Pharmacists and pharmacy students' perceptions on how a new teaching model supports their clinical decision-making.

BACKGROUND AND PURPOSE: Clinical decision-making (CDM) is crucial in pharmacy practice, necessitating effective teaching in undergraduate and postgraduate pharmacy education. This study aims to explore undergraduates and postgraduates' perceptions of how a new teaching model supports their CDM when addressing patient cases. EDUCATIONAL ACTIVITY AND SETTING: Implemented in a full-day CDM course for pharmacy students and a half-day course for pharmacists in the Netherlands, the model, accompanied by a learning guide, facilitated CDM in patient cases. Eight courses were conducted between September 2022 to June 2023, followed by an online survey measuring participants' agreement on how the model supported their CDM, using a 5-point Likert scale. Additionally, three open-ended questions were included to elicit learning outcomes and self-development opportunities. FINDINGS: Of 175 invited participants, 159 (91%) completed the survey. Most agreed the teaching model supported their CDM, particularly in considering the patient's healthcare needs and context (96%), and exploring all available options (96%). Participants found the model provided a clear structure (97%), and fostered critical thinking (93%). The most frequently mentioned learning outcomes and self-development opportunities included collecting sufficient relevant information, maintaining a broad perspective, and decelerating the process to avoid premature closure. SUMMARY: Participants agreed that the teaching model helped them to make clinical decisions. Both undergraduate and postgraduate pharmacy education could possibly benefit from the teaching model's implementation in supporting pharmacy students and pharmacists conducting CDM in pharmacy practice.

Potential for pharmacist prescribing in primary care: A Dutch citizen perspective.

Background: Medication prescribing by pharmacists is a task shifting approach to help ensure quality and accessibility of healthcare. In many countries, like the Netherlands, pharmacist prescribing is not legally ensured, and it is unknown what citizens think of its potential introduction. Objective: To investigate citizen perspectives on the potential role of pharmacists in prescribing in primary care. Methods: A Citizen Platform with citizens (>18 years) from the Netherlands was conducted in October 2022. This consisted of a one-day program in which the participants were engaged in interactive assignments and received expert presentations to foster the development of informed opinions. In the final assignment, 3 participant groups designed their ideal future scenario including preconditions regarding the role of the pharmacist in prescribing in primary care. All assignments were recorded, and notes were taken. The researchers then consolidated the 3 scenarios into one version and categorized the preconditions. The Citizen Platform results were summarized and subsequently discussed in 2 online focus groups with other citizens in February 2023 to investigate the perspectives of less informed citizens. Focus group discussions were audio-recorded, transcribed, and thematically analyzed. Results: The Citizen Platform (n = 10) resulted in a shared scenario involving a primary care center where general practitioners (GPs) pharmacists and other healthcare professionals collaborate as a team. In this scenario, pharmacists can modify treatment in certain chronic diseases, manage minor ailments and support GPs with the care for patients with complex needs. Preconditions needed to realize this scenario include having shared medical records, the GP retaining the overview of the care for the patient and additional training for pharmacists. The focus groups (n = 6, in total) yielded 5 themes which acknowledge potential pharmacist prescribing but depict a more skeptical view towards pharmacist prescribing and include several concerns, for example pharmacists' potential conflict of interest. Conclusions: Citizens that are informed about opportunities for pharmacy prescribing are capable of sketching potential scenarios for pharmacist prescribing in a collaborative primary care context. Less informed citizens seem more skeptical towards pharmacist prescribing.

The complexities of communication at hospital discharge of older patients: a qualitative study of healthcare professionals' views.

BACKGROUND: Hospital discharge of older patients is a high-risk situation in terms of patient safety. Due to the fragmentation of the healthcare system, communication and coordination between stakeholders are required at discharge. The aim of this study was to explore communication in general and medication information transfer in particular at hospital discharge of older patients from the perspective of healthcare professionals (HCPs) across different organisations within the healthcare system. METHODS: We conducted a qualitative study using focus group and individual or group interviews with HCPs (physicians, nurses and pharmacists) across different healthcare organisations in Sweden. Data were collected from September to October 2021. A semi-structured interview guide including questions on current medication communication practices, possible improvements and feedback on suggestions for alternative processes was used. The data were analysed thematically, guided by the systematic text condensation method. RESULTS: In total, four focus group and three semi-structured interviews were conducted with 23 HCPs. Three main themes were identified: 1) Support systems that help and hinder describes the use of support systems in the discharge process to compensate for the fragmentation of the healthcare system and the impact of these systems on HCPs' communication; 2) Communication between two separate worlds depicts the difficulties in communication experienced by HCPs in different healthcare organisations and how they cope with them; and 3) The large number of medically complex patients disrupts the communication reveals how the highly pressurised healthcare system impacts on HCPs' communication at hospital discharge. CONCLUSIONS: Communication at hospital discharge is hindered by the fragmented, highly pressurised healthcare system. HCPs are at risk of moral distress when coping with communication difficulties. Improved communication methods at hospital discharge are needed for the benefit of both patients and HCPs.

Identifying older adults at increased risk of medication-related readmission to hospital within 30 days of discharge: development and validation of a risk assessment tool.

OBJECTIVE: Developing and validating a risk assessment tool aiming to identify older adults (≥65 years) at increased risk of possibly medication-related readmission to hospital within 30 days of discharge. DESIGN: Retrospective cohort study. SETTING: The risk score was developed using data from a hospital in southern Sweden and validated using data from four hospitals in the mid-eastern part of Sweden. PARTICIPANTS: The development cohort (n=720) was admitted to hospital during 2017, whereas the validation cohort (n=892) was admitted during 2017-2018. MEASURES: The risk assessment tool aims to predict possibly medication-related readmission to hospital within 30 days of discharge. Variables known at first admission and individually associated with possibly medication-related readmission were used in development. The included variables were assigned points, and Youden's index was used to decide a threshold score. The risk score was calculated for all individuals in both cohorts. Area under the receiver operating characteristic (ROC) curve (c-index) was used to measure the discrimination of the developed risk score. Sensitivity, specificity and positive and negative predictive values were calculated using cross-tabulation. RESULTS: The developed risk assessment tool, the Hospitalisations, Own home, Medications, and Emergency admission (HOME) Score, had a c-index of 0.69 in the development cohort and 0.65 in the validation cohort. It showed sensitivity 76%, specificity 54%, positive predictive value 29% and negative predictive value 90% at the threshold score in the development cohort. CONCLUSION: The HOME Score can be used to identify older adults at increased risk of possibly medication-related readmission within 30 days of discharge. The tool is easy to use and includes variables available in electronic health records at admission, thus making it possible to implement risk-reducing activities during the hospital stay as well as at discharge and in transitions of care. Further studies are needed to investigate the clinical usefulness of the HOME Score as well as the benefits of implemented activities.

Pharmacists in general practice: what do they do? A qualitative case study.

BACKGROUND: Pharmacists working in general practice are a relatively new phenomenon in many European countries. Providing insight into what pharmacists do in general practice may support further implementation of general practice-based pharmacist roles and enhance their contribution to health care. AIM: To explore the tasks performed by pharmacists in general practice in Sweden. METHOD: A case study was conducted in 7 general practices in Uppsala County, Sweden, where pharmacists were employed. Activities performed by pharmacists were self-reported during March 2021. Participant observations and semi-structured interviews with pharmacists were conducted between October and November 2021. Self-reported activities were categorised and analysed using descriptive statistics. Qualitative data were analysed using conventional content analysis. RESULTS: In total, 174 activities were self-reported by 8 pharmacists. Two pharmacists were observed for 2 days each, and 6 pharmacists were interviewed. Their main task was conducting medication reviews in older patients with polypharmacy. In addition, they handled a broad variety of drug-related questions and treatment follow-up. Pharmacists described working in a more efficient and needs-based manner over time. They stressed that working at the practice increased their accessibility to and their collaborative work with other healthcare professionals, and enabled them to meet patients face-to-face. Future challenges include defining tasks more clearly, assuming greater responsibility for patient care, and meeting the growing demand for pharmacists in general practice. CONCLUSION: Pharmacists in general practice in Sweden perform a broad variety of tasks related to identifying, resolving and preventing drug-related problems, mainly in older patients with polypharmacy.

Drug-related readmissions in older hospitalized adults: External validation and updating of OPERAM DRA prediction tool.

BACKGROUND: Drug-related readmissions (DRAs) are defined as rehospitalizations with an adverse drug event as their main or significant contributory cause. DRAs represent a major adverse health burden for older patients. A prediction model which identified older hospitalized patients at high risk of a DRA <1 year was previously developed using the OPERAM trial cohort, a European cluster randomized controlled trial including older hospitalized patients with multimorbidity and polypharmacy. This study has performed external validation and updated the prediction model consequently. METHODS: The MedBridge trial cohort (a multicenter cluster randomized crossover trial performed in Sweden) was used as a validation cohort. It consisted of 2516 hospitalized patients aged ≥65 years. Model performance was assessed by: (1) discriminative power, assessed by the C-statistic with a 95% confidence interval (CI); (2) calibration, assessed by visual examination of the calibration plot and use of the Hosmer-Lemeshow goodness-of-fit test; and (3) overall accuracy, assessed by the scaled Brier score. Several updating methods were carried out to improve model performance. RESULTS: In total, 2516 older patients were included in the validation cohort, of whom 582 (23.1%) experienced a DRA <1 year. In the validation cohort, the original model showed a good overall accuracy (scaled Brier score 0.03), but discrimination was moderate (C-statistic 0.62 [95% CI 0.59-0.64]), and calibration showed underestimation of risks. In the final updated model, the predictor "cirrhosis with portal hypertension" was removed and "polypharmacy" was added. This improved the model's discriminative capability to a C-statistic of 0.64 (95% CI 0.59-0.70) and enhanced calibration plots. Overall accuracy remained good. CONCLUSIONS: The updated OPERAM DRA prediction model may be a useful tool in clinical practice to estimate the risk of DRAs in older hospitalized patients subsequent to discharge. Our efforts lay the groundwork for the future development of models with even better performance.

Risk factors for and preventability of drug-related hospital revisits in older patients: A post-hoc analysis of a randomized clinical trial.

AIM: The aims of this study were (1) to identify older patients' risk factors for drug-related readmissions and (2) to assess the preventability of older patients' drug-related revisits. METHODS: Post hoc analysis of a randomized clinical trial with patients aged ≥65 years at eight wards within four hospitals in Sweden. (1) The primary outcome was risk factors for drug-related readmission within 12 months post-discharge. A Cox proportional hazards model was made with sociodemographic and clinical baseline characteristics. (2) Four hundred trial participants were randomly selected and their revisits (admissions and emergency department visits) were assessed to identify potentially preventable drug-related revisits, related diseases and causes. RESULTS: (1) Among 2637 patients (median age 81 years), 582 (22%) experienced a drug-related readmission within 12 months. Sixteen risk factors (hazard ratio >1, P < 0.05) related to age, previous hospital visits, medication use, multimorbidity and cardiovascular, liver, lung and peptic ulcer disease were identified. (2) The 400 patients experienced a total of 522 hospital revisits, of which 85 (16%) were potentially preventable drug-related revisits. The two most prevalent related diseases were heart failure (n = 24, 28%) and chronic obstructive pulmonary disease (n = 13, 15%). The two most prevalent causes were inadequate treatment (n = 23, 27%) and insufficient or no follow-up (n = 22, 26%). CONCLUSION: (1) Risk factors for drug-related readmissions in older hospitalized patients were age, previous hospital visits, medication use and multiple diseases. (2) Potentially preventable drug-related hospital revisits are common and might be prevented through adequate pharmacotherapy and continuity of care in older patients with cardiovascular or lung disease.

Drug-related emergency department visits in older patients: an applicability and reliability study of an existing assessment tool.

BACKGROUND: AT-HARM10 is a research tool to identify possible drug-related hospital admissions. It is unclear whether the tool can be applied to emergency department visits as well. AIM: The aim of this study was to investigate the applicability and reliability to identify drug-related emergency department visits in older patients with AT-HARM10. METHOD: A random sample of 400 patients aged 65 years or older from a clinical trial in four Swedish hospitals was selected. All patients' emergency department visits within 12 months after discharge were assessed with AT-HARM10. The main outcome measures were the percentage of successfully assessed visits for applicability and the interrater reliability (Cohen's kappa). RESULTS: Of the initial sample (n = 400), 113 patients [median age (interquartile range): 81 (76-88) years] had at least one emergency department visit within 12 months. The patients had in total 184 visits, of which 179 (97%) were successfully assessed. Fifty-three visits (29%) were possibly drug-related. The Cohen's kappa value was 0.70 (substantial). CONCLUSION: It seems applicable and reliable to identify possible drug-related emergency department visits in addition to hospital admissions in older patients with AT-HARM10. As a consequence, the tool has been updated to support its novel use in clinical research.

Assessment of requests for medication-related follow-up after hospital discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective chart review.

BACKGROUND: The discharge of older hospitalised patients is critical in terms of patient safety. Inadequate transfer of information about medications to the next healthcare provider is a known problem, but there is a lack of understanding of this problem in settings where shared electronic health records are used. The aims of this study were to evaluate the prevalence of patients for whom hospitals sent adequate requests for medication-related follow-up at discharge, the proportion of patients with unplanned hospital revisits because of inadequate follow-up requests, and the association between medication reviews performed during hospitalisation and adequate or inadequate follow-up requests. METHODS: We conducted a retrospective chart review. The study population was randomly selected from a cluster-randomised crossover trial which included patients 65 years or older who had been admitted to three hospitals in Sweden with shared electronic health records between hospital and primary care. Each patient was assessed with respect to the adequacy of the request for follow-up. For patients where the hospitals sent inadequate requests, data about any unplanned hospital revisits were collected, and we assessed whether the inadequate requests had contributed to the revisits. The association between medication reviews and adequate or inadequate requests was analysed with a Chi-square test. RESULTS: A total of 699 patients were included. The patients' mean age was 80 years; an average of 10 medications each were prescribed on hospital admission. The hospitals sent an adequate request for 418 (60%) patients. Thirty-eight patients (14%) had a hospital revisit within six months of discharge which was related to an inadequate request. The proportion of adequate or inadequate requests did not differ between patients who had received a medication review during hospitalisation and those who had not (p = 0.83). CONCLUSIONS: The prevalence of patients for whom the hospitals sent adequate follow-up requests on discharge was low. More than one in every ten who had an inadequate request revisited hospital within six months of discharge for reasons related to the request. Medication reviews conducted during hospitalisation did not affect the proportion of adequate or inadequate requests sent. A communication gap still exists despite the usage of a shared electronic health record between primary and secondary care levels.

Effects of Hospital-Based Comprehensive Medication Reviews Including Postdischarge Follow-up on Older Patients' Use of Health Care: A Cluster Randomized Clinical Trial.

Importance: Suboptimal use of medications is a leading cause of health care-related harm. Medication reviews improve medication use, but evidence of the possible benefit of inpatient medication review for hard clinical outcomes after discharge is scarce. Objective: To study the effects of hospital-based comprehensive medication reviews (CMRs), including postdischarge follow-up of older patients' use of health care resources, compared with only hospital-based reviews and usual care. Design, Setting, and Participants: The Medication Reviews Bridging Healthcare trial is a cluster randomized crossover trial that was conducted in 8 wards with multiprofessional teams at 4 hospitals in Sweden from February 6, 2017, to October 19, 2018, with 12 months of follow-up completed December 6, 2019. The study was prespecified in the trial protocol. Outcome assessors were blinded to treatment allocation. In total, 2644 patients aged 65 years or older who had been admitted to 1 of the study wards for at least 1 day were included. Data from the modified intention-to-treat population were analyzed from December 10, 2019, to September 9, 2020. Interventions: Each ward participated in the trial for 6 consecutive 8-week periods. The wards were randomized to provide 1 of 3 treatments during each period: CMR, CMR plus postdischarge follow-up, and usual care without a clinical pharmacist. Main Outcomes and Measures: The primary outcome measure was the incidence of unplanned hospital visits (admissions plus emergency department visits) within 12 months. Secondary outcomes included medication-related admissions, visits with primary care clinicians, time to first unplanned hospital visit, mortality, and costs of hospital-based care. Results: Of the 2644 participants, 7 withdrew after inclusion, leaving 2637 for analysis (1357 female [51.5%]; median age, 81 [interquartile range, 74-87] years; median number of medications, 9 [interquartile range, 5-13]). In the modified intention-to-treat analysis, 922 patients received CMR, 823 received CMR plus postdischarge follow-up, and 892 received usual care. The crude incidence rate of unplanned hospital visits was 1.77 per patient-year in the total study population. The primary outcome did not differ between the intervention groups and usual care (adjusted rate ratio, 1.04 [95% CI, 0.89-1.22] for CMR and 1.15 [95% CI, 0.98-1.34] for CMR plus postdischarge follow-up). However, CMR plus postdischarge follow-up was associated with an increased incidence of emergency department visits within 12 months (adjusted rate ratio, 1.29; 95% CI, 1.05-1.59) compared with usual care. There were no differences between treatment groups regarding other secondary outcomes. Conclusions and Relevance: In this study of older hospitalized patients, CMR plus postdischarge follow-up did not decrease the incidence of unplanned hospital visits. The findings do not support the performance of hospital-based CMRs as conducted in this trial. Alternative forms of medication reviews that aim to improve older patients' health outcomes should be considered and subjected to randomized clinical trials. Trial Registration: ClinicalTrials.gov Identifier: NCT02986425.

Intervention fidelity and process outcomes of medication reviews including post-discharge follow-up in older hospitalized patients: Process evaluation of the MedBridge trial.

WHAT IS KNOWN AND OBJECTIVE: Drug-related problems (DRPs) are a growing healthcare burden worldwide. In an ongoing cluster-randomized controlled trial in Sweden (MedBridge), comprehensive medication reviews (CMRs) including post-discharge follow-up have been conducted in older hospitalized patients to prevent and solve DRPs. As part of a process evaluation of the MedBridge trial, this study aimed to assess the intervention fidelity and process outcomes of the trial's interventions. METHODS: For intervention delivery, the percentage of patients that received intervention components was calculated per study group. Process outcomes, measured in about one-third of all intervention patients, included the following: the number of identified medication discrepancies, DRPs and recommendations to solve DRPs, correction rate of discrepancies, and implementation rate of recommendations. RESULTS AND DISCUSSION: The MedBridge trial included 2637 patients (mean age: 81 years). The percentage of intervention patients (n = 1745) that received the intended intervention components was 94%-98% during admission, and 40%-81% upon and after discharge. The percentage of control patients (n = 892) that received at least one unintended intervention component was 15%. On average, 1.1 discrepancies and 2.0 DRPs were identified in 652 intervention patients. The correction and implementation rates were 79% and 73%, respectively. Stop medication was the most frequently implemented recommendation (n = 293) and 77% of the patients had at least one corrected discrepancy or implemented recommendation. WHAT IS NEW AND CONCLUSION: The intervention fidelity within the MedBridge trial was high for CMRs during hospital stay and lower for intervention components upon and after discharge. The high prevalence of corrected discrepancies and implemented recommendations may explain potential effects of CMRs in the MedBridge trial.

Facilitators and barriers for performing comprehensive medication reviews and follow-up by multiprofessional teams in older hospitalised patients.

PURPOSE: There is a lack of knowledge about factors that influence the performance of comprehensive medication reviews (CMRs) by multiprofessional teams in hospital practice. This study aimed to explore the facilitators and barriers for performing CMRs and post-discharge follow-up in older hospitalised patients from the healthcare professional perspective. METHODS: Physicians and ward-based pharmacists were recruited from an ongoing trial at four hospitals in Sweden. Semi-structured interviews were conducted with 16 physicians and 7 pharmacists. Interview topics were working processes, resources, competences, medication-related problems, intervention effects and collaboration. The interviews were audio-recorded, transcribed verbatim and thematically analysed using the Consolidated Framework for Implementation Research (CFIR). Identified subthemes were categorised as facilitators or barriers and grouped into overarching main themes. RESULTS: In total, 21 facilitators and 25 barriers were identified across all CFIR domains and grouped in 6 main themes: (a) CMRs and follow-up are needed, but not in all patients; (b) there is a general belief in positive effects; (c) lack of resources is an issue, although the performance of CMRs may save time; (d) pharmacists' knowledge and skills are valuable, but they need more clinical competence; (e) compatibility with hospital practice is challenging, and roles and responsibilities are unclear and (f) personal contact at the ward is essential for physician-pharmacist collaboration. CONCLUSION: Multiple facilitators and barriers for performing CMRs and post-discharge follow-up in older hospitalised patients exist. These factors should be addressed in future initiatives with similar interventions by multiprofessional teams to ensure successful implementation and performance in hospital practice.

Comprehensive medication reviews by ward-based pharmacists in Swedish hospitals: What does the patient have to say?

RATIONALE, AIMS, AND OBJECTIVES: Inappropriate medication prescribing and use amongst older patients is a major patient safety and health care problem. To promote appropriate medication prescribing and use, comprehensive medication reviews (CMRs) by ward-based pharmacists, including follow-up telephone calls after hospital discharge, have been conducted in older patients in the context of a randomized controlled trial (RCT). One of the key actors in a CMR is the patient. To support the understanding of the effects of CMRs on patients' health outcomes and improve clinical practice, knowledge about the patient perspective is needed. We therefore aimed to explore older patients' experiences with, and views on, hospital-initiated CMRs and follow-up telephone calls by ward-based clinical pharmacists within an RCT. METHODS: We conducted in-depth semi-structured interviews with 15 patients (66-94 years) and carers from four hospitals in Sweden. Discussion topics included communication, information, decision-making, and effects on the patient. Interviews took place after discharge, were audio-recorded, transcribed verbatim, and thematically analysed using a framework approach. RESULTS: In general, patients' experiences and views were positive. Seven key themes were identified: (a) feeling of being taken care of and heterogenous health effects; (b) the pharmacist is competent; (c) despite the unclear role of pharmacists, their involvement is appreciated; (d) patients rely on health care professionals for decision-making; (e) importance of being informed, but receiving and retaining information is problematic; (f) time, location, and other factors influencing the effectiveness of CMRs; and (g) generic substitution is a problem. CONCLUSIONS: Older patients generally have positive experiences with and views on CMRs and follow-up telephone calls. However, some factors, like the unclear role of the ward-based pharmacist and problems with receiving and retaining information, may negatively impact the effectiveness of these interventions. Future initiatives on hospital-initiated CMRs by clinical pharmacists should address these negative factors and utilize the positive views.

A case study of the implementation and sustainability of medication reviews in older patients by clinical pharmacists.

BACKGROUND: Medication reviews have been introduced as healthcare interventions to decrease inappropriate polypharmacy in older patients, but implementation in practice is challenging. OBJECTIVE: This case study aimed to explore the events, actions and other factors that were involved in the implementation and sustainability of medication reviews in older patients by clinical pharmacists in Region Uppsala, Sweden. METHODS: A case study design informed by change management principles (Kotter) and normalization process theory, consisting of a review of published and grey literature, key informant interviews and focus group triangulation. Findings from additional literature review and interviews were integrated into a final thematic analysis. Ten healthcare professionals, managers and policy makers participated as key informants. The study included data up to 2015. RESULTS: Factors were identified across all Kotter's principles and normalization process theory domains, ranging from the first evidence on inappropriate polypharmacy in the 1980s until the creation of permanent clinical pharmacist positions in recent years. Examples of facilitating factors were a national focus on quality of care for the elderly, multiprofessional teamwork, key individuals with different professions, education, financial support and local evidence. Barriers included an unclear allocation of tasks and responsibilities, a lack of time and continuity, and a lack of a national plan for implementation, monitoring and evaluation. CONCLUSIONS: Multiple factors across the full range of change management and implementation principles were involved in the implementation and sustainability. A systems approach, including these factors, should be considered in similar future initiatives, both in Sweden and settings in other countries.

Assessment tool for hospital admissions related to medications: development and validation in older patients.

Background Medication-related hospital admissions (MRAs) are frequently used to measure outcomes in studies involving medication reviews. The process of identifying MRAs is subjective and time-consuming, and practical, validated alternatives are required. Objective The aim of this study was to develop and validate a practical tool to identify MRAs. Setting Uppsala University Hospital, Sweden. Method We reviewed existing literature on methods to identify MRAs. The tool AT-HARM10 was developed using an iterative process including content validity and feasibility testing. The tool's inter-rater reliability (IRR) and criterion-related validity (CRV) were assessed: four pairs of either final-year undergraduate or postgraduate pharmacy students applied the tool to one of two batches of 50 older patients' hospital admissions. Assessment of the same 100 admissions by two experienced clinicians acted as gold standard. Main outcome measure Cohen's and Fleiss' kappa for IRR, and sensitivity, specificity, and positive and negative predictive value for CRV. Results AT-HARM10 consists of ten closed questions to distinguish between admissions that are unlikely to be and those that are possibly medication-related. The IRR was moderate to substantial (Cohen's kappa values were 0.45-0.75 and Fleiss' kappa values were 0.46 and 0.58). The sensitivity and specificity values were 70/86% and 74/70%, positive and negative predictive values were 73/74% and 71/83% respectively. Both AT-HARM10 and the gold standard identified approximately 50% of the admissions as MRAs. Conclusion AT-HARM10 has been developed as a practical tool to identify MRAs and the tool is valid for use in older patients by final-year undergraduate and postgraduate pharmacy students.

A case study of polypharmacy management in nine European countries: Implications for change management and implementation.

BACKGROUND: Multimorbidity and its associated polypharmacy contribute to an increase in adverse drug events, hospitalizations, and healthcare spending. This study aimed to address: what exists regarding polypharmacy management in the European Union (EU); why programs were, or were not, developed; and, how identified initiatives were developed, implemented, and sustained. METHODS: Change management principles (Kotter) and normalization process theory (NPT) informed data collection and analysis. Nine case studies were conducted in eight EU countries: Germany (Lower Saxony), Greece, Italy (Campania), Poland, Portugal, Spain (Catalonia), Sweden (Uppsala), and the United Kingdom (Northern Ireland and Scotland). The workflow included a review of country/region specific polypharmacy policies, key informant interviews with stakeholders involved in policy development and implementation and, focus groups of clinicians and managers. Data were analyzed using thematic analysis of individual cases and framework analysis across cases. RESULTS: Polypharmacy initiatives were identified in five regions (Catalonia, Lower Saxony, Northern Ireland, Scotland, and Uppsala) and included all care settings. There was agreement, even in cases without initiatives, that polypharmacy is a significant issue to address. Common themes regarding the development and implementation of polypharmacy management initiatives were: locally adapted solutions, organizational culture supporting innovation and teamwork, adequate workforce training, multidisciplinary teams, changes in workflow, redefinition of roles and responsibilities of professionals, policies and legislation supporting the initiative, and data management and information and communication systems to assist development and implementation. Depending on the setting, these were considered either facilitators or barriers to implementation. CONCLUSION: Within the studied EU countries, polypharmacy management was not widely addressed. These results highlight the importance of change management and theory-based implementation strategies, and provide examples of polypharmacy management initiatives that can assist managers and policymakers in developing new programs or scaling up existing ones, particularly in places currently lacking such initiatives.

A modified Delphi study to determine the level of consensus across the European Union on the structures, processes and desired outcomes of the management of polypharmacy in older people.

BACKGROUND: Inappropriate use of multiple medicines (inappropriate polypharmacy) is a major challenge in older people with consequences of increased prevalence and severity of adverse drug reactions and interactions, and reduced medicines adherence. The aim of this study was to determine the levels of consensus amongst key stakeholders in the European Union (EU) in relation to aspects of the management of polypharmacy in older people. METHODS: Forty-six statements were developed on aspects of healthcare structures, processes and desired outcomes, with consensus defined at ≥ 80% agreement. Panel members were strategists (e.g. directors, leading clinicians and commissioners) from each of the 28 EU member states, with a target recruitment of five per member state. Three Delphi rounds were conducted via email, with panel members being provided with summative results and collated, anonymised comments at the commencement of Rounds 2 and 3. RESULTS: Ninety panel members were recruited (64.3% of target), with high participation levels throughout the three Delphi rounds (91.1%, 83.3%, 72.2%). During Round 1, consensus was obtained for 27/46 statements (58.7%), with an additional two statements in Round 2 and none in Round 3. Consensus was obtained for statements relating to: potential gain arising from polypharmacy management (3/4 statements); strategic development (7/7); change management (5/7) indicator measures (4/6); legislation (0/3); awareness raising (5/5); polypharmacy reviews (5/7); and EU vision (0/7). Analysis of free text comments indicated that the vision statements were too ambitious and not achievable by the specified timeframe of 2025. CONCLUSION: Consensus was obtained amongst key EU strategists around many aspects of polypharmacy management in older people. Notably, no consensus was achieved in relation to statements relating to the need to alter legislation in areas of healthcare delivery, remuneration and practitioner scope of practice. While the vision for the EU by 2025 was considered rather ambitious, there is great potential and clear opportunity to advance polypharmacy management throughout the EU and beyond.

Medication Reviews Bridging Healthcare (MedBridge): Study protocol for a pragmatic cluster-randomised crossover trial.

BACKGROUND: Mismanaged prescribing and use of medication among elderly puts major pressure on current healthcare systems. Performing a medication review, a structured critical examination of a patient's medications, during hospital stay with active follow-up into primary care could optimise treatment benefit and minimise harm. However, a lack of high quality evidence inhibits widespread implementation. This manuscript describes the rationale and design of a pragmatic cluster-randomised, crossover trial to fulfil this need for evidence. AIM: To study the effects of hospital-initiated comprehensive medication reviews, including active follow-up, on elderly patients' healthcare utilisation compared to 1) usual care and 2) solely hospital based reviews. DESIGN: Multicentre, three-treatment, replicated, cluster-randomised, crossover trial. SETTING: 8 wards with a multidisciplinary team within 4 hospitals in 3 Swedish counties. PARTICIPANTS: Patients aged 65years or older, admitted to one of the study wards. EXCLUSION CRITERIA: Palliative stage; residing in other than the hospital's county; medication review within the last 30days; one-day admission. INTERVENTIONS: 1, comprehensive medication review during hospital stay; 2, same as 1 with the addition of active follow-up into primary care; 3, usual care. PRIMARY OUTCOME MEASURE: Incidence of unplanned hospital visits during a 12-month follow-up period. DATA COLLECTION AND ANALYSES: Extraction and collection from the counties' medical record system into a GCP compliant electronic data capture system. Intention-to-treat-analyses using hierarchical models. RELEVANCE: This study has a high potential to show a reduction in elderly patients' morbidity, contributing to more sustainable healthcare in the long run.

Buffers Strongly Modulate Fibrin Self-Assembly into Fibrous Networks.

Fibrin is a plasma protein with a central role in blood clotting and wound repair. Upon vascular injury, fibrin forms resilient fibrillar networks (clots) via a multistep self-assembly process, from monomers, to double-stranded protofibrils, to a branched network of thick fibers. In vitro, fibrin self-assembly is sensitive to physicochemical conditions like the solution pH and ionic strength, which tune the strength of the noncovalent driving forces. Here we report a surprising finding that the buffer-which is necessary to control the pH and is typically considered to be inert-also significantly influences fibrin self-assembly. We show by confocal microscopy and quantitative light scattering that various common buffering agents have no effect on the initial assembly of fibrin monomers into protofibrils but strongly hamper the subsequent lateral association of protofibrils into thicker fibers. We further find that the structural changes are independent of the molecular structure of the buffering agents as well as of the activation mechanism and even occur in fibrin networks formed from platelet-poor plasma. This buffer-mediated decrease in protofibril bundling results in a marked reduction in the permeability of fibrin networks but only weakly influences the elastic modulus of fibrin networks, providing a useful tuning parameter to independently control the elastic properties and the permeability of fibrin networks. Our work raises the possibility that fibrin assembly in vivo may be regulated by variations in the acute-phase levels of bicarbonate and phosphate, which act as physiological buffering agents of blood pH. Moreover, our findings add a new example of buffer-induced effects on biomolecular self-assembly to recent findings for a range of proteins and lipids.