Quality management in hospitals: analysis of the prescribing practice of cardiovascular medicines

The goal of this study is to analyse the prescribing practice and risk of drug related errors in a Cardiology clinic of University Hospital. Semistructured open-ended interview aiming to reveal the risk of potential errors was performed with physicians, nurses, pharmacists, and hospital managers. Observational analysis of 915 prescriptions, prescribed by the physicians in two cardiology departments was conducted. Prescribing practice was evaluated by the means of its complexity, frequency of prescribing of particular pharmacology groups, and the related costs. Most often gaps detected in prescribing and dispensing of medicinal products were associated with missing or incorrect dosages, and unspecified quantity. Our analysis showed preference to combination therapies. Monotherapy was given only in 24.82% of the acute cases treated and in 24% of the cases treated in the internal ward. Two medicinal products were identified in 24.48% of the prescriptions (intensive care unit) and in 19.24% of the prescriptions from the internal ward. The most prescribed medicinal products were bisoprolol and glyceryl trinitrate in a combination. Approximately 45% of the patients were prescribed up to 3 medicinal products.The increase of therapy complexity leads to increase of probability for drug-drug interactions and nearly 30% of prescriptions were evaluated as potentially risky for interactions. The relative shares of potentially risky combinations vary from 4% to 32% out of all prescriptions reviewed. The likelihood of drug-related problems in the observed Cardiology clinic was determined as high but no practice for recording of ADRs was found in place

Pharmaceutical biotechnology in pharmacy education: USA pharmacy schools

ABSTRACT Pharmaceutical biotechnology, pharmacogenomics, pharmacogenetics, combinatorial chemistry, in close relation to highthroughput screening technologies, and bioinformatics are major advances that give a new direction to pharmaceutical sciences and education. Biotechnology influenced not only the pharmaceutical science and education but also the practice in pharmacies. The aim of our study was to review the scientific literature on biotechnology inclusion in pharmacy curriculum and to systematize the approaches that the colleges and schools of pharmacy in the United States of America (USA) apply to address this education. For the period 1989-2010 a total of 18 publications satisfying the search criteria were found. The articles were systematized in historical order following the date of publication. The developments in modern pharmacy practice are taken into account and implemented in the pharmacy curriculum in the colleges and schools of pharmacy in the United States. In 78% of the USA universities this is achieved by integrating biotechnology content in the PharmD curriculum. Together with the development of biotechnology science the educational programs are improving but they still delay providing knowledge, especially for undergraduate students

Farmakoterapija arterijske hipertenzije u ambulantnim uslovima - troškovi na godišnjem nivou na teret sredstava zdravstvenog osiguranja

Expenditures for the treatment of hypertension and its complication differ among countries and represent huge burden for National Health Funds. The aim of this study is to determine the expenditures charged off obligated health insurance funds and also the prescribing practice of ambulatory treatment of arterial hypertension (AH) in 2006. Retrospective study included 2764 patients with diagnosis AH (I10-I15) and its complications (I20, I21, I25, I50 and I69). Therapy was analyzed according to complexity (number of diagnosis) and frequency of the prescribed medications. The annual expenditures for antihypertensive drugs were compared with total expenditures from National Health Insurance Fund (NHIF) for prescribed medicines. Uncomplicated AH was diagnosed in 1856 (67,15%), while complicated AH in 908 (32,85%) patients. ACE inhibitors were the most frequently prescribed medications (37,01%). NHIF participated with 86,47% in total expenditures for the treatment of AH. More then 55% of total NHIF expenditures for prescribed medications gone on therapy AH. High percentage of patients with complications show late beginning of therapy, irregular visits to general practitioner and inadequate compliance. The expenditures of ambulatory treatment of AH demonstrate that NHIF participate in therapy expenditures with great amount, making the therapy available to patients.Troškovi terapije arterijske hipertenzije (AH) i njenih komplikacija razlikuju se od zemlje do zemlje i istovremeno predstavljaju veliko opterećenje za nacionalne zdravstvene fondove. Cilj ove studije je određivanje troška farmakoterapije AH u ambulantnim uslovima za 2006.godinu na teret sredstava obaveznog zdravstvenog osiguranja, kao i propisivačke prakse. Retrospektivna studija je uključila 2764 pacijenta sa dijagnozom AH (I10-I15) i njenim komplikacijama (I20, I21, I25, I50 i I69). Terapija je analizirana po kompleksnosti (br. dijagnoza) i učestalosti propisivanja farmakoloških grupa lekova. Godišnji troškovi terapije AH su poređeni sa ukupnim izdvajanjem Republičkog zavoda za zdravstveno osiguranje (RZZO) za lekove na recept. Pacijenata bez komplikacija AH bilo je 1856 (67,15%), a pacijenata sa komplikacijama 908 (32,85%). Najpropisivanija grupa AH lekova su ACE inhibitori (37,01%). RZZO učestvuje sa 86,47% u ukupnim troškovima terapije AH. Preko 55% svih sredstava RZZO utrošeno je na medikamentoznu terapiju obolelih od AH. Visok procenat obolelih od komplikacija AH u Srbiji ukazuje na kasno započinjanje lečenja AH, neredovno javljanje lekaru, kao i nedovoljnu komplijansu. Analizom troška terapije pacijenata sa AH u ambulantnim uslovima pokazano je da RZZO u trošku terapije učestvuje sa visokim procentom, čineći terapiju AH dostupnu pacijentima

Analiza troškovne isplativosti različitih vrsta porođaja kod jednoplodnih trudnoća - podaci iz prakse

Introduction Views on the conduct of labor have changed over time, and a significant difference exists in relation to obstetric centers. Objective To assess cost, clinical outcomes and cost-effectiveness of different types of labor in singleton pregnancies. Methods A decision model was used to compare vaginal labor, induced labor and planned cesarean section. All data were taken from the Book of Labor from the University Hospital for Gynecology and Obstetrics 'Narodni Front', Belgrade, Serbia for labors conducted during one month period in 2011. Successful delivery (i.e. labor that began up to 42 gestation weeks, without maternal mortality and the newborn Apgar scores greater than or equal to seven in the fifth minute of life) was considered as the outcome of the cost effectiveness-analysis. To test the robustness of this definition probabilistic sensitivity analysis was performed. Results From a total of 667 births, vaginal labor was conducted in 98 cases, induced vaginal in 442, while planned cesarean section was performed 127 times. Emergency cesarean section as a complication was much higher in the vaginal labor cohort compared to the induced vaginal cohort (OR=17.374; 95% CI: 8.522 to 35.418; p lt 0.001). The least costly type of labor was induced vaginal labor: average cost 461 euro, with an effectiveness of 98.17%. Both, vaginal and planned cesarean labor were dominated by the induced labor. The results were robust. Conclusion Elective induction of labor was associated with the lowest cost compared to other types of labor, with favorable maternal and neonatal outcomes.Uvod Način porođaja se tokom godina menjao, a značajna razlika postoji u pogledu kliničkog centra u kojem se porođaj obavlja. Cilj rada Cilj rada je bio da se procene troškovi, klinički ishodi i troškovna isplativost različitih vrsta porođaja kod jednoplodnih trudnoća. Metode rada Za potrebe rada konstruisano je 'drvo' odlučivanja, radi poređenja spontanog vaginalnog, indukovanog vaginalnog porođaja i planiranog carskog reza. Iz knjige porođaja GAK 'Narodni front' uzeti su podaci o svim porođajima obavljenim u jednomesečnom periodu 2011. godine. Kao ishod analize troškovne isplativosti posmatran je uspešan porođaj, definisan kao porođaj koji je počeo do navršene 42. nedelje gestacije, bez smrtnost majke i sa Apgar skorom novorođenčeta većim ili jednakim 7 u petom minutu po rođenju. Primenom probabilističke analize osetljivosti ispitana je pouzdanost rezultata. Rezultati Od ukupno 667 porođaja, vaginalni porođaj je urađen u 98 slučajeva, indukovani u 442 slučaja, a planirani carski rez 127 puta. Hitni carski rez, kao komplikacija, bio je znatno češći kod žena sa spontanim vaginalnim porođajem nego kod žena koje su porođene primenom indukcije (OR=17,374; 95%CI: 8,522-35,418; p lt 0,001). Indukovani vaginalni porođaj je imao najmanje troškove (461 evro), s efektivnošću od 98,17%. Spontani vaginalni i planirani carski rez su bile skuplje strategije s manjom efektivnošću (dominirane strategije). Rezultati su bili pouzdani. Zaključak Elektivan indukovani porođaj je imao najniže troškove u odnosu na druge vrste porođaja, sa željenim ishodima po majku i dete

Pharmacy network and access to medicines in selected eastern European countries: comparative analysis

Aim To analyze the pharmacy network (structure and resources) in Bulgaria, Croatia, Serbia, and Slovenia and its relation to public expenditures for medicines. Methods We performed a cross-sectional study using the officially published data for the period 2003-2008 in four selected countries. Data sources were relevant national institutions. Results In 2008, Serbia had 27.5, Bulgaria 66.8, Croatia 59.5, and Slovenia 71.2 pharmacists per 100 000 inhabitants. There was a significant difference in the number of pharmacists per 100 000 inhabitants between all countries except between Bulgaria and Slovenia. The number of inhabitants per one pharmacy was significantly different between all observed countries. The expenditures for medicines per capita in 2008 were between €30.34 in Bulgaria to €137.03 in Slovenia, with a significant difference between all countries except between Bulgaria and Serbia. The number of pharmacists per 100 000 inhabitants and expenditures for medicines per capita were positively correlated in all observed countries, except in Bulgaria. Conclusion There were significant difference in the structure and availability of the pharmacy service in all selected countries. Expenditures for medicines were positively correlated with the number of pharmacists in all countries, except in Bulgaria. Our findings could be valuable to national regulatory bodies for the creation of national drug policies

Cost of outpatient hypertension pharmacotherapy: Comparative study between Bulgaria and Serbia

Objective: To compare the prescribing practice and pharmacotherapy outpatient cost of hypertension and its common complications between two neighboring countries, Bulgaria and Serbia. The study questions focus on consistency of the prescribing practice with the treatment guidelines, comparability of the treatment patterns among both countries, and burden of hypertension cost to the population and third party payer in the countries under consideration. Methods: Retrospective study, one year time horizon is for outpatient therapy. Results: Patients with arterial hypertension in Bulgaria are most often on monotherapy (61% vs 6% in Serbia), as well as those with complications (66% vs 0% Serbia). In both countries the first choice of therapy are the ACE inhibitors (37.01% in Serbia and 41% in Bulgaria) and then follows the calcium antagonists, beta-blockers, and diuretics. The weighed monthly cost of hypertension and complicated hypertension is almost doubled in Serbia (12.56 vs 8.23 EUR for hypertension, and 13.39 vs 8.23 EUR) and prevailing part is reimbursed (88% vs 44% in Bulgaria). Conclusion: Our study confirms that hypertension and its complications therapy consumes a huge amount of financial resources. In both countries under consideration the therapy is corresponding with the European treatment guidelines. The international cost comparisons are possible but they depend on many external factors as the regulatory measures, prescribing habits and reimbursement policy and should be analysed within this framework

Economic evaluation of different screening alternatives for patients with clinically suspected acute deep vein thrombosis

Introduction: We examined the cost-effectiveness of the three different D-dimer measurements in the screening of DVT in models with and without calculation of pre-test probability (PTP) score. Moreover, we calculated the minimal cost in DVT detection. Material and methods: In the group of 192 patients with clinically suspected acute DVT, we examined the three different D-dimer measurements (Innovance D-dimer, Hemosil D-dimer HS and Vidas D-dimer Exclusion II) in combination with and without PTP assessment. Results: The diagnostic alternative employing Vidas D-dimer Exclusion II assay without and with PTP calculation gave lower incremental cost-effectiveness ratio (ICER) than the alternative employing Hemosil D-dimer HS assay (0.187 Euros vs. 0.998 Euros per one additional DVT positive patient selected for CUS in model without PTP assessment and 0.450 vs. 0.753 Euros per one DVT positive patient selected for CUS in model with PTP assessment). According to sensitivity analysis, the Hemosil D-dimer HS assay was the most cost effective alternative when one patient was admitted to the vascular ambulance per day. Vidas D-dimer Exclusion II assay was the most cost effective alternative when more than one patient were admitted to the vascular ambulance per day. Cost minimisation analysis indicated that selection of patients according to PTP score followed by D-dimer analysis decreases the cost of DVT diagnosis. Conclusions: ICER analysis enables laboratories to choose optimal laboratory tests according to number of patients admitted to laboratory. Results support the feasibility of using PTP scoring and D-dimer measurement before CUS examination in DVT screening

Real World Experience of Disease Activity in Patients With Rheumatoid Arthritis and Response to Treatment With Varios Biologic DMARDs

The current study investigate the disease activity and effectiveness of treatment in patients with RA on biological disease modifying antirheumatic drugs (bDMARDs) in combination with a conventional synthetic DMARD (csDMARD) and determine whether or not the benefits of different therapies were sustained over a follow up period of 1 year. 124 patients were selected with a mean age 55.26 ± 13, 18SD years, meeting the 1987 ACR and /or ACR/ EULAR (2010) classification criteria for Rheumatoid arthritis (RA). Patients were arranged according to treatment regimens: Tocilizumab (TCL) – 30 patients, Certolizumab (CZP) – 16, Golimumab (GOL) – 22, Etanercept (ETN) 20, Adalimumab (ADA) 20, Rituximab (RTX) – 16. Disease activities was the primary concern. Independent joint assessor evaluated 28 joints on baseline, 6th and 12th month’s thereafter. C-reactive protein (CRP) was used to measure the inflammatory process. DAS28-CRP, clinical disease activity index (CDAI) and simplified disease activity index (SDAI) were calculated. On baseline all of the patients’ groups had severe disease activity (mean DAS28-CRP > 5.2, mean CDAI > 22, mean SDAI > 26. It was noted that, during the 6th month follow-up period all of the treatment groups significantly decreased DAS28-CRP, CDAI, SDAI and reach moderate disease activity. After 6th and 12th months of treatment all of the groups on bDMARDs had significantly lower disease activity. The GOL group reach remission only according to DAS28-CRP: 2.49 ± 0.76, and low disease activity as measured by CDAI: 6.78 ± 4.51 and SDAI 7.80 ± 5.67. The other 5 groups after 12 months reach the level of low disease activity according to the three activity parameters: DAS28-CRP (TCL 3.07 ± 0.73, CZP 3.06 ± 0.65, ETN 2.85 ± 0.55, ADA 3.15 ± 0.82, RTX 2.90 ± 0.70), CDAI (TCL 9.80 ± 4.91, CZP – 9.33 ± 4.22, ETN 7.97 ± 3.80, ADA 10.00 ± 5.25, RTX 7.48 ± 2.99) and SDAI (TCL 10.45 ± 5.14, CZP 9.94 ± 4.43, ETN 9.03 ± 4.25, ADA 10.50 ± 5.61, RTX 8.08 ± 3.24). The therapy with different bDMARDs added to a csDMARD led to very similar results – a minimal disease activity and a state of remission in the GOL treatment group only as per DAS28-CRP

Evaluating potentially inappropriate medications in elderly patients in a pharmacy setting in Bulgaria: A pilot study utilizing the EU (7)-PIM List

Objective: The primary aim of this study was to evaluate, for the first time, the use of the EU-7 PIM List in identifying potentially inappropriate medications among older patients. Researchers have firmly established the connection between drug-related problems, which include increased morbidity and mortality rates and the heightened utilization of healthcare services. While previous studies have focused on methodologies for identifying potentially inappropriate medications in Bulgaria, further research is warranted to explore the applicability of the widely recognized EU(7)- PIM List. Materials and methods: A prospective review was conducted on patient prescriptions aligned with the National Health and Insurance Fund, explicitly focusing on patients aged over 65 years from a single pharmacy in Veliko Turnovo City, Bulgaria. The review spanned from November 2022 to April 2023. The prescriptions analyzed in this study exclusively comprised medications covered by the insurance fund. The pharmacy manager provided patient prescription data in a coded form, which included information on the patients’ age, corresponding medications, and accompanying ICD codes. Results: The study analyzed a sample of 255 patients. Healthcare providers prescribed 2,623 medications, and 61.96% of the patients had polypharmacy, taking more than five medications daily. Among the study population, 67% with polypharmacy had at least one PIM based on the EU (7)-PIM List criteria. In total, 173 potentially inappropriate medications (PIMs) were identified. The main PIMs were categorized into four groups: alimentary tract and metabolism, blood and blood-forming organs, cardiovascular system (CVS), and nervous system. Most PIMs (75.72%) were in the ATC cardiovascular system. Within the CVS category, 11 PIMs were associated with digoxin intake and 11 with antiarrhythmics such as propafenone, flecainide, and amiodarone. In addition, trimetazidine was linked to 9 PIMs, and centrally acting antiadrenergic agents had 22 PIMs, with moxonidine being the most prevalent (n=16). Peripherally acting agents were linked to 22 PIMs, primarily doxazosin. The study identified 24 PIMs related to diuretics, specifically spironolactone, and 18 PIMs related to selective calcium channel blockers such as verapamil. The antithrombotic agent category had the highest share, with 30 identified PIMs, including acenocoumarol, dabigatran, rivaroxaban, and apixaban. Furthermore, the examination of ICD codes confirmed that most PIMs occurred within CVS, with patients having ICD I11.0 and ICD I11.9 being associated with 40 and 47 PIMs, respectively. Conclusion: This study highlights many PIMs among patients with cardiovascular diseases. Using the EU (7)-PIM List as a pilot study demonstrates its effectiveness in managing adult patients’ conditions. Given the significant role of PIMs in deprescribing strategies for older patients with polypharmacy, there is a need for prescribers, educators, and drug regulatory institutions to show increased interest in regulatory measures and specific aspects related to PIM use. This is important because the demographic trend of population ageing continues, and organizations increasingly focus on the elderly population