Severity of Diabetes Mellitus and Total Hip or Knee Replacement: A Population-Based Case-Control Study

Contains fulltext : 171491.pdf (publisher's version ) (Open Access)It is generally thought that people with diabetes mellitus (DM) are more likely to suffer from osteoarthritis (OA) due to an increased body mass index (BMI), resulting in mechanical destruction of cartilage. However, previous studies have suggested a coexisting metabolic causality.To evaluate the risk of hip or knee replacement, as a proxy for severe OA, in patients with DM. We additionally evaluated the risk of total joint replacement (TJR) with various proxies for increased DM severity.A population-based case-control study was performed, using the Clinical Practice Research Datalink (CPRD). Cases (n = 94,609) were defined as patients >18 years who had undergone TJR between 2000 and 2012. Controls were matched by age, gender, and general practice. Conditional logistic regression was used to estimate the risk of total knee (TKR) and total hip replacement (THR) surgery associated with use of antidiabetic drugs (ADs). We additionally stratified current AD users by proxies for DM severity.Current AD use was significantly associated with a lower risk of TKR (OR = 0.86 (95% CI = 0.78-0.94)) and THR (OR = 0.90 (95% CI = 0.82-0.99)) compared to patients not using ADs. Moreover, risk of TKR and THR was decreased with increasing HbA1c.This study does not support the theory that DM patients are more likely to suffer from severe OA as compared to patients without diabetes. Moreover, risk of severe OA necessitating TJR decreases with increasing DM severity. This is possibly due to dissimilarities in methodology, a decrease in eligibility for surgery, or variability of OA phenotypes

Effect of Pharmacist-Led Interventions on (Non)Motor Symptoms, Medication-Related Problems, and Quality of Life in Parkinson Disease Patients: A Pilot Study

Item does not contain fulltextINTRODUCTION: Patients with Parkinson disease (PD) use multiple drugs. This pill burden with consequent poor adherence may cause worsening of motor symptoms and drug-related problems. Therefore, a multifaceted pharmacist-led intervention program was designed to improve adherence, motor-functioning, and quality of life (QoL) in PD patients. METHODS: This prospective pilot study was performed in an outpatient PD clinic, where usual care was compared with stepwise introduction of 3 interventions: unit dose packaging (UDP), Parkinson KinetiGraph (PKG), and pharmacist-led medication review (MR).The study analyzed endpoints at 6 weeks (stage 1, usual care), 10 weeks (stage 2, UDP), 14 weeks (stage 3, UDP + PKG), and 26 weeks (UDP + PKG + MR) on motor symptoms, medication adherence, and QoL. RESULTS: Medication adherence improved significantly after the combined UDP, PKG, and MR intervention in nonadherent patients. On time significantly increased from 56% (+/-30) at stage 1, to 64% (+/-25) at stage 3, and to 68% (+/-27) at stage 4, which correlated with an increase of 1.4 and 2.2 hours in stage 3 and 4, respectively. Quality of life only improved significantly after MR (Parkinson's Disease Questionnaire with 8 domains, 21.0 +/- 3.5 in stage 3 vs 19.5 +/- 5.3 in stage 4, P = 0.01). CONCLUSIONS: Our data did not support the added value of UDP alone or in combination with PKG. Only the combined intervention of UDP, PKG, and MR showed significant improvements in medication adherence, on time, and QoL. This supports the effectiveness of MR by a clinical pharmacist for PD patients in an outpatient setting. Therefore, this small scale study should be followed by larger-scale trials on this topic

Community Pharmacy-Based eGFR Screening for Early Detection of CKD in High Risk Patients

Contains fulltext : 220623.pdf (publisher's version ) (Open Access)BACKGROUND: Chronic kidney disease (CKD) is a condition presenting with long-term slow progression of structural and/or functional damage to the kidneys. Early detection is key to preventing complications and improving outcomes. Point-of-care estimated glomerular filtration rate (eGFR) screening technology allows for detection of abnormal kidney function in the community pharmacy setting. OBJECTIVE: To evaluate the effectiveness of a community pharmacist-directed point-of-care screening program and to identify the prevalence of CKD in high-risk patients. DESIGN: Quantitative observational. SETTING: Four community pharmacies in British Columbia over a 6-month period. PATIENTS: In all, 642 participants with at least one CKD risk factor were identified and screened. Mean age was 60 years and females accounted for 55% of the study population. MEASUREMENTS: Serum creatinine was measured from peripheral blood using the HeathTab® screening system (Piccolo® Renal Function Panel with the Piccolo® blood chemistry analyzer). eGFR was calculated according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. METHODS: Patients provided a sample of peripheral blood via a self-administered finger-prick and analytical data to assess kidney function was reported including blood urea nitrogen (BUN), serum creatinine, and electrolytes by the HealthTab(®) screening system. Once results were available, the pharmacist conducted a comprehensive medication review with the patient and recommended certain follow-up actions if appropriate. RESULTS: CKD risk factor included diabetes (30%), hypertension (45%), cardiovascular disease (12%), family history of kidney disease (13%), age over 55 years (68%), and an Aboriginal, Asian, South Asian, or African ethnic background (82%). A total of 11.5% of patients had eGFR values lower than 60 mL/min (abnormal renal function) and 34% had an eGFR between 60 and 89 mL/min (minimally reduced renal function). Overall pharmacists' actions included blood pressure check (98%), education on CKD and risk factors (89%), medication review (72%), and physician follow-up (38%). Limitations included lack of follow-up beyond the 3-month study period prevented medical confirmation of CKD and limited the ability to quantify the impact of pharmacist interventions on the clinical outcomes of patients with low eGFR. CONCLUSION: These results illustrate the prevalence of abnormal renal function among undiagnosed, high-risk patients in the community. Pharmacists, as the most accessible healthcare practitioners, are ideally positioned to utilize novel point-of care technologies to improve access to CKD screening, facilitate follow-up, and increase awareness around the importance of early detection

Down-titration and discontinuation of infliximab in rheumatoid arthritis patients with stable low disease activity and stable treatment: an observational cohort study

Item does not contain fulltextDown-titration, or discontinuing infliximab, has proven to be feasible in RA patients. Therefore, our local treatment protocol includes tapering infliximab dose. This observational study describes the prevalence of successful down-titration in daily clinical practice and its effect on costs and quality of life (QoL). METHODS: Infliximab was down-titrated with 25% of the original dose (3 mg/kg) every 8-12 weeks without interval change until discontinuation or flare in all RA patients with stable low 28-joint disease activity score (DAS28) and stable treatment for >6 months. During 1 year DAS28, RA medication, outpatient clinic visits, RA related absenteeism and EuroQoL5D (European QoL questionnaire, EQ5D) were documented. Prevalence of successful down-titration and changes in DAS28, QoL and costs were described. RESULTS: In 16% (95% CI 6 to 26) and 45% (95% CI 31 to 59), respectively, infliximab could be discontinued or down-titrated. Mean infliximab dose decreased significantly from 224 mg (95% CI 212 to 236 mg) at start, to 130 mg (95% CI 105 to 154 mg) after 1 year. Median DAS28 increased from 2.5 (p25-75=2.0-2.9) to 2.8 (2.2-3.6) (p=0.002). Extra corticosteroids were given in 8% of the visits. Disease modifying antirheumatic drugs were seldom changed. There was no statistical difference in QoL after down-titration. Mean reduction in the costs was euro3474 (95% CI 2457 to 4492) per patient. CONCLUSION: In the majority of patients with stable low DAS28 and stable treatment, infliximab can be down-titrated or discontinued, which results in a considerable reduction in costs without influencing QoL

Willingness of patients to use unused medications returned to the pharmacy by another patient

Background and objective: Redispensing by pharmacies of medications unused by another patient could contribute to optimal use of healthcare resources. Patient co-operation is essential for implementation of the redispensing process. However, insight into patient willingness to use redispensed medication is limited. This study aims to assess patient willingness to use medication returned by another patient and patient characteristics associated with this willingness. Setting and method: A survey was conducted in 41 community and 5 outpatient pharmacies between April-December 2014 in the Netherlands. Pharmacy visitors completed a questionnaire regarding their willingness to use medication returned unused to the pharmacy by another patient, assuming quality was guaranteed. Patient sociodemographic characteristics were also collected and their associations with patient willingness were analysed using logistic regression analysis, reported as odds ratios (OR) with 95% confidence intervals. Main outcome measures: The proportion of patients willing to use redispensed medication and patient characteristics associated with this willingness. Results: In total, 2215 patients (mean [SD] age 50.6 [18.0] years; 61.4% female) participated, 6.4% were returning medication for disposal. The majority (61.2%) was willing to use medication returned unused to the pharmacy by another patient. Patients who were unwilling mostly found it too risky. Men were more willing to use returned medication (OR 1.3 [1.1-1.6]), as did patients with a high educational level (OR 1.8 [1.3-2.5]), those who regularly use 1-3 medications (OR 1.3 [1.1-1.7]), those who returned medication to the pharmacy for disposal (OR 1.5 [1.0-2.3]) and those who ever had unused medications themselves (OR 1.3 [1.1-1.6]). Patients with non- Dutch cultural background were less willing to use returned medication (OR 0.3 [0.3-0.4]). Conclusion: When quality is guaranteed, a substantial proportion of patients are willing to use medication returned unused to the pharmacy by another patient. This suggests that implementation of redispensing is likely to be supported by a majority of patients. Further elucidating and addressing reasons for patient unwillingness may increase the success rate of implementation

Willingness of patients to use unused medications returned to the pharmacy by another patient

Background and objective: Redispensing by pharmacies of medications unused by another patient could contribute to optimal use of healthcare resources. Patient co-operation is essential for implementation of the redispensing process. However, insight into patient willingness to use redispensed medication is limited. This study aims to assess patient willingness to use medication returned by another patient and patient characteristics associated with this willingness. Setting and method: A survey was conducted in 41 community and 5 outpatient pharmacies between April-December 2014 in the Netherlands. Pharmacy visitors completed a questionnaire regarding their willingness to use medication returned unused to the pharmacy by another patient, assuming quality was guaranteed. Patient sociodemographic characteristics were also collected and their associations with patient willingness were analysed using logistic regression analysis, reported as odds ratios (OR) with 95% confidence intervals. Main outcome measures: The proportion of patients willing to use redispensed medication and patient characteristics associated with this willingness. Results: In total, 2215 patients (mean [SD] age 50.6 [18.0] years; 61.4% female) participated, 6.4% were returning medication for disposal. The majority (61.2%) was willing to use medication returned unused to the pharmacy by another patient. Patients who were unwilling mostly found it too risky. Men were more willing to use returned medication (OR 1.3 [1.1-1.6]), as did patients with a high educational level (OR 1.8 [1.3-2.5]), those who regularly use 1-3 medications (OR 1.3 [1.1-1.7]), those who returned medication to the pharmacy for disposal (OR 1.5 [1.0-2.3]) and those who ever had unused medications themselves (OR 1.3 [1.1-1.6]). Patients with non- Dutch cultural background were less willing to use returned medication (OR 0.3 [0.3-0.4]). Conclusion: When quality is guaranteed, a substantial proportion of patients are willing to use medication returned unused to the pharmacy by another patient. This suggests that implementation of redispensing is likely to be supported by a majority of patients. Further elucidating and addressing reasons for patient unwillingness may increase the success rate of implementation

[Reducing medication waste; a challenge for care providers and society]

Annually, in the Netherlands, at least 100 million euro is wasted on unused medication. This waste not only has considerable economic implications, but is also associated with an unnecessary burden on the environment and suboptimal care due to nonadherence to therapy. The reasons for medication wastage can be found throughout the entire pharmaceutical supply and use chain, which includes manufacturers, distributors/wholesalers, prescribers, pharmacists and patients, both in the community and hospital setting. A number of strategies are needed to minimize the waste of medication, one of which should be a preventative approach. Involvement of all stakeholders in the supply chain is a prerequisite for a successful outcome. It is important that prescribers are aware of the extent and consequences of wastage, and of the possible ways to reduce it

[Reducing medication waste; a challenge for care providers and society]

Item does not contain fulltextAnnually, in the Netherlands, at least 100 million euro is wasted on unused medication. This waste not only has considerable economic implications, but is also associated with an unnecessary burden on the environment and suboptimal care due to nonadherence to therapy. The reasons for medication wastage can be found throughout the entire pharmaceutical supply and use chain, which includes manufacturers, distributors/wholesalers, prescribers, pharmacists and patients, both in the community and hospital setting. A number of strategies are needed to minimize the waste of medication, one of which should be a preventative approach. Involvement of all stakeholders in the supply chain is a prerequisite for a successful outcome. It is important that prescribers are aware of the extent and consequences of wastage, and of the possible ways to reduce it

Quantity and economic value of unused oral cancer drugs among patients who discontinue their therapy

Setting and Method: At least one-third of patients using oral cancer drugs (OCD) discontinue their therapy early due to a lack of efficacy, adverse events or high out-of-pocket costs. Therapy discontinuation may lead to medication waste if the patient has not used all dispensed medication. Insight into the waste of OCDs could provide guidance for the development of waste-minimizing strategies. The objective of this study was therefore to determine the proportion of patients who have unused OCDs after therapy discontinuation, the reasons thereof, and the quantity and economic value of these unused medications. A retrospective follow-up study was conducted using a Dutch outpatient pharmacy database. Patients (C 18 years) who did not refill an OCD prescription, which was dispensed between November 2015 and February 2016, were contacted by phone and asked about their unused medication. The economic value was calculated using Dutch medication prices. Data were descriptively analysed in STATA13. Main outcome measures: The proportion of patients with unused OCDs after therapy discontinuation, their reason for discontinuation, and the quantity of packages that remained unused, including the economic value. Results: The database included 605 patients, of whom 90 patients likely had discontinued therapy and were contacted. Of these, 42 were excluded (18 had refilled their medication, 23 could not be contacted, 1 other). Of the 48 patients who had discontinued therapy (mean age 62.6 (SD -13.0) years, 52.1% female), 22 (45.8%) patients had unused medications. Patients primarily discontinued therapy early due to adverse effects (43.5%), followed by therapy changed (17.4%) and insufficient effect (17.4%). A total of 31 packages remained unused, with a median value of 179 (IQR 24-2487), amounting to a total of 34.500. Most patients kept the unused medications at home (60.9%) or returned them to the pharmacy (26.1%). Conclusion: Almost half of patients who discontinue OCD therapies have unused medications. The majority of patients do not dispose of their unused medications. Pharmacist interventions are needed to reduce the waste of expensive cancer therapies and to educate patients about safe disposal of unused medications

Drug-related problems in a clinical setting: a literature review and cross-sectional study evaluating factors to identify patients at risk

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