Drug-related problems: assessments of risk and relevance

Pharmacotherapy is the most frequently used form of treatment intervention. The benefits of the therapy need to be weighed carefully against its risks, as drugs also cause up to 25% of all emergency department visits. Preventable inappropriate prescribing and medication errors, including the patient’s own mishandling, manifest in drug therapy failures and adverse drug events, which subsequently may generate costly hospitalisations. Of the adult Swiss population aged over 65 years, 21% are prescribed a potentially inappropriate medication. Within this setting, medication reviews are a method of assessing the patient’s drug regimen regarding its appropriateness and the patient’s preferences in order to address inappropriate prescribing and prevent medication errors. Medication reviews reduce the number of drug-related problems (DRPs) and decrease drug-related emergency department visits as well as hospital length of stay. But medication reviews are a time-consuming intervention. In a country like Switzerland, where 35.9 full-time equivalents of clinical pharmacists should promote safe, economic, and appropriate medicinal therapies for 1.4 million hospitalisations per year, there is a demand for risk stratification and patient prioritisation. Newly developed algorithms that generate alerts for clinical pharmacists on pooled electronic data, however, do not take into account the patient-centred causes of DRPs. The Drug-Associated Risk Tool (DART) was developed to identify hospitalised patients at greater risk of DRPs and in need of clinical pharmacy services, i.e. medication reviews. As a self-administered questionnaire for patients, the screening tool assesses items concerning the patients’ medical information in combination with their opinions and concerns about the pharmacotherapy whilst not increasing the workload of any caregiver. In this thesis, the DART was validated regarding its ability to discriminate between patients with lower and higher numbers of DRPs. Issues concerning the patients’ current pharmacotherapy were identified with a medication review with pooled data on drug regimens, diagnoses, laboratory values, and structured patient interviews. The medication reviews combined implicit and explicit criteria of inappropriate prescribing to balance the benefits and drawbacks of each approach. This thesis looked into the performance of the criteria used and reports on the number of DRPs identified with each method. The structured patient interview was newly developed by combining a remunerated public pharmacy interview on adherence with questions on concerns about the medication. This thesis describes the benefits of the patient interview by presenting the type of DRPs identified and weighs it against the additional clinical pharmacy resource requirements. The DART validation study also necessitated the use of a tool to estimate the potential relevance of pharmacists’ interventions. With the translation and subsequent reliability testing of the French tool CLEO, this thesis reports on the performance of a validated German version. CLEOde may help German-speaking pharmacists to estimate the potential relevance of their own interventions in three distinct dimensions: Patient-centred clinical, cost-focusing economic, and institution-based organisational. The study focused on interrater and test–retest reliability of CLEOde and presented an overview of clinical pharmacists’ activity within three Swiss-German hospitals. This thesis also critically evaluated the performance of another tool for risk stratification and patient prioritisation concerning one specific drug-related problem: The RISQ-PATH score and its ability to predict drug-induced QT-prolongation and heart arrhythmias. The thesis encompassed the execution of medication reviews, including patient interviews, for 110 geriatric patients within a study period of 10 months, identifying 595 DRPs estimated to be of minor to lifesaving relevance. The performed patient interviews identified over one third of all DRPs with insufficient patient knowledge and incomplete patient documentation as most the prominent and not otherwise identifiable causes. This thesis reports an average time of 16.6 minutes needed for the individual structured patient interviews. The ability of the DART to distinguish between patients with low and high numbers of current DRPs was demonstrated: Cluster analysis and subsequent discriminant function analysis allowed for an item reduction to five questions associated with the number of DRPs. These questions allow targeting patients who would benefit most from direct engagement and bedside interventions. CLEOde was used by 10 clinical pharmacists working in three hospitals during 13 days of routine clinical pharmacy services to estimate the relevance of 324 performed pharmacists’ interventions. The use of CLEOde was seen as appropriate, acceptable, feasible, and precise. Statistical analysis showed good interrater reliability and excellent test–retest reliability for the clinical and economic dimension, whereas the organisational dimension achieved poor interrater and fair test–retest reliability. By critically examining the association between the RISQ-PATH scores and the measured QTc intervals, we identified an already previously present prolonged QTc interval as moderating variable, necessitating subgroup generation for score interpretation. These results also allowed this thesis to articulate a simple code of practice when handling drugs with the potential to prolong the QTc interval. This thesis, entitled “Drug-Related Problems: Assessments of Risk and Relevance,” presents a validated self-administered patient questionnaire to stratify for drug-related risk, a validated assessment to estimate the relevance of drug-related problems, a structured patient interview to identify issues on drug-related adherence, handling, and concerns, and a valid score to detect patients at risk of drug-induced QT-prolongation

Drug-Associated Risk Tool: development and validation of a self-assessment questionnaire to screen for hospitalised patients at risk for drug-related problems

Identifying patients with a high risk for drug-related problems (DRPs) might optimise the allocation of targeted pharmaceutical care during the hospital stay and on discharge.; To develop a self-assessment screening tool to identify patients at risk for DRPs and validate the tool regarding feasibility, acceptability and the reliability of the patients' answers.; Prospective validation study.; Two mid-sized hospitals (300-400 beds).; 195 patients, exclusion criteria: under 18 years old, patients with a health status not allowing a meaningful communication (eg, delirium, acute psychosis, advanced dementia, aphasia, clouded consciousness state), palliative or terminally ill patients.; Twenty-seven risk factors for the development of DRPs, identified in a previous study, provided the basis of the self-assessment questionnaire, the Drug-Associated Risk Tool (DART). Consenting patients filled in DART, and we compared their answers with objective patient data from medical records and laboratory data.; One hundred and sixty-four patients filled in DART V.1.0 in an average time of 7 min. After a first validation, we identified statements with a low sensitivity and revised the wording of the questions related to heart insufficiency, renal impairment or liver impairment. The revised DART (V.2.0) was validated in 31 patients presenting heart insufficiency, renal impairment or liver impairment as comorbidity and reached an average specificity of 88% (range 27-100) and an average sensitivity of 67% (range 21-100).; DART showed a satisfying feasibility and reliability. The specificity of the statements was mostly high. The sensitivity varied and was higher in statements concerning diseases that require regular disease control and attention to self-care and drug management. Asking patients about their conditions, medications and related problems can facilitate getting a first, broad picture of the risk for DRPs and possible pharmaceutical needs

Community Pharmacist-Administered COVID-19 Vaccinations: A Pilot Customer Survey on Satisfaction and Motivation to Get Vaccinated

In response to the coronavirus disease 2019 (COVID-19) pandemic, Swiss health authorities approved and ordered two mRNA vaccines in 2021. The canton of Zurich was the second in Switzerland to allow community pharmacists to administer the COVID-19 mRNA Vaccine Moderna to the adult population. We aimed to pilot a customer satisfaction questionnaire regarding COVID-19 vaccinations in Zurich pharmacies. Questions focused on satisfaction with different aspects of the service, motivation for getting the vaccination, and reasons for being vaccinated in a pharmacy. Zurich pharmacies administered 68,169 COVID-19 doses until June 2021, and 421 questionnaires were filled. Respondents’ mean age was 43.5 (±13.2) years, with 42.3% reporting being women and 46.1% being men. Of the 372 complete questionnaires, 98.7% of the respondents would have recommended the service to others. High levels of satisfaction were reported concerning pre-vaccination discussion (98.9%), pharmacies’ information level on COVID-19 vaccines (98.9%), general comfort with receiving the vaccination in a pharmacy (99.5%), injection technique (99.2%), and premises used (98.1%). Most respondents (57.3%) would have had the option of another vaccination provider, but the pharmacies were chosen for their opening hours, ease of access, and perceived trust. The availability of pharmacist-administered services may be an important contributor to a successful vaccination programme in Switzerland

External validation of the PAR-Risk Score to assess potentially avoidable hospital readmission risk in internal medicine patients

BACKGROUND Readmission prediction models have been developed and validated for targeted in-hospital preventive interventions. We aimed to externally validate the Potentially Avoidable Readmission-Risk Score (PAR-Risk Score), a 12-items prediction model for internal medicine patients with a convenient scoring system, for our local patient cohort. METHODS A cohort study using electronic health record data from the internal medicine ward of a Swiss tertiary teaching hospital was conducted. The individual PAR-Risk Score values were calculated for each patient. Univariable logistic regression was used to predict potentially avoidable readmissions (PARs), as identified by the SQLape algorithm. For additional analyses, patients were stratified into low, medium, and high risk according to tertiles based on the PAR-Risk Score. Statistical associations between predictor variables and PAR as outcome were assessed using both univariable and multivariable logistic regression. RESULTS The final dataset consisted of 5,985 patients. Of these, 340 patients (5.7%) experienced a PAR. The overall PAR-Risk Score showed rather poor discriminatory power (C statistic 0.605, 95%-CI 0.575-0.635). When using stratified groups (low, medium, high), patients in the high-risk group were at statistically significant higher odds (OR 2.63, 95%-CI 1.33-5.18) of being readmitted within 30 days compared to low risk patients. Multivariable logistic regression identified previous admission within six months, anaemia, heart failure, and opioids to be significantly associated with PAR in this patient cohort. CONCLUSION This external validation showed a limited overall performance of the PAR-Risk Score, although higher scores were associated with an increased risk for PAR and patients in the high-risk group were at significantly higher odds of being readmitted within 30 days. This study highlights the importance of externally validating prediction models

Assessment of minor health disorders with decision tree-based triage in community pharmacies

Background Triaging in community pharmacies can lower the burden of minor health disorders on other primary health care settings. The netCare service, introduced in 2012 by the Swiss association of pharmacists, provides community pharmacists with 27 decision trees for the triage of minor health disorders. Objectives (1) to describe the utilization and symptom resolving rate of decision trees in community pharmacies; (2) to identify the need for additional decision trees. Methods A descriptive, explorative analysis was conducted of netCare consultations between January 2019 and March 2020, as documented in phS-net, a service platform for public pharmacies. Client characteristics, weekdays, recommended course of action, availability of a general practitioner, and hypothetical course of action if netCare would not have been available were investigated. Follow-up information was assessed for resolution of symptoms and prevention of needing additional services. Data from consultations with empty assessment forms were used to identify minor health disorders in need of an additional decision tree. Results Information on 4256 performed netCare consultations were identified over a 14-month observation period, resulting in an average of 284 decision tree consultations per month in Switzerland. Customers were mainly female (n = 3253, 76.4%) with a mean age of 40.7 years (±18.5 years). Cystitis (39.5%), conjunctivitis (19.5%), and pharyngitis (10.9%) were the primary reasons for consultation. Minor health disorders were managed by pharmacists themselves (88.2%) and achieved a resolution rate of 84.7%. Eyelid inflammations were identified as in need for an additional decision tree. Conclusion Pharmacist-led structured triaging services in Switzerland led to an 84.7% resolution rate of minor health disorders, thereby identifying the potential for pharmacists to minimize the demand on other primary health care providers

Prevalence of potentially inappropriate medications among newly treated patients with type 2 diabetes in UK primary care

AimsThe aim of this study was to estimate the prevalence of potentially inappropriate prescriptions (PIPs) in patients starting their first noninsulin antidiabetic treatment (NIAD) using two explicit process measures of the appropriateness of prescribing in UK primary care, stratified by age and polypharmacy status.MethodsA descriptive cohort study between 2016 and 2019 was conducted to assess PIPs in patients aged >= 45 years at the start of their first NIAD, stratified by age and polypharmacy status. The American Geriatrics Society Beers criteria 2015 was used for older (>= 65 years) patients and the Prescribing Optimally in Middle-age People's Treatments criteria was used for middle-aged (45-64 years) patients. Prevalence of overall PIPs and individual PIPs criteria was reported using the IQVIA Medical Research Data incorporating THIN, a Cegedim Database of anonymized electronic health records in the UK.ResultsAmong 28 604 patients initiating NIADs, 18 494 (64.7%) received polypharmacy. In older and middle-aged patients with polypharmacy, 39.6% and 22.7%, respectively, received >= 1 PIP. At the individual PIP level, long-term proton pump inhibitors (PPI) use was the most frequent PIP among older adults, and strong opioid without laxatives was the most frequent PIP in middle-aged patients with polypharmacy (11.1% and 4.1%, respectively).ConclusionsThis study revealed that patients starting NIAD treatment receiving polypharmacy have the potential for pharmacotherapy optimization.ISSN:1365-2125ISSN:0306-525

An explorative analysis of pharmacovigilance data of oxytocin and its analogue carbetocin, with a focus on haemodynamic adverse effects

Background Oxytocin and its analogue carbetocin are uterotonics whose prophylactic use is recommended to prevent postpartum haemorrhage, which is one of the leading causes of maternal deaths worldwide. However, both drugs can cause specific adverse effects and haemodynamic challenges. Aim The aim of this work was to exploratively examine reports of adverse drug events of both drugs and to establish a comparative haemodynamic profile. Method Using data extracted from the World Health Organization’s pharmacovigilance database VigiBase, a descriptive analysis was performed of all reports for oxytocin and carbetocin as a suspected or interacting drug followed by a disproportionality analysis for haemodynamic events. Reporting odds ratios (ROR) of carbetocin for hypertension, hypotension, tachycardia, and bradycardia were calculated, with oxytocin-related reports serving as comparators. Results Oxytocin and carbetocin were mentioned as suspected or interacting drugs in 11,258 and 374 reports, respectively. Resulting RORs for carbetocin were 3.45 (95%CI: 1.72–6.92) for hypertension, 2.65 (1.64–4.28) for hypotension, 2.84 (1.79–4.49) for tachycardia, and 2.00 (0.87–4.60) for bradycardia, when compared to oxytocin. Of 231 patients for whom oxytocin-related tachycardia was reported, 2.6% died, and of 91 patients for whom bradycardia was reported, 2.2% died. No deaths were reported with carbetocin for any of the haemodynamic adverse events.ISSN:2210-7703ISSN:0928-1231ISSN:2210-771