Are multidose drug dispensing systems initiated for the appropriate patients?

PURPOSE: It is unknown if multidose drug dispensing (MDD) systems are initiated for the appropriate patients. Therefore, the objective of this study was to compare the medication management problems of patients who were about to start with a MDD system (MDD patients) and patients who continued manually dispensed medication (non-MDD users) in order to identify if the appropriate patients receive a MDD system. METHODS: Patient interviews (semi-structured) were conducted by 44 community pharmacists at the patient's home. Patients over 65 years of age, home dwelling and using at least five chronic drugs, were eligible for the study. An assessment tool was developed including 22 potential medication management problems, covering four domains: functional (7), organizational (7), medication adherence (6), and medication knowledge (2). Median scores were calculated with the interquartile range. Additionally, cognitive function was assessed with the Mini-Cog and frailty using the Groningen Frailty Indicator. RESULTS: One hundred eighty-eight MDD users and 230 non-MDD users were interviewed. MDD users were older, more often female, and using more drugs. Forty-two percent of the MDD users were possibly cognitively impaired and 63% were assessed as frail compared to 20 and 27% respectively of the non-MDD users. MDD users had more potential organizational problems (3 vs. 1; p < 0.01), functional problems (2 vs. 1; p < 0.01), medication adherence problems (1 vs. 0; p < 0.01), and medication knowledge problems (1 vs. 0; p < 0.01) compared to non-MDD users. Seventy percent of the MDD users scored six or more potential medication management problems while this was 22% among non-MDD users. CONCLUSIONS: The majority of MDD systems were initiated for patients who experienced multiple potential medication management problems suggesting a decreased medication management capacity.

Drug-related problems identified during medication review before and after the introduction of a clinical decision support system.

WHAT IS KNOWN AND OBJECTIVE: To facilitate the identification of drug-related problems (DRPs) during medication review, several tools have been developed. Explicit criteria, like Beers criteria or STOPP (Screening Tool of Older Peoples' Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria, can easily be integrated into a clinical decision support system (CDSS). The aim of this study was to investigate the effect of adding a CDSS to medication review software on identifying and solving DRPs in daily pharmacy practice. METHODS: Pre- to post-analysis of clinical medication reviews (CMRs) performed by 121 pharmacies in 2012 and 2013, before and after the introduction of CDSS into medication review software. Mean number of DRPs per patient, type of DRPs and their resolution rates were compared in the pharmacies pre- and post-CDSS using paired t tests. RESULTS AND DISCUSSION: In total, 9151 DRPs were identified in 3100 patients pre-CDSS and 15 268 DRPs were identified in 4303 patients post-CDSS. The mean number of identified DRPs per patient (aggregated per pharmacy) was higher after the introduction of CDSS (3.2 vs 3.6 P < .01). The resolution rate was lower post-CDSS (50% vs 44%; P < .01), which overall resulted in 1.6 resolved DRPs per patient in both groups (P = .93). After the introduction of CDSS, 41% of DRPs were detected by the CDSS. The resolution rate of DRPs generated by CDSS was lower than of DRPs identified without the help of CDSS (29% vs 55%; P < .01). The two most prevalent DRP types were "Overtreatment" and "Suboptimal therapy" in both groups. The prevalence of "Overtreatment" was equal in both groups (mean DRPs per patient: 0.84 vs 0.77; P = .22), and "Suboptimal therapy" was more frequently identified post-CDSS (mean DRPs per patient: 0.54 vs 1.1; P < .01). WHAT IS NEW AND CONCLUSION: The introduction of CDSS to medication review software generated additional DRPs with a lower resolution rate. Structural assessment including a patient interview elicited the most relevant DRPs. Further development of CDSS with more specific alerts is needed to be clinical relevant.

[Multidose drug dispensing: what does it really involve?] / Medicatie op rol, wat komt er bij kijken?

- Multidose drug dispensing (MDD) systems are individualised forms of distribution that give structure to medication use. - Starting to use a multidose drug dispensing system must be initiated in joint discussion with the patient, once alternatives such as dosing schemes or automatic repeat-prescription services have been considered. The patient's autonomy and self-management are central.- Studies have shown positive effects of individualised forms of distribution on intermediary outcome measures such as HbA1c, LDL cholesterol, blood pressure and adherence. - Changes in medication should preferably be implemented when the pharmacist orders a new multidose drug dispensing system. It is difficult for the pharmacist to determine whether an immediate change is necessary if the indication and other possible reasons for change are not known. - The prescriber should preferably enquire whether the patient has a multidose dispensing system and should state the moment or the reason for the change on the prescription.- Pharmacotherapy in patients using a multidose drug dispensing system should be reviewed annually.

Completeness of medication reviews provided by community pharmacists.

WHAT IS KNOWN AND OBJECTIVES: Little is known about the ability of community pharmacists who are inexperienced in medication review to identify drug-related problems (DRPs). The objective of our study was to investigate the completeness of DRPs in terms of number, type and clinical relevance identified by community pharmacists when performing home medication reviews (HMRs). METHODS: This is a cross-sectional study within the intervention arm of a randomized controlled trial among community-dwelling patients (≥65 years, ≥5 drugs) in ten Dutch community pharmacies. Community pharmacists, who were inexperienced in medication review, received 2-day training in medication review. These pharmacists interviewed patients at home about their medicines, identified potential DRPs and made recommendations in combination with medication and clinical records. Expert reviewers completed the number of potential DRPs and recommendations by reviewing all available information, including patient interview reports. RESULTS AND DISCUSSION: In 155 patients, community pharmacists identified a mean of 3·6 (SD 2·8) potential DRPs per patient and expert reviewers added 6·5 (SD 3·2) DRPs. Community pharmacists formulated 2·6 (SD 2·3) recommendations per patient and reviewers added 7·5 (SD 3·3) recommendations. Community pharmacists identified a higher proportion of clinically relevant DRPs compared with expert reviewers, as assessed by DRPs with high priority [OR = 1·8 (95% CI 1·4-2·2)], DRPs associated with recommendations for drug change [OR = 1·9 (95% CI 1·5-2·3)] and implemented recommendations for drug change [OR = 2·1 (95% CI 1·6-2·7)]. WHAT IS NEW AND CONCLUSION: This study shows that the completeness of medication reviews by inexperienced community pharmacists with limited training could be improved, although they identified a higher proportion of potentially clinically relevant DRPs compared with expert reviewers. The results suggest that community pharmacists with limited experience in medication review may need more intensive post-graduate training.

The contribution of patient interviews to the identification of drug-related problems in home medication review.

WHAT IS KNOWN AND OBJECTIVE: To determine to what extent patient interviews contribute to the identification of drug-related problems (DRPs) in home medication reviews, in terms of number, type and clinical relevance. METHODS: We performed a cross-sectional study within the intervention arm of a randomized controlled trial. Patients were recruited from 10 Dutch community pharmacies. Patients were eligible if they were home-dwelling, aged 65 years and over and used five or more different drugs, including at least one cardiovascular or antidiabetic drug. The community pharmacist interviewed the patient at home about the medicines and identified potential DRPs in combination with medication and clinical records. This medication review was assessed and modified by an independent pharmacist reviewers' panel. Outcomes were the number and type of DRPs and recommendations and percentage of clinical relevant DRPs. Clinical relevance of DRPs was assessed by DRPs assigned a high priority, DRPs followed by recommendations for drug change and DRPs followed by implemented recommendations for drug change. RESULTS: A total of 1565 potential DRPs and recommendations (10 per patient).were identified for 155 patients (median age, 76 years; 54% women). Fifty-eight per cent of all recommendations involved a drug change; 27% of all DRPs were identified during patient interviews and 74% from medication and clinical records. Compared to DRPs identified from patient medication and clinical records, DRPs identified during patient interviews were more frequently assigned a high priority (OR = 1.8 [1.4-2.2]), were more frequently associated with recommendations for drug change (OR = 2.4 [1.9-3.1]) and were implemented recommendations for drug change (OR = 2.8 [2.1-3.7]). WHAT IS NEW AND CONCLUSION: This study shows that more than a quarter of all DRPs were identified during patient interviews. DRPs identified during patient interviews were more frequently assigned a higher clinical relevance.

Eating-induced dopamine release from mesolimbic neurons is mediated by NMDA receptors in the ventral tegmental area: a dual-probe microdialysis study.

This study was aimed at identifying the neuronal pathways that mediate the eating-induced increase in the release of dopamine in the nucleus accumbens of the rat brain. For that purpose, a microdialysis probe was implanted in the ventral tegmental area and a second probe was placed in the ipsilateral nucleus accumbens. Receptor-specific compounds acting on GABA(A) (40 microM muscimol; 50 microM bicuculline), GABA(B) (50 microM baclofen), acetylcholine (50 microM carbachol), NMDA [30 microM (+/-)-3-(2-carboxypiperazin-4-yl)propyl-1-phosphonic acid (CPP)], and non-NMDA [300 microM 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX)] receptors were infused into the ventral tegmental area by retrograde dialysis, whereas extracellular dopamine was recorded in the ipsilateral nucleus accumbens. Intrategmental infusion of muscimol or baclofen decreased extracellular dopamine in the ipsilateral nucleus accumbens; CPP and CNQX were without effect, and bicuculline and carbachol increased dopamine release. During infusion of the various compounds, food-deprived rats were allowed to eat for 10 min. The infusions of muscimol, bicuculline, baclofen, carbachol, and CNQX did not prevent the eating-induced increase in extracellular dopamine in the nucleus accumbens. However, during intrategmental infusion of CPP, the eating-induced increase in extracellular dopamine in the nucleus accumbens was suppressed. These results indicate that a glutamatergic projection to the ventral tegmental area mediates, via an NMDA receptor, the eating-induced increase in dopamine release from mesolimbic dopamine neurons.

The pharmacology of mesolimbic dopamine neurons: a dual-probe microdialysis study in the ventral tegmental area and nucleus accumbens of the rat brain.

Receptor-specific compounds were applied by retrograde microdialysis to the ventral tegmental area (VTA) of the rat brain. The effect of the intrategmental infusions on extracellular dopamine in the ipsilateral nucleus accumbens were recorded with a second microdialysis probe. Intrategmental infusion of muscimol (10-40 microM) or baclofen (50 microM) decreased extracellular dopamine in the nucleus accumbens. Intrategmental infusion of NMDA (1 mM, 15 min) or kainate (50 microM, 15 min) increased extracellular dopamine in the nucleus accumbens. The effects of the excitatory amino acids were suppressed by co-infusion of MK-801 (1 MM), (+)-3-amino-1-hydroxy-2-pyrrolidone [(+)-HA966; 1 mM], (+/-)-3(2-carboxypiperazin-4-yl)-propyl-1-phosphonic acid (CPP; 100 microM), and 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX;300 microM). Intrategmental infusion of of carbachol (50 microM) increased extracellular dopamine in the nucleus accumbens. These results provide evidence for localization of GABAA, GABAB NMDA, non-NMDA, and cholinergic receptors on dopamine neurons in the VTA. Infusions of CPP, (+)-MK-801, (+)-HA966, CNQX, mecamylamine, atropine, or 3-[[(3,4-dichlorophenyl)methyl]propyl](diethoxymethyl) phosphonic acid (CGP 52432) into the VTA did not modify extracellular dopamine in the nucleus accumbens. Infusion of bicuculline (50 microM) and (-)-sulpiride (50 microM) was followed by an increase in extracellular dopamine in the nucleus accumbens. These data suggest that dopamine neurons in the VTA are tonically inhibited by GABA and dopamine by acting on GABAA, and D2 receptors, respectively. A tonic stimulation by glutamatergic or cholinergic neurons was not detected. Finally, results on A10 neurons are compared with earlier data on A9 neurons. A striking difference was found in that GABAA-dopamine interactions are indirect in the substantia nigra and direct in the VTA.