Moniammatillisen lääkehoidon kokonaisarviointimallin kehittäminen ja soveltaminen iäkkäille avohoitopotilaille

Populations in Western countries are ageing. At the same time, use of medications is increasing among older people. Age-related changes in the body make the elderly vulnerable to adverse drug events. Thus, ensuring medication safety among this patient group is a growing health care concern. The aim of this study was to examine the Finnish collaborative Comprehensive Medication Review (CMR) model as a means to improve the appropriateness of pharmacotherapy among community-dwelling elderly. The specific aims were 1) to determine the prevalence of potentially inappropriate medication use according to the Beers 2003 criteria among Finnish non-institutionalized population aged ≥65 years; 2) to describe the development and assess participant satisfaction on the CMR accreditation training; 3) to describe the development of the CMR procedure and related documentation; and 4) to assess the drug-related problems (DRPs) pharmacists report to collaborating physicians during CMR and the resulting interventions among outpatients aged ≥65 years. The prevalence of potentially inappropriate drug use was studied by using the drug reimbursement register of the Social Insurance Institution covering the entire non-institutionalized population aged ≥65 years in 2007 (n=841 509, Study I). The development of the CMR procedure and accreditation training involved a review of literature and international medication review procedures, and pilot testing by 26 experienced pharmacists undergoing the CMR training in 2005 - 2006 (Studies II, III). Pharmacists satisfaction on the CMR training (n=38) and documentation (n=27) were assessed by surveys completed by CMR training participants in 2006 - 2007 (Studies II, III). The DRPs reported to the collaborating physicians were studied by a retrospective review of CMR case reports (n=121) by 26 community pharmacists attending the CMR training in 2006 - 2007 (Study IV). Approximately 15% of the non-institutionalized population aged ≥65 years used potentially inappropriate medications in 2007. The most worrying finding was the common use of benzodiazepines, particularly high-dose temazepam. The 1.5-year CMR accreditation training for practicing pharmacists combines distance learning and face-to-face learning. The participating pharmacists satisfaction with the training was high but several factors prevent them from conducting CMRs after the training. The collaborative CMR procedure involves access to clinical patient information, in-home patient interview, a case conference with the collaborating physician and standard documentation to support the process. The procedure covers four dimensions critical for safe and appropriate geriatric pharmacotherapy: Aging and Safety; Co-Morbidities; Polypharmacy; and Adherence. During CMR pharmacists reported to collaborating physicians an average of 6.5 DRPs/patient. Most common DRPs were inappropriate drug selection, especially involving psychotropics, and undertreatment. Also treatment of pain was often found to need improvement. Approximately half of the pharmacists recommendations led to medication changes, i.e., to an average of 3 changes/patient. The most common agreed change was to stop hypnotics or sedatives. The CMR procedure could be beneficial for improving pharmacotherapy among older outpatients as a large portion of DRPs identified by pharmacists led to medication changes. Actions to facilitate implementation of the model to Finnish health care system are needed. Also, further studies are needed to evaluate the effects of CMR on clinical, humanistic and economic outcomes.MONIAMMATILLINEN LÄÄKEHOIDON KOKONAISARVIOINTI VÄHENTÄÄ IÄKKÄIDEN LÄÄKEHOIDON ONGELMIA Väestön ikääntyminen johtaa lääkekäytön lisääntymiseen ja altistaa lääkkeiden aiheuttamille haitoille. Mm. sosiaali- ja terveysministeriö on suositellut moniammatillisten toimintamallien käyttöönottoa ikääntyvien lääkehoidon turvallisuuden varmistamiseksi. Tässä väitöskirjatutkimuksessa selvitettiin moniammatillisen lääkehoidon kokonaisarvioinnin (LHKA) soveltuvuutta ja tarvetta avohoidossa olevilla ikääntyvillä Suomessa. Kelan valtakunnalliseen rekisteritietoon perustuva tutkimus osoitti, että vuonna 2007 15% suomalaisista 65 vuotta täyttäneistä avohoitopotilaista käytti vähintään yhtä iäkkäillä haitallista lääkettä. Selvästi yleisimpiä näistä olivat unilääkkeinä käytettävät bentsodiatsepiinit, etenkin tematsepaami. Tutkimuksessa kehitetyssä lääkehoidon kokonaisarviointimallissa erityispätevyyskoulutuksen suorittanut farmaseutti tai proviisori toimii kiinteässä yhteistyössä hoitavan lääkärin ja tarvittaessa hoitajien kanssa. Lääkehoidon arviointi perustuu lääkäriltä saatujen hoitotietojen ja potilaalta itseltään kotikäynnin yhteydessä kerättyjen tietojen syvälliseen läpikäymiseen. Arvioinnissa esille tulleet lääkehoidon ongelmat kirjataan raporttiin ja käydään läpi hoitavan lääkärin kanssa henkilökohtaisesti. Tutkimuksen osana kehitettiin yhteneväinen lomakkeisto, johon arviointitulokset kirjataan. Tässä tutkimuksessa farmaseutit ja proviisorit raportoivat hoitavalle lääkärille LHKA:n yhteydessä keskimäärin 6,5 lääkehoitoon liittyvää ongelmaa/iäkäs potilas. Yleisimmät ongelmat olivat epätarkoituksenmukaisen lääkkeen käyttö (koskien etenkin uni- ja rauhoittavia lääkkeitä) sekä alilääkitys. Myös kivun lääkehoitoon liittyvät ongelmat olivat yleisiä. Lääkärit hyväksyivät noin puolet farmaseuttien/proviisoreiden tekemistä lääkitysmuutosehdotuksista (keskimäärin 3 muutosta/potilas). Yleisin muutos oli unilääkkeen lopettaminen. Väitöskirjassa kuvataan myös valtakunnallisen LHKA-koulutuksen kehittäminen ja toteutus (1,5 vuotta, 35 opintopistettä). Koulutus on proviisoreille ja farmaseuteille suunnattu erityispätevyyskoulutus, joka suoritetaan yhteistyössä paikallisen terveydenhuollon kanssa. Keskeisenä osana koulutusta ovat oikeat potilastapaukset. Koulutukseen osallistuneet farmaseutit ja proviisorit olivat siihen erittäin tyytyväisiä, vaikka kaikki eivät ole täysimääräisesti pystyneet hyödyntämään osaamistaan koulutuksen jälkeen. Erityispätevyyden suorittaneita on noin 150 eri puolilla Suomea. Tutkimus antaa viitteitä, että moniammatillisen lääkehoidon kokonaisarvioinnin avulla on mahdollista vähentää iäkkäillä haitallisten lääkkeiden käyttöä ja lääkehoidon ongelmia. LHKA:n jalkauttamiseksi suomalaiseen terveydenhuoltoon tarvitaan kuitenkin lisätoimenpiteitä. Lisäksi tarvitaan tutkimuksia LHKA:n hoidollisista ja taloudellisista vaikutuksista sekä vaikutuksesta potilaiden elämänlaatuun. Tutkimuksen aineisto kerättiin Kelan lääkekorvaustiedostosta, analysoimalla kirjallisia lääkehoidon kokonaisarviointiraportteja sekä tekemällä kyselyitä lääkehoidon kokonaisarviointikoulutukseen osallistuville farmaseuteille ja proviisoreille

Drug-related problems and pharmacy interventions in non-prescription medication, with a focus on high-risk over-the-counter medications

Background The risks associated with over-the-counter medication are often underestimated by consumers. The incorrect use of certain medications can lead to significant patient harm. Inappropriate use can be prevented by pharmaceutical counselling. Objective To determine the number and nature of drug-related problems in over-the-counter medication with a special emphasis on high-risk over-the-counter medications. Setting Fifty-two community pharmacies in Finland. Method This observational study was conducted as a questionnaire survey. The pharmacists working in participating pharmacies documented the observed drug-related problems and pharmacy interventions in over-the-counter medication during 1 week using an electronic study form based on the Westerlund drug-related problem classification system. Main outcome measure The prevalence of drug-related problems and problem types in different medication categories. Results The 52 community pharmacies documented 339 drug-related problems in 0.6% of over-the-counter customers, the most common problem being "Uncertainty about the indication for the drug" (39.2%). A significant proportion of the documented problems (26.3%) concerned high-risk over-the-counter medications, and the majority of these cases were associated with non-steroidal anti-inflammatory drugs (21.8%). In total, pharmacies made 641 interventions to resolve the drug-related problems. For majority of drug-related problems (87%), pharmacist's intervention involved counselling. In more than half of the problem cases, the pharmacy intervention was precautionary. Conclusion Pharmacists intervene in and prevent problems related to over-the-counter medications, including high-risk medications like analgesics, in which inappropriate use due to consumers' lack of knowledge can lead to severe consequences. As the selection and use of over-the-counter medications is continuously increasing, pharmaceutical counselling should be readily available and actively provided for consumers to achieve safer self-medication.Peer reviewe

An In-home Advanced Robotic System to Manage Elderly Home-care Patients' Medications : A Pilot Safety and Usability Study

Purpose: We examined the safety profile and usability of an integrated advanced robotic device and telecare system to promote medication adherence for elderly home-care patients. Methods: There were two phases. Phase I aimed to verify under controlled conditions in a single nursing home (n = 17 patients) that no robotic malfunctions would hinder the device's safe use. Phase II involved home-care patients from 3 sites (n = 27) who were on long-term medication. On-time dispensing and missed doses were recorded by the robotic system. Patients' and nurses' experiences were assessed with structured interviews. Findings: The 17 nursing home patients had 457 total days using the device (Phase I; mean, 26.9 per patient). On-time sachet retrieval occurred with 97.7% of the alerts, and no medication doses were missed. At baseline, Phase II home-dwelling patients reported difficulty remembering to take their medicines (23%), and 18% missed at least 2 doses per week. Most Phase II patients (78%) lived alone. The device delivered and patients retrieved medicine sachets for 99% of the alerts. All patients and 96% of nurses reported the device was easy to use. (C) 2017 The Authors. Published by Elsevier HS Journals, Inc.Peer reviewe

Lääkehoidon kokonaisarviointi lääkärin työkaluna

Iä­käs ih­minen ensim­mäistä ker­taa vastaa­no­tolla, ai­kaa varat­tuna 20 mi­nuuttia akuutin vai­van hoi­toon. Poti­laalla pal­jon muu­takin asiaa, lääk­keitä nähtä­västi viiti­sen­ toista. Pe­rehtyä ha­luaisi, mut­ta ai­ka ei rii­tä edes kaik­kien diag­noosien selvit­tä­miseen. Rat­kaisu voi ol­la moniam­ma­til­linen lääke­hoidon koko­nai­sar­viointi

Can Topographic Variation in Climate Buffer against Climate Change-Induced Population Declines in Northern Forest Birds?

Increased attention is being paid to the ecological drivers and conservation measures which could mitigate climate change-induced pressures for species survival, potentially helping populations to remain in their present-day locations longer. One important buffering mechanism against climate change may be provided by the heterogeneity in topography and consequent local climate conditions. However, the buffering capacity of this topoclimate has so far been insufficiently studied based on empirical survey data across multiple sites and species. Here, we studied whether the fine-grained air temperature variation of protected areas (PAs) affects the population changes of declining northern forest bird species. Importantly to our study, in PAs harmful land use, such as logging, is not allowed, enabling the detection of the effects of temperature buffering, even at relatively moderate levels of topographic variation. Our survey data from 129 PAs located in the boreal zone in Finland show that the density of northern forest species was higher in topographically heterogeneous PAs than in topographically more homogeneous PAs. Moreover, local temperature variation had a significant effect on the density change of northern forest birds from 1981–1999 to 2000–2017, indicating that change in bird density was generally smaller in PAs with higher topographic variation. Thus, we found a clear buffering effect stemming from the local temperature variation of PAs in the population trends of northern forest birds

Can Topographic Variation in Climate Buffer against Climate Change-Induced Population Declines in Northern Forest Birds?

Increased attention is being paid to the ecological drivers and conservation measures which could mitigate climate change-induced pressures for species survival, potentially helping populations to remain in their present-day locations longer. One important buffering mechanism against climate change may be provided by the heterogeneity in topography and consequent local climate conditions. However, the buffering capacity of this topoclimate has so far been insufficiently studied based on empirical survey data across multiple sites and species. Here, we studied whether the fine-grained air temperature variation of protected areas (PAs) affects the population changes of declining northern forest bird species. Importantly to our study, in PAs harmful land use, such as logging, is not allowed, enabling the detection of the effects of temperature buffering, even at relatively moderate levels of topographic variation. Our survey data from 129 PAs located in the boreal zone in Finland show that the density of northern forest species was higher in topographically heterogeneous PAs than in topographically more homogeneous PAs. Moreover, local temperature variation had a significant effect on the density change of northern forest birds from 1981–1999 to 2000–2017, indicating that change in bird density was generally smaller in PAs with higher topographic variation. Thus, we found a clear buffering effect stemming from the local temperature variation of PAs in the population trends of northern forest birds