes of the management of polypharmacy in older people. PLoS One 2017; 12:e0188348. [PMID: 29155870 PMCID: PMC5695766 DOI: 10.1371/journal.pone.0188348] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 11/06/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Inappropriate use of multiple medicines (inappropriate polypharmacy) is a major challenge in older people with consequences of increased prevalence and severity of adverse drug reactions and interactions, and reduced medicines adherence. The aim of this study was to determine the levels of consensus amongst key stakeholders in the European Union (EU) in relation to aspects of the management of polypharmacy in older people. METHODS Forty-six statements were developed on aspects of healthcare structures, processes and desired outcomes, with consensus defined at ≥ 80% agreement. Panel members were strategists (e.g. directors, leading clinicians and commissioners) from each of the 28 EU member states, with a target recruitment of five per member state. Three Delphi rounds were conducted via email, with panel members being provided with summative results and collated, anonymised comments at the commencement of Rounds 2 and 3. RESULTS Ninety panel members were recruited (64.3% of target), with high participation levels throughout the three Delphi rounds (91.1%, 83.3%, 72.2%). During Round 1, consensus was obtained for 27/46 statements (58.7%), with an additional two statements in Round 2 and none in Round 3. Consensus was obtained for statements relating to: potential gain arising from polypharmacy management (3/4 statements); strategic development (7/7); change management (5/7) indicator measures (4/6); legislation (0/3); awareness raising (5/5); polypharmacy reviews (5/7); and EU vision (0/7). Analysis of free text comments indicated that the vision statements were too ambitious and not achievable by the specified timeframe of 2025. CONCLUSION Consensus was obtained amongst key EU strategists around many aspects of polypharmacy management in older people. Notably, no consensus was achieved in relation to statements relating to the need to alter legislation in areas of healthcare delivery, remuneration and practitioner scope of practice. While the vision for the EU by 2025 was considered rather ambitious, there is great potential and clear opportunity to advance polypharmacy management throughout the EU and beyond.
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Affiliation(s)
- Derek Stewart
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, Scotland, United Kingdom
| | - Kathrine Gibson-Smith
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, Scotland, United Kingdom
| | - Katie MacLure
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, Scotland, United Kingdom
| | - Alpana Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh, Scotland, United Kingdom
| | - Albert Alonso
- Directorate of Research and Innovation, Fundació Clínic per a la Recerca Biomèdica (FCRB), Barcelona, Spain
| | - Carles Codina
- Pharmacy Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Antonio Cittadini
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Fernando Fernandez-Llimos
- Institute for Medicines Research (iMed.Ulisboa), Department of Social Pharmacy, Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal
| | - Glenda Fleming
- Medicines Optimisation Innovation Centre, Northern Health & Social Care Trust, Belfast, Northern Ireland
| | - Dimitra Gennimata
- Department of Social and Educational Policy, University of Peloponnese, Corinthos, Greece
| | - Ulrika Gillespie
- Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
| | - Cathy Harrison
- Department of Health Social Services and Public Safety, Belfast, Northern Ireland
| | - Ulrike Junius-Walker
- Institute for General Medicine, Medizinische Hochschule Hannover, Hannover, Germany
| | - Przemysław Kardas
- Department of Family Medicine, Medical University of Lodz, Lodz, Poland
| | - Thomas Kempen
- Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
| | - Moira Kinnear
- NHS Lothian Pharmacy Service, Western General Hospital, Edinburgh, Scotland, United Kingdom
| | - Pawel Lewek
- Department of Family Medicine, Medical University of Lodz, Lodz, Poland
| | - Joao Malva
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Jennifer McIntosh
- Directorate of Research and Innovation, Fundació Clínic per a la Recerca Biomèdica (FCRB), Barcelona, Spain
| | - Claire Scullin
- School of Pharmacy, Queen’s University, Belfast, Northern Ireland, United Kingdom
| | - Birgitt Wiese
- Institute for General Medicine, Medizinische Hochschule Hannover, Hannover, Germany
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Gillespie U, Dolovich L, Dahrouge S. Activities performed by pharmacists integrated in family health teams: Results from a web-based survey. Can Pharm J (Ott) 2017; 150:407-416. [PMID: 29123600 DOI: 10.1177/1715163517733998] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Family health teams (FHTs), an interprofessional primary care practice model, were established in Ontario in 2005. As of October 2014, 191 FHT organizations were in operation, and 111 (58%) included one or several pharmacists. The objective of this study was to document the focus of pharmacist activities in FHTs. Approach We invited all 155 known FHT pharmacists to a web-based survey. The survey was constructed using information obtained from previously done semi-structured telephone interviews with pharmacists working in FHTs. The survey consisted of a list of activities, grouped into 5 main categories, and participants were asked to estimate time spent on each category. Free-text response questions allowed participants to identify activities not listed. Survey results were analyzed using descriptive statistics and content analysis for open-ended responses. Results Seventy (45%) pharmacists completed the survey. The mean respondent age was 43 years, and the average length of time working in an FHT was 4 years. All pharmacists reported being engaged in some form of direct patient care, including managing single therapeutic issues (96%), conducting general medication reviews (70%) and medication reconciliation after hospitalization (63%). Most reported providing education and drug information (83%). Pharmacists felt their work would increase patient medication adherence (94%) and physician adherence to recommended guidelines (86%), as well as reduce inappropriate prescribing (93%), polypharmacy (90%), emergency room and hospital utilization (70%-81%). Conclusion Pharmacists in FHTs are strongly focused on direct patient care activities, managing specific medication issues and unstructured drug information to physicians. The majority of pharmacists reported that their activities had a substantial impact on patient medication use and health. The findings from this survey can assist pharmacists new to FHT practice, health policy planning and health research to assess associations between pharmacist activities and measures of health and health care system performance.
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Affiliation(s)
- Ulrika Gillespie
- Uppsala University Hospital (Gillespie), Department of Family Medicine, University of Ottawa, Bruyère Research Institute, Ottawa, Ontario
| | - Lisa Dolovich
- Uppsala University Hospital (Gillespie), Department of Family Medicine, University of Ottawa, Bruyère Research Institute, Ottawa, Ontario
| | - Simone Dahrouge
- Uppsala University Hospital (Gillespie), Department of Family Medicine, University of Ottawa, Bruyère Research Institute, Ottawa, Ontario
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Kempen TGH, Bertilsson M, Lindner KJ, Sulku J, Nielsen EI, Högberg A, Vikerfors T, Melhus H, Gillespie U. Medication Reviews Bridging Healthcare (MedBridge): Study protocol for a pragmatic cluster-randomised crossover trial. Contemp Clin Trials 2017; 61:126-132. [PMID: 28739539 DOI: 10.1016/j.cct.2017.07.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 07/18/2017] [Accepted: 07/20/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Mismanaged prescribing and use of medication among elderly puts major pressure on current healthcare systems. Performing a medication review, a structured critical examination of a patient's medications, during hospital stay with active follow-up into primary care could optimise treatment benefit and minimise harm. However, a lack of high quality evidence inhibits widespread implementation. This manuscript describes the rationale and design of a pragmatic cluster-randomised, crossover trial to fulfil this need for evidence. AIM To study the effects of hospital-initiated comprehensive medication reviews, including active follow-up, on elderly patients' healthcare utilisation compared to 1) usual care and 2) solely hospital based reviews. DESIGN Multicentre, three-treatment, replicated, cluster-randomised, crossover trial. SETTING 8 wards with a multidisciplinary team within 4 hospitals in 3 Swedish counties. PARTICIPANTS Patients aged 65years or older, admitted to one of the study wards. EXCLUSION CRITERIA Palliative stage; residing in other than the hospital's county; medication review within the last 30days; one-day admission. INTERVENTIONS 1, comprehensive medication review during hospital stay; 2, same as 1 with the addition of active follow-up into primary care; 3, usual care. PRIMARY OUTCOME MEASURE Incidence of unplanned hospital visits during a 12-month follow-up period. DATA COLLECTION AND ANALYSES Extraction and collection from the counties' medical record system into a GCP compliant electronic data capture system. Intention-to-treat-analyses using hierarchical models. RELEVANCE This study has a high potential to show a reduction in elderly patients' morbidity, contributing to more sustainable healthcare in the long run.
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Affiliation(s)
- Thomas G H Kempen
- Pharmacy Department, Uppsala University Hospital, Ing.13 2 tr, 751 85 Uppsala, Sweden.
| | - Maria Bertilsson
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Johanna Sulku
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden; Department of Development, Region Gävleborg, Gävle, Sweden
| | - Elisabet I Nielsen
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | | | - Tomas Vikerfors
- Department of Infectious Diseases, Västerås Hospital, Västerås, Sweden
| | - Håkan Melhus
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Ulrika Gillespie
- Pharmacy Department, Uppsala University Hospital, Ing.13 2 tr, 751 85 Uppsala, Sweden
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Abstract
AIM The aim of this study was to examine the situation for elderly patients with diabetes living in nursing homes with regard to diabetes treatment, clinical variables, and vascular complications associated with diabetes. A second aim was to evaluate if the patients were at risk of hypoglycaemia. METHODS This was a cross-sectional study including diabetes patients from all 30 nursing homes in Uppsala County, Sweden. Current antidiabetic medications, HbA1c, hypoglycaemic events, and diabetes complications were registered from the medical records. The patients were stratified into a general group and divided into three groups according to HbA1c (<52, 52-73, and >73 mmol/mol). RESULTS Of 1,350 individuals, 218 patients were identified with diabetes mellitus. The diabetes duration was 11.2 ± 9.4 years and their serum HbA1c concentration 56.0 ± 1.2 mmol/mol. Hypoglycaemic events were reported in 24% of the diabetic individuals, and 43.1% of them had HbA1c <52 mmol/mol (mean value 44.0 ± 1.1 mmol/mol). Of these, 36% were taking antidiabetic drugs. Another 35.8% of the patients had HbA1c values between 52-73 mmol/mol (mean value 60.0 ± 1.1 mmol/mol), and 82% of these patients were taking antidiabetic drugs. Almost 80% of the diabetic patients had either micro- or macrovascular complications, with diabetes duration as an association for both micro- or macrovascular complications and hypoglycaemic events. CONCLUSIONS A reduction of the use of antidiabetic drugs with follow-up of HbA1c level should be considered, especially for multimorbid elderly patients with low HbA1c and hypoglycaemia.
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Affiliation(s)
| | - Maja Sehlberg
- Uppsala University, Faculty of Biomedicine, Uppsala, Sweden
| | - Ulrika Gillespie
- Uppsala University Hospital (Akademiska Sjukhuset), Uppsala, Sweden
| | | | - Hans-Erik Johansson
- Östervåla Primary Health Care Centre, Östervåla, Sweden
- Department of Public Health and Caring Sciences/Geriatrics, Uppsala University, Uppsala, Sweden
- CONTACT Hans-Erik Johansson, MD, PhD Department of Public Health and Caring Sciences/Geriatrics, Uppsala University, Uppsala Science Park, 75185 Uppsala, Sweden
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Bjerre LM, Ramsay T, Cahir C, Ryan C, Halil R, Farrell B, Thavorn K, Catley C, Hawken S, Gillespie U, Manuel DG. Assessing potentially inappropriate prescribing (PIP) and predicting patient outcomes in Ontario's older population: a population-based cohort study applying subsets of the STOPP/START and Beers' criteria in large health administrative databases. BMJ Open 2015; 5:e010146. [PMID: 26608642 PMCID: PMC4663446 DOI: 10.1136/bmjopen-2015-010146] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Adverse drug events (ADEs) are common in older people and contribute significantly to emergency department (ED) visits, unplanned hospitalisations, healthcare costs, morbidity and mortality. Many ADEs are avoidable if attention is directed towards identifying and preventing inappropriate drug use and undesirable drug combinations. Tools exist to identify potentially inappropriate prescribing (PIP) in clinical settings, but they are underused. Applying PIP assessment tools to population-wide health administrative data could provide an opportunity to assess the impact of PIP on individual patients as well as on the healthcare system. This would open new possibilities for interventions to monitor and optimise medication management on a broader, population-level scale. METHODS AND ANALYSIS The aim of this study is to describe the occurrence of PIP in Ontario's older population (aged 65 years and older), and to assess the health outcomes and health system costs associated with PIP-more specifically, the association between PIP and the occurrence of ED visits, hospitalisations and death, and their related costs. This will be done within the framework of a population-based retrospective cohort study using Ontario's large health administrative and population databases. Eligible patients aged 66 years and older who were issued at least 1 prescription between 1 April 2003 and 31 March 2014 (approximately 2 million patients) will be included. ETHICS AND DISSEMINATION Ethical approval was obtained from the Ottawa Health Services Network Ethical Review Board and from the Bruyère Research Institute Ethics Review Board. Dissemination will occur via publication, presentation at national and international conferences, and ongoing exchanges with regional, provincial and national stakeholders, including the Ontario Drug Policy Research Network and the Ontario Ministry of Health and Long-Term Care. TRIAL REGISTRATION NUMBER Registered with clinicaltrials.gov (registration number: NCT02555891).
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Affiliation(s)
- Lise M Bjerre
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES@ uOttawa, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Timothy Ramsay
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Catriona Cahir
- Economic and Social Research Institute, Trinity College Dublin, Dublin, Ireland
| | - Cristín Ryan
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Roland Halil
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Barbara Farrell
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Kednapa Thavorn
- ICES@ uOttawa, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Steven Hawken
- ICES@ uOttawa, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Douglas G Manuel
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES@ uOttawa, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Alassaad A, Melhus H, Hammarlund-Udenaes M, Bertilsson M, Gillespie U, Sundström J. A tool for prediction of risk of rehospitalisation and mortality in the hospitalised elderly: secondary analysis of clinical trial data. BMJ Open 2015; 5:e007259. [PMID: 25694461 PMCID: PMC4336459 DOI: 10.1136/bmjopen-2014-007259] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/16/2015] [Accepted: 01/19/2015] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To construct and internally validate a risk score, the '80+ score', for revisits to hospital and mortality for older patients, incorporating aspects of pharmacotherapy. Our secondary aim was to compare the discriminatory ability of the score with that of three validated tools for measuring inappropriate prescribing: Screening Tool of Older Person's Prescriptions (STOPP), Screening Tool to Alert doctors to Right Treatment (START) and Medication Appropriateness Index (MAI). SETTING Two acute internal medicine wards at Uppsala University hospital. Patient data were used from a randomised controlled trial investigating the effects of a comprehensive clinical pharmacist intervention. PARTICIPANTS Data from 368 patients, aged 80 years and older, admitted to one of the study wards. PRIMARY OUTCOME MEASURE Time to rehospitalisation or death during the year after discharge from hospital. Candidate variables were selected among a large number of clinical and drug-specific variables. After a selection process, a score for risk estimation was constructed. The 80+ score was internally validated, and the discriminatory ability of the score and of STOPP, START and MAI was assessed using C-statistics. RESULTS Seven variables were selected. Impaired renal function, pulmonary disease, malignant disease, living in a nursing home, being prescribed an opioid or being prescribed a drug for peptic ulcer or gastroesophageal reflux disease were associated with an increased risk, while being prescribed an antidepressant drug (tricyclic antidepressants not included) was linked to a lower risk of the outcome. These variables made up the components of the 80+ score. The C-statistics were 0.71 (80+), 0.57 (STOPP), 0.54 (START) and 0.63 (MAI). CONCLUSIONS We developed and internally validated a score for prediction of risk of rehospitalisation and mortality in hospitalised older people. The score discriminated risk better than available tools for inappropriate prescribing. Pending external validation, this score can aid in clinical identification of high-risk patients and targeting of interventions.
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Affiliation(s)
- Anna Alassaad
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Uppsala University Hospital, Uppsala, Sweden
| | - Håkan Melhus
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | | | | | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala, Sweden
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Alassaad A, Bertilsson M, Gillespie U, Sundström J, Hammarlund-Udenaes M, Melhus H. The effects of pharmacist intervention on emergency department visits in patients 80 years and older: subgroup analyses by number of prescribed drugs and appropriate prescribing. PLoS One 2014; 9:e111797. [PMID: 25364817 PMCID: PMC4218816 DOI: 10.1371/journal.pone.0111797] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 10/07/2014] [Indexed: 11/19/2022] Open
Abstract
Background Clinical pharmacist interventions have been shown to have positive effect on occurrence of drug-related issues as well as on clinical outcomes. However, evidence about which patients benefiting most from the interventions is limited. We aimed to explore whether pharmacist intervention is equally effective in preventing emergency department (ED) visits in patients with few or many prescribed drugs and in those with different levels of inappropriate prescribing. Methods Patient and outcome data from a randomized controlled trial exploring the clinical effects of a ward-based pharmacist intervention in patients, 80 years and older, were used. The patients were divided into subgroups according to the number of prescribed drugs (<5 or ≥5 drugs) and the level of inappropriate prescribing [using the Screening Tool Of Older People's potentially inappropriate Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START) with a score of ≥2 (STOPP) and ≥1 (START) as cutoff points]. The effect of the intervention on the number of times the different subgroups visited the ED was analyzed. Results The pharmacist intervention was more effective with respect to the number of subsequent ED visits in patients taking <5 drugs on admission than in those taking ≥5 drugs. The rate ratio (RR) for a subsequent ED visit was 0.22 [95% confidence interval (CI) 0.09–0.52] for <5 drugs and 0.70 (95% CI 0.47–1.04) for ≥5 drugs (p = 0.02 for the interaction). The effect of intervention did not differ between patients with high or low STOPP or START scores. Conclusion In this exploratory study, the pharmacist intervention appeared to be more effective in preventing visits to the ED for patients who were taking fewer drugs before the intervention. Our analysis of STOPP and START scores indicated that the level of inappropriate prescribing on admission had no effect on the outcomes of intervention with respect to ED visits.
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Affiliation(s)
- Anna Alassaad
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Uppsala University Hospital, Uppsala, Sweden
- * E-mail:
| | | | | | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - Håkan Melhus
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Gillespie U, Alassaad A, Hammarlund-Udenaes M, Mörlin C, Henrohn D, Bertilsson M, Melhus H. Effects of pharmacists' interventions on appropriateness of prescribing and evaluation of the instruments' (MAI, STOPP and STARTs') ability to predict hospitalization--analyses from a randomized controlled trial. PLoS One 2013; 8:e62401. [PMID: 23690938 PMCID: PMC3656885 DOI: 10.1371/journal.pone.0062401] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 03/21/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Appropriateness of prescribing can be assessed by various measures and screening instruments. The aims of this study were to investigate the effects of pharmacists' interventions on appropriateness of prescribing in elderly patients, and to explore the relationship between these results and hospital care utilization during a 12-month follow-up period. METHODS The study population from a previous randomized controlled study, in which the effects of a comprehensive pharmacist intervention on re-hospitalization was investigated, was used. The criteria from the instruments MAI, STOPP and START were applied retrospectively to the 368 study patients (intervention group (I) n = 182, control group (C) n = 186). The assessments were done on admission and at discharge to detect differences over time and between the groups. Hospital care consumption was recorded and the association between scores for appropriateness, and hospitalization was analysed. RESULTS The number of Potentially Inappropriate Medicines (PIMs) per patient as identified by STOPP was reduced for I but not for C (1.42 to 0.93 vs. 1.46 to 1.66 respectively, p<0.01). The number of Potential Prescription Omissions (PPOs) per patient as identified by START was reduced for I but not for C (0.36 to 0.09 vs. 0.42 to 0.45 respectively, p<0.001). The summated score for MAI was reduced for I but not for C (8.5 to 5.0 and 8.7 to 10.0 respectively, p<0.001). There was a positive association between scores for MAI and STOPP and drug-related readmissions (RR 8-9% and 30-34% respectively). No association was detected between the scores of the tools and total re-visits to hospital. CONCLUSION The interventions significantly improved the appropriateness of prescribing for patients in the intervention group as evaluated by the instruments MAI, STOPP and START. High scores in MAI and STOPP were associated with a higher number of drug-related readmissions.
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Affiliation(s)
- Ulrika Gillespie
- Division of Pharmacokinetics and Drug Therapy, Department of Pharmaceutical Biosciences, Uppsala University and Uppsala University Hospital, Uppsala, Sweden.
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Alassaad A, Gillespie U, Bertilsson M, Melhus H, Hammarlund-Udenaes M. Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: an observational and interventional study. J Eval Clin Pract 2013; 19:185-91. [PMID: 22212455 DOI: 10.1111/j.1365-2753.2011.01798.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Medication errors frequently occur when patients are transferred between health care settings. The main objective of this study was to investigate the frequency, type and severity of prescribing and transcribing errors for drugs dispensed in multidose plastic packs when patients are discharged from the hospital. The secondary objective was to correct identified errors and suggest measures to promote safe prescribing. METHODS The drugs on the patients' multidose drug dispensing (MDD) order sheets and the medication administration records were reconciled prior to the MDD orders being sent to the pharmacy for dispensing. Discrepancies were recorded and the prescribing physician was notified and given the opportunity to change the order. Discrepancies categorized as unintentional and related to the discharge process were subject to further analysis. RESULTS Seventy-two (25%) of the 290 reviewed MDD orders had at least one discharge error. In total, 120 discharge errors were identified, of which 49 (41%) were assessed as being of moderate and three (3%) of major severity. Orders with a higher number of medications and orders from the orthopaedic wards had a significantly higher error rate. CONCLUSION The main purpose of the MDD system is to increase patient safety by reducing medication errors. However, this study shows that prescribing and transcribing errors frequently occur when patients are hospitalized. Because the population enrolled in the MDD system is an elderly, physically vulnerable group with a high number of prescribed drugs, preventive measures to ensure safe prescribing of MDD drugs are warranted.
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Affiliation(s)
- Anna Alassaad
- Apoteket Farmaci AB, Hospital Pharmacy, Uppsala University Hospital, Uppsala, Sweden.
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Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, Kettis-Lindblad A, Melhus H, Mörlin C. A Comprehensive Pharmacist Intervention to Reduce Morbidity in Patients 80 Years or Older. ACTA ACUST UNITED AC 2009; 169:894-900. [PMID: 19433702 DOI: 10.1001/archinternmed.2009.71] [Citation(s) in RCA: 411] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ulrika Gillespie
- Division of Pharmacokinetics and Drug Therapy, Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden.
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