Managing a Curriculum Innovation Process.

Curriculum reform is a long-term project that needs to be managed through detailed strategy. To create this strategy, the management team has to analyse the current situation by doing a thorough environmental scan and by identifying the gap between the current state and the desired program. To be implemented, the vision of the new program needs to rely on the generation of several potential avenues to come up with optimal solutions, likely involving some form of innovation. Indeed, to come up with the most promising ideas, there needs to be an environment conducive to reflection and experimentation. Throughout the phases of analysis, decision making and implementation, specific activities need to be organised to engage college members. Furthermore, such a profoundly impacting project needs to include a parallel change management strategy to account for expected human resistance, both individual and collective (internal culture). This article proposes a method and several concrete actions to help leaders and managers support the development and implementation of a new and innovative curriculum to promote and support advancement of local professional practice.

Assessing the knowledge, perception and practices of physicians and pharmacists towards medication reconciliation in Kuwait governmental hospitals: a cross-sectional study.

OBJECTIVES: To assess the knowledge, perception and practices towards medication reconciliation (MedRec) and its related institutional policies among physicians and pharmacists in governmental hospitals in Kuwait and identifying potential obstacles that prevent the successful implementation of MedRec. DESIGN: A descriptive, cross-sectional study. SETTING: Six governmental hospitals across Kuwait in January-May 2017. PARTICIPANTS: 351 physicians and 214 pharmacists. BRIEF INTERVENTION: A self-administered questionnaire distributed to the participants. MAIN OUTCOME MEASURES: Knowledge, perception, attitudes and practices of hospital physicians and pharmacists towards MedRec, and major barriers to implementing a MedRec process in their institution/department. RESULTS: Of the 739 questionnaires distributed, 565 were completed (351 physicians and 214 pharmacists), giving a response rate of 76.5%. Results showed that most participants were familiar with the term MedRec (n=419; 75.2%) with significantly more pharmacists compared with physicians (n=171; 81.8% vs n=248; 71.3%; p=0.005). Most participants (n=432; 80.0%) reported perceiving MedRec as a valuable process for patient safety. However, significantly more physicians compared with pharmacists were aware of a MedRec policy in their institution (n=195; 55.9% vs n=78; 37.9%; p<0.001) and routinely asked patients about their current list of medication on arrival (n=339; 96.6% vs n=129; 61.1%; p<0.001) and provided an updated list on discharge (n=281; 80.1% vs n=107; 52.0%; p<0.001). These results are supported by the findings that participants perceived physicians as providers, mainly responsible for various steps of MedRec. CONCLUSIONS: Overall, this study showed low awareness among physicians and pharmacists of hospital policy despite MedRec being perceived as valuable. Physicians were the providers most responsible and involved in MedRec, who may be driven by the policy putting them at core of the process. The current findings could pave the way for the expansion of the existing MedRec policies and processes in Kuwait to include pharmacists and improve patient safety.

Stakeholder driven development of a multi-criteria decision analysis tool for purchasing off-patent pharmaceuticals in Kuwait.

BACKGROUND: In Kuwait, the government is planning to improve the specifications for purchase of medicine and to improve the tendering system intending to slow the growth of the expenditure for medicine and to improve the sustainability of the healthcare system. Multiple Criteria Decision Analysis (MCDA) is a method which can help to assess multiple and sometimes conflicting criteria in the evaluation of the available alternatives. The objective of this initiative was to develop collaboratively a MCDA tool which is locally relevant, and which could be used to improve the use of performance indicators in the purchasing of off-patent pharmaceuticals. METHODS: Nineteen leading experts representing a broad range of pharmaceutical policy stakeholders elaborated a locally adapted MCDA format by following a 7-step process for criteria selection, scoring, ranking and weighting. RESULTS: The most important criterion was the price measured as savings versus the originator product with a weight of 35% in the final decision and a full score with a 60% price reduction. In addition, eight criteria were considered important for assessing the product performance in the Kuwaiti healthcare system: 'equivalence with the reference product' (weight of 16.2%), 'stability and drug formulation' (13.5%), 'quality assurance' (11.2%), 'reliability of drug supply' (8.8%), 'macroeconomic benefit' (5.5%), 'real world outcomes (clinical and economic)' (4.2%), 'pharmacovigilance' (3.3%), and 'added value services related to the product' (2.3%). CONCLUSIONS: A MCDA model was successfully adapted to the Kuwait decision context by a group of Kuwaiti pharmacists from a broad range of institutions. The participants agreed with the approach and considered it suitable to improve the transparency and consistency of decision making for off-patent pharmaceuticals in Kuwait. A pilot implementation project was proposed.

Medication adherence in chronic illness: do beliefs about medications play a role?

BACKGROUND: Several medicines are prescribed for chronic disease management; however, adherence to long-term therapy remains poor. Culture influences beliefs about medications and, ultimately, adherence to treatment. There is a paucity of data with regard to beliefs about medications in the Middle East region, and it remains to be determined how these beliefs would impact treatment adherence. OBJECTIVES: To investigate the relationship between patients' beliefs about medications with self-reported adherence to treatment among a chronically ill multicultural patient population. METHODS: A prospective cross-sectional study was conducted among patients treated for chronic illnesses in the Ministry of Health primary care clinics in Kuwait. Patients completed a questionnaire that consisted of questions to collect information about their health status and demographics using validated instruments: the Beliefs about Medication, Sensitive Soma Assessment Scale, and Medication Adherence Report Scale-5 items. The main outcome measures were self-reported adherence to medications, beliefs, and perceived sensitivity toward medications. RESULTS: Of the 1,150 questionnaires distributed, 783 were collected - giving a response rate of 68.1%. Of the 783 patients, 56.7% were male, 73.7% were married, 53.3% were non-Kuwaitis, and 49.4% had low income (<1,000 KD/3,350 USD monthly). Patients self-reported having a cardiovascular illness (80.2%), diabetes mellitus (67.7%), respiratory disease (24.3%), or mood disorder (28.6%). Participants had a mean of two comorbid illnesses and indicated taking an average of four prescription medicines to treat them. A structural equation model analysis showed adherence to medications was negatively impacted by higher negative beliefs toward medications (beta = -0.46). Factors associated with negative beliefs toward medications included marital status (being unmarried; beta = -0.14), nationality (being Kuwaiti; beta = 0.15), having lower education level (beta = -0.14), and higher illness severity (beta = 0.15). Younger age (beta = 0.10) and higher illness severity (beta = -0.9) were independently associated with lower medication adherence. Income and gender did not influence medication adherence or beliefs about medications. The combined effect of variables tested in the model explained 24% of the variance in medication adherence. CONCLUSION: Medication adherence is a complex, multifaceted issue and patient beliefs about medications contribute significantly, although partially, to adherence among a multicultural Middle Eastern patient population.

Clinical pharmacy in Kuwait: Services provided, perceptions and barriers.

INTRODUCTION: Pharmacy practice has considerably evolved from a dispensing role to a patient-centered profession. Kuwait has minimal clinical pharmacy services established in its healthcare settings. OBJECTIVES: The objectives of this study were to document existing clinical pharmacy services in public hospitals, identify barriers to their implementation and assess perceptions regarding pharmacists providing clinical services. MATERIAL & METHOD: A cross sectional study using self-administered questionnaires among a total of 166 pharmacists and 284 physicians across 6 public hospitals in Kuwait was conducted. RESULTS: Over half of pharmacists (54%) provided clinical services, with the most common service being education and drug information (86%). Forty percent (40%) of the pharmacists reported that clinical services offered were of their own initiative but most of them (71%) were not sure whether they would offer additional services in the future. The majority of physicians were receptive to an expanded patient-centered role of the pharmacist (97%), believed pharmacists add to patient clinical care (92%) and considered pharmacists members of the healthcare team (96%). Major barriers reported by pharmacists to implement clinical pharmacy services included lack of policy (49%), time (36%) and clinical skills (28%), which is similar to barriers reported by physicians. CONCLUSION: Although clinical pharmacy is in its infancy in Kuwait, it is well perceived and requested by physicians. Major barriers must be addressed and in this context, having a national framework for pharmacy practice from Ministry of Health, supported by cutting edge education and a pro-active professional association would be key assets to evolve the practice in Kuwait.

Reporting of Adverse Drug Reactions in Primary Care Settings in Kuwait: A Comparative Study of Physicians and Pharmacists.

OBJECTIVE: To investigate and compare knowledge, attitudes, and practices regarding pharmacovigilance (PV) and the reporting of adverse drug reactions (ADR) among physicians and pharmacists in primary care settings. SUBJECTS AND METHODS: A cross-sectional study was conducted, in which a validated self-administered questionnaire was distributed to 386 physicians and 197 pharmacists in 38 primary care clinics in Kuwait. Categorical variables were described using numbers and percentages. The Pearson χ2 test, Fisher exact test, and Mann-Whitney U test were used as appropriate. p < 0.05 was considered statistically significant. RESULTS: Of the 583 questionnaires distributed, 485 were completed (by 318 physicians and 167 pharmacists), giving an overall response rate of 83.2%. A total of 52.8% (n = 256) and 70.5% (n = 341) of the study participants were knowledgeable about the definitions of PV and ADR, respectively, with pharmacists demonstrating significantly better knowledge of PV (n = 105/167 vs. 151/318, i.e., 62.9 vs. 47.5%; p < 0.001) and purpose (n = 123/167 vs. 177/318, i.e., 74.1 vs. 55.7%; p < 0.001). However, the majority (n = 434/485; 89.4%) were not aware of an ADR reporting system in Kuwait. Almost every participant (n = 474/485; 97.7%) thought it was necessary to report ADR. However, significantly fewer physicians than pharmacists (n = 248/318 vs. 147/167, i.e., 78.0 vs. 88.0%; p < 0.01) believed that ADR reporting was a professional obligation. Only 27.8% (n = 133/485) had reported ADR, with pharmacists having reported significantly fewer than physicians (n = 35/167 vs. 98/318, i.e., 21.7 vs. 30.8%; p = 0.036). CONCLUSIONS: This study indicated that the attitude was positive but there was suboptimal knowledge and poor practice among primary care physicians and pharmacists with regard to ADR reporting. Targeted training about ADR reporting while ensuring a robust regulatory framework would encourage ADR reporting practices in the primary health care setting in Kuwait.

Public Perceptions, Expectations, and Views of Community Pharmacy Practice in Kuwait.

OBJECTIVES: This study was designed to determine public patterns for use of community pharmacies, perceptions of pharmacists, confidence and trust in pharmacists, and expectations about the pharmacist's roles, and to explore the public views and satisfaction with the current pharmacy services. SUBJECTS AND METHODS: A descriptive, cross-sectional survey was performed using a pretested self-administered questionnaire on a sample of 481 individuals selected using a 2-stage stratified cluster sampling design. Descriptive and multivariate logistic regression analyses were used for data analysis. p < 0.05 was considered statistically significant. RESULTS: The most common reasons for visiting a pharmacy were to purchase medications (prescription: n = 338 [78.1%] and nonprescription: n = 296 [68.4%]). Of the 433 respondents, 87 believed that pharmacists had a good balance between health and business matters; regarding any drug-related problem, 229 (52.9%) identified the physician as the first person to contact, followed by the pharmacist (n = 140; 32.3%); 255 (58.9%) agreed that they trust pharmacists, while 237 (54.8%) agreed that pharmacists have the ability to answer drug- or disease-related questions. Of the 433 respondents, 236 (54.5%) did not expect the pharmacist's role to include monitoring health progress to ensure safe and effective use of medications, and 258 (59.6%) were satisfied with the current pharmacy services. CONCLUSION: The current study indicated that respondents had overall negative perceptions of community pharmacists, expressed moderate expectations of their role, and viewed the current pharmacy services as slightly positive. These findings highlight the need for designing multifaceted interventions targeting specific areas to advance the community pharmacy practice in Kuwait.

Knowledge, attitude and practices of pharmacovigilance and adverse drug reaction reporting among pharmacists working in secondary and tertiary governmental hospitals in Kuwait.

Introduction: Pharmacovigilance (PV) is essential to detect and prevent adverse drug reactions (ADR) after a drug is marketed. However, ADRs are significantly underreported worldwide. Objective: The aims of this study were to document the knowledge, attitude and practices (KAP) of pharmacists toward PV and ADR reporting and to explore the barriers to implementing a fully functional PV program in Kuwait. Material and methods: Pharmacists working at governmental hospitals were asked to complete a paper-based 25-item questionnaire. Results: A total of 414 pharmacists received the questionnaire and 342 agreed to participate, giving a response rate of 82.6%. Most pharmacists were knowledgeable about the concepts of PV (61.5%) and ADRs (72.6%) and the majority (88.6%) was willing to implement ADR reporting in their clinical practice. Despite this positive attitude, only 26.8% of participants had previously reported an ADR and the main reason for underreporting was stated as not knowing how to report (68.9%). Barriers that hinder the implementation of a PV center included lack of cooperation and communication by healthcare professionals and patients (n = 62), lack of time and proper management (n = 57), lack of awareness of staff and patients (n = 48) and no qualified person to report ADRs (n = 35). Conclusions: Overall this study shows that hospital pharmacists in Kuwait had good knowledge and positive attitude toward PV and ADRs reporting. However, the majority of them have never reported ADRs. These results suggest that targeted educational interventions and a well-defined policy for ADR reporting may help increase ADR reporting and support the implementation of a fully functional independent PV center in Kuwait.

Pregabalin for peripheral neuropathic pain: a multicenter, enriched enrollment randomized withdrawal placebo-controlled trial.

OBJECTIVES: To date, published neuropathic pain randomized controlled trials of pregabalin have involved primarily diabetic peripheral neuropathy (DPN) and postherpetic neuralgia (PHN). This multicenter trial evaluated pregabalin in a broader range of neuropathic pain etiologies. METHODS: In this enriched enrollment randomized withdrawal trial, 256 patients received single blind, flexible dose pregabalin for 4 weeks; stable concomitant analgesics were allowed. One hundred sixty-five (65%) had a ≥30% pain improvement and 157 were randomized and treated, double blind, to either continue pregabalin (n=80) or to receive placebo (n=77) for 5 weeks. RESULTS: Of the single blind responders randomized, 81% on placebo and 86% on pregabalin completed the double-blind phase. At the double-blind endpoint, mean (SD) pain scores were 2.9 (1.9) in the pregabalin group and 3.5 (1.7) in the placebo group (P=0.002). These modest yet significant pregabalin-placebo differences were observed within each of the subgroups of patients with a diagnosis of either DPN or PHN (P=0.03), and with other diagnoses (P=0.02). Significant differences were also observed in sleep interference, Hospital Anxiety and Depression Scale Anxiety and Depression subscales, and other secondary measures. In total, 28 out of 80 (35.0%) in the pregabalin group and 28 out of 77 (36.4%) in the placebo group had either a meaningful increase in pain or discontinued the double-blind phase. Adverse events were consistent with the known tolerability profile of pregabalin and led to discontinuation of 9 during the single-blind phase, and 5 and 2 patients from the placebo and pregabalin groups, respectively. DISCUSSION: These results support previous evidence of pregabalin efficacy but further demonstrate efficacy and tolerability in a broader range of peripheral neuropathic pain conditions beyond just DPN and PHN.

Neointimal-specific induction of apoptosis by losartan results in regression of vascular lesion in rat aorta.

We previously reported that initiating treatment with the angiotensin II receptor antagonist losartan, prior to and immediately after balloon injury, attenuates neointimal hyperplasia via induction of smooth muscle cell (SMC) apoptosis in the aorta of spontaneously hypertensive rats (SHR). The present study examines whether losartan can induce regression of an established neointima. Balloon angioplasty was performed in the aorta of 1 1 week-old SHR. Five weeks were allowed for neointima formation before rats received placebo or losartan (30 mg/kg/day) for 1 to 4 weeks. Blood pressure was measured by tail cuff plethysmography. Losartan significantly reduced blood pressure (16%) versus placebo within 2 weeks of treatment. In situ labeling with terminal deoxynucleotidyl transferase among neointimal SMC was transiently increased with losartan (10-fold at 2 weeks; P=0.004) in correlation with internucleosomal fragmentation of vascular DNA. Accordingly, losartan reversed neointimal hyperplasia by 43% (P=0.002) and 61% (P=0.007) at weeks 2 and 4, respectively, and neointimal mass by 63% (P<0.001) and 75% (P<0.001) at weeks 2 and 4, respectively, as compared to pre-treatment values. No change in aortic medial hyperplasia or mass was observed during losartan treatment. Taken together, endothelial denudation rendered the underlying media resistant to drug-induced remodeling, while losartan treatment induced vascular lesion regression by inducing apoptosis selectively in neointimal SMC, an effect that may contribute to the reduction of cardiovascular complications in hypertension.

Metabolic and additional vascular effects of thiazolidinediones.

Several cardiovascular risk factors (dyslipidaemia, hypertension, glucose intolerance, hypercoagulability, obesity, hyperinsulinaemia and low-grade inflammation) cluster in the insulin resistance syndrome. Treatment of these individual risk factors reduces cardiovascular complications. However, targeting the underlying pathophysiological mechanisms of the insulin resistance syndrome is a more rational treatment strategy to further improve cardiovascular outcome. Our understanding of the so-called cardiovascular dysmetabolic syndrome has been improved by the discovery of nuclear peroxisome proliferator-activated receptors (PPARs). PPARs are ligand-activated transcription factors belonging to the nuclear receptor superfamily. As transcription factors, PPARs regulate the expression of numerous genes and affect glycaemic control, lipid metabolism, vascular tone and inflammation. Activation of the subtype PPAR-gamma improves insulin sensitivity. Expression of PPAR-gamma is present in several cell types involved in the process of atherosclerosis. Thus, modulation of PPAR-gamma activity is an interesting therapeutic approach to reduce cardiovascular events. Thiazolidinediones are PPAR-gamma agonists and constitute a new class of pharmacological agents for the treatment of type 2 (non-insulin-dependent) diabetes mellitus. Two such compounds are currently available for clinical use: rosiglitazone and pioglitazone. Thiazolidinediones improve insulin sensitivity and glycaemic control in patients with type 2 diabetes. In addition, improvement in endothelial function, a decrease in inflammatory conditions, a decrease in plasma levels of free fatty acids and lower blood pressure have been observed, which may have important beneficial effects on the vasculature. Several questions remain to be answered about PPAR-gamma agonists, particularly with respect to the role of PPAR-gamma in vascular pathophysiology. More needs to be known about the adverse effects of thiazolidinediones, such as hepatotoxicity, increased low-density lipoprotein cholesterol levels and increased oedema. The paradox of adipocyte differentiation with weight gain concurring with the insulin-sensitising effect of thiazolidinediones is not completely understood. The decrease in blood pressure induced by thiazolidinedione treatment seems incompatible with an increase in the plasma volume, and the discrepancy between the stimulation of the expression of CD36 and the antiatherogenic effects of the thiazolidinediones also needs further explanation. Long-term clinical trials of thiazolidinediones with cardiovascular endpoints are currently in progress. In conclusion, studying the effects of thiazolidinediones may shed more light on the mechanisms involved in the insulin resistance syndrome. Furthermore, thiazolidinediones could have specific, direct effects on processes involved in the development of vascular abnormalities.