Clinical pharmacy services for tuberculosis management: a systematic review.

Objective: This study aims to systematically review the content and potential effects of clinical pharmacy services in tuberculosis (TB) care management. Methods: Searches were performed in PubMed, Embase, Cochrane, Scopus, and Web of Science databases following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Study characteristics and outcomes were extracted, and clinical pharmacy service components were characterized using the Descriptive Elements of Pharmacist Intervention Characterization Tool. Results: Twenty articles were included for full-text assessment, of which 10 fulfilled inclusion criteria, comprising 1,168 patients (N = 39 to 258 per study). These articles included five prospective cohort studies, two case-control studies, two quasi-experimental studies, and one cross-sectional study. Intervention foci within clinical pharmacy services were medication adherence (50%), medication safety (40%), education to patients/caregivers regarding needs/beliefs (30%), optimizing medication/therapy effectiveness (30%), emphasizing HRQoL (10%), and drug selections (10%). The three most frequently applied interventions were drug information/patient counseling (80%), adverse drug reaction monitoring (50%), and drug use evaluation (20%). Based on the World Health Organization (WHO) outcome classification, treatment success ranged from 72% to 93%, with higher cure outcomes (53%-86%) than treatment completion (7%-19%). Other outcomes, including isoniazid metabolites, medication counts, sputum conversion, adherence/compliance, knowledge, and quality of life, were better in the intervention group than those in comparator groups, and/or they improved over time. Risk of bias analysis indicated that the included studies were not comparable to a randomized clinical trial. Conclusion: Clinical pharmacy services as single or composite interventions potentially improve TB outcomes, but its evidence is still inconsistent and limited due to the lack of randomized controlled studies using the WHO outcome classification. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=199028, identifier CRD42020199028.

Clinical and economic impact of medication non-adherence in drug-susceptible tuberculosis: a systematic review.

BACKGROUND: Despite considerable efforts to globally eradicate TB, and the availability of effective antibiotics, TB elimination goals are falling behind. While non-adherence to TB drug regimens may compromise effective treatment, its full impact is still unknown.OBJECTIVE: To determine the clinical and economic impact of non-adherence to TB medication on treatment outcomes in drug-susceptible TB patients (DS-TB).METHODS: A systematic review was performed using PubMed and Embase for studies published between 2009 and 2019 reporting associations between adherence and WHO-defined TB treatment outcomes and economic outcomes in DS-TB patients.RESULTS: A total of 14 studies were included. Eight focused on the association between non-adherence and death, 2 on treatment failure, 1 study on successful treatment outcome, 1 study on both successful and unsuccessful treatment outcomes and 2 on cost outcomes. Most studies (71.4%) were retrospective cohort or case-control studies. The results showed that non-adherence to TB drug regimens was associated with death, treatment failure and lower cure rates.CONCLUSION: Non-adherence to TB drugs has a profound impact on both clinical and economic TB outcomes. To reach WHO TB elimination goals, preventing non-adherence and the implementation of cost-effective intervention programmes should receive the highest priority.

Influence of age on real-life effects of doxycycline for acute exacerbations among COPD outpatients: a population-based cohort study.

INTRODUCTION: Although bacteria contribute significantly to acute exacerbations of chronic obstructive pulmonary disease (AECOPD), the added value of antibiotics remains controversial, especially in outpatient settings. Age may affect antibiotic effectiveness, but real-world evidence is lacking. We aimed to assess the influence of age on the effectiveness of doxycycline for AECOPD. METHODS: A retrospective cohort study among outpatients with the first recorded AECOPD treated with oral corticosteroids was conducted using a large pharmacy dispensing database. The primary outcome was treatment failure within 15-31 days after treatment start. Secondary outcome was time to second exacerbation. All analyses were stratified by age groups. RESULTS: We identified 6300 outpatients with the first AECOPD. 2261 (36%) received doxycycline and 4039 (64%) did not receive any antibiotic (reference group). Overall, there was no difference in treatment failure (adjusted OR: 0.97, 95% CI: 0.84 to 1.12) between two groups. Similarly, no difference in treatment failure was observed in younger groups. However, in patients with advanced age (≥75 years), treatment failure was significantly reduced by doxycycline compared with reference (16% vs 20%, adjusted OR: 0.77, 95% CI: 0.62 to 0.97). Overall, median time to second exacerbation was 169 days (95% CI: 158 to 182 days) in doxycycline group compared with 180 days (95% CI: 169 to 191 days) in reference group (adjusted HR: 1.06, 95% CI: 0.99 to 1.12). Although in older patients there was a trend within 3 months towards longer time of next exacerbation by doxycycline, it did not achieve statistical significance. CONCLUSIONS: Our findings showed short-term treatment benefit of doxycycline added to oral corticosteroids for chronic obstructive pulmonary disease patients with advanced age. This value remains unclear for persons aged under 75 years in current primary care. Long-term preventive benefits of doxycycline for the next exacerbation were not observed, irrespective of age.

Effects of targeting disease and medication management interventions towards patients with COPD.

OBJECTIVE: Suboptimal adherence in chronic obstructive pulmonary disease (COPD) patients is associated with decreased clinical and economic outcomes. Intervention programs, targeted at patients with suboptimal adherence and exacerbations, offer opportunities for cost-effective COPD care. We have aimed to assess the effects of the Medication Monitoring and Optimization (MeMO) targeted COPD intervention. METHODS: Twenty community pharmacies participated in this 1 year real-world study with a pre-test/post-test design. Patients with a physician-confirmed COPD diagnosis, oral corticosteroid use, suboptimal adherence and Clinical COPD Questionnaire (CCQ) score ≥1 were selected by pharmacists. Pharmacy interventions included inhalation instruction, medication information and motivational interviewing regarding adherence and smoking cessation. Proposals for dose, medication and/or inhaler change and physical activity or diet recommendations were discussed with the general practitioner (GP), physiotherapist or dietician, when deemed relevant. Primary endpoint was the change in CCQ score. Secondary outcomes were adherence, exacerbations, healthcare utilization, quality of life (EQ-5D), modified Medical Research Council (mMRC) dyspnea score and cost-effectiveness. RESULTS: Interventions were performed in 88 patients (mean age: 69; 52% male; mean CCQ: 2.10). The most often performed interventions were inhalation instruction (89%), medication education (98%) and adherence counseling (58%). Respectively 9%, 45% and 16% were referred to GP, physiotherapist or dietician. After 1 year, mean CCQ decrement was 0.12 and 38% showed a clinically relevant improvement. There was a significant decrease in exacerbations (-0.82) per patient per year. Adherence, mMRC and EQ-5D hardly changed. Per patient, annual medication costs were €26 higher, interventions cost €33, but total healthcare costs were €333 lower. The small sample size and lack of a control group were the main limitations. CONCLUSION: By specifically targeting COPD patients with potential room for improvement, the MeMO COPD program has the potential to be an effective and cost-saving method for preventing exacerbations. However, no effects on quality of life have been observed. Larger studies are therefore recommended.

Proactive pharmaceutical care interventions decrease patients' nonadherence to osteoporosis medication.

UNLABELLED: Using a protocolled intervention program, pharmacists can decrease nonadherence to osteoporosis medication, by continuous monitoring and tailored counseling sessions, starting at treatment initiation. In the usual care group, 32.8% of patients initiating osteoporosis medication discontinued or were nonadherent, compared to 19.0% of patients in the intervention group. PURPOSE: While community pharmacies have been shown to offer a promising platform for osteoporosis management in patients with osteoporosis, more research is needed to determine pharmacists' effects on improving adherence. The aim of this study was to determine the effects of a community pharmacists' intervention program on the 1-year discontinuation and nonadherence rates of patients initiating osteoporosis medication. METHODS: This intervention study included 937 patients, recruited from 13 Dutch community pharmacies, initiating osteoporosis medication. The intervention group (N = 495), received the Medication Monitoring and Optimization (MeMO) intervention, comprising of continuous monitoring of patients' adherence to their osteoporosis medication and tailored counseling sessions with nonadherent patients. Results were compared to an internal (n = 442) reference group, receiving usual pharmacy care. Primary study outcomes were therapy discontinuation and nonadherence; results were adjusted for potential confounders using Cox proportional hazard analysis. Secondary outcome was patients' satisfaction. RESULTS: In the usual care group, 32.8% of patients initiating osteoporosis medication discontinued or were nonadherent, compared to 19.0% of patients in the intervention group (P < 0.001). Ninety-three percent of the respondents were satisfied with the pharmacies' services provided. Notably, 31% mentioned that the pharmacy was the only place where they received information on various aspects of administration and acting of their medication. CONCLUSION: Pharmacists can decrease nonadherence and discontinuation with osteoporosis medication by providing tailored counseling sessions and continuous monitoring of drug use. Pharmaceutical care programs, such as MeMO, contribute to more optimal use of osteoporosis medication.

COPD in the working age population: the economic impact on both patients and government.

OBJECTIVES: To explore the full economic impact, on both patients and government, as a result of COPD in the working age population. METHODS: The economic impact of COPD due to medical treatment, impaired productivity and early retirement was assessed in a cross sectional cost analysis of the Dutch COPD population aged 45-64 years. The costing year was 2009 and input parameters were derived from both national data sources and the international COPD uncovered survey. RESULTS: While direct medical costs for COPD patients of working age were relatively low (€ 91 million), the amount of lost productivity (income) due to early retirement (€ 223 million) exceeded over two times their medical costs. In addition, costs for the government were considerable because of lost tax revenues (€ 77 million) and COPD related disability pensions paid (€ 180 million). Apart from lost productivity due to early retirement, costs due to impaired productivity for working COPD patients were € 63 million. CONCLUSIONS: The costs of COPD for both patients of working age as for the government were considerable, making this population a priority for prevention and intervention programs of healthcare providers, employers and government.

The pharmacists' potential to provide targets for interventions to optimize pharmacotherapy in patients with asthma.

BACKGROUND: Despite of pharmacists' specialized knowledge of medication and his/her regular contact with patients, the expertise of the pharmacist may not be used enough yet. Furthermore, the potential of pharmacy dispensing data is underestimated. OBJECTIVE: To provide targets for tailored interventions in asthma patients and to illustrate the potential value of pharmacists in the identification of these targets using individual pharmacy dispensing data. SETTING: We performed a cross sectional retrospective analysis assessing the quality of asthma patients' pharmacotherapeutic treatment. METHOD: Drug dispensing data from 2008 to 2009 were retrieved from a Dutch pharmacy database. All asthma patients were screened for potential suboptimal pharmacotherapy in 2009. Results were projected to a single community pharmacy to provide an estimate of the number of patients eligible for potential interventions. MAIN OUTCOME MEASURES: (1) frequent use of short-acting ß-agonists without preventive medication, (2) concomitant use of ß-blockers, (3) multiple short courses of oral corticosteroids without using inhaled corticosteroids and 4) use of long-acting ß-agonist without inhaled corticosteroids. RESULTS: A total of 8,504 patients were eligible for analysis of the quality of their asthma treatment. 20.9 % of all asthma patients used >100 DDD short-acting ß-agonists per year, whereas between 21.2 % (≥ 400 DDD) and 31.4 % (100-199 DDD) of these patients did not receive preventive medication. Approximately 5.2 % of the asthma patients are using ß-blockers concomitantly and 21.8 % of them received non-cardioselective ß-blockers. 6.3 % of the asthma patients received two or more oral courses of corticosteroids in 2008 and 17.4 % of these patients did not receive inhaled corticosteroids in 2009. 2.9 % of the patients used a long-acting ß-agonists without inhaled corticosteroids. 8.4 % of the asthma patients using both long-acting ß-agonists and inhaled corticosteroids received these drugs in two separate inhalers. We estimated that about 400 asthma patients could be identified in an average pharmacy population (8,000 patients) and 33 (95 % CI 22-44) of these patients would be eligible for interventions. CONCLUSION: This study shows the potential for pharmacists to use their own pharmacy records to identify suboptimal therapy of asthma patients, who may be targets for tailored interventions.