The Impact of Clinical Pharmacists on Drug-Related Problems and Clinical Outcomes

Beskriver en litteraturstudie hvor hensikten var å undersøke betydningen av kliniske farmasøyt på legemiddel interaksjoner og klinisk utbytte for pasienter.Drug‐related problems are frequent and may result in reduced quality of life, and even morbidity and mortality. Many studies have shown that clinical pharmacists can effectively identify and prevent clinically significant drug‐related problems and that physicians acknowledge and act on the clinical pharmacist's suggestions for interventions to the drug‐related problems. A pro‐active rather than a reactive approach on the part of the pharmacists seems prudent for obtaining most benefit. This includes participation of pharmacists in the multidisciplinary team discussions – at the stage of ordering and prescribing – where all types of drug‐related problems, including also potential problems, should be discussed. In addition, counselling by pharmacists about medication on discharge and follow‐up after discharge resulted in better outcomes. Furthermore, clinical pharmacists can positively influence other outcomes, such as improvement of levels of markers for drug use (e.g. optimization of lipid levels, anticoagulation levels and blood pressure). Some studies have reported positive effects on hard clinical outcomes, such as reduced length of stay, fewer re‐admissions and fewer disease events (e.g. heart failure events and thromboembolism). However, more studies should be undertaken with larger patient populations, including patients from multiple sites. More knowledge about patient‐specific factors that predict improved care is also needed. In conclusion, there is increasing evidence that participation and interventions of clinical pharmacists in health care positively influence clinical practice

Klassifisering av legemiddelrelaterte problemer

Beskriver utvikling og testing av et norsk klassifiseringsverktøy for legemiddelrelaterte problem.Bakgrunn: legemiddelrelaterte problemer forekommer hyppig og påfører pasientene betydelig sykelighet og i noen tilfeller død, samt økte utgifter for samfunnet. Et klassifiseringssystem kan bidra til å identifisere slike problemer slik at de kan løses og forebygges. Materiale og metode: vi sendte et utkast til klassifiseringssystem til en bredt sammensatt høringsgruppe fra medisinske og farmasøytiske fagmiljøer. Konsensus ble oppnådd etter to påfølgende høringsrunder hvor klassifiseringens struktur, innhold og relevans ble diskutert. Ved hjelp av korte kasuistikker ble klassifiseringen deretter validert med hensyn til ulike fagpersoners oppfatning og forståelse av de ulike kategoriene. Resultater. Klassifikasjonssystemet er hierarkisk og består av seks hovedkategorier (legemiddelvalg, dosering, bivirkning, interaksjon, avvikende legemiddelbruk og annet) med 12 underkategorier. Systemet kan benyttes i sykehus, allmennpraksis, sykehjem og apotek. Valideringen av systemet viste i gjennomsnitt 70 % enighet om valg av kategori. Fortolkning: vi foreslår et validert norsk system for klassifisering av legemiddelrelaterte problemer. Systemet kan bidra til å identifisere problemene og gi bedre og mer systematisk dokumentasjon og kommunikasjon av slike problemer

Multidisciplinary intervention to identify and resolve drug-related problems in Norwegian nursing homes

Beskriver hvordan et innovativt team identifiserte LRP hos beboere i sykehjem.Objective: to describe an innovative team intervention to identify and resolve DRPs (drug-related problems) in Norwegian nursing homes. Design: descriptive intervention study. Setting: three nursing homes in Bergen, Norway. Subjects: a total of 142 long-term care patients (106 women, mean age 86.9 years). Results: systematic medication reviews performed by pharmacists in 142 patients revealed altogether 719 DRPs, of which 504 were acknowledged by the patients ’ physician and nurses, and 476 interventions were completed. “ Unnecessary drug ” and “ Monitoring required ” were the most frequently identified DRPs. Drugs for treating the nervous system and the alimentary tract and metabolism were most commonly questioned. Conclusions: the multidisciplinary team intervention was suitable to identify and resolve drug-related problems in nursing home settings. Systematic medication reviews and involvement of pharmacists in clinical teams should therefore be implemented on a regular basis to achieve and maintain high-quality drug therapy

Drugs with narrow therapeutic index as indicators in the risk management of hospitalised patients

Drugs with narrow therapeutic index (NTI-drugs) are drugs with small differences between therapeutic and toxic doses. The pattern of drug-related problems (DRPs) associated with these drugs has not been explored. Objective: To investigate how, and to what extent drugs, with a narrow therapeutic index (NTI-drugs), as compared with other drugs, relate to different types of drug-related problems (DRPs) in hospitalised patients. Methods: Patients from internal medicine and rheumatology departments in five Norwegian hospitals were prospectively included in 2002. Clinical pharmacists recorded demographic data, drugs used, medical history and laboratory data. Patients who used NTI-drugs (aminoglycosides, ciclosporin, carbamazepine, digoxin, digitoxin, flecainide, lithium, phenytoin, phenobarbital, rifampicin, theophylline, warfarin) were compared with patients not using NTI-drugs. Occurrences of eight different types of DRPs were registered after reviews of medical records and assessment by multidisciplinary hospital teams. The drug risk ratio, defined as number of DRPs divided by number of times the drug was used, was calculated for the various drugs. Results: Of the 827 patients included, 292 patients (35%) used NTI-drugs. The NTI-drugs were significantly more often associated with DRPs than the non-NTI-drugs, 40% versus 19% of the times they were used. The drug risk ratio was 0.50 for NTI-drugs and 0.20 for non-NTI-drugs. Three categories of DRPs were significantly more frequently found for NTI-drugs: non-optimal dose, drug interaction, and need for monitoring. Conclusion: DRPs were more frequently associated with NTI-drugs than with non-NTI-drugs, but the excess occurrence was solely related to three of the eight DRP categories recorded. The drug risk ratio is a well-suited tool for characterising the risk attributed to various drugs.Los medicamentos con estrecho margen terapéutico (NTI) son medicamentos con pequeñas diferencias entre las dosis terapéuticas y tóxicas. No se han explorado los problemas relacionados con medicamentos (DRPs) de estos medicamentos. Objetivo: Investigar cómo y cuanto se relacionan los tipos de problemas relacionados con medicamentos de estrecho margen terapéutico con los de otros medicamentos en pacientes hospitalizados. Métodos: Se incluyeron prospectivamente en 2002 los pacientes de medicina interna y reumatología de 5 hospitales noruegos. Farmacéuticos clínicos registraron los datos demográficos, medicamentos utilizados, historial médico y datos de laboratorio. Los pacientes que usaban NTI (aminoglucósidos, ciclosporina, carbamazepina, digoxina, digitoxina, flecainamida, litio, fenitoina, fenobarbital, rifampicina, teofilina, warfarina) se compararon con pacientes que no usaban NTI. Se registraron las apariciones de los 8 tipos de DRPs después de revisiones de los registros médicos y evaluación del equipo multidisciplinario del hospital. Se calculó para los varios medicamentos el ratio de riesgo de medicamento, definido como el número de DRP dividido por el número de veces que se uso el medicamento. Resultados: De los 827 pacientes incluidos, 292 (35%) utilizaron NTI. Los NTI estaban significativamente más asociados a DRP que los no NTI, 40% contra 19% de las veces que se utilizaron. El ratio de riesgo de medicamento fue de 0,50 para los NTI y de 0,20 para los no-NTI. Tres categorías de DRP que se encontraron más significativamente en los NTI: dosis no-óptima, interacción medicamentosa, y necesidad de monitorización. Conclusión: Los DRP estaban más frecuentemente asociados a medicamentos NTI que a los no-NTI, pero el exceso de aparición de DRP estaba relacionado solamenrte con tres de las ocho categorías de DRP. El ratio de riesgo de medicamento es una herramienta apropiada para caracterizar el riesgo atribuido a diversos medicamentos

Emergency department physicians' distribution of time in the fast paced-workflow-a novel time-motion study of drug-related activities.

Abstract Background In the emergency department physicians are forced to distribute their time to ensure that all admitted patients receive appropriate emergency care. Previous studies have raised concerns about medication discrepancies in patient’s drug lists at admission to the emergency department. Thus, it is important to study how emergency department physicians distribute their time, to highlight where workflow redesign can be needed. Aim to quantify how emergency department physicians distribute their time between various task categories, with particular focus on drug-related tasks. Method Direct observation, time-motion study of emergency department physicians at Diakonhjemmet Hospital, Oslo, Norway. Physicians’ activities were categorized in discrete categories and data were collected with the validated method of Work Observation Method By Activity Timing between October 2018 to January 2019. Bootstrap analysis determined 95% confidence intervals for proportions and interruption rates. Results During the observation time of 91.4 h, 31 emergency department physicians were observed. In total, physicians spent majority of their time gathering information (36.5%), communicating (26.3%), and documenting (24.2%). Further, physicians spent 17.8% (95% CI 16.8%, 19.3%) of their time on drug-related tasks. On average, physicians spent 7.8 min (95% CI 7.2, 8.6) per hour to obtain and document patients’ drug lists. Conclusion Emergency department physicians are required to conduct numerous essential tasks and distributes a minor proportion of their time on drug-related tasks. More efficient information flow regarding drugs should be facilitated at transitions of care. The presence of healthcare personnel dedicated to obtaining drug lists in the emergency department should be considered

Evaluating categorization and clinical relevance of drug-related problems in medication reviews

Beskriver en intervensjonsstudie hvor hensikten var å evaluere kategorisering og klinisk relevans av legemiddelrelaterte problem identifisert av kommune-farmasøyter, og vurdere kvaliteten på intervensjoner med pasienter og leger som dokumentert av farmasøyter.Objectives: we aimed to evaluate the categorisation and clinical relevance of DRPs identified by community pharmacists, and further, to assess the quality of interventions with the patients and the physicians as documented by the pharmacists. Setting 23 Norwegian community pharmacies. Method: patients with type 2 diabetes were recruited by 24 community pharmacists who performed structured medication reviews based on the patients’ drug profiles and patient interviews. The DRPs identified were subsequently categorised. An evaluation group (EG) retrospectively evaluated the reviews. Clinical/practical relevance of each DRP and quality of community pharmacists’ intervention with patients and physician were scored. Average agreement between the EG and the community pharmacists was calculated. Internal agreement in the EG was calculated using a modified version of Fleiss’ Kappa coefficient. Results: a total of 73 patients were included (mean age 62 years, 52% female, on average prescribed 8.7 drugs). The pharmacists identified 88 DRPs in 43 of the patients. The most common DRPs were adverse drug reactions (22%) and wrong drug or dose used by patient (14%). Anti-diabetic drugs and lipid modifying drugs were associated with the most DRPs. The EG agreed with detection and categorisation of DRPs in more than 80% of the cases. The clinical/practical relevance of the detected DRPs was scored by the EG to be high or medium in 87% of the cases. The quality of the follow-up with patients and physicians was scored to be good or satisfactory in 93 and 98% of the cases, respectively. Conclusions: pre-defined categories of DRPs supported by structured forms were reliable and valid tools for identifying DRPs. The evaluation demonstrated that community pharmacists were able to identify DRPs of high to medium clinical/practical relevance, and to perform follow-ups of the DRPs with the patients and the physicians with a good or satisfactory quality