Feasibility, acceptability and potential effectiveness of an information technology-based, pharmacist-led intervention to prevent an increase in anticholinergic and sedative load among older community-dwelling individuals.

BACKGROUND: Anticholinergic/sedative medications are frequently used by older people, despite their negative impacts on cognitive and physical function. We explore the feasibility, acceptability and potential effectiveness of an innovative information technology (IT)-based intervention to prevent an increase in anticholinergic/sedative load in older people. METHODS: This was a prospective study in 51 Dutch community pharmacies. Pharmacists used an IT-based tool to identify patients aged ⩾65 years, with existing high anticholinergic/sedative loads (drug burden index ⩾2) and a newly initiated anticholinergic/sedative medication. We determined the following. Feasibility: number of eligible patients identified. Acceptability: pharmacists' satisfaction with the intervention, pharmacists' time investment and patients' willingness to reduce medication use. Potential effectiveness: number of recommendations, rate of agreement of general practitioners (GPs) with proposed recommendations and factors associated with agreement. To evaluate the latter, pharmacists conducted medication reviews and proposed recommendations to GPs for 5-10 patients selected by the IT-based tool. RESULTS: We included 305 patients from 47 pharmacies. Feasibility: a mean of 17.0 (standard deviation, 8.8) patients were identified per pharmacy. Acceptability: 43 pharmacists (91.5%) were satisfied with the intervention. The median time investment per patient was 33 min (range 6.5-210). Of 35 patients, 30 (85.7%) were willing to reduce medication use. Potential effectiveness: pharmacists proposed 351 recommendations for 212 patients (69.5%). GPs agreed with recommendations for 108 patients (35.4%). Agreement to stop a medication was reached in 19.8% of recommendations for newly initiated medications (37 of 187) and for 15.2% of recommendations for existing medications (25 of 164). Agreement was more likely for recommendations on codeine [odds ratio (OR) 3.30; 95% confidence interval (CI) 1.14-9.57] or medications initiated by a specialist (OR 2.85; 95% CI 1.19-6.84) and less likely for pharmacies with lower level of collaboration with GPs (OR 0.15; 95% CI 0.02-0.97). CONCLUSION: This innovative IT-based intervention was feasible, acceptable and potentially effective. In one-third of patients an increase in anticholinergic/sedative load was prevented within reasonable time investment.

Anticholinergic and sedative medication use in older community-dwelling people: A national population study in the Netherlands.

PURPOSE: To identify the proportion of older adults with a high anticholinergic/sedative load and to identify patient subgroups based on type of central nervous system (CNS)-active medication used. METHODS: A cross-sectional study of a nationwide sample of patients with anticholinergic/sedative medications dispensed by 1779 community pharmacies in the Netherlands (90% of all community pharmacies) in November 2016 was conducted. Patients aged older than 65 years with a high anticholinergic/sedative load defined as having a drug burden index (DBI) greater than 1 were included. Proportion of patients with a high anticholinergic/sedative load was calculated by dividing the number of individuals in our study population by the 2.4 million older patients using medications dispensed from study pharmacies. Patient subgroups based on type of CNS-active medications used were identified with latent class analysis. RESULTS: Overall, 8.7% (209 472 individuals) of older adults using medications had a DBI greater than 1. Latent class analysis identified four patient subgroups (classes) based on the following types of CNS-active medications used: "combined psycholeptic/psychoanaleptic medication" (class 1, 57.9%), "analgesics" (class 2, 17.9%), "antiepileptic medication" (class 3, 17.8%), and "anti-Parkinson medication" (class 4, 6.3%). CONCLUSIONS: A large proportion of older adults in the Netherlands had a high anticholinergic/sedative load. Four distinct subgroups using specific CNS-active medication were identified. Interventions aiming at reducing the overall anticholinergic/sedative load should be tailored to these subgroups.

Effectiveness of interventions by community pharmacists to reduce risk of gastrointestinal side effects in nonselective nonsteroidal anti-inflammatory drug users.

PURPOSE: Upper gastrointestinal (UGI) complications in elderly users of nonselective nonsteroidal anti-inflammatory drugs (ns-NSAIDs) without concomitant use of gastroprotective agents (GPAs) were a leading cause of potentially avoidable drug-related hospital admissions in the Netherlands. We aimed to determine the effectiveness of community pharmacists' interventions to improve safety in ns-NSAID use in patients at UGI risk. METHODS: In this prospective cohort study, pharmacists in participating pharmacies (intervention group, IG) received feedback on drug dispensing in ns-NSAID users of ≥60 years of age at risk for UGI damage and were instructed to select patients to improve ns-NSAID prescribing, in collaboration with primary care physicians. Ns-NSAID users from other pharmacies without concomitant GPA use were followed in parallel as a control group (CG). Changes in the UGI risk of ns-NSAID users between baseline and follow-up measurement, assessed either by the addition of GPAs or the cessation of ns-NSAIDs, were compared between the two study arms. RESULTS: At baseline, 14% of ns-NSAID users at UGI risk did not receive GPAs. Persistent ns-NSAID users from the selected IG patients had an additional 7% likelihood of reduced UGI risk at follow-up (odds ratio 0.93, 95% confidence interval 0.89-0.97) compared with CG patients. In the IG, 91% of selected IG patients at UGI risk from ns-NSAIDs at baseline were no longer at increased risk at follow-up because of cessation of ns-NSAIDS or to concomitant GPA use. CONCLUSION: Although concomitant gastroprotection use in susceptible ns-NSAID users in the Netherlands is high, pharmacist-led interventions could further improve prescribing of ns-NSAIDs.

Pharmacist-led intervention study to improve drug therapy in asthma and COPD patients.

BACKGROUND: Pharmacists can play an important role in identifying and instructing pulmonary patients on their inhalation techniques in their patient contacts when dispensing inhalation medication. Pharmacy dispensing data can be used to identify inappropriate drug use in asthma and chronic obstructive pulmonary disease (COPD) patients. Recent studies found beneficial effects of pharmacy care services in improving drug adherence of pulmonary patients. However, large-scale and rigorous evaluations on pharmacist-led interventions in community care settings to enhance evidence-based drug treatment in patients with asthma and COPD seems to be lacking and results from studies on pharmacist-led interventions for pharmacotherapy improvements are inconsistent. This study evaluated the effectiveness of pharmacist-led interventions on suboptimal drug use patterns with asthma or COPD medication with substantial numbers of pharmacies and patients involved. SETTING: A prospective cohort study in a group of community pharmacies (intervention group) with a matched control group of Dutch community pharmacies was conducted between May 2011 and February 2012. Algorithms on 19 potential problems with asthma or COPD medication in a national dispensing database were used to signal patients to pharmacists of the intervention group (IG). METHODS: IG pharmacists selected patients for comprehensive care by a structured program. Changes in problems were measured during 10 months in selected and all users of asthma and COPD medication of IG pharmacies and in compared to a control pharmacies (CG) without the structured program. Primary outcome was reduction of oral high dosage corticosteroids or antibiotics (HDT). Secondary outcomes were changes in the persistence of 19 potential problems in the IG compared to CG. RESULTS: In the 107 IG pharmacies, 3,757 patients were selected for comprehensive care from totally 102,497 asthma or COPD patients and compared with 105,507 patients from 105 CG pharmacies. The mean number of HDT decreased in selected IG patients by an additional 0.54 (95 % CI 0.21-0.86) HDT treatments. From the problems with specific COPD and asthma medication, all problems decreased additionally to the CG within the total asthma or COPD population from the IG. Within the selected IG population the following problems decreased additionally for obsolete medication by 35 % (95 % CI 6-54 %), contra-indicated medication by 61 % (95 % CI 38-75 %) and lower use of powder inhalers in elderly patients by 29 % (95 % CI 13-42 %). CONCLUSION: Community pharmacists actively providing comprehensive pharmacy care could improve effective treatment in asthma and COPD patients and thereby decrease the number of prescriptions for exacerbations for these patients.

Linking community pharmacy dispensing data to prescribing data of general practitioners.

BACKGROUND: Databases are frequently used for pharmacoepidemiological research. However, most of these databases consist either of prescribing, dispensing or administrative data and therefore lack insight in the interaction between the several health professionals around the patient. METHODS: To determine the success rate of linking records from the dispensing database of the Foundation for Pharmaceutical Statistics to the prescribing database of the second Dutch national survey of general practice, conducted by NIVEL (Netherlands Institute for Health Services Research), a deterministic record linkage approach was used with patient and prescription characteristics as matching variables between the two databases. RESULTS: The catchment area included 123 community pharmacies, 90 GP practices and approximately 170,000 unique patients. Overall 110,102 (64.8%) unique patients were linked using the matching variables patient's gender, year of birth, the 4-digit part of the postal code, date of dispensing/prescribing and ATC-code. The final database contains of the 110,102 both prescribing data from 83 GP practices and dispensing data of 112 community pharmacies. CONCLUSION: This study shows that linkage of dispensing to prescribing data is feasible with a combination of patient characteristics, such as gender, year of birth and postal code, and prescription characteristics like prescription date and ATC-code. We obtained a linkage proportion of 64.8% resulting in complete prescribing and dispensing history of 110,102 patients. This offers an opportunity to gain insight in the mechanisms and factors influencing drug utilisation in general practice.