Investigating the effect of clinical pharmacist intervention in transitions of care on drug-related hospital readmissions among the elderly: study protocol for a randomised controlled trial.

INTRODUCTION: Drug-related problems (DRPs) are a major cause of unplanned hospital admissions among elderly people, and transitions of care have been emphasised as a key area for improving patient safety. We have designed a complex clinical pharmacist intervention that targets people ≥75 years of age undergoing transitions of care from hospital to home and primary care. The main objective is to investigate if the intervention can reduce the risk of unplanned drug-related readmission within the first 180 days after the person is discharged from hospital. METHODS AND ANALYSIS: This is a randomised, controlled, superiority trial with two parallel arms. A total of 700 people ≥75 years will be assigned to either intervention or routine care (control). The intervention, which aims to find and manage DRPs, is initiated within a week of the person being discharged from hospital and combines repeated medical chart reviews, phone interviews and in some cases medication reviews. People in both study arms may have been the subject of a medication review during their ward stay. As the primary outcome, we will measure time until unplanned drug-related readmission within 180 days of leaving hospital and use log rank tests and Cox proportional hazard models to analyse differences between the groups. Further investigations of subgroup effects and adjustments of the regression models will be based on heart failure and cognitive impairment as prognostic factors. ETHICS AND DISSEMINATION: The study has been approved by the Regional Ethical Review Board in Umeå (registration numbers 2017-69-31M, 2018-83-32M and 2018-254-32M). We intend to publish the results with open access in international peer-reviewed journals and present our findings at international conferences. The trial is expected to result in more than one published article and form part of two PhD theses. TRIAL REGISTRATION NUMBER: NCT03671629.

Cardiovascular drug use among people with cognitive impairment living in nursing homes in northern Sweden.

PURPOSE: The aim of this study was to describe changes in the pattern of cardiovascular agents used in elderly people living in nursing homes between 2007 and 2013. Further, the aim was to analyse the use of cardiovascular drugs in relation to cognitive impairment and associated factors within the same population, where prescription of loop diuretics was used as a proxy for heart failure. METHODS: Two questionnaire surveys were performed including 2494 people in 2007 and 1654 people in 2013 living in nursing homes in northern Sweden. Data were collected concerning drug use, functioning in activities of daily living (ADL) and cognition, using the Multi-Dimensional Dementia Assessment Scale (MDDAS). The use of different drugs and drug classes among people at four different levels of cognitive function in 2007 and 2013 were compared. RESULTS: The proportion of people prescribed ASA and diuretics was significantly lower at all four levels of cognitive function in 2013 compared to 2007. Among people prescribed loop diuretics, the use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARBs) increased from 37.8 to 45.6%, ß-blockers from 36.0 to 41.8% and warfarin from 4.4 to 11.4%. The use of warfarin, ACEI/ARBs, ß-blockers and mineralocorticoid receptor antagonists (MRAs) were less common among individuals with more severe cognitive impairment. CONCLUSION: The results indicate that cardiovascular drug treatment has improved between 2007 and 2013, but there is room for further improvement, especially regarding adherence to guidelines for heart failure. Increasing cognitive impairment had an effect on treatment patterns for heart failure and atrial fibrillation.

Who enrols and graduates from web-based pharmacy education - Experiences from Northern Sweden.

INTRODUCTION: As a response to the shortage of prescriptionists in Northern Sweden, a web-based Bachelor of Science in Pharmacy program was introduced at Umeå University in 2003. This study explored who is likely to enrol and graduate from the web-based bachelor program and whether the program has addressed the shortage of prescriptionists in rural Northern Sweden. METHODS: Data from three different sources were included in this study; the initial cohort including students admitted to the program in 2003 (survey), the entire cohort including all people admitted to the program between 2003 and 2014 (university's admissions data) and the alumni cohort including graduates who participated in an alumni survey in 2015. RESULTS: A typical student of the web-based pharmacy program is female, over 30 years of age, married or in a de-facto relationship and has children. Furthermore, the students graduating before 2009 were more likely to live in Northern Sweden compared to those graduating later. DISCUSSION AND CONCLUSION: The results indicate that the introduction of a web-based bachelor of pharmacy program at Umeå University was to some extent able to address the shortage of prescriptionists in Northern Sweden. Web-based education may potentially help address the maldistribution of health professionals by providing flexible education opportunities.

Individualised dosing of amikacin in neonates: a pharmacokinetic/pharmacodynamic analysis.

PURPOSE: To examine the pharmacokinetics of amikacin and its pharmacokinetic pharmacodynamic (PKPD) relationship in neonates. To develop an alternative dosing strategy for amikacin in neonates. METHODS: A population PKPD analysis was performed using data collected from 80 neonates with gestational ages from 24 to 41 weeks. The final pharmacokinetic model analysed 358 amikacin concentrations. All neonates were > 72 hours postnatal age. Simulations were performed to develop a new dosing strategy. RESULTS: The final covariate model was clearance = 0.23 x (current weight/2)(0.691) x (postmenstrual age/40)(3.23) and volume of distribution = 0.957 x (current weight/2)(0.89). Following the logistic regression analysis of treatment failure, new amikacin target concentrations were estimated and used in development of an alternative dosing strategy. CONCLUSION: Simulation of a new dosing regimen yielded the following recommendations: 15 mg/kg at 36-h intervals, 14 mg/kg at 24-h intervals and 15 mg/kg at 24-h intervals for neonates < or = 28 weeks, 29-36 weeks and > or = 37 weeks postmenstrual age respectively.