Optimize Medication Use Research Articles

Optimization of Medication Use at Accountable Care Organizations.

Optimized medication use involves the effective use of medications for better outcomes, improved patient experience, and lower costs. Few studies systematically gather data on the actions accountable care organizations (ACOs) have taken to optimize medication use. To (a) assess how ACOs optimize medication use; (b) establish an association between efforts to optimize medication use and achievement on financial and quality metrics; (c) identify organizational factors that correlate with optimized medication use; and (d) identify barriers to optimized medication use. This cross-sectional study consisted of a survey and interviews that gathered information on the perceptions of ACO leadership. The survey contained a medication practices inventory (MPI) composed of 38 capabilities across 6 functional domains related to optimizing medication use. ACOs completed self-assessments that included rating each component of the MPI on a scale of 1 to 10. Fisher's exact tests, 2-proportions tests, t-tests, and logistic regression were used to test for associations between ACO scores on the MPI and performance on financial and quality metrics, and on ACO descriptive characteristics. Of the 847 ACOs that were contacted, 49 provided usable survey data. These ACOs rated their own system's ability to manage the quality and costs of optimizing medication use, providing a 64% and 31% affirmative response, respectively. Three ACOs achieved an overall MPI score of 8 or higher, 45 scored between 4 and 7.9, and 1 scored between 0 and 3.9. Using the 3 score groups, the study did not identify a relationship between MPI scores and achievement on financial or quality benchmarks, ACO provider type, member volume, date of ACO creation, or the presence of a pharmacist in a leadership position. Barriers to optimizing medication use relate to reimbursement for pharmacist integration, lack of health information technology interoperability, lack of data, feasibility issues, and physician buy-in. Compared with 2012 data, data on ACOs that participated in this study show that they continue to build effective strategies to optimize medication use. These ACOs struggle with both notification related to prescription use and measurement of the influence optimized medication use has on costs and quality outcomes. Compared with the earlier study, these data find that more ACOs are involving pharmacists directly in care, expanding the use of generics, electronically transmitting prescriptions, identifying gaps in care and potential adverse events, and educating patients on therapeutic alternatives. ACO-level policies that facilitate practices to optimize medication use are needed. Integrating pharmacists into care, giving both pharmacists and physicians access to clinical data, obtaining physician buy-in, and measuring the impact of practices to optimize medication use may improve these practices. This research was sponsored and funded by the National Pharmaceutical Council (NPC), an industry funded health policy research group that is not involved in lobbying or advocacy. Employees of the sponsor contributed to the research questions, determination of the relevance of the research questions, and the research design. Specifically, there was involvement in the survey and interview instruments. They also contributed to some data interpretation and revision of the manuscript. Leavitt Partners was hired by NPC to conduct research for this study and also serves a number of health care clients, including life sciences companies, provider organizations, accountable care organizations, and payers. Westrich and Dubois are employed by the NPC. Wilks, Krisle, Lunner, and Muhlestein are employed by Leavitt Partners and did not receive separate compensation. Study concept and design were contributed by Krisle, Dubois, and Muhlestein, along with Lunner and Westrich. Krisle and Muhlestein collected the data, and data interpretation was performed by Wilks, Krisle, and Muhlestein, along with Dubois and Westrich. The manuscript was written primarily by Wilks, along with Krisle and Muhlestein, and revised by Wilks, Westrich, Lunner, and Krisle. Preliminary versions of this work were presented at the following: National Council for Prescription Drug Programs Educational Summit, November 1, 2016; Academy Health 2016 Annual Research Meeting, June 27, 2016; Accountable Care Learning Collaborative Webinar, June 16, 2016; the 21st Annual PBMI Drug Benefit Conference, February 29, 2016; National Value-Based Payment and Pay for Performance Summit, February 17, 2016; National Accountable Care Congress, November 17, 2015; and American Journal of Managed Care's ACO Emerging Healthcare Delivery Coalition, Fall 2015 Live Meeting, October 15, 2015.

212 The Prevalence of Benzodiazepine Use in a Geriatric Emergency Department Population

The American Geriatric Society (AGS) has placed both benzodiazepines and non-benzodiazepine GABAA receptor (NGBR) agonists on the Beers list of medications to avoid in patient over 65 years old because of the increased risk of confusion, falls/fractures, and overall mortality. Although traditionally used for ambulatory care settings, emergency departments (ED) are starting to use the Beers criteria as a guide for ED prescribing. Despite existing recommendations, these medications are still administered in this vulnerable age group. The purpose of this study was to evaluate emergency department (ED) patients age 65 years old or older who received a benzodiazepine or NGBR during their ED stay. This was a retrospective observational study conducted at a tertiary care ED from July 1, 2012 to June 30, 2016. Charts from all patients age 65 years old or older were analyzed. We sought to determine the prevalence and pattern of benzodiazepine and NGBR agonist administration while admitted to an emergency department. Descriptive statistics are reported for patients who received these medications. There were 28,356 patients over the age of 65 years old presenting to our ED from July 1, 2012 to June 30, 2016. A total of 1750 (6.2%) patients received a benzodiazepine or NBGR agonist during their ED stay. Of these patients, 784 were males (45%) and 966 were females (55%). Most patients (n=989, 57%) were between 65 years old and 74 years old, followed by 541 (31%) between 75-84 years old. 220 (13%) patients were 85 years old or older. The most frequently administered medication was lorazepam (n=820, 47%), followed by diazepam (n=534, 31%). Zolpidem was given to 265 patients (15%). Chlordiazepoxide was the least frequently administered (n=17). 101 (6%) patients received more than one type of benzodiazepine. The five most common chief complaints in which benzodiazepines or NBGR agonists were used were shortness of breath (n=176, 10%) neck/back pain (n=175, 10%), dizziness/vertigo (n=129, 7%), abdominal pain (n=125, 7%), and chest pain (n=100, 6%). A minority of patients who received these medications presented with a psychiatric chief complaint (24 patients with suicidal ideations; 17 patients with anxiety). Only 10 patients received benzodiazepines for an alcohol-related problem; and 21 patients received benzodiazepines for seizures. 60 patients obtained a psychiatric evaluation during their ED stay. 1026 (58%) patients were admitted to the hospital or transferred to another acute care hospital. 712 (41%) patients were discharged, and 12 patients left against medical advice. Although several major psychiatric and geriatric organizations advise against the use of benzodiazepines and NBGR agonists in patient older than 65 years old, these medications continue to be used for a variety of conditions. Optimizing medication use to treat conditions in the ED while avoiding adverse drug events is often challenging, particularly in the older adult who is already at risk for drug-related problems. Although benzodiazepine administration may at times be indicated, further education is warranted. Providing emergency physicians with evidence-based alternatives to benzodiazepine use and designing ED specific guidelines need to be explored.

Population health management: An independent physician organization approach.

The role of clinical pharmacists and their impact on population health and value-based contracts within a multidisciplinary care management team are described. The Greater Rochester Independent Practice Association (GRIPA) has promoted high-quality, value-based care since its foundation 20 years ago. One of several ways that GRIPA enables its physicians to succeed in shared-savings agreements is by providing a community-based multidisciplinary care management team. The multidisciplinary team's primary goal is to help physicians manage the care of their most costly and complex patients. In addition, clinical pharmacists concentrate on lowering the amount of money spent on medications. The outcome goals for this team include (1) reducing hospitalizations, emergency room visits, and the use of unnecessary or inappropriate medications and (2) improving medication adherence and other measurable outcomes. Care management provided by clinical pharmacists for patients meeting GRIPA's high-risk criteria (≥2 inpatient or ≥3 emergency room visits in the 12 months before care management engagement) between 2013 and August 2015 resulted in a 42% decrease in 30-day readmissions, a 45% decrease in hospital admissions, a 16% decrease in emergency room visits, and a 20% decrease in annual medical charges. Through individualized pharmacy reviews and a unique approach to managing high-cost drugs, the clinical pharmacists at GRIPA have been successful in reducing hospitalizations and emergency room visits as well as promoting appropriate use of medications while reducing pharmacy waste. As part of a multidisciplinary team, clinical pharmacists are able to optimize medication use and engage patients and physicians to reduce medical and medication costs for contracted patients.

The Use of Medication by Adolescents and Young Adults

This paper articulates the Society for Adolescent Health and Medicine positions regarding access to, and use of, medications by adolescents and young adults (AYA). AYA encounter a significant number of medication-related challenges. System barriers such as supply disruption, cost, and complicated refill systems affect adherence and contribute to complications and long-term sequelae. AYA need to be able to access medications easily, confidentially, at minimal (or no) cost, and without stigma. Optimal use of medications should ideally result from a process negotiated through the triadic relationship between AYA, their parents/caregivers, and health professionals. This should be underpinned by access to developmentally appropriate information, support and education, including credible online sources developed to support AYA self-management. Self-management should be facilitated by meaningful AYA and parent/caregiver involvement in decision-making so that medication regimens are built around the life and developmental context of the AYA and form an integral part of their transition to adult health services. In addition, there should be facilitated involvement of AYA in the development of, licensing of, and access to new medications, including clinical trials. The positions presented in this paper are a comprehensive set of recommendations to improve AYA access to, and use of, medications for chronic illness, contraception, and self-limiting conditions.

Implications of True and Perceived Treatment Burden on Cardiovascular Medication Use.

Background: Clinical decisions require weighing possible risks and benefits, which are often based on the provider’s sense of treatment burden. Patients often have a different view of how heavily treatment burden should be weighted. Objective: To examine how much small variations in patient treatment burden would influence optimal use of antihypertensive medications and how much over- and undertreatment can result from clinicians misunderstanding their patients’ values. Methods: Analysis—Markov chain model. Data sources—Existing literature, including an individual-level meta-analysis of blood pressure trials. Target population—US representative sample, ages 40 to 85, no history of cardiovascular disease. Time horizon—Effect of 10 years of treatment on estimated lifetime quality-adjusted life-year (QALY) burden. Perspective—Patient. Outcome measures: QALYs gained by treatment. Results: Fairly small differences in true patient burden from blood pressure treatment alter the number of blood pressure medications that should be recommended and alters treatment’s potential benefit dramatically. We also found that a clinician misunderstanding the patient’s burden could lead to almost 30% of patients being treated inappropriately. Limitations: Our results are based on simulation modeling. Conclusions: Clinical decisions that fail to account for patient treatment burden can mistreat a very large proportion of the public. Successful treatment choices closely depend on a clinician’s ability to accurately gauge a patient’s treatment burden.

Optimization of Medication Use at Accountable Care Organizations.

Optimized medication use involves the effective use of medications for better outcomes, improved patient experience, and lower costs. Few studies systematically gather data on the actions accountable care organizations (ACOs) have taken to optimize medication use. To (a) assess how ACOs optimize medication use; (b) establish an association between efforts to optimize medication use and achievement on financial and quality metrics; (c) identify organizational factors that correlate with optimized medication use; and (d) identify barriers to optimized medication use. This cross-sectional study consisted of a survey and interviews that gathered information on the perceptions of ACO leadership. The survey contained a medication practices inventory (MPI) composed of 38 capabilities across 6 functional domains related to optimizing medication use. ACOs completed self-assessments that included rating each component of the MPI on a scale of 1 to 10. Fisher's exact tests, 2-proportions tests, t-tests, and logistic regression were used to test for associations between ACO scores on the MPI and performance on financial and quality metrics, and on ACO descriptive characteristics. Of the 847 ACOs that were contacted, 49 provided usable survey data. These ACOs rated their own system's ability to manage the quality and costs of optimizing medication use, providing a 64% and 31% affirmative response, respectively. Three ACOs achieved an overall MPI score of 8 or higher, 45 scored between 4 and 7.9, and 1 scored between 0 and 3.9. Using the 3 score groups, the study did not identify a relationship between MPI scores and achievement on financial or quality benchmarks, ACO provider type, member volume, date of ACO creation, or the presence of a pharmacist in a leadership position. Barriers to optimizing medication use relate to reimbursement for pharmacist integration, lack of health information technology interoperability, lack of data, feasibility issues, and physician buy-in. Compared with 2012 data, data on ACOs that participated in this study show that they continue to build effective strategies to optimize medication use. These ACOs struggle with both notification related to prescription use and measurement of the influence optimized medication use has on costs and quality outcomes. Compared with the earlier study, these data find that more ACOs are involving pharmacists directly in care, expanding the use of generics, electronically transmitting prescriptions, identifying gaps in care and potential adverse events, and educating patients on therapeutic alternatives. ACO-level policies that facilitate practices to optimize medication use are needed. Integrating pharmacists into care, giving both pharmacists and physicians access to clinical data, obtaining physician buy-in, and measuring the impact of practices to optimize medication use may improve these practices. This research was sponsored and funded by the National Pharmaceutical Council (NPC), an industry funded health policy research group that is not involved in lobbying or advocacy. Employees of the sponsor contributed to the research questions, determination of the relevance of the research questions, and the research design. Specifically, there was involvement in the survey and interview instruments. They also contributed to some data interpretation and revision of the manuscript. Leavitt Partners was hired by NPC to conduct research for this study and also serves a number of health care clients, including life sciences companies, provider organizations, accountable care organizations, and payers. Westrich and Dubois are employed by the NPC. Wilks, Krisle, Lunner, and Muhlestein are employed by Leavitt Partners and did not receive separate compensation. Study concept and design were contributed by Krisle, Dubois, and Muhlestein, along with Lunner and Westrich. Krisle and Muhlestein collected the data, and data interpretation was performed by Wilks, Krisle, Muhlestein, along with Dubois and Westrich. The manuscript was written primarily by Wilks, along with Krisle and Muhlestein, and revised by Wilks, Westrich, Lunner, and Krisle. Preliminary versions of this work were presented at the following: National Council for Prescription Drug Programs Educational Summit, November 1, 2016; Academy Health 2016 Annual Research Meeting, June 27, 2016; Accountable Care Learning Collaborative Webinar, June 16, 2016; the 21st Annual PBMI Drug Benefit Conference, February 29, 2016; National Value-Based Payment and Pay for Performance Summit, February 17, 2016; National Accountable Care Congress, November 17, 2015; and American Journal of Managed Care's ACO Emerging Healthcare Delivery Coalition, Fall 2015 Live Meeting, October 15, 2015.

The Active Implementation Frameworks: A roadmap for advancing implementation of Comprehensive Medication Management in Primary care.

Implementation of evidence-based health services interventions is complex and often limited in scope. The Active Implementation Frameworks (AIFs) are an evidence-based set of frameworks to use when attempting to put into practice any innovation of known dimensions. This article describes the novel application of the AIFs to facilitate the implementation and improvement of Comprehensive Medication Management (CMM) in primary care practices to optimize medication use and improve care for patients.

Description of drug therapy problem resolution in a statewide care management program

ObjectiveTo describe drug therapy problem (DTP) resolution as part of a statewide, team-based care management program. MethodsThis was a retrospective, observational study of DTPs documented between March 1 and August 31, 2015. Data were retrieved from a Web-based platform 5 months after the observation period. DTPs were placed into groups based on the credentials of the person who documented the DTP. Next, they were identified as being documented in a transitional or nontransitional care setting. DTPs were further classified into 1 of 3 categories: medication adherence, discrepancy, or optimization. Lastly, DTP resolution was assessed. Results were analyzed using descriptive statistics. ResultsDuring the 6-month study period, 135,100 DTPs were documented, with 99% (n = 133,847) being documented by social work care managers, nurse care managers, and pharmacy staff personnel. Pharmacy staff personnel documented the majority of DTPs (51.5%), and the majority of DTPs (55%) were identified in the transitional care setting. Nurse care managers resolved more discrepancy DTPs (59.3%), whereas pharmacy staff personnel resolved more optimization DTPs (47.2%). Social work care managers resolved more medication adherence DTPs (68.6%). ConclusionsPharmacy staff personnel primarily identified and resolved opportunities to optimize medication use, whereas nurse care managers primarily identified and resolved medication discrepancies. Social work care managers primarily identified and resolved problems related to medication adherence. When each member of the interdisciplinary care team functioned at the top of their license, all types of DTPs were effectively identified and resolved.

The Evolving Evidence for Therapeutic Drug Monitoring of Monoclonal Antibodies in Inflammatory Bowel Disease.

Biological medications are effective in inflammatory bowel disease (IBD) but adverse events, cost, and loss of response make their use challenging. Therapeutic drug monitoring (TDM) allows clinicians to more safely, effectively, and efficiently use medications. The purpose of this article is to review and summarize the most recent literature pertaining to TDM in IBD. Measurement of biological drug trough levels predicts ongoing patient response and can be used to titrate the medication to be more effective and efficient. Antibodies against the medications predict loss of response and adverse events. Using both parameters can predict response to subsequent biologicals. Newer biologicals show similar characteristics to those more commonly used. Management protocols using drug and antibody levels optimize medication use and may be cost-effective. Recent evidence suggests benefit to TDM of biologicals in IBD.

Impact of early in-hospital medication review by clinical pharmacists on health services utilization.

BackgroundAdverse drug events are a leading cause of emergency department visits and unplanned admissions, and prolong hospital stays. Medication review interventions aim to identify adverse drug events and optimize medication use. Previous evaluations of in-hospital medication reviews have focused on interventions at discharge, with an unclear effect on health outcomes. We assessed the effect of early in-hospital pharmacist-led medication review on the health outcomes of high-risk patients.MethodsWe used a quasi-randomized design to evaluate a quality improvement project in three hospitals in British Columbia, Canada. We incorporated a clinical decision rule into emergency department triage pathways, allowing nurses to identify patients at high-risk for adverse drug events. After randomly selecting the first eligible patient for participation, clinical pharmacists systematically allocated subsequent high-risk patients to medication review or usual care. Medication review included obtaining a best possible medication history and reviewing the patient’s medications for appropriateness and adverse drug events. The primary outcome was the number of days spent in-hospital over 30 days, and was ascertained using administrative data. We used median and inverse propensity score weighted logistic regression modeling to determine the effect of pharmacist-led medication review on downstream health services use.ResultsOf 10,807 high-risk patients, 6,416 received early pharmacist-led medication review and 4,391 usual care. Their baseline characteristics were balanced. The median number of hospital days was reduced by 0.48 days (95% confidence intervals [CI] = 0.00 to 0.96; p = 0.058) in the medication review group compared to usual care, representing an 8% reduction in the median length of stay. Among patients under 80 years of age, the median number of hospital days was reduced by 0.60 days (95% CI = 0.06 to 1.17; p = 0.03), representing 11% reduction in the median length of stay. There was no significant effect on emergency department revisits, admissions, readmissions, or mortality.LimitationsWe were limited by our inability to conduct a randomized controlled trial, but used quasi-random patient allocation methods and propensity score modeling to ensure balance between treatment groups, and administrative data to ensure blinded outcomes ascertainment. We were unable to account for alternate level of care days, and therefore, may have underestimated the treatment effect in frail elderly patients who are likely to remain in hospital while awaiting long-term care.ConclusionsEarly pharmacist-led medication review was associated with reduced hospital-bed utilization compared to usual care among high-risk patients under 80 years of age, but not among those who were older. The results of our evaluation suggest that medication review by pharmacists in the emergency department may impact the length of hospital stay in select patient populations.

Carotid femoral pulse wave velocity in type 2 diabetes and hypertension: capturing arterial health effects of step counts.

Objective:Optimal medication use obscures the impact of physical activity on traditional cardiometabolic risk factors. We evaluated the relationship between step counts and carotid-femoral pulse wave velocity (cfPWV), a summative risk indicator, in patients with type 2 diabetes and/or hypertension.Research design and methods:Three hundred and sixty-nine participants were recruited (outpatient clinics; Montreal, Quebec; 2011–2015). Physical activity (pedometer/accelerometer), cfPWV (applanation tonometry), and risk factors (A1C, Homeostatic Model Assessment–Insulin Resistance, blood pressure, lipid profiles) were evaluated. Linear regression models were constructed to quantify the relationship of steps/day with cfPWV.Results:The study population comprised 191 patients with type 2 diabetes and hypertension, 39 with type 2 diabetes, and 139 with hypertension (mean ± SD: age 59.6 ± 11.2 years; BMI 31.3 ± 4.8 kg/m2; 54.2% women). Blood pressure (125/77 ± 15/9 mmHg), A1C (diabetes: 7.7 ± 1.3%; 61 mmol/mol), and low-density lipoprotein cholesterol (diabetes: 2.19 ± 0.8 mmol/l; without diabetes: 3.13 ± 1.1mmol/l) were close to target. Participants averaged 5125 ± 2722 steps/day. Mean cfPWV was 9.8 ± 2.2 m/s. Steps correlated with cfPWV, but not with other risk factors. A 1000 steps/day increment was associated with a 0.1 m/s cfPWV decrement across adjusted models and in subgroup analysis by diabetes status. In a model adjusted for age, sex, BMI, ethnicity, immigrant status, employment, education, diabetes, hypertension, medication classes, the mean cfPWV decrement was 0.11 m/s (95% confidence interval −0.2, −0.02).Conclusions:cfPWV is responsive to step counts in patients who are well controlled on cardioprotective medications. This ability to capture the ‘added value’ of physical activity supports the emerging role of cfPWV in arterial health monitoring.

Navigating the Institutional Review Board (IRB) Process for Pharmacy-Related Research.

Pharmacists' specialized training and knowledge qualify them to lead and engage in research pertaining to optimal medication use. Performing research promotes pharmacy professionalism and fosters interdisciplinary collaboration. To conduct research appropriately, one must have thorough knowledge of when institutional review board (IRB) approval is required and how to successfully navigate IRB processes. The overarching mission of the IRB overseeing research at an organization per federal guidelines is to protect the rights and welfare of human subjects participating in research. This article discusses the following general pharmacy practice-based considerations relating to IRB processes: strategies for developing research projects, key distinctions between quality improvement and research, practical considerations for submitting IRB applications and documentation, different categories of IRB submission, informed consent and conditions for waivers or alterations of consent, and principal investigator obligations for approved research. Pharmacists should also account for organization-specific IRB processes when designing, submitting, and implementing research projects.

Effectiveness of medication review: a systematic review and meta-analysis of randomized controlled trials

BackgroundMedication review is often recommended to optimize medication use. In clinical practice it is mostly operationalized as an intervention without co-interventions during a short term intervention period. However, most systematic reviews also included co-interventions and prolonged medication optimization interventions. Furthermore, most systematic reviews focused on specific patient groups (e.g. polypharmacy, elderly, hospitalized) and/or on specific outcome measures (e.g. hospital admissions and mortality). Therefore, the objective of this study is to assess the effectiveness of medication review as an isolated short-term intervention, irrespective of the patient population and the outcome measures used.MethodsA literature search was performed in MEDLINE, EMBASE and Web of Science from their inception through September 2015. Randomized controlled trials (RCTs) with medication review as isolated short term intervention (<3 months) were included. There were no restrictions with regard to patient characteristics and outcome measures. One reviewer extracted and a second checked data. The risk of bias of studies was evaluated independently by two reviewers. A best evidence synthesis was conducted for every outcome measure used in more than one trial. In case of binary variables a meta-analysis was performed in addition to the best evidence synthesis, to quantify the effect.ResultsThirty-one RCTs were included in this systematic review (55% low risk of bias). A best evidence synthesis was conducted for 22 outcome measures. No effect of medication review was found on clinical outcomes (mortality, hospital admissions/healthcare use, the number of patients falling, physical and cognitive functioning), except a decrease in the number of falls per patient. However, in a sensitivity analysis using a more stringent threshold for risk of bias, the conclusion for the effect on the number of falls changed to inconclusive. Furthermore no effect was found on quality of life and evidence was inconclusive about the effect on economical outcome measures. However, an effect was found on most drug-related problems: medication review resulted in a decrease in the number of drug-related problems, more changes in medication, more drugs with dosage decrease and a greater decrease or smaller increase of the number of drugs.ConclusionsAn isolated medication review during a short term intervention period has an effect on most drug-related outcomes, minimal effect on clinical outcomes and no effect on quality of life. No conclusion can be drawn about the effect on economical outcome measures. Therefore, it should be considered to stop performing cross-sectional medication reviews as standard care.

The Effects of Medication on Activity and Rehabilitation of Older People – Opportunities and Risks

Multiple medication use, or polypharmacy, is common in people undergoing rehabilitation. Polypharmacy is also common in older people, where it has the potential to impact on habitual physical activity. Despite this, the interactions between medication, disease, activity, and rehabilitation outcomes are insufficiently researched. In this review, we consider common classes of medications that can affect physical activity levels and outcomes of rehabilitation. We consider medications that improve disease processes and improve limiting symptoms (eg, breathlessness in heart failure and lung disease, pain in arthritis), unwanted side effects of medications (eg, central slowing caused by opioids and hypnotics), and also medication classes that might have the ability to improve activity and rehabilitation outcomes via beneficial effects on neuromuscular function (eg, angiotensin-converting enzyme inhibitors). We conclude by giving practical advice on how to review and optimise medication use to support habitual physical activity and ensure the best results from rehabilitation.

Innovations in Medication Preparation Safety and Wastage Reduction: Use of a Workflow Management System in a Pediatric Hospital

Background: USP <797> regulatory requirements have mandated that pharmacies improve aseptic techniques and cleanliness of the medication preparation areas. In addition, the Institute for Safe Medication Practices (ISMP) recommends that technology and automation be used as much as possible for preparing and verifying compounded sterile products. Objective: To determine the benefits associated with the implementation of the workflow management system, such as reducing medication preparation and delivery errors, reducing quantity and frequency of medication errors, avoiding costs, and enhancing the organization's decision to move toward positive patient identification (PPID). Methods: At Texas Children's Hospital, data were collected and analyzed from January 2014 through August 2014 in the pharmacy areas in which the workflow management system would be implemented. Data were excluded for September 2014 during the workflow management system oral liquid implementation phase. Data were collected and analyzed from October 2014 through June 2015 to determine whether the implementation of the workflow management system reduced the quantity and frequency of reported medication errors. Data collected and analyzed during the study period included the quantity of doses prepared, number of incorrect medication scans, number of doses discontinued from the workflow management system queue, and the number of doses rejected. Data were collected and analyzed to identify patterns of incorrect medication scans, to determine reasons for rejected medication doses, and to determine the reduction in wasted medications. Results: During the 17-month study period, the pharmacy department dispensed 1,506,220 oral liquid and injectable medication doses. From October 2014 through June 2015, the pharmacy department dispensed 826,220 medication doses that were prepared and checked via the workflow management system. Of those 826,220 medication doses, there were 16 reported incorrect volume errors. The error rate after the implementation of the workflow management system averaged 8.4%, which was a 1.6% reduction. After the implementation of the workflow management system, the average number of reported oral liquid medication and injectable medication errors decreased to 0.4 and 0.2 times per week, respectively. Conclusion: The organization was able to achieve its purpose and goal of improving the provision of quality pharmacy care through optimal medication use and safety by reducing medication preparation errors. Error rates decreased and the workflow processes were streamlined, which has led to seamless operations within the pharmacy department. There has been significant cost avoidance and waste reduction and enhanced interdepartmental satisfaction due to the reduction of reported medication errors.

Going digital: a narrative overview of the clinical and organisational impacts of eHealth technologies in hospital practice.

Objective The aim of the present study was to determine the effects of hospital-based eHealth technologies on quality, safety and efficiency of care and clinical outcomes. Methods Systematic reviews and reviews of systematic reviews of eHealth technologies published in PubMed/Medline/Cochrane Library between January 2010 and October 2015 were evaluated. Reviews of implementation issues, non-hospital settings or remote care or patient-focused technologies were excluded from analysis. Methodological quality was assessed using a validated appraisal tool. Outcome measures were benefits and harms relating to electronic medical records (EMRs), computerised physician order entry (CPOE), electronic prescribing (ePrescribing) and computerised decision support systems (CDSS). Results are presented as a narrative overview given marked study heterogeneity. Results Nineteen systematic reviews and two reviews of systematic reviews were included from 1197 abstracts, nine rated as high quality. For EMR functions, there was moderate-quality evidence of reduced hospitalisations and length of stay and low-quality evidence of improved organisational efficiency, greater accuracy of information and reduced documentation and process turnaround times. For CPOE functions, there was moderate-quality evidence of reductions in turnaround times and resource utilisation. For ePrescribing, there was moderate-quality evidence of substantially fewer medications errors and adverse drug events, greater guideline adherence, improved disease control and decreased dispensing turnaround times. For CDSS, there was moderate-quality evidence of increased use of preventive care and drug interaction reminders and alerts, increased use of diagnostic aids, more appropriate test ordering with fewer tests per patient, greater guideline adherence, improved processes of care and less disease morbidity. There was conflicting evidence regarding effects on in-patient mortality and overall costs. Reported harms were alert fatigue, increased technology interaction time, creation of disruptive workarounds and new prescribing errors. Conclusion eHealth technologies in hospital settings appear to improve efficiency and appropriateness of care, prescribing safety and disease control. Effects on mortality, readmissions, total costs and patient and provider experience remain uncertain. What is known about the topic? Healthcare systems internationally are undertaking large-scale digitisation programs with hospitals being a major focus. Although predictive analyses suggest that eHealth technologies have the potential to markedly transform health care delivery, contemporary peer-reviewed research evidence detailing their benefits and harms is limited. What does this paper add? This narrative overview of 19 systematic reviews and two reviews of systematic reviews published over the past 5 years provides a summary of cumulative evidence of clinical and organisational effects of contemporary eHealth technologies in hospital practice. EMRs have the potential to increase accuracy and completeness of clinical information, reduce documentation time and enhance information transfer and organisational efficiency. CPOE appears to improve laboratory turnaround times and decrease resource utilisation. ePrescribing significantly reduces medication errors and adverse drug events. CDSS, especially those used at the point of care and integrated into workflows, attract the strongest evidence for substantially increasing clinician adherence to guidelines, appropriateness of disease and treatment monitoring and optimal medication use. Evidence of effects of eHealth technologies on discrete clinical outcomes, such as morbid events, mortality and readmissions, is currently limited and conflicting. What are the implications for practitioners? eHealth technologies confer benefits in improving quality and safety of care with little evidence of major hazards. Whether EMRs and CPOE can affect clinical outcomes or overall costs in the absence of auxiliary support systems, such as ePrescribing and CDSS, remains unclear. eHealth technologies are evolving rapidly and the evidence base used to inform clinician and managerial decisions to invest in these technologies must be updated continually. More rigorous field research using appropriate evaluation methods is needed to better define real-world benefits and harms. Customisation of eHealth applications to the context of patient-centred care and management of highly complex patients with multimorbidity will be an ongoing challenge.

Repurposing Medications for Hospice/Palliative Care Symptom Control Is No Longer Sufficient: A Manifesto for Change

The World Health Organization essential medications list for hospice/palliative care reflects that, with the judicious use of currently available medications, the majority of symptoms can be lessened, and some controlled completely. Even with optimal use of current medications, symptom control is still unacceptable for many people. Currently available medications offer great benefit to a minority of patients, some benefit to an additional group, and no benefit or harms to others. In symptom control, development of new drugs is advancing at a glacial pace, contrasting to the rapid advances seen in many other disciplines. Specialists in palliative care should agree on several principles consequently: 1) Access to symptom-control drugs codified in the World Health Organization Essential Medicines list deserves the strongest support from national policies and professional guidelines, especially in resource-challenged countries. 2) The optimal use of currently available symptom-control drugs cannot yield acceptably high rates of net benefits. 3) There is a compelling need to identify patient subgroups that are likely to benefit from available medications and provide rigorous empirical support for indications, dosing, and route of administration for clinical practice. 4) New therapies are needed requiring an accelerated effort to investigate further the pathophysiology, neurobiology, and pharmacogenetics of distressing symptoms, and factors contributing to variations in drug response. This development requires a lengthy lead time. 5) Smarter ways to promote new knowledge into practice are needed as no drug will be suitable for all patients. We need to improve clinical characterization and biomarker technology to bring the best drugs to the right patients every time.

Medication management policy, practice and research in Australian residential aged care: Current and future directions

Eight percent of Australians aged 65 years and over receive residential aged care each year. Residents are increasingly older, frailer and have complex care needs on entry to residential aged care. Up to 63% of Australian residents of aged care facilities take nine or more medications regularly. Together, these factors place residents at high risk of adverse drug events. This paper reviews medication-related policies, practices and research in Australian residential aged care. Complex processes underpin prescribing, supply and administration of medications in aged care facilities. A broad range of policies and resources are available to assist health professionals, aged care facilities and residents to optimise medication management. These include national guiding principles, a standardised national medication chart, clinical medication reviews and facility accreditation standards. Recent Australian interventions have improved medication use in residential aged care facilities. Generating evidence for prescribing and deprescribing that is specific to residential aged care, health workforce reform, medication-related quality indicators and inter-professional education in aged care are important steps toward optimising medication use in this setting.

Benefits and Risks of Long-Term Asthma Management in Children: Where Are We Heading?

International guidelines provide recommendations for a stepwise approach to the management of asthma in children 0-4 years old, 5-11 years old, and adolescents who are treated as adults. Therapy is aimed at two domains of control: current impairment and future risk. The long-term controller medications, inhaled corticosteroids (ICSs), ICSs in combination with long-acting β2 agonists, leukotriene receptor antagonists, and immunomodulators, exhibit different efficacies for these domains. The risk:benefit ratios of the available medications need to be carefully assessed. This review briefly presents the benefits and the potential risks of available asthma medications in children to assist the practitioner in the optimal use of asthma medications. Specifically, the systemic activity of the ICSs and how to minimize their effects on growth and adrenal activity are reviewed as well as other potential adverse effects. Dosing strategies such as intermittent therapy are also assessed.

“Sometimes I feel like a pharmacist”: identity and medication use among adolescents with juvenile arthritis

BackgroundTaking medicines as intended is difficult for everybody, but young people going through adolescence have greater problems than adults and younger children. One of the most important things that happen during the teenage years is the development of individual identities, which might not remain constant during this time and can be affected deeply by the diagnosis of a long-term condition. The aim of this study was to examine the relationships between identity and medication use among young people with juvenile arthritis.MethodsA prospective qualitative study was undertaken to collect private online ‘blog’ style data from young people (aged 11–19 years) with juvenile arthritis, and their parents, to examine their views about their condition, identity, medication and use of health services. Participants were identified from a large paediatric hospital in the UK.ResultsYoung people (n = 21) with a median age 14 years (range 11–17 years) posted a median (range) of 8 (1–36) blogs and parents (n = 6) posted 4 (1–12) blogs. Young people gave a strong sense of both private and public identity that was intertwined with their arthritis and treatment. It was evident that young people’s self-care was intrinsically linked to their attempts to maintain a sense of individually and socially constructed definitions of normality. The act of taking medication, and the consequences (positive or negative) of that act, had an impact both personally and socially.ConclusionsYoung people with juvenile arthritis reflect on their medication as a factor affecting their perception of themselves. Acknowledging the roles of both personal and social identity will be important in any strategies to support optimal medication use. This includes an understanding of the identity transformations that young people can experience and how decision-making may be affected by their attempts to retain pre-diagnosis identities and/or develop new social identities.