Acceptability of a cross-sectoral hospital pharmacist intervention for patients in transition between hospital and general practice: a mixed methods study.

Background and objective: Drug-related problems (DRPs) are often seen when a patient is transitioning from one healthcare sector to another, for example, when a patient moves from the hospital to a General Practice (GP) setting. This transition creates an opportunity for information on medication changes and follow-up plans to be lost. A cross-sectoral hospital pharmacist intervention was developed and pilot-tested in a large GP clinic. The intervention included medication history, medication reconciliation, medication review, follow-up telephone calls, identification of possible DRPs and communication with the GP. It is unknown whether the intervention is transferable to other GP clinics. The aim of the study was to explore similarities and differences between GP clinics in descriptive data and intervention acceptability. Methods: A convergent mixed methods study design was used. The intervention was tested in four GP clinics with differing characteristics. Quantitative data on the GP clinics, patients and pharmacist activities were collected. Qualitative data on the acceptability were collected through focus group interviews with general practitioners, nurses and pharmacists. The Theoretical Framework of Acceptability was used. Results: Overall, the intervention was found acceptable and relevant by all. There were differences between the GP clinics in terms of size, daily physician work form and their use of pharmacists for ad hoc tasks. There were similarities in patient characteristics across GP clinics. Therefore, the intervention was found equally relevant for all of the clinics. Shared employment with unique access to health records in both sectors was important in the identification and resolution of DRPs. Economy was a barrier for further implementation. Conclusions: The intervention was found acceptable and relevant by all; therefore, it was considered transferable to other GP clinics. Hospital pharmacists were perceived to be relevant healthcare professionals to be utilized in GP, in hospitals and in the cross-sectoral transition of patients.

Acceptability of a pharmacist activity for patients transitioning between hospital and general practice Why was the study done? Drug-related problems are often seen in patients transitioning across healthcare sectors. A pharmacist activity was developed and pilot-tested in a large General Practice (GP) clinic. It was unknown whether the activity was transferable to other GP clinics.The pharmacist activity included talking to the patients about their usual medication and adjustment of prescriptions accordingly. The pharmacist activity also included a review of their medications, a follow-up telephone call to the patients and communication with the GP in case of drug-related problems.The aim of the study was to test the activity in different GP clinics and to explore similarities and differences in descriptive data and acceptability. What did the researchers do? The activity was tested in four GP clinics within the same geographical area for three months.Descriptive data about the GP clinics, the patients and the pharmacist's activities performed were collected.Data about acceptability of the activity was collected through focus group interviews with general practitioners, nurses and hospital pharmacists.This qualitative data was combined with descriptive data to explore similarities and differences between GP clinics. What did the researchers find? Overall, the activity was found to be acceptable and relevant by all.There were differences between the GP clinics in terms of size, daily physician work form and their use of the pharmacist for ad hoc tasks.There were similarities in patients across GP clinics e.g. in terms of the number of medications or drug-related problems. The activity was found equally relevant for every clinic.Shared employment with access to health records in both sectors was important in the identification and resolution of drug-related problems. The pharmacist had the possibility to bring issues back and forth between the hospital and the GP clinic.Economy was a barrier for further implementation. What do the findings mean? The activity was found acceptable and relevant by all; therefore, it was considered transferable to other GP clinics.Hospital pharmacists were perceived to be relevant healthcare professionals to be utilised in GP, in hospitals and in the cross-sectoral transition of patients.

Developing and piloting a cross-sectoral hospital pharmacist intervention for patients in transition between hospital and general practice.

Background: Healthcare is challenged by a rapidly growing group of patients with multi-morbidity and polypharmacy. Increasing activity and specialization puts pressure on healthcare sectors. Medication errors in cross-sectoral transition of patients are often seen. The aim of the study was to explore drug-related problems (DRPs) in the transition of patients between sectors and to develop and pilot-test a cross-sectoral hospital pharmacist intervention to overcome some of these problems. Methods: DRPs in cross-sectoral transitions were explored from four perspectives; the literature, the primary and secondary healthcare sector and the patients. An intervention was developed from the findings through co-creation between pharmacists, doctors and a nurse. The intervention was piloted and evaluated from data on the included patients and the activities performed. Results: DRPs in transitions from general practice (GP) to hospital were caused by inadequate focus on updating the Shared Medication Record (SMR). For patients being discharged, DRPs were described with multiple facets; for example, missing information on medication changes, lacking patient involvement and problems with dose-dispensed medicine or electronic prescriptions. An intervention with a pharmacist in a shared employment between Hospital Pharmacy and GP was developed and piloted. The intervention included medication reconciliation and updating SMR for patients referred to hospital; and medication review, overview of medication changes and follow-up telephone calls for patients discharged from hospital. The intervention identified and solved several DRPs; in this way, medication errors were avoided. Access to health records in both sectors was important in the identification and resolution of DRPs. Conclusion: DRPs in cross-sectoral transitions are multifaceted and the experiences depend on the point of view. The cross-sectoral hospital pharmacist intervention identified and solved several DRPs and medication errors were avoided. The intervention made sense to both healthcare sectors and patients. Shared employment and unique access to health records in both sectors showed to be of importance in the identification and resolution of DRPs. Plain language summary: Development and pilot-test of a pharmacist intervention for patients in transition between hospital and general practice Background: Healthcare is challenged by a rapidly growing group of patients with multiple chronic diseases treated with several drugs at the same time. The aim of the study was to explore drug-related problems in the transition of patients between the hospital and patients' general practitioner and to develop and pilot-test a pharmacist intervention to overcome some of these problems.Methods: Drug-related problems in patient transitions were explored from the perspectives of the hospital, the general practitioner, the patients and the literature. An intervention was developed from the findings by pharmacists, doctors and a nurse. The intervention was pilot-tested and evaluated from the descriptions of the included patients and activities performed.Results: Drug-related problems in transitions from general practice to hospital were caused by inadequate focus on updating the Shared Medication Record.For patients being discharged, drug-related problems were related to for examplemissing information on medication changessparse involvement of the patient in their own treatmentproblems with medicine dispensed on a dose dispensing machine at the local pharmacy.An intervention with a pharmacist in a shared employment between Hospital Pharmacy and general practice was developed and piloted. The intervention includedtalking to the patient about their medication and updating the Shared Medication Record for patients referred to hospitalmedication review, overview of medication changes and follow-up telephone calls for patients discharged from hospital to general practice.The intervention identified and solved several drug-related problems. Access to health records in both the general practice and at the hospital was important in the identification of drug-related problems.Conclusions: Drug-related problems in cross-sectoral transitions are multifaceted. The pharmacist intervention identified and solved several drug-related problems. The intervention made sense to the general practitioner, hospital and patients. Shared employment and unique access to health records in both the general practice and at the hospital showed to be of importance in the identification of drug-related problems.

Correlation between the use of 'over-the-counter' medicines and adherence in elderly patients on multiple medications.

BACKGROUND: Medication adherence is a multifaceted issue that is influenced by various factors. One factor may be the concurrent use of over-the-counter (OTC)medicines. The use of OTC medicine has been reported as common amongst elderly patients. OBJECTIVE: To determine if a correlation exists between the use of OTC medicines and adherence to prescribed medications in elderly patients. SETTING: Non-institutionalised elderly patients in Denmark. METHODS: Elderly unassisted patients aged ≥65 prescribed five or more prescription drugs were included in the study. Information on the use of concurrent OTC medications (herbal medicines, dietary supplements, or non-prescribed drugs) was elicited during home visit interviews. Prescription drug adherence was determined by pill counts. A patient was categorised as non-adherent if the me an adherence rate for all drugs consumed was\80 %. Different sensitivity analyses were made where adherence was defined different. MAIN OUTCOME MEASURE: Medication adherence based on pill-count. RESULTS: A total of 253 participants included 72 % who used OTC medicines and 11 % who did not adhere to their prescriptions. Users of OTC medicines, however, were significantly more likely to be adherent than were non-users (odds ratio 0.41; 95 %confidence interval 0.18­0.91). Sensitivity analyses where adherence was defined different show no relationship between adherence and use of OTC medicine. Furthermore,separate analyses of herbal medicines, dietary supplements,or non-prescribed drugs did not correlate with adherence to prescriptions. CONCLUSION: Amongst elderly patients on multiple medications a positive relationship was found between the overall use of OTC medicines and adherence to prescription drugs, in contrast to none when adherence were defined different or herbal medicines, dietary supplements, or non-prescribed drugs were analysed separately.

Impact of pharmaceutical care on adherence, hospitalisations and mortality in elderly patients.

BACKGROUND: Elderly polypharmacy patients may be more at risk of not adhering to medication. If so, the underlying reasons may be more readily disclosed during private discussions with patients. Hence pharmaceutical care discussions at home might improve treatment adherence. OBJECTIVE: The aim of this study was to investigate the impact of pharmaceutical care on medication adherence, hospitalisation and mortality in elderly patients prescribed polypharmacy. SETTING: Pharmaceutical care discussed at home. METHODS: A randomised controlled trial with two arms; pharmaceutical care (n = 315) and controls (n = 315) was designed. It involved patients aged 65+ years living in Aarhus, Denmark who used five drugs or more without assistance. Pharmacists visited the pharmaceuticalcare patients at home, once only, and followed them during the subsequent year with three telephone calls. Non-adherence was measured by a pill-count. Patients were categorised as non-adherent if their mean adherence rate for all drugs consumed was <80 %. The impact of pharmaceutical care on non-adherence and hospitalisation was analysed by 2 × 2 tables, and mortality by Cox regression. MAIN OUTCOME MEASURE: Medication adherence, hospitalisation and mortality. RESULTS: The final analyses included 517 patients (median age 74 years; females 52 %). Dropouts were more frequent for the pharmaceutical-care group than for controls. Pharmacists encountered drug-related problems amongst 72 % of pharmaceutical-care patients. Pharmaceutical-care patients (11 %) and control patients (10 %) were similarly nonadherent (Odds ratio 1.14; 95 % confidence interval 0.65-2.00), and similar with respect to hospitalisation frequency (30 vs. 28 %; Odds ratio 1.14; 95 % confidence interval 0.78-1.67) and mortality (7.5 vs. 5 %; Hazard ratio 1.41; 95 % confidence interval 0.71-2.82). CONCLUSIONS: Pharmaceutical care given to our elderly polypharmacy patients made no significant impact on medication adherence, hospitalisation or mortality, when compared to comparable control patients.

Correlation between the use of 'over-the-counter' medicines and adherence in elderly patients on multiple medications.

Background Medication adherence is a multifaceted issue that is influenced by various factors. One factor may be the concurrent use of over-the-counter (OTC) medicines. The use of OTC medicine has been reported as common amongst elderly patients. Objective To determine if a correlation exists between the use of OTC medicines and adherence to prescribed medications in elderly patients. Setting Non-institutionalised elderly patients in Denmark. Methods Elderly unassisted patients aged ≥65 prescribed five or more prescription drugs were included in the study. Information on the use of concurrent OTC medications (herbal medicines, dietary supplements, or non-prescribed drugs) was elicited during home visit interviews. Prescription drug adherence was determined by pill counts. A patient was categorised as non-adherent if the mean adherence rate for all drugs consumed was <80 %. Different sensitivity analyses were made where adherence was defined different. Main outcome measure Medication adherence based on pill-count. Results A total of 253 participants included 72 % who used OTC medicines and 11 % who did not adhere to their prescriptions. Users of OTC medicines, however, were significantly more likely to be adherent than were non-users (odds ratio 0.41; 95 % confidence interval 0.18-0.91). Sensitivity analyses where adherence was defined different show no relationship between adherence and use of OTC medicine. Furthermore, separate analyses of herbal medicines, dietary supplements, or non-prescribed drugs did not correlate with adherence to prescriptions. Conclusion Amongst elderly patients on multiple medications a positive relationship was found between the overall use of OTC medicines and adherence to prescription drugs, in contrast to none when adherence were defined different or herbal medicines, dietary supplements, or non-prescribed drugs were analysed separately.

Generic substitution does not seem to affect adherence negatively in elderly polypharmacy patients.

PURPOSE: To investigate the association between generic substitutions and medication adherence in elderly patients with prescribed polypharmacy. METHODS: Our study included 672 patients aged 65+ years, living at home in the municipality of Aarhus (Denmark), who at the time of enrolment took at least five prescription drugs daily including both short-term and long-term treatment independently of kind of administration route but without assistance. In this paper, only oral drugs for long-term treatment are included in the analysis resulting in median of three drugs per patient. Adherence was assessed by pill counts. Patients with a mean adherence rate <80% across all oral drugs consumed for long-term treatment were categorised as non-adherent. The number of generic substitutions during 1 year was retrieved from the National Health Insurance prescription database. Each change in either a drug's or a manufacturer's name was regarded as a substitution. The association between generic substitution and the mean adherence rate to all drugs was analysed by contingency table analyses and a trend test. RESULTS: During 1 year, at least one substitution was experienced by 83.6% of patients (n = 562). Patients non-adherent to long-term oral treatment (n = 46) amounted to 8% of all patients who experienced substitutions. Amongst 110 elderly patients (16.4%) who did not experience substitutions, 16% were non-adherent (odds ratio 0.46; 95% confidence interval 0.25-0.82). CONCLUSION: As generic substitution in elderly patients undergoing polypharmacy appears not to affect adherence to long-term drug treatment negatively, there seems to be no obvious reason for avoiding generic substitution in such patients.

Suitability of an electronic reminder device for measuring drug adherence in elderly patients with complex medication.

We evaluated an electronic reminder device for detecting non-adherence in elderly patients with complex medication regimens. Randomly selected, home-living elderly patients were studied. The patients were aged over 65 years and were taking more than four drugs. Patients received an electronic reminder device which contained a GSM communications module. They were visited three times over a one-year period by a nurse who counted their medicine supply. We compared the adherence measured by the electronic device with the actual adherence measured by the pill count. Almost half of the 315 patients dropped out of the study for various reasons, so the calculations were performed on 168 patients. The adherence measured by the electronic reminder system was 79% and was 92% measured by pill count (P<0.0001). The limits of agreement estimated by a Bland-Altman analysis were -57 to +30. We also compared electronically measured adherence at morning/evening intake times with pill count adherence in the morning/evening only. For the pill count, there was almost no difference between morning and evening adherence rates (93%). For electronic measurement, adherence rates were lower in the evening (75%) than in the morning (81%). Electronic reminders were less reliable than the pill count in measuring adherence. However, the electronic system may be a useful supplement to other, more time consuming methods for measuring adherence.

Reinforcing effect of subcutaneous morphine in a modified Ettenberg runway.

Alley running has been successfully used as an operant to demonstrate both the positive and negative reinforcing effect of intravenously administered drugs of abuse in a bona fide operant conditioning paradigm, the Ettenberg runway, in which confounding drug effects on motor performance and drug accumulation are avoided. While Ettenberg and colleagues focus on the intravenous route of drug administration, we tested the practicability of the subcutaneous route of administration in this runway paradigm in Sprague Dawley rats, using morphine as the investigated drug of abuse. We also modified the Ettenberg runway, most notably in that either food (sweetened condensed milk), no food, morphine, or saline was presented outside the runway in a separate cage. This made shaping, i.e., the initial presentation of a food reinforcer within the runway, necessary to establish responding. The manipulations necessary to administer subcutaneous (sc) injections were well tolerated by over 90% of the tested rats (n = 93). However, sc injections increased runtimes to the experimenter cutoff of 60 s within 20 once-daily sessions. Because of strong experimenter effects, all morphine doses or saline had to be adminstered blind. Under these experimenter-blind conditions, 0.1 and 1 mg/kg subcutaneous morphine proved to be reinforcing in that these doses significantly slowed down the gradual increase in runtimes imposed upon by the sc injection procedure. Thus, morphine can be demonstrated to be a positive reinforcer in a modified Ettenberg runway even when given subcutaneously. This effect, however, is eventually overcome by the negative reinforcing effect of subjecting the animals to sc injection procedure.