9 research outputs found

    Optimising drug therapy in older patients. Exploring different approaches across the patient pathway

    Get PDF
    Background - Drug therapy contributes to healthy aging but has a key duality: It prolongs and can improve quality of life, but drugs can also cause serious harm. Harm from drugs include falls, cognitive decline, lowered quality of life, hospitalisation, and death. Older patients are especially at risk for harm from drug therapy, therefore optimising drug therapy is imperative for this group. Aim - To generate new knowledge of drug therapy optimisation for older patients by exploring the impact of drug burden and investigating different approaches to optimise drug therapy across the patient pathway. Methods - This thesis used data from The Norwegian patient registry, The Norwegian Prescription Database and data collected in a randomised controlled trial (RCT). Observational data of the delivery of the RCT-intervention was included. In Paper I the association between anticholinergic (AC) and sedative (SED) drug burden and post-discharge institutionalisation (PDI) was assessed using multiple regression. Paper II described an RCT investigating the effect of an in-hospital pharmacist intervention. Paper III presented the fidelity and process outcomes of the intervention (Paper II). In Paper IV, an observational tool was developed and time distribution for the pharmacists running the RCT examined. Results - Number of drugs used before hospitalisation was mean 7.11 (SD 4.09) and at hospitalisation median 6.0 (range 4-9). Prevalence of AC/SED drugs was 45.5%. All measures of AC/SED drug burden was significantly associated with PDI. The number of AC drugs were most sensitive (OR 1.13, per AC drug), and the DBI most challenging to apply. The clinical pharmacist contributed to identify and solve discrepancies for 72% of the patients (median 1) and DRPs for 94.6% of the patients (median 4), and the acceptance rate was 67%. Intervention fidelity at admission was 100%, and 57% overall. The pharmacists advanced communication of drug therapy across the patient pathway. About 41% of pharmacist time was spent on administrative RCT-tasks and the estimated intervention time was >3.5 hours/patient. Conclusions - The drug burden is high in older patients acutely admitted to hospital in Norway and assessing AC/SED drug use can reduce the risk of PDI. The in-hospital pharmacist intervention contributed to drug therapy optimisation and facilitated communication across the patient pathway. These measures can contribute to optimisation of drug therapy but are time consuming and costly. It is essential to establish models for drug therapy optimisation across the pathway, including primary care

    Is anticholinergic and sedative drug burden associated with postdischarge institutionalization in community-dwelling older patients acutely admitted to hospital? A Norwegian registry-based study

    Get PDF
    Purpose: Investigate the association between anticholinergic (AC) and sedative (SED)drug burden before hospitalization and postdischarge institutionalization (PDI) incommunity-dwelling older patients acutely admitted to hospital.Methods: A cross-sectional study using data from the Norwegian Patient Registryand the Norwegian Prescription Database. We studied acutely hospitalizedcommunity-dwelling patients≥70 years during 2013 (N=86 509). Patients acutelyadmitted to geriatric wards underwent subgroup analyses (n=1715). We calculateddrug burden by the Drug Burden Index (DBI), use of AC/SED drugs, and the number of AC/SED drugs. Piecewise linearity of DBI versus PDI and a knot point(DBI=2.45) was identified. Statistical analyses included an adjusted multivariable logistic regression model.Results: In the total population, 45.4% were exposed to at least one AC/SED drug,compared to 52.5% in the geriatric subgroup. AC/SED drugs were significantly asso-ciated with PDI. The DBI with odds ratios (ORs) of 1.11 (95% CI 1.07–1.15) forDBI Conclusions: The use of AC/SED drugs was highly prevalent in older patients beforeacute hospital admissions, and significantly associated with PDI. The number, or justusing AC/SED drugs, gave similar associations with PDI compared to applying theDBI. Using AC drugs showed higher sensitivity, indicating that to reduce the risk ofPDI, a clinical approach could be to reduce the number of AC drugs

    Translation and validation of the Norwegian version of the postoperative quality of recovery score QoR-15

    Get PDF
    Background As patient-centered care gains more attention, assessing the patient's perspective on their recovery has become increasingly important. In response to the need for a reliable and valid patient reported outcome measurement tool for major surgical resections in Norway. The Norwegian Registry for Gastrointestinal Surgery (NORGAST) initiated a project to translate and evaluate QoR-15's psychometric properties for patients going through general, gastrointestinal (GI), and hepato-pancreato-biliary (HPB) resectional surgery. Methods After a translation and adaption of the original version of QoR–15 into Norwegian, the QoR–15NO was psychometrically evaluated including a confirmatory factor analysis to test for unidimensionality, as well as tests for content validity, internal consistency, measurement error, construct validity, feasibility, and responsiveness. This process included cognitive interviews using a structured interview guide. Further, patients who underwent various types of GI/HPB surgery at five hospitals in different parts of Norway completed the QoR-15NO before surgery and on the first or second day after surgery. The impact of surgery was classified according to Surgical Outcome Risk Tool v2 (SORT), in extra major/complex, major, intermediate, and minor. Results This study included 324 patients with 83% return rate with both pre- and postoperative forms. There were negative correlations between duration of surgery and postoperative QoR-15 score and the difference between post- and preoperative score (change score). Individuals who had gone through surgery with major impact had a lower postoperative mean QoR-15 score (97) than their counterparts who had experienced either medium (QoR-15: 110) or minor (QoR15: 119) impact surgery. Cronbach's alpha (0.88) and Omega Alpha Total (ωt = 0.90) indicate that the scale has good to very good internal consistency. Test–retest reliability was measured by Intra-class Correlation Coefficient to ICC = 0.70. Confirmatory factor analyses supported that a one-factor model with correlated residuals had a good fit to data. Conclusion This study supports QoR-15NO as a valid, essentially unidimensional, feasible, and responsive instrument among patients undergoing general, GI, and HPB resectional surgery in Norway. The total QoR-15NO score provides important information that can be used in an everyday clinical setting and integrated into NORGAST

    Time distribution for pharmacists conducting a randomized controlled trial — An observational time and motion study.

    Get PDF
    Introduction - An expected future increase in older adults will demand changes in health care delivery, making development, implementation and evaluation of new health care models essential. The rationale for political decision-making concerning the implementation and application of interventions in health care should include cost estimations, specifically those involving clinical interventions. To provide such data knowledge of time spent on the intervention is imperative. Time and motion methodology is suitable to quantify health care personnel’s time distribution. Aim - To investigate the time distribution for pharmacists conducting a randomized controlled trial (RCT) implementing a clinical intervention. Materials and methods - The setting was an RCT with a 5-step pharmacist-intervention in collaboration with the interdisciplinary team in a geriatric ward. Two pharmacists were involved in the trial during the observation period. Pharmacist activities, classified as RCT-tasks (intervention or administrative), non-RCT tasks and social/breaks, were recorded applying the Work Observation Method By Activity Timing methodology, enabling recording of predefined work tasks as well as interruptions and multitasking. One observer collected data over eight weeks. Results - In total, 109.1 hours were observed resulting in 110.2 hours total task time, including multitasking. RCT tasks comprised 85.4% of the total observed time, and nearly 60% of the RCT time was spent on intervention tasks. Medication reviews was the most time consuming task, accounting for 32% of the observed time. The clinical pharmacists spent 14% of the intervention time communicating verbally, mainly with patients and healthcare professionals. Conclusion - During the RCT, the clinical pharmacists spent about half their time performing the actual intervention. Consequently, costs for providing such a clinical pharmacist service should reflect actual time spent; otherwise, we may risk overestimating theoretical costs

    The impact of hospitalisation to geriatric wards on the use of medications and potentially inappropriate medications - A health register study

    No full text
    Background - The use of potentially inappropriate medications (PIMs) are associated with negative health effects for older adults. The purpose of this study was to apply national register data to investigate the impact of hospitalisation to geriatric wards in Norway on the use of medications and PIMs, and to compare two explicit PIM identification tools. Methods - We included 715 patients ≥65 years (mean 82.5, SD = 7.8) admitted to Norwegian geriatric wards in 2013 identified from The Norwegian Patient Registry, and collected their medication use from the Norwegian Prescription Database. Medication use before and after hospitalisation was compared and screened for PIMs applying a subset of the European Union (EU)(7)-PIM list and the Norwegian General Practice – Nursing Home (NORGEP-NH) list part A and B. Results - The mean number of medications increased from 6.5 (SD = 3.5) before to 7.5 (SD = 3.5) (CI:1.2–0.8, p p p = 0.73). The EU(7)-PIM list and the NORGEP-NH list had more than 70% agreement on the classification of patients as PIM users. Conclusions - Medication use increased after hospitalisation to geriatric wards. We did not find that geriatric hospital care leads to a general improvement in PIM use after hospitalisation. According to a subset of the EU(7)-PIM list, PIM use increased after hospitalisation. This increase was not identified by the NORGEP-NH list part A and B. It is feasible to use health register data to investigate the impact of hospitalisation to geriatric wards on medication use and PIMs

    Intervention fidelity and process outcomes of the IMMENSE study, a pharmacist-led interdisciplinary intervention to improve medication safety in older hospitalized patients

    Get PDF
    What is known and Objective - The majority of hospitalized older patients experience medication-related problems (MRPs), and there is a call for interventions to solve MRPs and improve clinical outcomes like medical visits. The IMMENSE study is a randomized controlled trial investigating the impact of a pharmacist-led interdisciplinary intervention on emergency medical visits. Its multistep intervention is based on the integrated medicines management methodology and includes a follow-up step with primary care. This study aims to describe how the intervention in the IMMENSE study was delivered and its process outcomes. Methods - The study includes the 221 intervention patients in the per-protocol group of the IMMENSE study. Both intervention delivery, reasons for not performing interventions and process outcomes were registered daily by the study pharmacists in a Microsoft Access® database. Process outcomes were medication discrepancies, MRPs and how the team solved these. Results and discussion - A total of 121 (54.8%) patients received all intervention steps if appropriate. All patients received medication reconciliation (MedRec) and medication Review (MedRev) (step 1 and 2), while between 10% and 20% of patients were missed for medication list in discharge summary (step 3), patient counselling (step 4), or communication with general practitioner and nurse (step 5). A total of 437 discrepancies were identified in 159 (71.9%) patients during MedRec, and 1042 MRPs were identified in 209 (94.6%) patients during MedRev. Of these, 292 (66.8%) and 700 (67.2%), respectively, were communicated to and solved by the interdisciplinary team during the hospital stay. What is new and Conclusion - The fidelity of the single steps of the intervention was high even though only about half of the patients received all intervention steps. The impact of the intervention may be influenced by not implementing all steps in all patients, but the many discrepancies and MRPs identified and solved for the patients could explain a potential effect of the IMMENSE study

    Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) – a randomized controlled trial

    Get PDF
    Background Suboptimal medication use contributes to a substantial proportion of hospitalizations and emergency department visits in older adults. We designed a clinical pharmacist intervention to optimize medication therapy in older hospitalized patients. Based on the integrated medicine management (IMM) model, the 5-step IMMENSE intervention comprise medication reconciliation, medication review, reconciled medication list upon discharge, patient counselling, and post discharge communication with primary care. The objective of this study was to evaluate the effects of the intervention on healthcare use and mortality. Methods A non-blinded parallel group randomized controlled trial was conducted in two internal medicine wards at the University Hospital of North Norway. Acutely admitted patients ≥ 70 years were randomized 1:1 to intervention or standard care (control). The primary outcome was the rate of emergency medical visits (readmissions and emergency department visits) 12 months after discharge. Results Of the 1510 patients assessed for eligibility, 662 patients were asked to participate, and 516 were enrolled. After withdrawal of consent and deaths in hospital, the modified intention-to-treat population comprised 480 patients with a mean age of 83.1 years (SD: 6.3); 244 intervention patients and 236 control patients. The number of emergency medical visits in the intervention and control group was 497 and 499, respectively, and no statistically significant difference was observed in rate of the primary outcome between the groups [adjusted incidence rate ratio of 1.02 (95% CI: 0.82–1.27)]. No statistically significant differences between groups were observed for any of the secondary outcomes, neither in subgroups, nor for the per-protocol population. Conclusions We did not observe any statistical significant effects of the IMMENSE intervention on the rate of emergency medical visits or any other secondary outcomes after 12 months in hospitalized older adults included in this study. Trial registration The trial was registered in clinicaltrials.gov on 28/06/2016, before enrolment started (NCT02816086)

    Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (IMMENSE study): study protocol for a randomised controlled trial

    No full text
    Introduction: Drug-related problems (DRPs) are common in the elderly, leading to suboptimal therapy, hospitalisations and increased mortality. The integrated medicines management (IMM) model is a multifactorial interdisciplinary methodology aiming to optimise individual medication therapy throughout the hospital stay. IMM has been shown to reduce readmissions and drug-related hospital readmissions. Using the IMM model as a template, we have designed an intervention aiming both to improve medication safety in hospitals, and communication across the secondary and primary care interface. This paper presents the study protocol to explore the effects of the intervention with regard to healthcare use, health-related quality of life (HRQoL) and medication appropriateness in elderly patients. Methods and analysis: A total of 500 patients aged ≥70 years will be included and randomised to control (standard care) or intervention group (1:1). The intervention comprises five steps mainly performed by pharmacists: (1) medication reconciliation at admission, (2) medication review during hospital stay, (3) patient counselling about the use of medicines, (4) a comprehensible and patientfriendly medication list with explanations in discharge summary and (5) postdischarge phone calls to the primary care level. The primary outcome is the difference between intervention and control patients in the rate of emergency medical visits (acute readmissions and visits to emergency department) 12 months after discharge. Secondary outcomes include length of index hospital stay, time to first readmission, mortality, hip fractures, strokes, medication changes, HRQoL and medication appropriateness. Patient inclusion started in September 2016. Ethics and dissemination: The trial was approved by the Norwegian Centre for Research Data and the Norwegian Data Protection Authority. We aim to publish the results in international peer-reviewed open access journals, at national and international conferences, and as part of two PhD theses
    corecore