International Journal of Clinical Pharmacy最新文献

Background: The Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy (STOPPFrail) criteria aim to reduce inappropriate/unnecessary medications in frail older adults, which should minimise adverse drug events and additional healthcare expenditure. Little is known about the economic outcomes of applying these criteria as an intervention.

Aim: To evaluate cost avoidance of pharmacist-led application of STOPPFrail to frail older nursing home residents with limited life expectancy.

Method: Pharmacist-identified STOPPFrail-defined potentially inappropriate medications that were deprescribed by patients' general practitioners were assigned a rating by a multidisciplinary panel, i.e. the probability of an adverse drug event occurring if the medication was not deprescribed. The intervention's net cost benefit and cost-benefit ratio were then determined by factoring in adverse drug event cost avoidance (calculated from probability of adverse drug event ratings), direct cost savings (deprescribed medication costs/reimbursement fees), and healthcare professionals' salaries.

Results: Of the 176 potentially inappropriate medications deprescribed across 69 patients, 65 (36.9%) were rated as having a medium or high probability of an adverse drug event occurring if not deprescribed. With €27,162 for direct cost savings, €61,336 for adverse drug event cost avoidance, and €2,589 for healthcare professionals' salary costs, there was a net cost benefit of €85,909 overall. The cost-benefit ratio was 33.2 and remained positive in all scenarios in sensitivity analyses.

Conclusion: Pharmacist-led application of STOPPFrail to frail older nursing home residents is associated with significant cost avoidance. Wider implementation of pharmacist interventions in frail older nursing home residents should be considered to reduce potentially inappropriate medications and patient harm, alongside substantial cost savings for healthcare systems.

Background: Osteoarthritis is a widely prevalent cause of pain and disability among older adults. It is an incurable condition, and most treatments are aimed at alleviating symptoms.

Aim: This study aimed to investigate the impact of statins on osteoarthritis by using a two-sample Mendelian randomization approach, using genetic variants associated with statin use as instrumental variables.

Method: Information on single nucleotide polymorphisms associated with statin medication was obtained from the FinnGen study, and data on osteoarthritis were sourced from the UK Biobank. The inverse variance weighted method was used as the primary analytical approach for the Mendelian randomization analysis. Sensitivity analyses were conducted to evaluate horizontal pleiotropy and heterogeneity. To examine the genetic relationship between statins and osteoarthritis, linkage disequilibrium score regression-based estimates were used.

Results: Mendelian randomization analysis indicated a positive effect of statin use on the treatment of osteoarthritis (odds ratio 0.951, 95% confidence interval 0.914-0.99, p < 0.05). This conclusion was supported by various Mendelian randomization methods. Sensitivity analyses revealed no significant directional pleiotropy or influential single nucleotide polymorphisms that could compromise the overall causal inference. Linkage disequilibrium score regression-based estimates suggested a modest genetic correlation between statin use and osteoarthritis (Rg = 0.098, Se = 0.034, p < 0.05), thus reinforcing the robustness of the Mendelian randomization analysis.

Conclusion: Statins reduce the risk of osteoarthritis, aligning with the results of observational studies. Further research is essential to validate these results and explore the underlying mechanisms in detail.

Background: Standardisation, a widely accepted concept for risk management, entails designing and implementing task-specific operating procedures. In community pharmacies, Standardised Operating Procedures (SOPs) are a mandatory requirement and are recognised as essential for upholding safety and quality.

Aim: This study aimed to investigate community pharmacists' (CPs) compliance with SOPs when checking prescriptions, and the reasons for variations between standardised protocols and practice.

Method: Eight sets of SOPs underwent hierarchical task analysis (HTA) to generate a normative description of clinical checking execution as per protocols. Subsequently, twelve CPs were engaged in a simulated clinical checking exercise, verbalising their thoughts while checking virtual prescriptions. Transcribed data underwent content analysis, aligned with a descriptive model to uncover engagement patterns, and disparities between SOPs and CPs' practices. Finally, a focus group discussion took place to contextualise the observed variations.

Results: HTA aided in constructing a clinical checking model with six primary subtasks and 28 lower subtasks. CPs often omitted subtasks during checks, diverging from prescribed protocols. These deviations, observed in controlled environment, reveal an ingrained aspect within the professional culture of pharmacists, where there may be a tendency not to strictly adhere to protocols, despite variations in work conditions. Contributing factors to this culture include the exercise of professional judgment, reliance on others, and prioritisation of patient preferences.

Conclusion: This study highlights ongoing deviations from SOPs during clinical prescription checks in community pharmacies, suggesting a cultural tendency. Future research should delve into risk management strategies for these deviations and address the delicate balance between flexibility and stringent compliance.

Background: Low medication literacy is prevalent among older adults and is associated with adverse drug events. The Medication Literacy Test for Older Adults (TELUMI) was developed and content validated in a previously published study.

Aim: To evaluate the psychometric properties and provide norms for TELUMI scores.

Method: This was a cross-sectional methodological study with older adults selected from the community and from two outpatient services. Descriptive item-analysis, exploratory factor analysis (EFA), item response theory (IRT), reliability, and validity analysis with schooling and health literacy were performed to test the psychometric properties of the TELUMI. The classification of the TELUMI scores was performed using percentile norms.

Results: A total of 344 participants, with a mean age of 68.7 years (standard deviation = 6.7), were included; most were female (66.6%), black/brown (61.8%), had low schooling level (60.2%) and low income (55.2%). The EFA pointed to the one-dimensional structure of TELUMI. A three-parameter logistic model was adopted for IRT. All items had an adequate difficulty index. One item had discrimination < 0.65, and three items had an unacceptable guessing index (< 0.35) and were excluded. The 29-item version of TELUMI had excellent internal consistency (KR20 = 0.89). There was a positive and strong association between TELUMI scores and health literacy and education level. The scores were classified as inadequate medication literacy (≤ 10.0 points), medium medication literacy (11-20 points), and adequate medication literacy (≥ 21 points).

Conclusion: The results suggest that the 29-item version of TELUMI is psychometrically adequate for measuring medication literacy in older adults.

Background: Sub-optimal medicines use is a challenge globally, contributing to poorer health outcomes, inefficiencies and waste. The Medicines Optimisation Innovation Centre (MOIC) was established in Northern Ireland by the Department of Health (DH) in 2015 to support implementation of the Medicines Optimisation Quality Framework.

Aim: To demonstrate how MOIC informs policy and provides support to commissioners to improve population health and wellbeing.

Setting: MOIC is a regional centre with multidisciplinary and multi-sector clinical expertise across Health and Social Care and patient representation.

Development: Core funded by DH, MOIC has a robust governance structure and oversight programme board. An annual business plan is agreed with DH. Rigorous processes have been developed for project adoption and working collaboratively with industry.

Implementation: MOIC has established partnerships with academia, industry, healthcare and representative organisations across Europe, participating in research and development projects and testing integrated technology solutions. A hosting programme has been established and evaluation and dissemination strategies have been developed.

Evaluation: MOIC has established numerous agreements, partnered in three large EU projects and strengthened networks globally with extensive publications and conference presentations. Informing pathway redesign, sustainability and COVID response, MOIC has also assisted in the development of clinical pharmacy services and antimicrobial stewardship in Europe and Africa. Northern Ireland has been recognised as a 4-star European Active and Healthy Ageing Reference Site and the Integrated Medicines Management model as an example of best practice in Central and Eastern Europe.

Conclusion: MOIC has demonstrated considerable success and sustainability and is applicable to health systems globally.

Background: Comprehensive medication management (CMM) programs optimize the effectiveness and safety of patients' medication regimens, but CMM may be underutilized. Whether healthcare claims data can identify patients appropriate for CMM is not well-studied.

Aim: Determine the face validity of a claims-based algorithm to prioritize patients who likely need CMM.

Method: We used claims data to construct patient-level markers of "regimen complexity" and "high-risk for adverse effects," which were combined to define four categories of claims-based CMM-need (very likely, likely, unlikely, very unlikely) among 180 patient records. Three clinicians independently reviewed each record to assess CMM need. We assessed concordance between the claims-based and clinician-review CMM need by calculating percent agreement as well as kappa statistic.

Results: Most records identified as 'very likely' (90%) by claims-based markers were identified by clinician-reviewers as needing CMM. Few records within the 'very unlikely' group (5%) were identified by clinician-reviewers as needing CMM. Interrater agreement between CMM-based algorithm and clinician review was moderate in strength (kappa = 0.6, p < 0.001).

Conclusion: Claims-based pharmacy measures may offer a valid approach to prioritize patients into CMM-need groups. Further testing of this algorithm is needed prior to implementation in clinic settings.

Background: Proton pump inhibitors (PPIs) are among the most prescribed drugs. A clinical decision support system (CDSS) could improve their rational use.

Aim: The impact of an electronic algorithm (e-algorithm) implemented in a CDSS on potentially missing or inappropriately prescribed PPIs at hospital discharge, its specificity and sensitivity, and the outcome of the alerts issued were analysed.

Method: An e-algorithm continuously monitored patients of a tertiary care hospital for missing or inappropriate PPIs. Following relevance assessment by a pharmacist, the alerts raised were either displayed in the patients' electronic record or dismissed. After a three-month period, all adult patients' records were retrospectively reviewed for missing or inappropriate PPIs at discharge. The results were compared with a corresponding period before CDSS introduction. Sensitivity, specificity and outcome of alerts were quantified.

Results: In a 3-month period with 5018 patients, the CDSS created 158 alerts for missing PPIs and 464 alerts for inappropriate PPIs. PPI prescribing was proposed 81 times and PPI termination 122 times, with acceptance rates of 73% and 34%, respectively. A specificity of 99.4% and sensitivity of 92.0% for missing PPIs and a specificity of 97.1% and a sensitivity of 69.7% for inappropriate PPIs were calculated. The algorithm reduced incidents of missing PPIs by 63.4% (p < 0.001) and of inappropriate PPIs by 16.2% (p = 0.022).

Conclusion: The algorithm identified patients without necessary gastroprotection or inappropriate PPIs with high specificity and acceptable sensitivity. It positively impacted the rational use of PPIs by reducing incidents of missing and inappropriate PPIs.

Background: Polypharmacy is associated with the prescription of inappropriate medications and avoidable medication-related harm. A novel pharmacist-led intervention aims to identify and resolve inappropriate medication prescriptions in older adults with polypharmacy.

Aim: To conduct a preliminary feasibility assessment of the intervention in primary care, testing whether specific components of the intervention procedures and processes can be executed as intended.

Method: The mixed-methods study was approved by the New Zealand Health and Disability Ethics Committees and public health agency. Patients from a New Zealand general practice clinic were recruited over 4 weeks to receive the intervention. The preliminary feasibility assessment included measures of intervention delivery, patient-reported outcome measures, and perspectives from ten patients and six clinicians. Data were analysed quantitatively and qualitatively to determine if a full-scale intervention trial is warranted. The study's progression criteria were based on established research and guided the decision-making process.

Results: The intervention met the study's progression criteria, including patient recruitment, retention, and adherence to the intervention procedures. However, several modifications were identified, including: (1) enhancing patient recruitment, (2) conducting a preliminary meeting between the patient and pharmacist, (3) supporting pharmacists in maintaining a patient-centred approach, (4) reviewing the choice of patient-reported outcome measure, (5) extending the 8-week follow-up period, (6) allocating more time for pharmacists to conduct the intervention.

Conclusion: The study found the intervention feasible; however, additional development is required before progressing to a full-scale trial. This intervention has the potential to effectively reduce medication-related harm and improve outcomes for older adults with polypharmacy.

Trial registration number: ACTRN12621000268842 Date registered: 11/03/2021.

Background: Chronic non-cancer pain may affect up to 51% of the general population. Pharmacist interventions have shown promise in enhancing patient safety and outcomes. However, our understanding of the scope of pharmacists' interventions remains incomplete.

Aim: Our goal was to characterise pharmacists' interventions for the management of chronic non-cancer pain.

Method: Medline, Embase, PsycINFO via Ovid, CINAHL via EBSCO databases and the Cochrane Library were systematically searched. Abstracts and full texts were independently screened by two reviewers. Data were extracted by one reviewer, and validated by the second. Outcomes of studies were charted using the dimensions of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT).

Results: Forty-eight reports were included. Interventions ensuring appropriate drug prescription occurred in 37 (79%) studies. Patient education and healthcare professional education were reported in 28 (60%) and 5 (11%) studies, respectively. Therapy monitoring occurred in 17 (36%) studies. Interventions regularly involved interprofessional collaboration. A median of 75% of reported outcome domains improved due to pharmacist interventions, especially patient disposition (adherence), medication safety and satisfaction with therapy.

Conclusion: Pharmacists' interventions enhanced the management of chronic non-cancer pain. Underreported outcome domains and interventions, such as medication management, merit further investigation.

This commentary narrates on the building of an effective and innovative medicines optimisation model. It discusses the essential features, emphasizes the need, and considers the strong health and pharmacy system as a prerequisite before such a model could be built. The paper argues that it is important to strengthen the health system before the elements of pharmaceutical care and medicine optimisation can take shape. It discusses the discourse and interplay between medicine use and medicine access research. The other important elements to include are the "selection of medicines by health technology assessment", "economic evaluation of pharmacy services", "pharmacists' remuneration by the government", "Health system strengthening status", "quality use of generic medicines programmes", "rationale prescribing", "access to medicines and medicines pricing", "medicines advertising" and the "state of pharmacy practice and the development of the pharmacist's role". A set of different high-, middle- and low-income countries are used to provide examples of the status of the health system and the subsequent development of pharmacy practice and medicines optimisation. The countries include the UK, Australia, New Zealand, Pakistan, Türkiye, Malaysia, India, and Pakistan.