Impact of a community pharmacist-led medication review on medicines use in patients on polypharmacy - a prospective randomised controlled trial

In 2010 the 'Polymedication Check' (PMC), a pharmacist-led medication review, was newly introduced to be delivered independently from the prescriber and reimbursed by the Swiss health insurances. This study aimed at evaluating the impact of this new cognitive service focusing on medicines use and patients' adherence in everyday life.; This randomised controlled trial was conducted in 54 Swiss community pharmacies. Eligible patients used ≥4 prescribed medicines over >3 months. The intervention group received a PMC at study start (T-0) and after 28 weeks (T-28) while the control group received only a PMC at T-28. Primary outcome measure was change in patients' objective adherence, calculated as Medication Possession Ratio (MPR) and Daily Polypharmacy Possession Ratio (DPPR), using refill data from the pharmacies and patient information of dosing. Subjective adherence was assessed as secondary outcome by self-report questionnaires (at T-0 and T-28) and telephone interviews (at T-2 and T-16), where participants estimated their overall adherence on a scale from 0-100 %.; A total of 450 patients were randomly allocated to intervention (N = 218, 48.4 %) and control group (N = 232, 51.6 %). Dropout rate was fairly low and comparable for both groups (N Int = 37 (17.0 %), NCont = 41 (17.7 %), p = 0.845). Main addressed drug-related problem (DRP) during PMC at T-0 was insufficient adherence to at least one medicine (N = 69, 26.7 %). At T-28, 1020 chronic therapies fulfilled inclusion criteria for MPR calculation, representing 293 of 372 patients (78.8 %). Mean MPR and adherence to polypharmacy (DPPR) for both groups were equally high (MPRInt = 88.3, SD = 19.03; MPRCont = 87.5, SD = 20.75 (p = 0.811) and DPPRInt = 88.0, SD = 13.31; DPPRCont = 87.5, SD = 20.75 (p = 0.906), respectively). Mean absolute change of subjective adherence between T-0 and T-2 was +1.03 % in the intervention and -0.41 % in the control group (p = 0.058). The number of patients reporting a change of their adherence of more than ±5 points on a scale 0-100 % between T-0 and T-2 was significantly higher in the intervention group (NImprovement = 30; NWorsening = 14) than in the control group (NImprovement = 20; NWorsening = 24; p = 0.028).; Through the PMC pharmacist were able to identify a significant number of DRPs. Participants showed high baseline objective adherence of 87.5 %, providing little potential for improvement. Hence, no significant increase of objective adherence was observed. However, regarding changes in subjective adherence of more than ±5 % the PMC showed a positive effect.; Clinical trial registry database, NCT01739816 ; first entry on November 27, 2012

Raucherentwöhnung in Apotheken — Evaluation der Raucherentwöhnungskampagne "Tabak adieu” der Apotheker/-innen beider Basel

Zusammenfassung: Nach wie vor stellt der Tabakkonsum ein grosses gesundheitliches Problem in der Schweiz dar. Dementsprechend werden viele Anstrengungen und Massnahmen zur Reduktion des Tabakkonsums unternommen. Obwohl sich auch die Offizinapothekerl-innen in den letzten Jahren vermehrt im Bereich der Gesundheitsförderung und der Prävention engagierten, existiert bisher keine Dokumentation ihrer Rolle bei der Tabakprävention. Die Raucherentwöhnungskampagne "Tabak adieu”, die von Apothekerl-innen im Jahr 1996 in Basel als niederschwelliges Angebot durchgeführt wurde, und deren Evaluation ist ein Versuch, diese Rolle zu untersuchen. In der Evaluation wurden einerseits die beteiligten Apotheken befragt und ihre auf diesem Gebiet geleisteten Dienstleistungen erfasst. Andererseits wurden diejenigen aufhörwilligen Raucherl-innen, die sich während der Kampagne in der Apotheke über die Raucherentwöhnung beraten liessen, mittels standardisiertem Fragebogen über ihr Rauchverhalten und die in den Apotheken gemachten Erfahrungen befragt. Das Interesse am niederschwelligen Angebot der Apotheken für die Raucherentwöhnung war sehr gross: Während der vierwöchigen Kampagne wurden in den 63 beteiligten Apotheken rund 2000 Kundenkontakte mit an Raucherentwöhnung interessierten Personen registriert. Im Vergleich zur Situation vor der Kampagne verschob sich dabei die nachfrage zu den beratungsintensiven Dienstleistungen hin. Die in den Apotheken beratenen Entwöhnungswilligen beurteilten die erhaltene Raucherberatung als gut. Neben der Raucherberatung wurden den Aufhörwilligen auch Betreuung während der Entwöhnungsphase angeboten. In 76 Prozent der dokumentierten Raucherberatungen wurden Folgebesuche zwischen den Entwöhnungwilligen und dem Apothekenteam vereinbart. Die Untersuchung zeigt, dass Raucherberatung in Apotheken möglich ist, und dass das niederschwellige Angebot genutzt wird. Ein weiterer Ausbau dieser Präventionsmassnahme über die öffentlichen Apotheken scheint aufgrund der durchgeführten Evaluation sinnvoll. Voraussetzungen für erfolgreiche pharmazeutische Raucherberatungen und-ent-wöhnungen sind aber eine eingehende Fortbildung und ein motiviertes Tea

Success of a sustained pharmaceutical care service with electronic adherence monitoring in patient with diabetes over 12 months

We report on the first polypharmacy adherence monitoring over 371 days, integrated into a pharmaceutical care service (counselling, electronic multidrug punch cards, feedback on recent electronic records) for a 65-year-old man with diabetes after hospital discharge. The initial daily regimen of four times per day with 15 pills daily changed after 79 days into a daily regimen of two times per day with 9 pills daily for the next 292 days. The patient removed all medication from the multidrug punch cards (taking adherence 100%) and had 96.9% correct dosing intervals (timing adherence). The 57 evening doses showed the least variation in intake times at 17 h 45 min±8 min. Over the observation year, the patient was clinically stable. He was very satisfied with the multidrug punch card and the feedback on electronic records. In conclusion, long-term monitoring of polypharmacy was associated with the benefit of successful disease management

Hospital discharge: What are the problems, information needs and objectives of community pharmacists? A mixed method approach

After hospital discharge, community pharmacists are often the first health care professionals the discharged patient encounters. They reconcile and dispense prescribed medicines and provide pharmaceutical care. Compared to the roles of general practitioners, the pharmacists' needs to perform these tasks are not well known.; This study aims to a) Identify community pharmacists' current problems and roles at hospital discharge, b) Assess their information needs, specifically the availability and usefulness of information, and c) Gain insight into pharmacists' objectives and ideas for discharge optimisation.; A focus group was conducted with a sample of six community pharmacists from different Swiss regions. Based on these qualitative results, a nationwide online-questionnaire was sent to 1348 Swiss pharmacies.; The focus group participants were concerned about their extensive workload with discharge prescriptions and about gaps in therapy. They emphasised the importance of more extensive information transfer. This applied especially to medication changes, unclear prescriptions, and information about a patient's care. Participants identified treatment continuity as a main objective when it comes to discharge optimisation. There were 194 questionnaires returned (response rate 14.4%). The majority of respondents reported to fulfil their role as defined by the Joint-FIP/WHO Guideline on Good Pharmacy Practice (rather) badly. They reported many unavailable but useful information items, like therapy changes, allergies, specifications for "off-label" medication use or contact information. Information should be delivered in a structured way, but no clear preference for one particular transfer method was found. Pharmacists requested this information in order to improve treatment continuity and patient safety, and to be able to provide better pharmaceutical care services.; Surveyed Swiss community pharmacists rarely receive sufficient information along with discharge prescriptions, although it would be needed for medication reconciliation. According to the pharmacist's opinions, appropriate pharmaceutical care is therefore impeded

Drug use problems with self-injected low-molecular-weight heparins in primary care

Purpose: Outpatient subcutaneous therapies are becoming increasingly common. A literature search failed to find produced any studies on application problems pertaining to the self-injection of low-molecular-weight heparins (LMWH) in a heterogeneous outpatient population under daily-life conditions. We therefore designed a study with the aim of recording drug use problems, patient satisfaction, compliance, problems arising from the injection site (abdomen vs. thigh), and residual drug volumes in pre-filled syringes used in self-injection therapy. Methods: Patients were recruited in community pharmacies by 95 trained Master's students in pharmacy. Data were collected during recruitment and by means of structured questionnaire-based telephone interviews that were carried out at the beginning and the end of the LMWH treatment. Results: The median age of the 213 patients enrolled in the study was 54years [interquartile range (IQR) 39-70 years]; of these, 15.5% had their injections administered by a third person. The rate of self-reported non-compliance was 17.1%. At least one relevant problem was recorded in 85.0% of the cases. At the end of the treatment, 38.9% of the patients stated self-administration of the injections required some effort. The preferred injection site was the thigh (68.5%). An overall mean residual drug volume ≥10.0% was detected for 3.9% of the patients. If residual drug was present, a median of 11.2% (IQR 8.6-17.6%) of the total drug volume had not been injected. Patients injecting into the thigh showed a higher risk of leaving residual medication (odds ratio 2.16, 95% confidence interval 1.04-4.51). Conclusions: Most patients had drug use problems, whereas no clear factors were associated with non-compliance, the injection site (apart from residual drug), and discomfort or effort required (apart from prior injection use

Needs and use of drug information sources in community pharmacies: a questionnaire based survey in German-speaking Switzerland

Methods: Postal survey to a random sample of 223 (26% out of 859) community pharmacies from the German-speaking part of Switzerland. The 48-item questionnaires were processed automatically with the Cardiff TELEform®-Software. In addition, a telephone-survey to a random sample of 20 non-responders was performed in order to test for non-response bias. Results: A total of 108 pharmacists (response rate 48%) reported that the official Swiss drug reference book is still the most popular source of drug information used to solve all kinds of drug related problems. The Internet as a source of drug information is of minor importance, even though 88% of the pharmacies have Internet access. Deficits in drug information were reported for paediatrics, phytotherapy, drugs during pregnancy/lactation and for therapy guidelines. According to 35% of the pharmacists, the importance of offering drug information to customers will increase in the future. Most of the pharmacists are not afraid that Internet pharmacies would replace them. Conclusions: The results show that the majority of the community pharmacists are only partially satisfied with the sources of drug information currently available. The Internet still plays a minor role for solving drug-related problems in daily practice, even though the available infrastructure makes the community pharmacies able to use the Internet more frequently. The pharmacists need more websites tailored to their needs. The pharmacists have clear visions about possible future developments. They do, however, have to adopt quickly to the changes ahead in order to remain competitiv

Management of potential drug interactions in community pharmacies: a questionnaire-based survey in Switzerland

Objective: To analyze the current drug-interaction management in Swiss community pharmacies, with a particular focus on electronic systems, and to compare the results with those expressed by German general practitioners in a recent survey. Methods: Data were collected with a postal questionnaire which was randomly sent to 500 out of 833 community pharmacies in the German part of Switzerland. Results: The response rate was 57.4%, and only 24.7% pharmacists reported that they were confronted less than daily with potential drug interactions. Use of computer software to identify potential drug interactions was widespread in community pharmacies (90.2%), and the software was the primary source of information (81.2 ± 29.6%). The quality of the interaction software was judged sensitive (identifying all dangerous interactions) by 80.5 ± 21.5%, but specific (identifying only relevant interactions) by only 38.3 ± 32%. Pharmacists declared a low override rate (14%) of drug interaction alerts, although unjustified alerts were reported by 60.6 ± 33.1%. In contrast to general practitioners, pharmacists opted less often for information on the mechanism of the interaction, and more frequently for details for dose adjustment. Both groups complained about deficient information on non-interacting alternatives. Conclusion: The information needs of community pharmacists differed considerably from general practitioners, and pharmacists were overwhelmed by inappropriate alerts because of a lack of specificity of their drug-interaction systems. Substantial improvement of drug-interaction software systems is thus required at least in two important aspects, the suppression of inappropriate alerts and the tailoring to the needs of the use

Early biomarker response and patient preferences to oral and intramuscular vitamin B12 substitution in primary care: a randomised parallel-group trial

Vitamin B12 (VB12) deficiency can be treated with oral high-dose substitution or intramuscular (i.m.) injection of VB12. Whenever alternative routes of administration exist, patient preferences should be considered when choosing the treatment. We aimed to assess outpatient preferences towards oral or IM VB12 substitution and confirm noninferiority of early biomarker response with oral treatment, in a typical primary care population.; Prospective randomised nonblinded parallel-group trial. Patients were recruited by their general practitioner and randomly assigned to oral or IM treatment. Group O-oral was given 28 tablets of 1000 µg cyanocobalamin in a monthly punch card fitted with an electronic monitoring system. Group I-IM received four, weekly injections of 1000 µg hydroxocobalamin. Blood samples were drawn before the first administration and after 1, 2 and 4 weeks of treatment, and analysed for VB12, holotranscobalamin (HoloTc), homocysteine (Hcy) and methylmalonic acid (MMA). For group O-oral, treatment adher-ence and percentage of days with 2 dosing events were calcu-lated. Before and after 28 days of treatment, patients were asked to fill in a questionnaire about their preference for the therapy options and associated factors.; Between November 2013 and December 2015, 37 patients (age: 49.5 ± 18.5 years; women: 60.5%) were recruited for oral (19) or IM (18) treatment. Baseline values with 95% confidence intervals for serum VB12, HoloTc, Hcy and MMA were 158 pmol/l [145-172], 49.0 pmol/l [40.4-57.5], 14.8 µmol/l [12.0-17.7] and 304 nmol/l [219-390], respective-ly, in group O-oral and 164 pmol/l [154-174], 50.1 pmol/l [38.7-61.6], 13.0 µmol/l [11.0-15.1] and 321 nmol/l [215-427], respectively, in group I-IM (not significant). After 1 month of treatment, levels of VB12 and HoloTc showed a significant increase compared with baseline (group O-oral: VB12 354 pmol/l [298-410] and HoloTc 156 pmol/l [116-196]; group I-IM: VB12 2796 pmol/l [1277-4314] and HoloTc 1269 pmol/l [103-2435]). Hcy and MMA levels showed a significant decrease compared with baseline (group O-oral: Hcy 13.8 µmol/l [10.7-16.8] and MMA 168 nmol/l [134-202]; group I-IM: Hcy 8.5 µmol/l [7.1-9.8] and MMA 156 nmol/l [121-190]). HoloTc and MMA levels were normalised in all patients after 4 weeks of treatment, whereas normalisation of VB12 and Hcy was reached by all patients in group I-IM only. Response of VB12, HoloTc and Hcy was more pronounced in group I-IM (p <0.01) and the primary hypothesis that oral VB12 treatment would be noninfe-rior to IM treatment was rejected. Average adherence to thera-py was 99.6 ± 1.1% and days with 2 dosing events reached 5.6%. Before randomisation, preference was in favour of oral treatment (45.9%, n = 17) over IM administration (21.6%, n = 8). Twelve patients (32.4%) had no preference. Nine (24.3%) patients changed their preference after treatment. Patients who obtained their preferred route of administration main-tained their preference in the case of oral treatment and changed their preference after IM treatment.; Differences in VB12 levels between groups were higher than expected. Therefore, noninferiority of oral treat-ment had to be rejected. However, normalisation of HoloTc and MMA was reached by all patients after a 1-month treatment period. The clinical benefit of the exaggerated biomarker re-sponse after IM treatment within a typical primary care popula-tion is questionable. Midterm biomarker effects and patient preferences should be considered when a therapeutic scheme is chosen. Initial rating in favour of either IM or oral therapy can change over time and justifies repeated re-evaluation of patient preferences. (ClinicalTrials.gov ID NCT01832129)

Inappropriate prescribing: a systematic overview of published assessment tools

Background: Criteria to assess the appropriateness of prescriptions might serve as a helpful guideline during professional training and in daily practice, with the aim to improve a patient's pharmacotherapy. Objective: To create a comprehensive and structured overview of existing tools to assess inappropriate prescribing. Method: Systematic literature search in Pubmed (1991-2013). The following properties of the tools were extracted and mapped in a structured way: approach (explicit, implicit), development method (consensus technique, expert panel, literature based), focused patient group, health care setting, and covered aspects of inappropriate prescribing. Results: The literature search resulted in 46 tools to assess inappropriate prescribing.Twenty-eight (61%) of 46 tools were explicit, 8 (17%) were implicit and 10 (22%) used a mixed approach. Thirty-six (78%) tools named older people as target patients and 10 (22%) tools did not specify the target age group. Four (8.5%) tools were designed to detect inappropriate prescribing in hospitalised patients, 9 (19.5%) focused on patients in ambulatory care and 6 (13%) were developed for use in long-term care. Twenty-seven (59%) tools did not specify the health care setting. Consensus methods were applied in the development of 19 tools (41%), the others were based on either simple expert panels (13; 28%) or on a literature search (11; 24%). For three tools (7%) the development method was not described. Conclusion: This overview reveals the characteristics of 46 assessment tools and can serve as a summary to assist readers in choosing a tool, either for research purposes or for daily practice use