The CombiConsultation for patients with diabetes, COPD and cardiovascular diseases: Evaluation of interventions and personal health-related goals

Background: The CombiConsultation is a consultation with the community pharmacist for patients with diabetes, COPD and/or cardiovascular disease (CVD), aligned with the annual or quarterly consultation with the practice nurse (PN) or general practitioner (GP). The consultation is focused on the personal health-related goals of the patient. Objectives: To assess the number and types of personal health-related goals, drug-related problems (DRPs) and interventions identified by pharmacists during a CombiConsultation and to investigate which patients can benefit most from such consultation. Method: Twenty-one Dutch community pharmacies and associated GP practices were included in the CombiConsultation study. CombiConsultations were performed, involving patients with diabetes, COPD and/or (at risk of) CVD. The pharmacists set health-related goals together with the patients and identified DRPs. The number and types of personal health-related goals, DRPs and interventions were analysed. Associations between patient characteristics and the identification of at least one DRP were analysed by multivariate regression analysis. Results: In 834 patients (49% men, mean age: 70 years), 939 DRPs were identified, mostly (potential) side effects (33%), undertreatment (18%) and overtreatment (14%). In 71% of the patients, one or more DRPs were found, with a median of one DRP per patient. Pharmacists proposed 935 recommendations, of which 72% were implemented. DRPs were found more often in patients using a higher number of drugs for chronic conditions. A total of 425 personal health-related goals were set, of which 53% were (partially) attained. Conclusion: The CombiConsultation can be used as a compact health service contributing to safe and effective use of medication for patients with diabetes, COPD and/or (at risk of) CVD, also in patients under 65 or with less than 5 medications in use. The output of the CombiConsultation reflects its characteristics

Barriers and facilitators for the implementation of the CombiConsultation by general practitioners, pharmacists and practice nurses: a qualitative interview study

BACKGROUND: The CombiConsultation is a consultation with the pharmacist for patients with a chronic condition, aligned with the periodic consultation with the practice nurse or general practitioner. Implementation requires adjustments in the working methods of these healthcare providers and therefore behavioural changes. AIM: The aim of this study was to identify the barriers and facilitators that determine the behavioural changes by pharmacists, general practitioners and practice nurses required for the implementation of the CombiConsultation. METHOD: Ten community pharmacists, 5 practice nurses and 5 general practitioners were sampled from practices enrolled in the CombiConsultation study. Their views regarding the implementation of this clinical pharmacy service were explored using interviews based on the 14 domains of the Theoretical Domains Framework (TDF), which are linked to the Capability-Opportunity-Motivation-Behaviour-model. Barriers and facilitators in the domains were assessed by content analysis. RESULTS: Twelve barriers and 23 facilitators were found within 13 TDF domains with high agreement between the healthcare providers. Important facilitators for implementation were the pharmacists' expertise in pharmacotherapy (capability), access to medical data and physical proximity between professional practices (opportunity). Barriers were pharmacists' insufficient consultation- and clinical-reasoning skills (capability), insufficient staff (opportunity) and reimbursement and lack of coordination among all involved healthcare providers (motivation). CONCLUSION: All healthcare providers are motivated to implement the CombiConsultation. An existing collaborative practice, with a clear and accepted professional role of the pharmacist is essential. Training of pharmacists in consultation and clinical-reasoning skills can be beneficial, as well as arrangements on the consultation logistics, and reimbursement

The CombiConsultation: a new concept of sequential consultation with the pharmacist and practice nurse/general practitioner for patients with a chronic condition

The primary health care system is generally well organized for dealing with chronic diseases, but comprehensive medication management is still a challenge. Studies suggest that pharmacists can contribute to effective and safe drug therapy by providing services like a clinical medication review (CMR). However, several factors limit the potential impact of a CMR. Therefore, we propose a new pharmaceutical care service for patients with a chronic condition: the CombiConsultation. The CombiConsultation is a medication evaluation service conducted by the (community) pharmacist and either the practice nurse or general practitioner. It consists of 3 steps: medication check, implementation and follow-up. The pharmacist primarily focusses on setting treatment goals for 1 or 2 drug-related problems in relation to a specific chronic condition. In this manuscript we describe the process and characteristics of the CombiConsultation. We compare the CombiConsultation with the CMR and explain the choices made and the implications for implementation

Cost-utility and cost-effectiveness analysis of a clinical medication review focused on personal goals in older persons with polypharmacy compared to usual care: Economic evaluation of the DREAMeR study

AIMS: The ageing society may lead to increasing healthcare expenditure. A clinical medication review (CMR) could potentially reduce costs. The aim of this study is to perform a cost-utility and cost-effectiveness analysis from a societal perspective of a patient-centred CMR. METHODS: A trial-based cost-utility and cost-effectiveness analysis was performed as part of the DREAMeR study, a pragmatic controlled trial that randomised patients aged ≥70 years using at least seven drugs to either CMR or usual care. Over six months, healthcare consumption and drug use were collected to estimate costs, and effects were collected in terms of quality-adjusted life years (QALYs) measured with EQ-5D-5 L and EQ-VAS and as reduced health-related complaints with impact on patients' daily lives. RESULTS: The total mean costs per patient (n = 588) over six months were €4,189 ± 6,596 for the control group (n = 294) and €4,008 ± 6,678 for the intervention group (n = 294), including estimated intervention costs of €199 ± 67, which resulted in a mean incremental total cost savings of €181 for the intervention group compared to the control group. Compared to the control group, for the intervention group, the mean incremental QALYs over six months were: -0.00217 measured with EQ-5D and 0.003 measured with EQ-VAS. The incremental effect of reduced health-related complaints with impact was -0.34. There was a likelihood of >90% that the intervention was cost-saving. CONCLUSIONS: The benefits of a patient-centred CMR were inconsistent with no benefits on HR-QoL measured with EQ-5D-5 L and small benefits on HR-QoL measured with EQ-VAS and health-related complaints with impact on patients' daily lives. Additionally, a CMR could potentially be cost saving from a societal perspective

Optimaliseren geneesmiddelengebruik door ouderen

Kwint H-F, Faber A, Gussekloo J, Bouvy ML. Optimizing medication use for elderly patients. Huisarts Wet 2015;58(3):134-8. In conclusion, the studies presented in the thesis show the importance of the different steps of the medication review process when prescribing for elderly patients and the outcomes achieved. Studies of older users of multidose drug dispensing systems provide insight into the quality of medication use in these individuals. Further research is needed, for example, to determine which older patients will benefit the most from medication review or use of multidose drug dispensing systems. The thesis Improving appropriate medication use for older people in primary care investigated how the medication use of elderly patients on polypharmacy in primary care can be optimized, with emphasis on the effects of medication review and multidose dispensing systems. In this article, we present a series of studies from this thesis. We describe the effect of medication review on drug-related problems, disease-specific outcomes, and health-related quality of life. Thereafter we focus on the different steps of the medication review process, such as the medication history and the possible role of explicit STOPP-START criteria in the identification of drug-related problems. We investigated the extent of inappropriate prescribing to older patients receiving their drugs via multidose drug dispensers and compared the self-reported medication adherence and knowledge of these patients with those of patients receiving manually dispensed drugs

STOPP-START criteria cannot replace medication review

Achtergrond De STOPP- en START-criteria zijn opgesteld om ten onrechte gebruikte en ten onrechte achterwege gebleven medicatie bij ouderen op te sporen. Of daarmee alle farmacotherapiegerelateerde problemen (FTP’s) kunnen worden opgespoord is echter nog niet onderzocht. Wij gingen na in hoeverre de STOPP- en START-criteria te vergelijken zijn met een volledige medicatiebeoordeling. Methode Eénentwintig apothekers uit 13 apotheken in Zuidwest-Nederland voerden in 2011 samen met 65 huisartsen een volledige medicatiebeoordeling uit bij 457 thuiswonende 65-plussers die minimaal vijf geneesmiddelen gebruikten. Wij voerden een retrospectief dossieronderzoek uit in een geanonimiseerde database met de FTP’s van deze patiënten. Primaire uitkomsten waren aantal, type en implementatiegraad van de FTP’s waarop STOPP-START-criteria van toepassing waren. Resultaten De mediane leeftijd van de patiënten was 77 jaar (interkwartielafstand 73-81) en 60% was vrouw. Van de 1656 in de database vastgelegde FTP’s was 81% niet te identificeren met de STOPP-START-criteria. START-criteria waren vaker van toepassing op de FTP’s dan STOPP-criteria (13 versus 5,7%; p < 0,01), maar de implementatiegraad van STOPP-criteria was hoger (56 versus 39%; p < 0,01). Aanbevelingen die geen verband hielden met de STOPP-START-criteria werden echter het vaakst doorgevoerd (66%; p = 0,047). Conclusie Een volledige medicatiebeoordeling volgens de impliciete methode, die berust op medische kennis en een gestructureerd gesprek met de patiënt, is de beste methode voor het opsporen van farmacotherapiegerelateerde problemen bij ouderen in de eerste lijn. Expliciete screeningsmethoden, zoals de STOPP-START-criteria, kunnen als hulpmiddel worden gebruik

Persoonlijke behandeldoelen helpen bij medicatiebeoordelingen

Inleiding Medicatiebeoordelingen (MBO’s) kunnen farmacotherapiegerelateerde problemen (FTP’s) verminderen. Daarbij ligt de nadruk vaak meer op het volgen van richtlijnen en is er minder aandacht voor persoonlijke doelen van de patiënten. Wij onderzochten 1) of goal attainment scaling (GAS) een bruikbaar hulpmiddel is om tijdens een MBO persoonlijke doelen te formuleren en 2) of GAS een geschikt instrument is om het behalen van die doelen te meten. Methode We voerden een procesanalyse uit van de interventiegroep van het DREAMeR-onderzoek, een gerandomiseerd gecontroleerd onderzoek naar de effecten van een MBO op de kwaliteit van leven en gezondheidsklachten. De interventiegroep bestond uit 315 ouderen van ≥ 70 jaar die ≥ 7 geneesmiddelen gebruikten en meededen aan een MBO gericht op persoonlijke doelen. Uitkomstmaten voor dit deelonderzoek waren het percentage ouderen met een persoonlijk doel, het behalen van doelen gemeten met GAS na drie en zes maanden, en de implementatiegraad van aanbevelingen voor GAS-gerelateerde FTP’s en overige FTP’s. Resultaten Bij 280 ouderen werden 406 persoonlijke doelen opgesteld (90%). Na drie en zes maanden was respectievelijk 37% en 43% daarvan behaald. De meest voorkomende doelen waren: pijn verminderen (n = 66; 16%), aantal pillen verminderen (n = 57; 14%) en mobiliteit verbeteren (n = 37; 9%). De implementatiegraad van aanbevelingen behorende bij GAS-gerelateerde FTP’s was hoger dan van overige FTP’s (81% versus 62%, p < 0,05). Conclusie Goal attainment scaling lijkt een bruikbaar hulpmiddel bij het opstellen van persoonlijke doelen tijdens een MBO en is geschikt om het behalen van doelen te meten

Medication on a roll for the elderly patient living at home

Zelfstandig wonende oudere patiënten vinden het vaak lastig om hun medicatie goed te beheren en te gebruiken. Vaak kampen ze met ordeningsproblemen. Als ondersteuning gebruiken veel van deze patiënten medicatie op rol. Zo’n medicatierol biedt helaas niet alleen voordelen. In deze beschouwing beschrijven we de bevindingen uit een proefschrift over de toepassing van medicatie op rol bij de thuiswonende oudere patiënt

Vergelijking van therapietrouw en geneesmiddelenkennis bij oudere thuiswonende gebruikers van medicatie op rol en bij gebruikers van regulier verpakte geneesmiddelen

OBJECTIVE: To compare the self-reported medication adherence and knowledge of older patients receiving their drugs via multidose drug dispensing (MDD users) with patients receiving manually dispensed drugs (non-MDD users). METHODS: MDD users (≥65 years, ≥5 oral chronic drugs) were randomly selected from eight Dutch community pharmacies. Non-MDD users (≥5 oral chronic drugs) were matched on age and gender. Medication adherence was assessed by using the Medication Adherence Reporting Scale (MARS) and medication knowledge by asking the indication of drugs. Cognitive function was measured with Mini-Mental State Examination (MMSE) for a subselection of patients. RESULTS: The percentage of patients being adherent to all drugs was higher for MDD users (n = 119, 81%) than for non-MDD users (n = 96, 58%, P <0.001). The percentage of patients with adequate knowledge was lower for MDD users (40%) compared to non-MDD users (79%, P <0.001). The differences in adherence were independent of knowledge and MMSE scores. CONCLUSION: This study shows that older patients receiving their drugs via multidose drug dispensing reported a higher medication adherence than patients receiving manually dispensed drugs, despite a lower knowledge and lower cognitive function among patients receiving MDD