Collaborative medication reviews in community pharmacies-Drug-related problems and the process of communicating them with physicians: A retrospective validation study.

Background and Aims: Cooperation between practicing community pharmacists (PPs) and primary care physicians has traditionally been limited, with scarce communication on therapeutic issues. The aim of this study was to assess how PPs communicate in writing with physicians regarding (1) the clinically relevant problems they have identified in patients' medications and (2) recommendations to solve the problems to identify development needs in the communication process. Methods: This retrospective validation study assessed medication reviews conducted by PPs in collaboration with home care nurses, practice nurses, and physicians for 46 older (≥65 years) home care clients in the Municipality of Lohja, Finland. The therapeutic and communicative appropriateness of clinically relevant drug-related problems (DRPs) identified by PPs and reported in writing to physicians was blindly evaluated by (1) an accredited pharmacist (AP) and (2) two physicians specialized in geriatric pharmacotherapy. Descriptive statistical analysis was conducted to compare the assessments. Results: The PPs (n = 13) identified 189 DRPs and made 4.1 recommendations per patient in 46 written reports to physicians. Of the PPs' written recommendations for medication changes, 46% (155/334) were the same as those by the AP. The two specialized physicians evaluated 69% and 67% of PPs' recommendations to be clinically relevant. The way the DRPs and recommendations to solve them were communicated was evaluated as appropriate in 38% and 38%, respectively, of the case reports written by the PPs. Conclusion: The PPs were able identify DRPs quite well, particularly inappropriate medication use, according to current care guidelines and formularies. It was found that improvement was needed in the communication of DRPs in written reports with physicians. Interprofessional learning by working in care teams would be suitable for strengthening patient care-oriented competencies.

Harmonizing the definition of medication reviews for their collaborative implementation and documentation in electronic patient records: A Delphi consensus study.

BACKGROUND: Medication review practices have evolved internationally in a direction in which not only physicians but also other healthcare professionals conduct medication reviews according to agreed practices. Collaborative practices have increasingly highlighted the need for electronic joint platforms where information on medication regimens and their implementation can be documented, kept updated, and shared. OBJECTIVE: The aim of this study was to harmonize the definition of medication reviews and create a unified conceptual basis for their collaborative implementation and documentation in electronic patient records (definition appellation: collaborative medication review). METHODS: The study was conducted using the Delphi consensus survey with three interprofessional expert panel rounds in September-December 2020. The consensus rate was set at 80%. Experts assessed the proposed definition of collaborative medication review based on an international and national inventory of medication review definitions. The expert panel (n = 41) involved 12 physicians, 13 pharmacists, 10 nurses, and six information management professionals. The range of response rates for the rounds was 63-88%. RESULTS: The experts commented on which of the pre-selected items (n = 75) characterizing medication reviews should be included in the definition of collaborative medication review. The items were divided into the following five themes and 51 of them reached consensus: 1) Actions included in the collaborative medication review (n = 24/24), 2) Settings where the review should be conducted (n = 5/5), 3) Situations where the review should be considered as needed and carried out (n = 10/11), 4) Prioritization of top five benefits to be achieved by the review and 5) Prioritization of top five patient groups to whom the review should be targeted. CONCLUSIONS: A strong interprofessional consensus was reached on the definition of collaborative medication review. The most challenging was to identify individual patient groups benefiting from the review.

Medication risk checklist for older adults (LOTTA) - development and validation of a self-assessment tool.

BACKGROUND: Patient safety strategies highlight patients' own active involvement in ensuring medication safety. A prerequisite for involving patients in their medication therapy is having tools that can assist them in ensuring safe medicine use. Older home-dwelling adults with multiple medications are at high risk for medication-related problems, yet only a few age-specific patient self-administered medication risk screening tools exist. This study aimed to develop, validate, and assess the feasibility of a self-administered medication risk checklist for home-dwelling older adults ≥65 years. MATERIALS AND METHODS: The draft checklist was formed based on a validated practical nurse-administered Drug Related Problem Risk Assessment Tool supplemented with findings from two systematic literature reviews. The content validity of the draft checklist was determined by a three-round Delphi survey with a panel of 19 experts in geriatric care and pharmacotherapy. An agreement of ≥80% was required. A feasibility assessment (i.e. understandability of the items, fill-out time of the checklist) of the content-validated checklist was conducted among older adults ≥65 years (n = 87) visiting community pharmacies (n = 4). Data were analysed using qualitative content analysis. RESULTS: The final validated and feasibility-tested Medication Risk Checklist (LOTTA) for home-dwelling older adults consists of eight items screening the highest priority systemic risks (three items), potentially drug-induced symptoms (one item), adherence, and self-management problems (four items). The checklist proved feasible for self-administration, the mean fill-out time being 6.1 min. CONCLUSIONS: A wide range of potential medication risks related to the medication use process can be identified by patient self-assessment. Screening tools such as LOTTA can enhance early detection of potential medication risks and risk communication between older adults and their healthcare providers. A wider and more integrated use of the checklist could be facilitated by making it electronically available as part of the patient information systems.

Patient safety strategies highlight patients' own active involvement in ensuring medication safety, which in turn, requires easy-to-use tools to self-assess potential medication risks and communicate them with healthcare providers.This study produced a short, age-specific eight item Medication Risk Checklist (LOTTA) to be self-administered by home-dwelling older adults to identify major systemic risks, potential drug-induced symptoms, adherence, and self-management problems related to medication taking.To facilitate the use of the checklist in early detection of potential medication risks, future studies should focus on converting the LOTTA list into electronic form and pilot its use as an integrated part of the electronic patient information system.

Self-assessed medication risk factors as part of comprehensive health screening in home-dwelling older adults.

Background: Poor medication management may negatively impact the health and functional capacity of older adults. This cross-sectional study aimed to identify medication-related risk factors in home-dwelling residents using a validated self-assessment as part of comprehensive health screening. Methods: The data were derived from comprehensive health screening (PORI75) for older adults of 75 years living in Western Finland in 2020 and 2021. One of 30 validated measures in health screening focused on identifying medication-related risk factors (LOTTA Checklist). The Checklist items were divided into (1) systemic risk factors (10 items) and (2) potentially drug-induced symptoms (10 items). Polypharmacy was categorized according to the number of used drugs: (1) no polypharmacy (<5 drugs), (2) polypharmacy (≥5 and <10), and (3) excessive polypharmacy (≥10). The linearity across these three polypharmacy groups was evaluated using the Cochran-Armitage test. Results: Altogether, 1024 out of 1094 residents who participated in the health screening consented to this study (n = 569 in 2020 and n = 459 in 2021). The mean number of all drugs in use was 7.0 (range 0-26; SD 4.1), with 71% of the residents using >5 drugs, that is, having polypharmacy. Of the systemic risk factors most common was that the resident had more than one physician responsible for the treatment (48% of the residents), followed by missing drug list (43%), missing regular monitoring (35%), and unclear durations of the medication (35%). The most experienced potentially drug-induced symptoms were self-reported constipation (21%), urinating problems (20%), and unusual tiredness (17%). An increasing number of drugs in use, particularly excessive polypharmacy, was associated with various medication-related risk factors. Conclusion: As a part of comprehensive health screening the LOTTA Checklist provides useful information to prevent medication-related risk factors in home-dwelling older adults. The Checklist could be used to guide planning and implementing health services in the future.

Risk assessment tools for QT prolonging pharmacotherapy in older adults: a systematic review.

PURPOSE: Many drugs are associated with the risk of QT prolongation and torsades de pointes (TdP), and different risk assessment tools (RATs) are developed to help clinicians to manage related risk. The aim of this systematic review was to summarize the evidence of different RATs for QT prolonging pharmacotherapy. METHODS: A systematic review was conducted using PubMed and Scopus databases. Studies concerning risk assessment tools for QT prolonging pharmacotherapy, including older adults, were included. Screening and selection of the studies, data extraction, and risk of bias assessment were undertaken. RESULTS: A total of 21 studies were included, involving different risk assessment tools. Most commonly used tools were risk scores (n = 9), computerized physician order entry systems (n = 3), and clinical decision support systems (n = 6). The tools were developed mainly for physicians and pharmacists. Risk scores included a high number of risk factors, both pharmacological and non-pharmacological, for QT prolongation and TdP. The inclusion of patients' risk factors in computerized physician order entry and clinical decision support systems varied. CONCLUSION: Most of the risk assessment tools for QT prolonging pharmacotherapy give a comprehensive overview of patient-specific risks of QT prolongation and TdP and reduce modifiable risk factors and actual events. The risk assessment tools could be better adapted to different health information systems to help in clinical decision-making. Further studies on clinical validation of risk assessment tools with randomized controlled trials are needed.

Policy and vision for community pharmacies in Finland: a roadmap towards enhanced integration and reduced costs

Finland's community pharmacy system provides an example of a privately-owned regulated system being proactively developed by the profession and its stakeholders. Community pharmacists have a legal duty to promote safe and rational medicine use in outpatient care. The development of professionally oriented practice has been nationally coordinated since the 1990s with the support of a national steering group consisting of professional bodies, authorities, pharmacy schools and continuing education centers. The primary focus has been in patient counseling services and public health programs. The services have extended towards prospective medication risk management applying evidence-based tools, databases and digitalization. Research has been essential in informing progress by indicating high-risk patients, medications, practices and processes needing improvement. Despite the commitment of the profession and pharmacy owners, large-scale implementation of services has been challenging because of lack of remuneration, the pharmacy income still consisting primarily of sale of prescription and nonprescription medicines. Policy documents by the Ministry of Social Affairs and Health have supported the extension of the community pharmacists' role beyond traditional dispensing to promote rational pharmacotherapy. The current roadmap by the Ministry of Social Affairs and Health emphasizes ensuring adequate regional availability and accessibility of medicines, regardless of the future pharmacy system. It also emphasizes the importance of strong regulation on pharmacy business operations and sale of medicines to ensure medication safety. At the same time, the roadmap requires that the regulation must enable implementation of new patient-oriented services and procedures, and further promote digitalization in service provision. Competition and balance of funding should be enhanced, e.g., through price competition, but the risk of pharmaceutical market concentration should be managed. The regulation should also consider influence of the new social and health care system on drug delivery. Year 2021 will be crucial for making long-term political decisions on the future direction of tasks and finances of Finnish community pharmacies in this framework. Government-funded studies are underway to guide decision making. Ongoing Covid-19 crisis has demonstrated the readiness of Finnish community pharmacies to adapt fast to meet the changing societal needs

No disponible

Policy and vision for community pharmacies in Finland: A roadmap towards enhanced integration and reduced costs.

Finland's community pharmacy system provides an example of a privately-owned regulated system being proactively developed by the profession and its stakeholders. Community pharmacists have a legal duty to promote safe and rational medicine use in outpatient care. The development of professionally oriented practice has been nationally coordinated since the 1990s with the support of a national steering group consisting of professional bodies, authorities, pharmacy schools and continuing education centers. The primary focus has been in patient counseling services and public health programs. The services have extended towards prospective medication risk management applying evidence-based tools, databases and digitalization. Research has been essential in informing progress by indicating high-risk patients, medications, practices and processes needing improvement. Despite the commitment of the profession and pharmacy owners, large-scale implementation of services has been challenging because of lack of remuneration, the pharmacy income still consisting primarily of sale of prescription and nonprescription medicines. Policy documents by the Ministry of Social Affairs and Health have supported the extension of the community pharmacists' role beyond traditional dispensing to promote rational pharmacotherapy. The current roadmap by the Ministry of Social Affairs and Health emphasizes ensuring adequate regional availability and accessibility of medicines, regardless of the future pharmacy system. It also emphasizes the importance of strong regulation on pharmacy business operations and sale of medicines to ensure medication safety. At the same time, the roadmap requires that the regulation must enable implementation of new patient-oriented services and procedures, and further promote digitalization in service provision. Competition and balance of funding should be enhanced, e.g., through price competition, but the risk of pharmaceutical market concentration should be managed. The regulation should also consider influence of the new social and health care system on drug delivery. Year 2021 will be crucial for making long-term political decisions on the future direction of tasks and finances of Finnish community pharmacies in this framework. Government-funded studies are underway to guide decision making. Ongoing Covid-19 crisis has demonstrated the readiness of Finnish community pharmacies to adapt fast to meet the changing societal needs.

Enhanced coordination of care to reduce medication risks in older home care clients in primary care: a randomized controlled trial.

BACKGROUND: As populations are aging, a growing number of home care clients are frail and use multiple, complex medications. Combined with the lack of coordination of care this may pose uncontrolled polypharmacy and potential patient safety risks. The aim of this study was to assess the impact of a care coordination intervention on medication risks identified in drug regimens of older home care clients over a one-year period. METHODS: Two-arm, parallel, cluster randomized controlled trial with baseline and follow-up assessment at 12 months. The study was conducted in Primary Care in Lohja, Finland: all 5 home care units, the public healthcare center, and a private community pharmacy. PARTICIPANTS: All consented home care clients aged > 65 years, using at least one prescription medicine who were assessed at baseline and at 12 months. INTERVENTION: Practical nurses were trained to make the preliminary medication risk assessment during home visits and report findings to the coordinating pharmacist. The coordinating pharmacist prepared the cases for the triage meeting with the physician and home care nurse to decide on further actions. Each patient's physician made the final decisions on medication changes needed. Outcomes were measured as changes in medication risks: use of potentially inappropriate medications and psychotropics; anticholinergic and serotonergic load; drug-drug interactions. RESULTS: Participants (n = 129) characteristics: mean age 82.8 years, female 69.8%, mean number of prescription medicines in use 13.1. The intervention did not show an impact on the medication risks between the original intervention group and the control group in the intention to treat analysis, but the per protocol analysis indicated tendency for effectiveness, particularly in optimizing central nervous system medication use. Half (50.0%) of the participants with a potential need for medication changes, agreed on in the triage meeting, had none of the medication changes actually implemented. CONCLUSION: The care coordination intervention used in this study indicated tendency for effectiveness when implemented as planned. Even though the outcome of the intervention was not optimal, the value of this paper is in discussing the real world experiences and challenges of implementing new practices in home care. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02545257). Registered September 9 2015.

Coordinating resources for prospective medication risk management of older home care clients in primary care: procedure development and RCT study design for demonstrating its effectiveness.

BACKGROUND: The magnitude of safety risks related to medications of the older adults has been evidenced by numerous studies, but less is known of how to manage and prevent these risks in different health care settings. The aim of this study was to coordinate resources for prospective medication risk management of home care clients ≥ 65 years in primary care and to develop a study design for demonstrating effectiveness of the procedure. METHODS: Health care units involved in the study are from primary care in Lohja, Southern Finland: home care (191 consented clients), the public healthcare center, and a private community pharmacy. System based risk management theory and action research method was applied to construct the collaborative procedure utilizing each profession's existing resources in medication risk management of older home care clients. An inventory of clinical measures in usual clinical practice and systematic review of rigorous study designs was utilized in effectiveness study design. DISCUSSION: The new coordinated medication management model (CoMM) has the following 5 stages: 1) practical nurses are trained to identify clinically significant drug-related problems (DRPs) during home visits and report those to the clinical pharmacist. Clinical pharmacist prepares the cases for 2) an interprofessional triage meeting (50-70 cases/meeting of 2 h) where decisions are made on further action, e.g., more detailed medication reviews, 3) community pharmacists conduct necessary medication reviews and each patients' physician makes final decisions on medication changes needed. The final stages concern 4) implementation and 5) follow-up of medication changes. Randomized controlled trial (RCT) was developed to demonstrate the effectiveness of the procedure. The developed procedure is feasible for screening and reviewing medications of a high number of older home care clients to identify clients with severe DRPs and provide interventions to solve them utilizing existing primary care resources. TRIAL REGISTRATION: The study is registered in the Clinical Trials.gov ( NCT02545257 ). Registration date September 9 2015.