International Journal of Clinical Pharmacy最新文献

Introduction: Pharmacist prescribing is expanding across care settings, supported by pharmacists' expertise in pharmacology, therapeutics, disease management, and medication optimization. In settings where pharmacists can prescribe, patients and providers report positive outcomes. However, limited research has examined pharmacist prescribing in dialysis centers.

Aim: This study explored patient and clinician perspectives on potential pharmacist prescribing in the outpatient hemodialysis unit at Toronto General Hospital, University Health Network (TGH-UHN) in Toronto, Canada.

Method: Semi-structured, one-on-one interviews were conducted with English-speaking adults receiving hemodialysis, and clinicians, including nephrologists, pharmacists, dietitians, and nurse practitioners in the outpatient hemodialysis unit at TGH-UHN. Patient interviews focused on experiences receiving and filling prescriptions, interactions with pharmacists in the hemodialysis unit, and views on potential pharmacist prescribing in the unit. Clinician interviews explored the strengths and limitations of the current prescribing process in the hemodialysis unit, pharmacists' role in the unit, perceived benefits and challenges of potential pharmacist prescribing, and strategies for implementation. Participants were recruited through convenience sampling until data saturation was reached. Interviews were audio-recorded, transcribed, and analyzed thematically using an inductive approach.

Results: Eleven patients and 11 clinicians (six nephrologists, two pharmacists, two dietitians, and one nurse practitioner) were interviewed in June and July 2025. Reported challenges of the current prescribing process included communication gaps and delays in care, while accessibility of prescribers and interdisciplinary collaboration were identified as strengths. Pharmacists were recognized as valuable care team members for their expertise in medication management and rapport with patients. Anticipated benefits of pharmacist prescribing included improved medication optimization, workflow efficiency, timely care, and pharmaco-economic savings. Limited prescribing knowledge among some pharmacists was noted as a barrier. Implementation considerations included a collaborative approach, maintaining physician oversight, restricting prescribing to specific clinical areas, phased rollout, patient and clinician buy-in, adequate resources, and clearly defined roles and communication.

Conclusion: Patients and clinicians were generally supportive of potential pharmacist prescribing in the hemodialysis unit, contingent on several considerations for implementation. Interviews with additional stakeholders in other dialysis care settings could further inform strategies for broader adoption.

Introduction: The integration of learning from continuing professional development (CPD) activities into practice is shaped by behavioral, organizational, and broader system-level factors. However, there is scarce research utilizing theory to provide a comprehensive understanding of prevalent behavioral determinants.

Aim: To investigate key behavioral determinants that influence CPD participants' implementation of learning into their practice following participation in CPD activities.

Method: Eleven semi-structured interviews were conducted with healthcare professionals 4-6 weeks after they participated in a live, interactive CPD workshop. Interview questions were guided by the COM-B model to elucidate behavioral determinants; emerging themes were subsequently mapped to the COM-B domains. Recommended interventions were derived to optimize CPD outcomes using the Behavior Change Wheel (BCW).

Results: All participants (n = 11) reported applying their CPD learning in practice, either partially or fully). Analysis revealed that while Capability, Opportunity, and Motivation were all perceived to influence implementation, Motivation was an important driver, with professional responsibility and satisfaction from positive patient outcomes were also perceived to influence behavior. Opportunity was particularly challenging in community pharmacy settings due to time constraints, workload, and organizational factors. These findings informed targeted recommendations to optimize CPD implementation.

Conclusion: This study highlights the complex interplay of behavioral determinants that are perceived to influence the translation of CPD learning into routine clinical practice. Effective CPD programs should incorporate strategies to address setting-specific barriers-such as time constraints, emotional pressures, and organizational support to foster motivation and facilitate sustained practice change. Tailoring CPD design to these behavioral determinants can improve the integration of learning into practice and ultimately enhance patient care.

Introduction: Venous thromboembolism (VTE) is the leading cause of preventable hospital deaths. Adults hospitalised with psychiatric illness vary in their risk of VTE, and therefore in their likelihood of benefiting from thromboprophylaxis. There is a paucity of evidence-based practice guidelines addressing VTE prophylaxis for this population despite recognition of additional VTE risk factors in this population.

Aim: To develop an evidence-based guideline on VTE prophylaxis for patients hospitalised with psychiatric illness using Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

Method: An international, multidisciplinary, guideline panel including clinical experts, methodologists, and a patient partner was recruited by invitation. Panelists were selected based on methodological and clinical expertise on this subject. Panel members were diverse in geography (from Ireland, the United Kingdom, France, and Canada), expertise and gender. The panel was composed of four advanced specialist psychiatric pharmacists, four consultant haematologists, four consultant psychiatrists, one advanced nurse practitioner in psychiatry, one advanced nurse practitioner in anticoagulation, a methodologist with expertise using GRADE, and a patient partner with lived experience of VTE. The panel prioritised two clinical questions and related population, interventions, outcomes, and secondary analyses according to their importance for patients. GRADE was used to assess certainty of evidence and to move from evidence to risk-stratified recommendations.

Results: The panel made three recommendations: a strong recommendation against parenteral pharmacological prophylaxis for patients at low risk of VTE (moderate-certainty evidence); a conditional recommendation in favour of parenteral pharmacological prophylaxis in high-risk patients (low-certainty evidence); and a strong recommendation against graduated compression stockings in patients at high risk of VTE with a contraindication to parenteral pharmacological prophylaxis (low-certainty evidence).

Conclusion: Clinicians should not use parenteral pharmacological prophylaxis in adults hospitalised with psychiatric illness at low risk of VTE; and should consider using parenteral pharmacological prophylaxis for high-risk adults with no contraindications. Graduated compression stockings are not recommended in high-risk patients when parenteral pharmacological prophylaxis is contraindicated. These GRADE- based recommendations offer one of the first evidence-based practice guidelines for thromboprophylaxis decisions in psychiatric in-patient settings.

Introduction: Drug recalls occur regularly with some resulting in medication switches for patients. Limited research into this topic suggests that drug recalls can lead to anxiety and unrest for patients which in turn can affect confidence in and use of medication. In this context, a better understanding of patient perceptions and communication preferences is essential to adequately handle drug recalls and ensure continued medication adherence and trust.

Aim: The aim of this study was to elucidate patients' experiences, perceptions, and preferences regarding drug recalls.

Method: This qualitative study comprised focus group discussions with patients that experienced a drug recall, recruited through pharmacies from distinct locations in the Netherlands. We aimed to conduct at least two focus groups, each comprising a minimum of six participants. Audio recordings were transcribed verbatim and analyzed using a thematic analysis approach.

Results: It was found that patients had limited knowledge of drug recall procedures, often confused them with shortages, and struggled to interpret associated risks. Communication was frequently perceived as unclear, triggering varied emotional responses and, in some cases, reduced trust in and use of medications. Patients preferred pharmacist-led, personalized communication tailored to recall urgency, and emphasized the importance of shared decision-making, particularly during medication substitutions.

Conclusion: Drug recalls cause a range of emotions in patients, leading to reduced confidence and use of medication in some patients. Preferences centered on understandable, transparent, and personalized communication led by pharmacists. The findings of this study emphasize the importance of embedding patient engagement and tailored communication within pharmacovigilance systems to maintain trust and support shared decision-making during drug recalls.

Introduction: Warfarin initiation strategies vary, with some clinicians using either a fixed-dose or loading-dose regimen to achieve therapeutic anticoagulation. However, evidence comparing their effectiveness in multiethnic Asian populations without genotype-guided dosing remains limited.

Aim: To compare a fixed-dose regimen with a 3-day loading-dose regimen in terms of international normalized ratio (INR) stability and time in the therapeutic range (TTR) over 12 months in a multiethnic atrial fibrillation (AF) cohort. We also aimed to evaluate the relationship between the time to initial INR stabilization and the subsequent anticoagulation quality.

Method: This multicenter, retrospective cohort study included 780 warfarin-naïve patients with AF from two tertiary hospitals (2010 to 2022). Patients were grouped by the initiation strategy: fixed-dose (n = 501) or 3-day loading-dose (n = 279). The primary outcome was the TTR at 3, 6, and 12 months. The association between time to INR stabilization and TTR was assessed using Spearman's correlation, and a General Linear Model (GLM) was used to adjust for comprehensive demographic and clinical confounders.

Results: The time to initial INR stabilization showed a strong inverse correlation with TTR across all time points (Spearman's r = -0.600 to -0.710; p < 0.001). Although the unadjusted analysis suggested that the INR stabilized faster in the loading-dose group (mean: 111.8 vs. 138.6 days; p < 0.001), this difference became insignificant after accounting for confounding factors (adjusted mean: 94.1 vs 104.1 days; p = 0.248). Similarly, adjusted means of TTRs did not differ significantly between regimens at 3, 6, or 12 months.

Conclusion: The choice between fixed-dose and loading-dose warfarin initiation strategies does not independently influence long-term anticoagulation control. Instead, time to initial INR stabilization is the strongest predictor of TTR quality over 12 months. Clinical efforts should prioritize early and intensive INR monitoring in settings without genotype-guided dosing, as both baseline characteristics and the ongoing clinical management likely determine anticoagulation outcomes.

Introduction: Medication reconciliation (MR) in the emergency department (ED) is essential to ensure medication safety, especially for patients admitted to the hospital. However, performing MR for all ED patients, including those discharged, can be inefficient. To optimize prioritization, an artificial intelligence (AI)-powered hospital admission prediction dashboard was introduced.

Aim: The primary aim of this study was to evaluate the effect of an artificial intelligence (AI) powered hospital admission prediction dashboard on the proportion of patients admitted to the hospital with an MR performed in the ED. The secondary aim was to assess its effect on the proportion of patients discharged from the ED with an MR.

Method: This retrospective before-after study was conducted at Hospital Group Twente and included ED visits between March 15 and December 31 in both 2023 and 2024. In the pre-intervention period, MR was strived for any patient, including patients discharged directly from the ED (i.e. potentially unnecessary MR as the risk for errors is low) and for admitted patients (i.e. correct MR). In 2024, the post-intervention period, a set of Extreme Gradient Boosting (XGBoost) models was trained on historical data (2015-2022) and integrated into a real-time dashboard to prioritize patients with the highest admission probability to perform MR. Primary outcome was the proportion of patients with correct MR. Secondary outcome was the proportion of patients with a potentially unnecessary MR. Chi-square test was used to compare proportions before and after implementation of the dashboard.

Results: The study included 25,505 ED visits. Pre-intervention 12,743 ED visits were included with 5,252 MRs performed. Post-intervention 12,762 ED visits were included with 4,882 MRs. After implementing the dashboard, the proportion of patients with correct MR increased from 86.4 to 89.0% (p = 0.0002), and the proportion of patients with potentially unnecessary MR decreased from 17.9 to 12.6% (p < 0.0001).

Conclusion: The AI-powered hospital admission prediction dashboard improved the prioritization of MR in the ED. The proportion of patients with potentially unnecessary MR remains substantial and requires further improvement.

Introduction: Low-molecular-weight heparin (LMWH) is widely used for thromboprophylaxis and treatment in hospitalized patients; however, LMWH-related severe clinical bleeding (LSCB) remains a major concern. Existing risk scales have been developed for oral anticoagulants and have limited applicability to LMWH, leaving clinicians without reliable bedside tool.

Aim: This study aimed to evaluate the discriminatory performance of existing scales for predicting LSCB and develop a tailored nomogram for individualized risk prediction.

Method: Hospitalized medical patients prescribed LMWH between July 2021 and August 2024 at three tertiary hospitals in Hangzhou, China were retrospectively analyzed. Each LSCB case was matched with three non-LSCB controls from the same department and period. The prevalence of LSCBs, bleeding sites, and clinical characteristics are described. Receiver operating characteristic (ROC) curves were used to assess the predictive performance of existing scales. Variables with p < 0.10 in univariate analysis were entered into logistic regression, a backward stepwise elimination (stay p < 0.05) was applied to identify independent predictors and subsequently incorporated into a nomogram. Discrimination, calibration, and external validation were performed.

Results: Among 22,096 patients, 369 (1.67%) developed LSCB, most commonly severe gastrointestinal bleeding (74.3%), with a mean onset of 5.68 days. A total of 1,089 patients with non-LSCB were matched as controls. Existing scales performed limited predictive value (AUC 0.52-0.68). Logistic regression identified 12 independent predictors: hypoproteinemia (albumin < 30 g/L), anemia (Hb < 90 g/L), active gastrointestinal ulcer, thrombocytopenia (platelets < 75 × 10⁹/L), coagulation abnormalities (PT or aPTT > 1.2 × ULN), cefoperazone/latamoxef exposure > 7 days, hypocalcemia ([Ca²⁺] < 2.10 mmol/L), aspirin therapy, dual antiplatelet therapy, renal dysfunction (GFR < 60 mL/min), hepatic impairment (AST or ALT ≥ 3 or TBIL ≥ 2 × ULN), and age > 65 years. Odds ratios ranged from 6.16 (hypoproteinemia) to 1.47 (age > 65 years). A nomogram, named LSCB-Score, incorporating these factors achieved AUC 0.890 in the derivation cohort. Calibration was good (Hosmer-Lemeshow p = 0.312), and predictions closely matched the observations. External validation yielded an AUC of 0.876, confirming robustness.

Conclusion: The existing scales for predicting LSCB lack accuracy in hospitalized patients. This newly developed nomogram (LSCB-Score) provides a practical framework for individualized bleeding risk assessment and facilitates safe management of LMWH in hospitals.

Introduction: Pharmacist roles in primary care are evolving, with increasing involvement in long-term condition management. An example is their crucial role in the management of atrial fibrillation (AF), particularly in prescribing and monitoring oral anticoagulation therapy. However, their experiences and challenges in this area remain underexplored, particularly within the context of general practice.

Aim: This study aimed to explore the experiences, perceptions, and challenges of independent prescribing pharmacists when managing and prescribing for AF within general practice, using the Theoretical Domains Framework (TDF) to guide enquiry and analysis.

Method: We conducted a qualitative study underpinned by the Theoretical Domains Framework (TDF), which informed both the interview guide and the analytic coding framework. Independent prescribing pharmacists working in general practice in England were purposively recruited via professional networks; eligible participants were patient-facing and had experience prescribing for atrial fibrillation. One-to-one, semi-structured interviews were conducted via Microsoft Teams® in August 2024, audio-recorded, transcribed verbatim, and returned to participants for checking. Recruitment proceeded until thematic saturation. Two researchers independently applied the framework method, resolved discrepancies by consensus, and mapped final themes to relevant TDF domains.

Results: Twenty pharmacists took part in the study (9 men, 11 women; age 25-52 years), providing perspectives from a range of experience levels. Four overarching themes emerged: (1) confidence and experience in prescribing, (2) perceived role and responsibilities, (3) barriers to effective prescribing, and (4) strategies for effective prescribing. Pharmacists with extensive AF experience demonstrated higher confidence, whereas less experienced pharmacists relied on guidelines and colleagues. Perceived roles ranged from central to supportive within multidisciplinary teams, with some uncertainty about role boundaries. Key barriers included incomplete access to patient records, limited training, and workload pressures. Strategies to support prescribing included continuous professional development, decision support tools, and peer consultation.

Conclusion: The study emphasises the challenges pharmacists encounter in managing AF, highlighting the need for clearer role definitions, improved access to patient data and ongoing peer support. Addressing the identified barriers through targeted interventions could enhance the effectiveness of pharmacist-led AF management in general practice. Future research should evaluate interventions designed to support pharmacists in this evolving role.

Background: The combined use of antiplatelet medications with direct oral anticoagulants increases patients' risk of hemorrhage. In 2021, a multistate network of Veterans Affairs medical centers in the United States deployed a successful multicomponent stewardship initiative to reduce inappropriate anticoagulant-antiplatelet therapy.

Aim: Identify barriers, facilitators, and potential adaptations of the initiative to guide broader dissemination.

Methods: Clinical pharmacists and pharmacist managers were invited to participate in semi-structured interviews about their experiences with the initiative. Interviews were transcribed. Thematic analysis was informed by the Consolidated Framework for Implementation Research (CFIR).

Results: Fifteen interviews were completed (response rate 68%). The initiative was considered important and worth disseminating, and the addition of a visual alert to flag potential deprescribing candidates on an anticoagulation population management dashboard was considered especially beneficial. Three primary themes were identified using the CFIR. First, pharmacists often encountered barriers to coordination across specialties, with some clinicians unconvinced of the clinical evidence favoring antiplatelet deprescribing; breaking down these clinical silos, through targeted education and identifying meaningful clinician champions, is essential to increasing success of this initiative. Second, pharmacists sought clarification about how their deprescribing efforts, a relatively new activity, would be accounted for in performance evaluations, and how clinics would meet increased staffing needs. Third, adaptability of the initiative to local context was considered valuable.

Conclusion: As part of a multicomponent oral anticoagulant-antiplatelet stewardship initiative, preventing clinical silos, clarifying expectations around performance and staffing, and permitting adaptations to local context are important to maximizing impact.

Introduction: Vancomycin is a widely used antibiotic for the treatment of serious Gram-positive bacterial infections. However, its clinical utility is often limited by the risk of nephrotoxicity, typically reflected by abnormalities in serum creatinine levels, which may indicate the occurrence of acute kidney injury (AKI). Timely identification of patients at increased risk is essential for early intervention and improved clinical outcomes.

Aim: This study aimed to identify clinical risk factors associated with vancomycin-induced abnormalities in serum creatinine levels and to develop predictive models capable of identifying high-risk hospitalized patients during vancomycin therapy.

Method: We conducted a retrospective cohort study including 1,008 hospitalized patients who received vancomycin treatment between January 2018 and June 2022 at the First Affiliated Hospital of Shandong First Medical University. Patients were grouped based on the presence or absence of serum creatinine abnormalities, defined as an increase of ≥ 26.5 μmol/L or ≥ 50% from baseline. Multivariate logistic regression was applied to identify independent risk factors. Five machine learning algorithms-logistic regression, random forest, support vector machine, extreme gradient boosting, and gradient boosting machine (GBM)-were trained and compared. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity.

Results: The incidence of serum creatinine abnormalities was 9.22%. Chronic kidney disease, respiratory failure, pancreatitis, pneumonia, and mechanical ventilation were identified as significant risk factors (all p < 0.05). Among the models tested, the GBM algorithm showed the highest predictive performance with an AUC of 0.783, along with good balance between sensitivity and specificity. The final model was deployed as a freely accessible web-based prediction tool using the R Shiny framework.

Conclusion: Abnormalities in serum creatinine levels during vancomycin therapy remain a clinically significant concern, especially in patients with comorbidities or critical illness. The machine learning-based predictive model developed in this study offers a practical tool for individualized risk assessment, enabling early risk stratification and proactive management. Incorporating such tools into clinical workflows may enhance patient safety and optimize antibiotic use.