A role for pharmacists in community-based post-discharge warfarin management: protocol for the 'the role of community pharmacy in post hospital management of patients initiated on warfarin' study

<p>Abstract</p> <p>Background</p> <p>Shorter periods of hospitalisation and increasing warfarin use have placed stress on community-based healthcare services to care for patients taking warfarin after hospital discharge, a high-risk period for these patients. A previous randomised controlled trial demonstrated that a post-discharge service of 4 home visits and point-of-care (POC) International Normalised Ratio (INR) testing by a trained pharmacist improved patients' outcomes. The current study aims to modify this previously trialled service model to implement and then evaluate a sustainable program to enable the smooth transition of patients taking warfarin from the hospital to community setting.</p> <p>Methods/Design</p> <p>The service will be trialled in 8 sites across 3 Australian states using a prospective, controlled cohort study design. Patients discharged from hospital taking warfarin will receive 2 or 3 home visits by a trained 'home medicines review (HMR)-accredited' pharmacist in their 8 to 10 days after hospital discharge. Visits will involve a HMR, comprehensive warfarin education, and POC INR monitoring in collaboration with patients' general practitioners (GPs) and community pharmacists. Patient outcomes will be compared to those in a control, or 'usual care', group. The primary outcome measure will be the proportion of patients experiencing a major bleeding event in the 90 days after discharge. Secondary outcome measures will include combined major bleeding and thromboembolic events, death, cessation of warfarin therapy, INR control at 8 days post-discharge and unplanned hospital readmissions from any cause. Stakeholder satisfaction will be assessed using structured postal questionnaire mailed to patients, GPs, community pharmacists and accredited pharmacists at the completion of their study involvement.</p> <p>Discussion</p> <p>This study design incorporates several aspects of prior interventions that have been demonstrated to improve warfarin management, including POC INR testing, warfarin education and home visits by trained pharmacists. It faces several potential challenges, including the tight timeframe for patient follow-up in the post-discharge period. Its strengths lie in a strong multidisciplinary team and the utilisation of existing healthcare frameworks. It is hoped that this study will provide the evidence to support the national roll-out of the program as a new Australian professional community pharmacy service.</p> <p>Trial Registration</p> <p>Australian New Zealand Clinical Trials Registry Number <a href="http://www.anzctr.org.au/trial_view.aspx?ID=82959">12608000334303</a>.</p

Eliciting comprehensive medication histories in the emergency department: the role of the pharmacist.

The Australian Pharmaceutical Advisory Committee guidelines call for a detailed medication history to be taken at the first point of admission to hospital. Accurate medication histories are vital in optimising health outcomes and have been shown to reduce mortality rates. This study aimed to examine the accuracy of medication histories taken in the Emergency Department of the Royal Adelaide Hospital. Medication histories recorded by medical staff were compared to those elicited by a pharmacy researcher. The study, conducted over a six-week period, included 100 patients over the age of 70, who took five or more regular medications, had three or more clinical co-morbidities and/or had been discharged from hospital in three months prior to the study. Following patient interviews, the researcher contacted the patient’s pharmacist and GP for confirmation and completion of the medication history. Out of the 1152 medications recorded as being used by the 100 patients, discrepancies were found for 966 medications (83.9%). There were 563 (48.9%) complete omissions of medications. The most common discrepancies were incomplete or omitted dosage and frequency information. Discrepancies were mostly medications that treated dermatological and ear, nose and throat disorders but approximately 29% were used to treat cardiovascular disorders. This study provides support for the presence of an Emergency Department pharmacist who can compile a comprehensive and accurate medication history to enhance medication management along the continuum of care. It is recommended that the patient’s community pharmacy and GP be contacted for clarification and confirmation of the medication history

Pharmacists' role in the post-discharge management of patients with heart failure: a literature review

Background and Objective: The incidence of heart failure is increasing in developed countries. In the aged population, heart failure is a common cause of hospitalization and hospital readmission, which in conjunction with post-discharge care, impose a significant cost burden. Inappropriate medication management and drug-related problems have been identified as major contributors to hospital readmissions. In order to enhance the care and clinical outcomes, and reduce treatment costs, heart failure disease management programmes (DMPs) have been developed. It is recommended that these programmes adopt a multi-disciplinary approach, and pharmacists, with their understanding and knowledge of medication management, can play a vital role in the post-discharge care of heart failure patients. The aim of this literature review was to assess the role of pharmacists in the provision of post-charge services for heart failure patients. Method: An extensive literature search was undertaken to identify published studies and review articles evaluating the benefits of an enhanced medication management service for patients with heart failure post-discharge. Results: Seven studies were identified evaluating ‘outpatient’ or ‘post-discharge’ pharmacy services for patients with heart failure. In three studies, services were delivered prior to discharge with either subsequent telephone or home visit follow-up. Three studies involved the role of a pharmacist in a specialist heart failure outpatient clinic. One study focused on a home-based intervention. In six of these studies, positive outcomes, such as decreases in unplanned hospital readmissions, death rates and greater compliance and medication knowledge were demonstrated. One study did not show any difference in the number of hospitalizations between intervention and control groups. The quality of evidence of the randomized controlled trials was assessed using the Jadad scoring method. None of the studies achieved a score of more than 2, out of a maximum of 5, indicating the potential for bias. Discussion: The DMPs carried out by pharmacists have contributed to positive patient outcomes, which has highlighted the value of extending the traditional roles of pharmacists from the provision of professional guidance to the delivery of continuity of care through a more holistic and direct approach. Conclusion: This review has demonstrated the effectiveness of pharmacists’ interventions to reduce the morbidity and mortality associated with heart failure. However, there is an on-going need for the development and evaluation of pharmacy services for these patients.A. Ponniah, B. Anderson, S. Shakib, C.J. Doecke and M. Angle

Consumers' views of pharmacogenetics: A qualitative study

BACKGROUND: Adverse drug reactions are recognized as a significant public health issue. Pharmacogenetics (PGx) provides a potential means of preventing some adverse drug reactions by predicting the optimal medication dose for an individual; however, PGx is rarely used in clinical practice. Thus far, there have been few studies investigating consumers’ perceptions of the barriers to the implementation of PGx in clinical practice. OBJECTIVES: This study explored the views of the general public regarding their current use of medications, and their experiences of side effects and opinions on PGx. METHODS: Members of the general public who suffered a chronic medical condition and/or had an immediate family member with a chronic medical condition were recruited to form 5 separate focus groups (n ¼ 35). Three separate age ranges were used in the focus groups. A questioning route was developed and used in focus groups to determine participants’ experiences with medication use and opinions on PGx (referred to as ‘‘Personalized Medicine’’). Focus group discussions were transcribed by 2 separate investigators, and qualitative analysis, based on the framework approach, was applied to the data. Data were independently coded to identify key themes then compared both within and between focus groups. RESULTS: A common theme was a desire to have a holistic approach to disease diagnosis and medication selection. A wide range of views were expressed by the focus group participants. Concerns were raised regarding the current level of side effects experienced with medications. Storage and privacy of genetic information, and the costs involved, were also seen as potential barriers to implementation of PGx. CONCLUSIONS: PGx testing was seen as a potential positive contribution, but only if other factors were considered during the prescribing process. As participants desired a high level of information and effective communication from their health-care professionals, PGx education of clinicians and pharmacists will be essential to satisfy consumers’ requirements.Catherine A. Haddy, Helena M. Ward, Manya T. Angley, Ross A. McKinno

Hospital admissions caused by adverse drug events: an Australian prospective study

Objective: To assess the frequency of adverse drug event (ADE)-related admissions (ADE-RAs) during a prospective medical record review of patients admitted to a metropolitan tertiary referral hospital. Methods: Potential ADE-RA cases were identified by examination of case records of randomly selected patients. Cases were assessed by an expert panel to measure study outcomes, which were the frequency (ADEs and ADE-RAs) as well as type, likelihood of causality, severity, avoidability and detection of ADEs. Results: Of the 370 subjects, 59 (16.0%) had a confirmed ADE-RA, with 15 (4.1%) of these serious and preventable. The 59 ADE-RAs were a result of 72 discreet ADEs. Adverse drug reactions were the most common type of ADE, followed by non-compliance. Of the 72 discreet ADEs, 31.9% were classified as 'probable' or 'highly probable'. Most ADEs (54.2%) were classified as 'definitely avoidable', 34.7% were classified as 'severe' and 21.8% were classified as both 'definitely avoidable' and 'severe'. Half the ADEs were detected after the patient had been admitted and most were detected by medical practitioners. Antineoplastics followed by antidiabetic agents were most frequently implicated. Conclusions: Implementing a systems approach that involves multiple strategies, such as improving tertiary-to-primary care information transfer and promoting medication adherence through education programs, is necessary to tackle the problem of avoidable ADE-RAs and the associated cost burden. What is Known About the Topic? It is estimated that 2-3% of Australian hospital admissions are due to adverse drug events (ADEs), but recent data are lacking. According to the Australian Statistics on Medicines, over 250 million prescriptions were dispensed in 2007, compared with just under 180 million in 1997. This 40% increase in drug utilisation over the 10 years surpasses the Australian population growth of 14% in the same period. An increase in drug use per person indicates that the rate of ADEs and possible ADE-related admissions (ADE-RAs) is likely to have increased. What Does This Paper Add? This prospective study was conducted at a large Australian metropolitan teaching hospital and we report that 59 of 370 participants (16.0%) presenting to the Emergency Department had a confirmed ADE-RA, with 15 (4.1%) presenting with a serious and preventable ADE-RA. What Are The Implications For Practitioners? The findings of this study support implementing a systems approach involving multiple strategies to tackle the problem of avoidable ADE-RAs and the associated cost burden. This study reveals that half the ADEs were not detected until after the admission process, which reinforces the importance of focusing efforts towards preventing ADE-RAs and detecting ADE-RAs through measures such as those recommended in the Australian Pharmaceutical Advisory Council guiding principles.Alexandra L. Phillips, Olimpia Nigro, Karen A. Macolino, Kirsty C. Scarborough, Christopher J. Doecke, Manya T. Angley, Sepehr Shaki

Covariance Cost Functions for Scheduling Multistatic Sonobuoy Fields

Sonobuoy fields, comprising a network of sonar transmitters and receivers, are used to find and track underwater targets. For a given environment and sonobuoy field layout, the performance of such a field depends on the scheduling, that is, deciding which source should transmit, and which waveform should be transmitted at any given time. In this paper, we explore the choice of cost function used in myopic scheduling and its effect on tracking performance. Specifically, we consider 5 different cost functions derived from the predicted error covariance matrix of the track. Importantly, our cost functions combine both positional and velocity covariance information to allow the scheduler to choose the optimum source-waveform action. Using realistic multistatic sonobuoy simulations, we demonstrate that each cost function results in a different choice of source-waveform actions, which in turn affects the performance of the scheduler. In particular, we show there is a trade-off between position and velocity error performance such that no one cost function is superior in both

RRT* Trajectory Scheduling Using Angles-Only Measurements for AUV Recovery

Sensor trajectory optimisation involves extensive search over the sensor motion space against an optimisation criterion. The search under dynamic programming or fixed grid is often computationally nontrivial even for a myopic search scenario. In this paper, we study the problem of an autonomous underwater vehicle planning its return route to a moving recovery vessel. To complicate the issue, the AUV needs to localize the vessel using angle-only measurements. Accordingly, we propose a random sampling based trajectory planning algorithm that incorporates both a dynamic goal and the need to localize that goal. More precisely, we incorporate an information theoretic cost into a rapid-exploring random tree trajectory planning framework thus allowing the AUV to both localize and reach the recovery vessel. Our experimental results show that the proposed method may achieve the same trajectory optimisation performance as that under dynamic programming method but with greater computational efficiency