A dual intervention in geriatric patients to prevent drug-related problems and improve discharge management.

Background Drug-related problems (DRPs) endanger geriatric patients' safety. Especially a follow-up treatment with increased number of care transitions is a critical time for patients. Objective This study aimed at optimising medication therapy and the transfer of medication-related information to ambulatory care in geriatric rehabilitation patients. Setting German geriatric rehabilitation centre (GRC). Method A prospective, controlled intervention study was performed. Patients in the control group (CG) received standard care, those in the intervention group (IG) an additional dual pharmaceutical intervention: (i) medication review to optimise in-hospital medication and (ii) improvement of discharge letters for optimising transfer of medication-related information. Main outcome measure (i) Number of patients with at least one DRP at discharge and (ii) predefined quality criteria for the discharge letters. Results 150 patients were enrolled in CG and 163 in IG. (i) At discharge, 126 (84%) patients in the CG were affected by at least one DRP. In the IG, the number of affected patients decreased to 64 (39%, P < 0.05). (ii) In comparison to discharge letters in the CG, predefined quality criteria were improved in the IG. Following differences were measured (CG vs. IG, each P < 0.05): active ingredient indicated (60 vs. 99%), brand name indicated (60 vs. 96%), explanation of medication changes (47 vs. 68%), visualisation of explanations next to the discharge medication (26 vs. 91%) and recommended therapy duration for short-term medications (49 vs. 84%). Conclusion DRPs and incomplete discharge letters affected many patients. The dual intervention improved in-hospital medication therapy and optimised the transfer of medication-related information.

Drug-related problems in geriatric rehabilitation patients after discharge - A prevalence analysis and clinical case scenario-based pilot study.

BACKGROUND: Geriatric patients bear a high risk for having drug-related problems (DRPs). Transitions of care are especially susceptible to these DRPs. OBJECTIVE: To highlight the prevalence of DRPs in geriatric patients' post-discharge medication lists and to assess physicians' ability to identify DRPs by using clinical case scenarios. METHODS: A sequential prospective mixed-method study was performed. In a DRP prevalence analysis, an expert panel of clinical pharmacists analyzed DRPs in post-discharge medication lists of long-term hospitalized patients from a German inpatient geriatric rehabilitation center. Based on these results, the expert panel created two clinical case scenarios with applicable medication history. The cases were reflective of the most commonly identified DRPs. They were provided to hospital physicians and general practitioners (GPs) for assessment. Physicians were asked whether they approve the prescriptions in the clinical case scenarios. If a physician had not identified a prescription containing a defined DRP, the clinical pharmacist then provided drug information about it. With this, physicians' ability to identify DRPs and their response to a theoretical intervention was assessed. RESULTS: DRP prevalence analysis: A total of 639 prescriptions were analyzed from 63 enrolled patients of whom 52 (83%) were affected by at least one DRP. Twenty-eight hospital physicians and 26 GPs have been assessed. They identified 172 (46%) from 378 possible DRPs (seven DRPs multiplied by 54 physicians). For unidentified DRPs, physicians received tailored drug information and the number of identified DRPs rose to 298 (79%). CONCLUSIONS: A clear majority of patients were affected by DRPs. However, the results from the following pilot study confirm that many DRPs at care transitions can be reduced by providing applicable medication history and drug information. This intervention can be done by clinical pharmacists as part of the multidisciplinary care team in routine care. SYNOPSIS: Geriatric patients bear a high risk for having drug-related problems (DRPs). Strategies to protect them are needed, especially during transitions of care due to information and knowledge gaps. Therefore a sequential prospective mixed method study was performed. Initial post-discharge medication lists of geriatric patients were analyzed for DRPs with 83% of patients being affected. Afterwards, physicians' ability to identify DRPs was assessed based on clinical case scenarios. These clinical case scenarios included an applicable medication history and tailored drug information was provided. Under these conditions, physicians identified many of the defined DRPs.

The status of the performance of medication reviews in German community pharmacies and assessment of the practical performance.

Background Pharmacist-led medication reviews have shown to prevent drug-related problems (DRPs). So far, data is rare about the implementation in routine care, the conditions for intensifying this service and the practical skills of community pharmacists to perform medication reviews. Objective To assess the current status of medication review implementation in German community pharmacies and the performance of identifying DRPs in a ficticious patient example. Setting German community pharmacies. Method An online survey was conducted from July to September 2015 including questions about medication reviews currently performed in routine care of community pharmacies and hidden DRPs in a ficticious patient example. Pharmacists were invited via newsletters from three local chambers of pharmacists. Main outcome measure (i) Frequency, conditions for implementation, and criteria of medication reviews currently being performed in routine care, (ii) requested further information to perform medication reviews, and (iii) proportion of pharmacists who identify DRPs in the patient example. Results A total of 143 community pharmacists completed the questionnaire. (i) One hundred and twenty-seven respondents (89 %) reported reviewing the medication regularly in routine care, whereas 56 (39 %) stated that they performed medication reviews between one and five times monthly. For 124 pharmacists (87 %), remuneration would be a necessary condition for performing medication reviews more frequently. When reviewing the medication, 112 (78 %) of the pharmacists considered the criterion 'drug-drug interactions' and 107 (75 %) reviewed the criterion 'correct dosage'. One of the least reviewed criteria was 'effectiveness of medication' [22 (16 %)]. (ii) According to the participants, laboratory values should be available in the community pharmacy, since 87/143 (61 %) would appreciate the GFR and the HbA1c level. Twenty-two of 54 respondents (41 %) would appreciate further administration instructions and 5 of 54 (15 %) think they would benefit from information about the recommended duration of drug use. (iii) Depending on the category, 4 (3 %) to 49 (34 %) of all 143 pharmacists identified the hidden DRP in the patient example. Conclusion German community pharmacists reported reviewing the medication of their patients regularly; however, most of the respondents review the medication very rarely in routine care. Consequently, their practical performance needs to be improved.

Oral absorption of clarithromycin is nearly abolished by chronic comedication of rifampicin in foals.

The delivery of clarithromycin (CRL) to its site of action in bronchial/alveolar epithelial cells (EC), bronchial epithelial lining fluid (ELF), and bronchoalveolar lavage cells (BALC) may be influenced by CYP3A4 and the drug transporters, ATP-binding cassette (ABC) B1 and ABCC2 and organic anion-transporting polypeptides (OATPs), which can be modulated and/or up-regulated via the nuclear pregnane X receptor (PXR) by rifampicin (RIF). Therefore, we evaluated the disposition and pulmonary distribution of CLR (7.5 mg/kg b.i.d., 21 days) and expression of ABCB1, ABCC2, OATP1A2, and OATP2B1 in EC and BALC before and after comedication of RIF (10 mg/kg b.i.d., 11 days) in nine healthy foals (41-61 days, 115-159 kg) in which the genetic homology of drug transporters is close to that of their human analogs. After RIF comedication, relative bioavailability of CLR decreased by more than 90%. Concentrations in plasma (29.8 ± 26.3 versus 462 ± 368 ng/ml), ELF (0.69 ± 0.66 versus 9.49 ± 6.12 µg/ml), and BALC (10.2 ± 10.2 µg/ml 264 ± 375 µg/ml; all P < 0.05) were lowered drastically, whereas levels of the metabolite 14-hydroxyclarithromycin were not elevated despite higher 4ß-hydroxycholesterol/cholesterol plasma concentration ratio, a surrogate for CYP3A4 induction. In the presence of CLR, ABCC2 and PXR mRNA contents were significantly and coordinately (r(2) = 0.664, P < 0.001) reduced in BALC after RIF. In EC, mRNA expression of OATP1A2 increased but that of OATP2B1 decreased (both P < 0.05). RIF interrupts oral absorption and decreases CRL plasma levels below the minimal inhibitory concentration for eradication of Rhodococcus equi. Evidence that RIF influences the cellular uptake of CLR in bronchial cells and the PXR expression in BALC in the presence of high CLR concentrations exists.