Medication reconciliation-is it possible to speed up without compromising quality? A before-after study in the emergency department.

OBJECTIVE: The aim of this study was to investigate whether it was possible to decrease the time used for medication reconciliation (MR) in the emergency department without compromising quality. A more efficient method will enable more patients to receive MR as early as possible after admission to hospital. METHODS: Potential key factors for improvement of the standard method of MR by clinical pharmacists were identified through an observational period. A revised method was developed, focusing on decreasing time spent on the patient interview by use of a condensed checklist and probing questions based on information from a prescription database. Non-inferior quality (proportion of patients with at least one identified medication discrepancy and number of identified medication discrepancies per patient) of the revised method was evaluated using a before-after study design with 200 individuals in each group. Non-inferiority limit was set at 10%. The Mann-Whitney U test was used for statistical evaluation of the difference in time use per patient in the MR process between the before and after group. RESULTS: Mean age of the included patients was 78 years in both groups. The time used for MR in the after group was 34% shorter (37 min vs 56 min, p<0.0001) compared with the before group. The revised method was shown to be non-inferior compared with the original method with respect to the proportion of patients with at least one identified discrepancy (81%, 95% CI 76% to 86% vs 79%, 95% CI 73% to 84%). Also, non-inferiority was shown for the number of identified discrepancies per patient, where the average number of discrepancies per patient was 1.9 (95% CI 1.7 to 2.1) in both groups. CONCLUSION: This study showed that it was possible to speed up the MR process without compromising its effectiveness in identifying medication discrepancies.

Less Is More: The Impact of Deprescribing Psychotropic Drugs on Behavioral and Psychological Symptoms and Daily Functioning in Nursing Home Patients. Results From the Cluster-Randomized Controlled COSMOS Trial.

OBJECTIVE: To investigate the impact of medication reviews using collegial mentoring and systematic clinical evaluation on psychotropic prescriptions, behavioral and psychological symptoms of dementia (BPSD), and activities of daily living (ADL). DESIGN: Four-month multicenter, multicomponent, cluster-randomized, single-blinded controlled trial. SETTING: Thirty-three Norwegian nursing homes including 67 nursing home wards (clusters). PARTICIPANTS: A total of 723 enrolled patients, of which 428 participated in the study; 217 were randomized to the intervention and 211 to care as usual (control). INTERVENTION: The COSMOS intervention consisted of Communication, Systematic pain management, Medication reviews, Organization of activities, and Safety. During medication review, the nursing home physician evaluated treatment with colleagues systematically using the results from validated clinical assessments. MEASUREMENTS: Mean changes from baseline to month 4 in the number of prescribed psychotropic drugs (antipsychotics, anxiolytics, hypnotics or sedatives, antidepressants, and antidementia drugs); Neuropsychiatric Inventory Nursing Home Version (NPI-NH) and Cornell Scale of Depression in Dementia (CSDD); Lawton and Brody's Physical Self Maintenance Scale (PSMS). RESULTS: Compared to control, the mean change in prescribed psychotropic drugs was reduced both in total and regular number, while mean changes in NPI-NH and CSDD scores did not differ between the groups. Mean change in PSMS showed improvement in the intervention group, and deterioration in the control group. CONCLUSION: Medication reviews using collegial mentoring and systematic clinical evaluation led to safe deprescribing, as the reductions in psychotropic drug use did not negatively affect BPSD, while ADL improved.

Can subjective well-being and body concern in adolescence predict prescribed medication in adulthood? Findings from the Nord-Trøndelag Health Study and the Norwegian Prescription Database.

Aim: To examine whether subjective well-being (SW) and body concern among adolescents aged 15-19 years has an impact on adult health, measured by medications dispensed on average 18 years later. Methods: Data collected in the Nord-Trøndelag Health Study (HUNT) was paired with data from the Norwegian Prescription database (NorPD). We investigated the effects of adolescent SW and body concern on total number of medications, on use of anti-infectives (ATC-group J), medication for the musculo-skeletal system (ATC-group M), anxiolytics, hypnotics and sedatives (ATC-groups N05B and N05C), and finally antipsychotics, antidepressants and psychostimulants, agents used for attention-deficit/hyperactivity disorder and nootropics (ATC-groups N05A, N06A and N06B). We used multi-variable models where we entered body dissatisfaction and SW simultaneously in the models in order to adjust for the associations between the predictors, and also adjusted for possible confounders in the models. Results: Both body concern (dieting and dieting desire) and impaired SW predicted drug use 17-18 years after the participants were surveyed in adolescence. The impact was disease specific as body concern was the most influential predictor for drugs used for somatic diseases and complaints, whereas impaired SW was more strongly associated with drug use for mental health diseases and complaints. Conclusions: SW and body concern are important health determinants in the transition between adolescence and adulthood.

Implementing a novel strategy for interprofessional medication review using collegial mentoring and systematic clinical evaluation in nursing homes (COSMOS).

BACKGROUND: Multimorbid patients in nursing homes are prescribed long lists of medication, often without sufficient clinical evaluations beforehand. This results in poor clinical effects of the prescribed medication and significant side-effects, especially in patients with impaired cognition. The aim of this paper is to describe the process, content and implementation of a clinical medication review encompassing clinical testing and collegial support to prescribers. METHODS: The implementation process of a novel approach to medication review in nursing homes was logged thoroughly by structured staff feedback. Staff experienced promotors and barriers to implementation also were collected. The study was part of a cluster randomized controlled trial, in which 36 long-term care units received the COSMOS intervention. Nurses and physicians randomized to the intervention group participated in educational programs, training in clinical evaluation of the patients, and interprofessional medication review with collegial mentoring. RESULTS: The intervention group contained 297 patients from 36 nursing home units. There were 105 staff attendees for the education program. The units were served by 21 different physicians. Clinical medication reviews were performed in all units and all patients were assessed prior to the medication reviews. Of the 240 patients with a logged intervention process, 220 (92%) underwent a medication review. The intervention generated enthusiasm and improved communication among nursing staff and between nursing staff and physicians. The interprofessional discussions helped to facilitate difficult decisions pertaining to treatment levels. Reported barriers were lack of time, low engagement of all nursing staff and physicians, and ethical dilemmas. CONCLUSIONS: Clinical medication reviews were implemented for almost all patients, and every patient was systematically assessed prior to the medication review. The physicians perceived collegial mentoring as an asset, learning from each other facilitated decision making in terms of difficult aspects of prescribing. Knowledge about barriers and promotors can improve implementation of similar interventions in other nursing homes. TRIAL REGISTRATION: Clinicaltrials.gov ( NCT02238652 ). Registered July 7th 2014.

Quality Control of Norwegian Pharmacy HbA1c Testing: A Modest Beginning.

BACKGROUND: Many pharmacy services involve laboratory testing using point-of-care (POC) instruments. Our aim was to describe the implementation of quality control of the HbA1c POC instruments and investigate the performance in internal quality control (IQC) and external quality control (EQA) for HbA1c POC instruments in Norwegian community pharmacies. METHODS: Two project pharmacists from each of 11 pharmacies participated in a training program covering capillary blood sampling, how to use the POC HbA1c instrument (DCA Vantage) and IQC and EQA. The pharmacies were enrolled in an EQA program for HbA1c, and their performance was compared with that of general practitioners' (GP) offices. RESULTS: Two of 89 (2.2%) IQC measurements were outside the acceptance interval. Seven out of 11 pharmacies sent in results in EQA in all the three surveys during six months. Two pharmacies did not analyze the control material in any of the surveys, one pharmacy analyzed the control material in one of the surveys, and one pharmacy analyzed two of the surveys. Of these pharmacies, 56-100% obtained "very good" evaluation for trueness and 71-100% obtained "very good" evaluation for precision. The corresponding numbers for GP offices were 75-87% for trueness and 84-94% for precision. No pharmacies obtained a "poor" evaluation. CONCLUSIONS: Norwegian community pharmacies can perform IQC and EQA on a HbA1c POC instrument, and the performance is comparable with that of GP offices. The compliance in the EQA surveys was modest, but the duration of the study and participation in the EQA program was probably too short to implement all the new procedures for all pharmacies.

Dermatological cancer screening: Evaluation of a new community pharmacy service.

BACKGROUND: Skin cancer accounts for one third of all cancers. Prognosis is inversely related to identification stage. OBJECTIVES: To describe a novel service, mole scans, performed in community pharmacy, the findings from the first 3.5 years it was in place, and to explore patient acceptability of the service. METHODS: Norwegian Boots' pharmacies offer a mole scanning service in cooperation with ScreenCancer. Scans are undertaken within pharmacy consultation rooms. Image interpretation is undertaken remotely by a specialist. Number and result of scans performed from 2010 to 2014 are reported. A satisfaction questionnaire was returned by 10% of participants. RESULTS: A total of 25836 scans were performed on 15777 individuals. Of these, 83.6% had normal scans, 1% had melanoma, and 15.4% had another skin condition. In 2014 the service identified 4.1% of melanoma cases registered in the Norwegian Cancer Registry. Most responders (88%) would use a similar service again. Nearly all (99%) felt the pharmacy was a suitable venue, and 95% would recommend the service to others. In total, 99% of respondents scored their overall satisfaction as "good" or higher. CONCLUSIONS: This approach was acceptable among participants who provided feedback. Providing mole scanning through pharmacies enables individuals to obtain a rapid check of moles causing concern, in an acceptable environment with a high level of satisfaction.

Norwegian elderly patients' need for drug information and attitudes towards medication use reviews in community pharmacies.

OBJECTIVES: Medication use review (MUR) is a community pharmacy service in several countries. Knowledge about what patients want from such a service is limited. The aim of this study was therefore to investigate Norwegian elderly patients' need for drug information and their attitudes towards MURs. METHODS: In Norway's two largest cities, 162 patients (72% women; mean age: 78.9 years) who used at least one prescription drug were recruited from 18 senior centres. They were interviewed personally with a structured questionnaire (29 closed and 4 open-ended questions). KEY FINDINGS: The average number of prescription drugs used was 4.4. Seventy per cent also used over-the-counter drugs. The main source of drug information was the general practitioner (GP) followed by package inserts and pharmacy staff. For drug-related problems, 62% would contact the GP compared with 24% who preferred the pharmacist. Fifty per cent remembered no information when collecting prescriptions. However, 56% wanted to know more about their medication and 55% were interested in a MUR. The main topics they wished to address were effect/side effects and interactions. Lack of privacy was reported to be a major obstacle in the current situation. CONCLUSIONS: This study shows that community pharmacies in Norway play a minor role regarding drug information to elderly polypharmacy patients. The GP is both their main information source and whom they contact for drug-related problems. However, half of the patients would like to know more about their medication. More than half were positive towards taking part in a MUR.

Regional differences in sales of glucometer strips and antidiabetics.

BACKGROUND: Studies have shown that the prevalence of diabetes in Norway is 3-5 %, and that approximately 97,000 Norwegian patients perform self-monitoring of blood glucose. There is a need for studies of geographical differences in diabetes prevalence and treatment. This study investigates differences between counties in the prevalence of patients treated with antidiabetics in Norway, and in the use of glucometer strips. MATERIAL AND METHOD: Data on the sale of antidiabetes medication to non-institutionalized patients were acquired from the Norwegian Register of Prescriptions, while corresponding data on glucometer strips were received from the Norwegian Health Economics Administration (HELFO). RESULTS: We found a nationwide prevalence of medicinally treated diabetes of 2.9 %. The corresponding prevalence of use of glucometer strips was 2.1 %. There was a 27.5 % difference between the counties with the highest and lowest prevalence of medicinally treated diabetes, while the difference in use of glucometer strips was 31.5 %. The average cost of antidiabetes drugs was 23.7 % higher in the county with the highest average expenditure compared with the county with the lowest expenditure. There was a difference of up to 44 % between counties in the average purchase of glucometer strips per person. INTERPRETATION: The geographical differences may be due to different availability of health services or different therapy traditions. A shortage of guidelines on the frequency of self-monitoring of blood glucose may also have a bearing on the differences.

The prevalence of self-monitoring of blood glucose and costs of glucometer strips in a nationwide cohort.

OBJECTIVE: This study used nationwide data to determine the prevalence of self-monitoring of blood glucose (SMBG) among all non-institutionalized persons living in Norway and to estimate the prevalence of SMBG among diabetes patients, the frequency and cost of SMBG, and the use of different glucometers. METHODS: This retrospective, descriptive study is based on data of sales of glucometer strips to non-institutionalized persons in Norway in 2008. The data included gender, age group, month of purchase, sales place, type of strips, number of packages dispensed, and cost of strips. Additionally, statistics on sales of insulin and oral antidiabetes medications were obtained from the Norwegian Prescription Database. RESULTS: A total of 96,999 persons purchased strips, a prevalence of 2%. Approximately 70% of diabetes patients practiced SMBG. An average patient used 1.7 strips per day, and younger patients purchased more strips than older patients. Fewer than 50% of patients performed glucose measurements daily. One percent of patients used more than 10 strips daily and was accountable for 8% of total costs. Most patients used only one type of strips, but the number of strips purchased increased with the number of different strips. The average annual cost of strips was 446 euro per person. CONCLUSIONS: Two percent of all non-institutionalized inhabitants and an estimated 70% of patients using diabetes medication purchased SMBG strips. A small percentage of the patients incurred a substantial proportion of the costs. This, along with the fact that over half of the patients monitor less than once per day, calls for tighter follow-up of diabetes patients.

Implementation of a method for glucose measurements in community pharmacies.

OBJECTIVES: We aimed to implement a method for glucose measurements that could be used as a comparison method for asessing patients' self-monitoring of blood glucose. Further, we investigated whether pharmacies could achieve an analytical quality comparable to glucose measurements performed in general practice. METHODS: Sixteen Norwegian pharmacy employees were trained in glucose measurement, quality control and blood sampling. The comparison method, HemoCue Glucose 201+, was validated in four steps: (1) estimation of the variation between the HemoCue instruments to be used at the 16 pharmacies, (2) comparison between HemoCue results and a laboratory glucose method, (3) monitoring quality by internal quality controls and (4) an external quality-assessment scheme. The pharmacies' results of the external quality assessment were compared to those of 359 general practices. KEY FINDINGS: The coefficient of variation for HemoCue instruments was 6.1% at the low level and 1.7% at the normal and high levels. Bias was negligible at the normal level. The coefficients of variation for internal quality controls were 4.5, 1.5 and 1.2% for the low, normal and high levels, respectively. All pharmacies achieved good precision and acceptable or good trueness in the external quality assessment. The pharmacies exhibited significantly lower variation between sites (2.2 and 1.2%) than general practices (3.8 and 2.9%) on both external quality-assessment samples. CONCLUSIONS: Given correct training and the establishment of a system of quality assurance, pharmacies are capable of obtaining glucose measurements that can be used as comparison measurements for controlling patients' meters. The pharmacies had external quality-assessment results comparable to general practice.

Quality assessment of patients' self-monitoring of blood glucose in community pharmacies.

OBJECTIVE: To evaluate diabetes patients' self-monitoring of blood glucose using a community pharmacy-based quality assurance procedure, to investigate whether the procedure improved the quality of the patient performance of self monitoring of blood glucose, and to examine the opinions of the patients taking part in the study. METHODS: The results of patient blood glucose measurements were compared to the results obtained with HemoCue Glucose 201(+) by pharmacy employees in 16 Norwegian community pharmacies. Patient performance was monitored using an eight item checklist. Patients whose blood glucose measurements differed from pharmacy measurements by more than 20% were instructed in the correct use of their glucometer. The patients then re-measured their blood glucose. If the results were still outside the set limits, the control procedure was repeated with a new lot of glucometer strips, and then with a new glucometer. The patients returned for a follow-up visit after three months. RESULTS: During the first visit, 5% of the 338 patients had measurements that deviated from pharmacy blood glucose values by more than 20% and user errors were observed for 50% of the patients. At the second visit, there was no significant change in the analytical quality of patient measurements, but the percentage of patients who made user errors had decreased to 29% (p < 0.001). Eighty-five percent of the patients reported that they used their blood glucose results to adjust medication, exercise or meals. Fifty-one percent of the patients reported a greater trust in their measurements after the second visit. Eighty percent of patients wished to have their measurements assessed yearly. Of these patients, 83% preferred to have the assessment done at the community pharmacy. CONCLUSION: A community pharmacy-based quality assessment procedure of patients' self monitoring of blood glucose significantly reduced the number of user errors. The analytical quality of the patients' measurements was good and did not improve further during the study. The high analytical quality might be explained by a selection bias of participating patients. Patients also reported increased confidence in their blood glucose measurements after their measurements had been assessed at the pharmacy.

Diabetes care in Norwegian pharmacies: a descriptive study.

OBJECTIVE: To describe Norwegian pharmacies' involvement in diabetes care, to investigate pharmacists' views on future services and to investigate whether the recommendations in the Norwegian diabetes declaration for pharmacies have been implemented. Setting Hospital and community pharmacies in Norway. METHOD: All 543 pharmacies in Norway, of which 511 were community pharmacies and 32 were hospital pharmacies, received a link to a web-based questionnaire. One pharmacist from each pharmacy was asked to complete the questionnaire. The questionnaire covered subjects ranging from the diabetes declaration and the pharmacists' views on which services the pharmacy should offer in the future, to demographic characteristics. RESULTS: In total 358 (66%) questionnaires were completed. The diabetes declaration was read by 37% of the pharmacists. Almost all pharmacies complied with the declarations' recommendations regarding glucose monitoring services. Twenty four percent of the pharmacies could offer medication reviews, and roughly 10% could offer screening for undiagnosed diabetes. Counseling on lifestyle issues was the least implemented recommendation. Eighty one percent of the pharmacists reported a wish to expand their services towards diabetes patients. Services in regard to glucose monitoring had the highest score, however the views on which services should be offered varied a great deal. Already performing a service increased the chance of the pharmacist being positive towards offering it. CONCLUSION: Norwegian pharmacists report that they are involved in a wide range of diabetes related services, although only 37% report to have read the diabetes declaration. The pharmacists generally wish to actively support patients with diabetes, and further research should concentrate on identifying the areas where their involvement is most productive.