Healthcare system intervention for safer use of medicines in elderly patients in primary care—a qualitative study of the participants’ perceptions of self-assessment, peer review, feedback and agreement for change

The elderly population is increasing and with advanced age comes a higher risk for contracting diseases and excessive medicine use. Polypharmacy can lead to drug-related problems and an increased need of health care. More needs to be done to help overcome these problems. In order for new models to be successful and possible to implement in health care they have to be accepted by caregivers. The aim of this study was to evaluate participants' perceptions of the SÄKLÄK project, which aims to enhance medication safety, especially for elderly patients, in primary care

Health economic evaluation of the Lund Integrated Medicines Management Model (LIMM) in elderly patients admitted to hospital.

To evaluate the cost effectiveness of a multidisciplinary team including a pharmacist for systematic medication review and reconciliation from admission to discharge at hospital among elderly patients (the Lund Integrated Medicines Management (LIMM)) in order to reduce drug-related readmissions and outpatient visits

In-hospital medication reviews reduce unidentified drug-related problems

Purpose To examine the impact of a new model of care, in which a clinical pharmacist conducts structured medication reviews and a multi-professional team collates systematic medication care plans, on the number of unidentified DRPs in a hospital setting. Methods In a prospective two-period study, patients admitted to an internal medicine ward at the University Hospital of Lund, Sweden, were included if they were >= 65 years old, used >= 3 medications on a regular basis and had stayed on the ward for >= 5 weekdays. Intervention patients were given the new model of care and control patients received conventional care. DRPs were then retrospectively identified after study completion from blinded patient records for both intervention and control patients. Two pairs of evaluators independently evaluated and classified these DRPs as having been identified/unidentified during the hospital stay and according to type and clinical significance. The primary endpoint was the number of unidentified DRPs, and the secondary endpoints were the numbers of unidentified DRPs within each type and clinical significance category. Results The study included a total of 141 (70 intervention and 71 control) patients. The intervention group benefited from a reduction in the total number of unidentified DRPs per patient during the hospital stay: intervention group median 1 (1st-3rd quartile 0-2), control group 9 (6-13.5) (p < 0.001), and also in the number of medications associated with unidentified DRPs per patient: intervention group 1 (0-2), control group 8 (5-10) (p < 0.001). All sub-categories of DRPs that were frequent in the control group were significantly reduced in the intervention group. Similarly, the DRPs were less clinically significant in the intervention group. Conclusions A multi-professional team, including a clinical pharmacist, conducting structured medication reviews and collating systematic medication care plans proved very effective in reducing the number of unidentified DRPs for elderly in-patients

The process of identifying, solving and preventing drug related problems in the LIMM-study

Objective To avoid negative effects of drug treatment and need for additional medical care, drug treatment must be individualised. Our research group has developed a model for clinical pharmacy which improves several aspects of the patient's drug treatment. This study describes the process behind these improvements, i.e. drug related problems identified by pharmacists within a clinical pharmacy service. Setting Three wards at a department of internal medicine. Method Pharmacists performed systematic interventions during the patient's hospital stay, aiming to identify, solve and prevent drug related problems in the elderly. Identified drug related problems were put forward to the health care team and discussed. Information on identified problems, and their outcomes was collected and analysed. A questionnaire was used to evaluate the health care personnel's attitudes towards the process. Main outcome measure The number of drug related problems identified by the clinical pharmacists, the proportion of problems discussed with the physicians, the proportion of problems adjusted by the physicians and whether pharmacists and physicians prioritised any subgroup of drug related problems when choosing which problems to address. Finally, we wanted to evaluate the health care personnel's attitudes towards the model. Results In total, 1,227 problem were identified in 190 patients. The pharmacists discussed 685 (55.8%) of the identified problems with the physicians who accepted 438 (63.9%) of the suggestions. There was no significant difference in which subgroup to put forward and which to adjust. There was a high response rate (84%) to the questionnaire, and the health care personnel estimated the benefits to be very high, both for the patients and for themselves. Conclusion The process for identifying, solving and preventing drug related problems was good and the different types of problems were considered equally important. The addition of a clinical pharmacy service was considered very useful. This suggests that the addition of our clinical pharmacy service to the hospital setting add skills of great importance

Identifying older adults at increased risk of medication-related readmission to hospital within 30 days of discharge: development and validation of a risk assessment tool

OBJECTIVE: Developing and validating a risk assessment tool aiming to identify older adults (≥65 years) at increased risk of possibly medication-related readmission to hospital within 30 days of discharge. DESIGN: Retrospective cohort study. SETTING: The risk score was developed using data from a hospital in southern Sweden and validated using data from four hospitals in the mid-eastern part of Sweden. PARTICIPANTS: The development cohort (n=720) was admitted to hospital during 2017, whereas the validation cohort (n=892) was admitted during 2017-2018. MEASURES: The risk assessment tool aims to predict possibly medication-related readmission to hospital within 30 days of discharge. Variables known at first admission and individually associated with possibly medication-related readmission were used in development. The included variables were assigned points, and Youden's index was used to decide a threshold score. The risk score was calculated for all individuals in both cohorts. Area under the receiver operating characteristic (ROC) curve (c-index) was used to measure the discrimination of the developed risk score. Sensitivity, specificity and positive and negative predictive values were calculated using cross-tabulation. RESULTS: The developed risk assessment tool, the Hospitalisations, Own home, Medications, and Emergency admission (HOME) Score, had a c-index of 0.69 in the development cohort and 0.65 in the validation cohort. It showed sensitivity 76%, specificity 54%, positive predictive value 29% and negative predictive value 90% at the threshold score in the development cohort. CONCLUSION: The HOME Score can be used to identify older adults at increased risk of possibly medication-related readmission within 30 days of discharge. The tool is easy to use and includes variables available in electronic health records at admission, thus making it possible to implement risk-reducing activities during the hospital stay as well as at discharge and in transitions of care. Further studies are needed to investigate the clinical usefulness of the HOME Score as well as the benefits of implemented activities

Aspects on optimisation of drug therapy in the elderly

Introduction: Elderly patients often use many drugs, increasing the risk for drug-related problems. Aim: To optimise drug therapy in the elderly by identifying, resolving and preventing drug-related problems. Methods: (Paper I) Medication reviews were conducted on nursing home patients’ with epilepsy or Parkinson’s disease by a multi-speciality team, whom identified drug-related problems and when appropriate suggested therapy changes to the intervention patients’ responsible physician. The effect of this intervention was evaluated on health-related quality of life. (Paper II) GPs’ and nurses’ opinions towards the previous pharmacotherapeutic intervention, in Paper I, were evaluated using a questionnaire. (Paper III) Medication errors during the transfer between primary care and hospital were investigated for patient providing care by the community, by collecting and reviewing all medication notes used for the information transfer. (Paper IV) Clinical pharmacists interviewed patients admitted to the hospital using the developed Structured Medication Questionnaire, to identify medication errors and assess patients’ compliance to and beliefs about medicines. (Paper V) Systematic medication reviews and medication care plans were conducted on intervention inpatients, by a multidisciplinary team, to reduce the number of unidentified drug-related problems during the hospital stay, which were identified and evaluated retrospectively. The physicians’ and nurses’ opinions towards this working model were evaluated using a questionnaire. Result: (Paper I) Many drug-related problems were identified among the nursing home patients, but no improvement in health-related quality of life. (Paper II) Both GPs and nurses were positive towards further cooperation regarding pharmacotherapeutic interventions. (Paper III) On average two medication errors occurred each time a patient was transferred between primary and secondary care. (Paper IV) A majority of the patients (62%, CI 45-77%) had at least one medication error. Using this questionnaire, poor compliance and negative beliefs were also identified. (Paper V) Inpatients in the intervention group benefited from a reduction of unidentified drug-related problems. In general physicians and nurses were very positive towards this working model. Conclusion: The research comprising this thesis has demonstrated a need for attention towards drug treatment and drug-related problems in the elderly. The Structured Medication Questionnaire and structured medication reviews may be used as tools to identify drug-related problems. Once identified the drug-related problems have the potential to be prevented or resolved, thereby optimising drug therapy

Medication errors in primary health care records; a cross-sectional study in Southern Sweden

BACKGROUND: Drug-related problems due to medication errors are common and have the potential to cause harm. This study, which was conducted in Swedish primary health care, aimed to assess how well the medication lists in the medical records tally with the medications used by patients and to explore what type of medication errors are present. METHODS: We reviewed the electronic medical records (EMRs) at ten primary health care centers in Skåne county, Sweden. The medication lists in the EMRs were compared with the results of medication reconciliations, which were performed telephonically in a structured manner by a physician, two weeks after a follow-up visit to a general practitioner. Of 76 patients aged ≥18 years, who on a certain day in 2016 were visiting one of the included primary health care centers, a total of 56 were included. Descriptive statistics were used. The chi2-test and the Mann Whitney U-test were used for comparisons. The main outcome measure was the proportion of correctly updated medication lists. RESULTS: Following a recent visit to the general practitioner, a total of 16% of the medication lists in the medical records were consistent with the patients' actual medication use. The mean number of medication errors in the medical records was 3.8 (SD 3.8). Incorrect dose was the most common error, followed by additional drugs without indication/documentation. The most common medication group among all errors was analgesics and among dose errors the most common medication group was cardiovascular drugs. CONCLUSION: A total of 84% of the medication lists used by the general practitioners in the assessment and follow-up of the patients were not updated; this implies a great safety risk since medication errors are potentially harmful. Ensuring medication reconciliations in daily clinical practice is important for patient safety

Medication reviews in primary care in Sweden: importance of clinical pharmacists' recommendations on drug-related problems.

Background One way of preventing and solving drug-related problems in frail elderly is to perform team-based medication reviews. Objective To evaluate the quality of the clinical pharmacy service to primary care using structured medication reviews, focusing on the clinical significance of the recommendations made by clinical pharmacists. Setting A random sample of 150 patients (out of 1541) who received structured team based medication reviews. The patients lived at a geriatric nursing home or were ≥65 years and lived in ordinary housing with medication-related community help. Method Based on information on symptoms, kidney function, blood pressure, diagnoses and the medication list, a pharmacist identified possible drug-related problems and supplied recommendations for the general practitioner to act on. Two independent physicians retrospectively ranked the clinical significance of the recommendations according to Hatoum, with rankings ranging between 1 (adverse significance) and 6 (extremely significant). Main outcome measure The clinical significance of the recommendations. Results In total 349 drug-related problems were identified, leading to recommendations. The vast majority of the recommendations (96 %) were judged to have significance 3 or higher and more than the half were judged to have significance 4 or higher. Conclusion The high proportion of clinically significant recommendations provided by pharmacists when performing team-based medication reviews suggest that these clinical pharmacy services have potential to increase prescribing quality. As such, the medication reviews have the potential for contributing to a better and safer drug therapy for elderly patients