Effect of an In-Hospital Multifaceted Clinical Pharmacist Intervention on the Risk of Readmission: A Randomized Clinical Trial.

Importance: Hospital readmissions are common among patients receiving multiple medications, with considerable costs to the patients and society. Objective: To determine whether a multifaceted pharmacist intervention based on medication review, patient interview, and follow-up can reduce the number of readmissions and emergency department (ED) visits. Design, Setting, and Participants: This randomized clinical multicenter study (Odense Pharmacist Trial Investigating Medication Interventions at Sector Transfer [OPTIMIST]) enrolled patients from September 1, 2013, through April 23, 2015, with a follow-up of 6 months completed on October 31, 2015. Consecutive medical patients in an acute admission ward who were 18 years or older and who used 5 or more medications were invited to participate. Of 1873 patients invited to participate, 1499 (80.0%) accepted. The medication review and patient interview were conducted in the hospital and followed up in collaboration with primary care. Analysis was based on intention to treat. Interventions: The patients were randomized into 3 groups receiving usual care (no intervention), a basic intervention (medication review), and an extended intervention (medication review, 3 motivational interviews, and follow-up with the primary care physician, pharmacy, and nursing home). Main Outcomes and Measures: The prespecified primary outcomes were readmission within 30 or 180 days and ED visits within 180 days. The primary composite end point was readmission or an ED visit within 180 days. Secondary outcomes were drug-related readmissions within 30 and 180 days after inclusion, and all-cause mortality and drug-related mortality. Results: A total of 1467 patients (679 men [46.3%] and 788 women [53.7%]; median age, 72 years; interquartile range, 63-80 years) were part of the primary analysis, including 498 randomized to usual care, 493 randomized to the basic intervention, and 476 randomized to the extended intervention. The extended intervention had a significant effect on the numbers of patients who were readmitted within 30 days (hazard ratio [HR], 0.62; 95% CI, 0.46-0.84) or within 180 days (HR, 0.75; 95% CI, 0.62-0.90) after inclusion and on the number of patients who experienced the primary composite end point (HR, 0.77; 95% CI, 0.64-0.93). The study showed a nonsignificant reduction in drug-related readmissions within 30 days (HR, 0.65; 95% CI, 0.39-1.09) and within 180 days (HR, 0.80; 95% CI, 0.59-1.08) after inclusion and in deaths (HR, 0.83; 95% CI, 0.22-3.11). The number needed to treat to achieve the primary composite outcome for the extended intervention (vs usual care) was 12. Conclusions and Relevance: A multifaceted clinical pharmacist intervention may reduce the number of ED visits and hospital readmissions. Trial Registration: clinicaltrials.gov Identifier: NCT03079375.

Medication histories by pharmacy technicians and physicians in an emergency department.

BACKGROUND: Medication histories (MHs) obtained at the time of patients' admission to hospital are often incomplete, and lack of information about patients' actual medicine use can potentially lead to prescribing failures and serious adverse events. Uses of clinical pharmacists in obtaining MHs are beneficial, but due to limited economic resources clinical pharmacists cannot be present in every hospital ward, and therefore pharmacy technicians (PTs) could probably be trained in obtaining MHs. OBJECTIVE: To compare discrepancies in MHs obtained by physicians and PTs in an emergency department. Second to evaluate, whether PTs could assist and/or replace physicians in obtaining MHs. METHODS: The study was conducted in the emergency department at Svendborg Hospital, Denmark and patients treated with a minimum of three prescribed medicines were included. On patients' admission to hospital, physicians recorded the primary MHs, and within 48 h the secondary MHs were made by PTs. All MHs were conducted using standard guidelines. A clinical pharmacist reviewed the MHs, and based on these reviews, a final medication list was defined, and the MHs were compared to this. The discrepancies were registered with respect to type and therapeutic group (medicines). RESULTS: A total of 113 patients were included in this study, and data for 106 patients were analysed. On average, three discrepancies were detected for each patient in the primary MHs, and less than one discrepancy per patient in the secondary MHs. A total of 1075 prescriptions were registered, and for the physicians, 287 discrepancies (27 % of total prescriptions) were found, and for PTs the number was 28 (2 % of total prescriptions). The commonly detected discrepancy was "drug missing in the electronic patient record". The largest number of discrepancies was found for nervous system medications (ATC group N), medicines from ATC group A (alimentary tract and metabolism) and respiratory medicine (ATC group R). CONCLUSION: Fewer discrepancies in the MHs obtained by PTs than physicians were detected compared to standard medicine lists made by an experienced clinical pharmacist.

Medication reconciliation and prescribing reviews by pharmacy technicians in a geriatric ward.

OBJECTIVE: Incomplete medication histories obtained on hospital admission are responsible for more than 25% of prescribing errors. This study aimed to evaluate whether pharmacy technicians can assist hospital physicians' in obtaining medication histories by performing medication reconciliation and prescribing reviews. A secondary aim was to evaluate whether the interventions made by pharmacy technicians could reduce the time spent by the nurses on administration of medications to the patients. METHODS: This observational study was conducted over a 7 week period in the geriatric ward at Odense University Hospital, Denmark. Two pharmacy technicians conducted medication reconciliation and prescribing reviews at the time of patients' admission to the ward. The reviews were conducted according to standard operating procedures developed by a clinical pharmacist and approved by the Head of the Geriatric Department. FINDINGS: In total, 629 discrepancies were detected during the conducted medication reconciliations, in average 3 for each patient. About 45% of the prescribing discrepancies were accepted and corrected by the physicians. "Medication omission" was the most frequently detected discrepancy (46% of total). During the prescribing reviews, a total of 860 prescription errors were detected, approximately one per medication review. Almost all of the detected prescription errors were later accepted and/or corrected by the physicians. "Dosage and time interval errors" were the most frequently detected error (48% of total). The time used by nurses for administration of medicines was reduced in the study period. CONCLUSION: This study suggests that pharmacy technicians can contribute to a substantial reduction in medication discrepancies in acutely admitted patients by performing medication reconciliation and focused medication reviews. Further randomized, controlled studies including a larger number of patients are required to elucidate whether these observations are of significance and of importance for securing patient safety.

[Antiplatelet treatment after acute and chronic ischemic heart and brain events is insufficient according to recommendations]. / Trombocythaemning efter akutte og kroniske iskaemiske tilfaelde i hjerte og hjerne er utilstraekkelig i relation til rekommandationerne.

INTRODUCTION: Antiplatelet therapy is important in secondary prophylaxis in patients with ischemic heart, brain and vascular diseases. The aim of this study was to investigate the number of patients in Vejle County admitted to hospital in the second half of 2003 with acute and chronic heart, brain and vascular diseases to evaluate the kind of secondary prophylaxis and its duration. Moreover, the study registered the number of patients with diabetes mellitus treated with antiplatelet therapy. MATERIALS AND METHODS: The study included 2345 patients with ischemic heart, brain and vascular diseases, and patients with diabetes mellitus. Patients' data and information about medication were obtained from the hospital electronic database and public health insurance of Vejle County. Antiplatelet therapy was registered up to one year after onset of the disease. RESULTS: 1121 patients were admitted with cardiac diseases (including patients with angina pectoris), 624 patients had cerebral diseases, and 600 had diabetes mellitus. Acetylsalicylic acid (ASA) and a combination of ASA and clopidogrel were the most frequent forms of antiplatelet medication. Patients with diabetes and ischemic brain diseases made up 75% of those for whom medication was not registered. CONCLUSION: The study shows that in nearly all disease groups no antiplatelet therapy was registered for a very large number of % patients (up to 75%). A considerable number % of patients (up to 56%) with ischemic heart disease did not receive sufficient antiplatelet treatment according to Danish recommendations.

[Does generic lamotrigine lead to larger variations in plasma concentrations?]. / Giver generika af lamotrigin anledning til større svingninger i plasmakoncentrationen?

INTRODUCTION: As of 1st June 2005 it is possible to market generic epilepsy drugs with the active substance lamotrigine because the patent on the original product Lamictal had expired. We wanted to investigate if generic lamotrigine leads to larger variations in plasma concentrations of lamotrigine. MATERIALS AND METHODS: The citizens of the county of Vejle treated with lamotrigine were identified and classified in three groups according to the medication used after patent expiry: original brand only, generic brand only, or both generic and original brand. The defined daily dose (DDD) of lamotrigine was calculated for each patient and the data collected for each class. Thereafter a data search was carried out in the database from the department of Clinical Biochemistry in order to find corresponding patient levels of lamotrigine in plasma. RESULTS: The median plasma concentrations of lamotrigine before and after patent expiry for patients treated with the original brand only were 21.0 mmol/L before and 22.0 mmol/L after. For patients who changed their treatment from the original to the generic brand the concentrations were 15.5 mmol/L before and 20.5 mmol/L after. For patients who changed their treatment from the original to a mixture of original and generic brand the concentrations were 17.0 mmol/L before and 19.5 mmol/L after. The median of drug use of lamotrigine before/after patent expiry for patients mentioned in the same order was 167.5 DDD before and 141 DDD after (original after); 156 DDD before and 161 DDD after (generic only) and 147.5 DDD before and 160.5 DDD after (generic/original after). CONCLUSION: Generic lamotrigine does not lead to changes in plasma concentrations or larger variation in plasma concentrations. Consequently, there is no evidence to support that the effect is different when comparing the original brand and generic brands of lamotrigine. Further documentation can only be obtained by registering the numbers of seizures and side effects in a study comparing generic lamotrigine and the original brand.

The effects of introducing a clinical pharmacist on orthopaedic wards in Denmark.

OBJECTIVE: To assess the effects and cost effects of introducing clinical pharmacists on hospital wards. METHODS: Comparative prospective study on four orthopaedic surgical wards in two hospitals. The primary effect variables were 10 target areas widely considered to be indicators of good prescription practice. Prescriptions not following good practice in these intervention areas were defined as "sub-optimal prescriptions," and then discussed between a physician and a clinical pharmacist. The primary parameter was the difference in the number of days with a sub-optimal prescription (Mann-Whitney test). RESULTS: On an average 20% of all the patients had a sub-optimal prescription. Of these, 70% were changed by the physician after intervention by the clinical pharmacist. There was a statistically significant difference in the duration of days in treatment with a sub-optimal prescription. Where sub-optimal prescriptions were changed, 43% resulted in cost reductions. The reductions achieved could cover 47% of the costs of clinical pharmacy service. CONCLUSION: Clinical pharmacy services offered to four orthopaedic surgical wards resulted in reduction of sub-optimal prescriptions. Every time the pharmacist screened seven patients one sub-optimal prescription was found and adjusted. The reduction in medicine costs due to adjusted sub-optimal prescriptions could not cover the whole cost of clinical pharmacy service.