Implementation of clinical pharmacy services using problematization with Maguerez Arc: A quasi-experimental before-after study.

RATIONALE, AIMS, AND OBJECTIVES: The growth of clinical pharmacy services (CPS) has positively impacted clinical, economic, and humanistic health outcomes. However, detailed studies on the process of implementing CPS in healthcare systems are incipient. Thus, the present study aimed to evaluate the CPS implementation in certain public health units in a metropolis in northeast Brazil. METHODS: A quasi-experimental before-and-after study was carried out in Recife City, from July 2015 to March 2016. The study was carried out using the Methodology of Problematization with Maguerez Arc and was divided into: initial evaluation (before), planning, interventions, and preliminary evaluation (after). The participants were pharmacists, patients, health professionals, and local health managers. Descriptive statistics were used to report data. The statistical significance of the comparison between variables was evaluated using the Wilcoxon test (95% CI; P ≤ .05). RESULTS: Initial evaluation: Identified incipient CPS, a lack of structure and work process of pharmacists. Planning: Sixteen brainstorming meetings were held with the different actors resulting in a strategic plan. INTERVENTION: Twenty-two political-administrative meetings were held with managers and health teams and 768 hours of theoretical and practical training with mentoring for pharmacists. Preliminary evaluation: Structure indicators presented a statistically significant difference, differently from the process indicators. Pharmacists attended 842 patients and performed 1465 pharmaceutical consultations in 6 months. Regarding the outcome indicators, it was possible to identify changes in the clinical status of the most prevalent diseases among those patients who attended three pharmaceutical consultations. CONCLUSIONS: It was possible to evaluate the CPS implementation in certain public health units in a metropolis in Brazil, through the Methodology of Problematization with Maguerez Arc. This methodology may be part of models for future implementations of CPS in health systems.

Prevalence of clinically manifested drug interactions in hospitalized patients: A systematic review and meta-analysis.

AIMS: This review aims to determine the prevalence of clinically manifested drug-drug interactions (DDIs) in hospitalized patients. METHODS: PubMed, Scopus, Embase, Web of Science, and Lilacs databases were used to identify articles published before June 2019 that met specific inclusion criteria. The search strategy was developed using both controlled and uncontrolled vocabulary related to the following domains: "drug interactions," "clinically relevant," and "hospital." In this review, we discuss original observational studies that detected DDIs in the hospital setting, studies that provided enough data to allow us to calculate the prevalence of clinically manifested DDIs, and studies that described the drugs prescribed or provided DDI adverse reaction reports, published in either English, Portuguese, or Spanish. RESULTS: From the initial 5,999 articles identified, 10 met the inclusion criteria. The pooled prevalence of clinically manifested DDIs was 9.2% (CI 95% 4.0-19.7). The mean number of medications per patient reported in six studies ranged from 4.0 to 9.0, with an overall average of 5.47 ± 1.77 drugs per patient. The quality of the included studies was moderate. The main methods used to identify clinically manifested DDIs were evaluating medical records and ward visits (n = 7). Micromedex® (27.7%) and Lexi-Comp® (27.7%) online reference databases were commonly used to detect DDIs and none of the studies evaluated used more than one database for this purpose. CONCLUSIONS: This systematic review showed that, despite the significant prevalence of potential DDIs reported in the literature, less than one in ten patients were exposed to a clinically manifested drug interaction. The use of causality tools to identify clinically manifested DDIs as well as clinical adoption of DDI lists based on actual adverse outcomes that can be identified through the implementation of real DDI notification systems is recommended to reduce the incidence of alert fatigue, enhance decision-making for DDI prevention or resolution, and, consequently, contribute to patient safety.

Factors influencing the implementation of clinical pharmacy services for hospitalized patients: A mixed-methods systematic review.

BACKGROUND: Despite the evidence of benefits, clinical pharmacy services (CPS) are not uniformly implemented across healthcare institutions. Understanding the influencing factors and identifying the domains in which they act is the first step to a successful implementation. OBJECTIVE: To identify the factors that affect the implementation of CPS for inpatients and to categorize them. METHODS: Cochrane Library, Embase, CINAHL, IPA, Medline/PubMed, and Lilacs databases were researched up until January 2018. The search strategy was developed using text words or MESH terms related to the following four domains: "clinical pharmacy," "influencing factors," "implementation," and "hospital." Two reviewers selected original research articles that reported the factors influencing the implementation of CPS in hospitals, extracted data, and assessed the quality of the studies. After framework synthesis and categorization of the factors, a diagrammatic approach was used to present the results. RESULTS: Fifty-three factors were identified in the 21 studies that were included in this review. The most cited influencing factors were uniformly distributed across the following four domains: Attitudinal, POlitical, TEChnical and Administrative (APOTECA domains). However, in terms of level (pharmacist, healthcare team, patient, institution, and national organization), the "pharmacist" group had the highest concentration of factors. "Clinical skills and knowledge" was the most frequently cited implementation factor, followed by "time to implement CPS." CONCLUSION: Our findings showed the multifactorial nature of CPS implementation process. We suggest that factors from all four APOTECA domains need to be fully considered and strategies need to be addressed for all five groups of interest to successfully implement CPS in hospitals. Future studies on the influence of implementation stages, interrelationships of implementing factors, and strategies to overcome barriers could accelerate the successful adoption of these services. REGISTRATION: PROSPERO register CRD42016050140.

Integration of clinical pharmacy services into the Brazilian health system using Problematization with Maguerez Arc.

BACKGROUND: Clinical pharmacy services (CPS) have been evolving worldwide. However, it is estimated that CPS are not yet integrated into the Brazilian healthcare system. Thus, the objective of this study is to identify factors that influence the integration of CPS into the healthcare system and propose strategies for this integration. METHODS: A methodological development study was conducted from August 2016 to September 2017. Thus, interviews were conducted with key informants to identify barriers, facilitators, and strategies for CPS integration. Then these collected data were organized and confronted with the literature. Finally, a nominal group defined strategies for the integration of CPS into the Brazilian healthcare system. RESULTS: Interviews were conducted with five managers and seven decision-makers who listed 19 barriers and 20 facilitators. From these results, the nominal group proposed 41 integration strategies and prioritized five: formalize CPS; agree on care flows and referral protocols; evaluate and publicize CPS results/benefits; plan and define CPS; sensitize the health managers CONCLUSION: This study identified factors that influence the integration of CPS into the Brazilian health system and proposed strategies to achieve this integration. These results may contribute to future health decision-making processes.

Perceived barriers to the implementation of clinical pharmacy services in a metropolis in Northeast Brazil.

BACKGROUND: CLinical pharmacy services (CPS) are professional services provided by pharmacists, who use their skills and knowledge to take an active role in patient health. These services have expanded in health systems around the world. However, it is important to have a comprehensive understanding of factors that may hinder the implementation of CPS in health systems. OBJECTIVE: To identify pharmacists' and managers' perceptions of barriers regarding the implementation of CPS in some public health units in a metropolis in Northeast Brazil. METHODS: This is a qualitative study based on focus groups and semi-structured, face-to-face, in-depth interviews. Participants were health-system pharmacists and managers, selected based on their direct participation in the implementation process. Focus groups were carried out with the pharmacists, and interviews were carried out with managers. The audio and videos were transcribed verbatim in full, and were independently analyzed using content analysis. This study was approved by the Brazilian Committee of Ethics in Research and all participants signed informed consent forms. FINDINGS: There were two focus groups and five interviews. The discussions generated 240 minutes of recordings. The health-system pharmacists and managers expressed barriers were allocated into five categories to facilitate a comprehensive understanding of the implementation of CPS; these barriers were related to: the local healthcare networks, the healthcare team, the pharmacists, the implementation process, and the patients. CONCLUSIONS: This study revealed the perceptions of barriers associated with the participants involved in the implementation of CPS in some public health units in a metropolis in Northeast Brazil. The barriers reflect the challenges to be overcome in the CPS implementation process in the health systems.

Perceptions of a group of hospital pharmacists and other professionals of the implementation of clinical pharmacy at a high complexity public hospital in Brazil.

BACKGROUND: During the process of implementation of clinical pharmacy services, internal and external factors may favor or hinder the incorporation of care into the hospital routine. This study aimed to understand the perceptions of a group of hospital pharmacists and other professionals of the implementation of clinical pharmacy at a high complexity public hospital in Brazil. METHODS: A focus group with 16 pharmacists and interviews with tree key stakeholders including managers in the pharmaceutical, medical, and nursing profession were conducted to understand their perceptions of the implementation clinical pharmacy services in a high complexity public hospital in Brazil. The service proposal was presented to the selected participants before conducting the focus group. Professionals with an overview of the hospital and influence on the relevant departments for the implementation of clinical pharmacy at the institution were selected. Data collected were transcribed and analyzed using the Bardin Content Analysis technique. Data analyzed were systematized into categories and registration units. The methodology involves the organization and analysis of reported content to make inferences. RESULTS: The data obtained were divided into four categories: "Perception of the current situation", "Implementation expectations", "Barriers to implementation", "Implementation facilitators". Participants discussed the stagnation of clinical activities of the pharmaceutical profession in Brazil, a reality that results from a lack of clinical training in the country. Pharmacists expressed their expectations for changes in professional performance. According to the managers, such services would positively affect clinical outcomes for patients. Gaps in academic education, lack of knowledge, and poor communication skills were barriers reported in this study. Pharmacists' clinical experience has been reported to facilitate the provision of services. CONCLUSIONS: This study highlights factors that may influence the implementation of clinical pharmacy services in the institution analyzed, such as resistance, fear, and frustration as barriers, as well the experience in clinical pharmacy of some pharmacists in the institution was one of the facilitators most cited by participants. This knowledge may aid future planning for the implementation of clinical pharmacy in hospitals.

Tanacetum vulgare: antiherpes virus activity of crude extract and the purified compound parthenolide.

The present study demonstrated that the ethyl acetate extract and the isolated compound, parthenolide, from aerial parts of Tanacetum vulgare L. (Asteraceae), protected Vero cells from herpes simplex virus (HSV-1) infection in vitro. The extract and parthenolide were assayed against HSV-1 by the sulforhodamine B colorimetric assay and exhibited anti-HSV-1 activity with an EC(50) of 40 microg/mL and 0.3 microg/mL, respectively. In order to determine which stage of the virus-cell interaction was affected by parthenolide, the pure compound was used. No effect was observed when both viruses and cells were pretreated, or during early stages of infection, suggesting that parthenolide interfered with virus replication after the penetration stage, inhibiting approximately 40% of plaques formed at a concentration of 2.5 microg/mL when compared with an untreated control.