Pharmacist Intervention Research Articles

Effectiveness of pharmacist intervention on antidepressant medication knowledge, necessity, and concerns beliefs in patients with depression

Abstract Background Sub-optimal patient medication knowledge, negative beliefs, and concerns about the potential of medications to cause harm are important contributory factors to non-adherence in patients with depression. Objectives To assess the effectiveness of a pharmacist intervention on antidepressant medication knowledge, necessity, and concerns beliefs in patients with depression. Methods A prospective interventional study (approval number: ABUCUHSR/2020/018) was carried out between April 2019 and March 2020 at the Federal Neuro-Psychiatric Hospital, Maiduguri, Nigeria. Patients were randomized into the usual care or intervention group. The intervention consisted of an educational programme, and data were collected at baseline, 3 months, and 6 months. Patient knowledge about medicines and beliefs about medicines questionnaires were used to assess patient knowledge and beliefs. Key findings A total of 49 (81.6%) and 52 (86.6%) participants completed the 6-month follow-up in the usual care and intervention groups, respectively. Significant improvements in mean medication knowledge scores of participants in the intervention group were observed at 3 months (P < .001) and 6 months (P < .001), respectively. Significant improvements in mean medication necessity and concerns belief scores of participants in the intervention group were also observed at 3 months (P < .001) and 6 months (P < .001), respectively. Medication knowledge (P < .001, partial η2 = 0.203), medication necessity (P < .001, partial η2 = 0.329), and medication concerns (P < .001, partial η2 = 0.163) positively changed with time. Conclusion Pharmacist intervention significantly improved antidepressant medication knowledge, necessity, and concerns beliefs in patients with major depressive disorder.

Development and external validation of a prognostic model for time to readmission or death in multimorbid patients

ObjectiveTo develop and externally validate a prognostic model built on important factors predisposing multimorbid patients to all-cause readmission and/or death. In addition to identify patients who may benefit most from a comprehensive clinical pharmacist intervention. MethodsA multivariable prognostic model was developed based on data from a randomised controlled trial investigating the effect of pharmacist-led medicines management on readmission rate in multimorbid, hospitalised patients. The derivation set comprised 386 patients randomised in a 1:1 manner to the intervention group, i.e. with a pharmacist included in their multidisciplinary treatment team, or the control group receiving standard care at the ward. External validation of the model was performed using data from an independent cohort, in which 100 patients were randomised to the same intervention, or standard care. The setting was an internal medicines ward at a university hospital in Norway. ResultsThe number of patients who were readmitted or had died within 18 months after discharge was 297 (76.9 %) in the derivation set, i.e. the randomized controlled trial, and 69 (71.1 %) in the validation set, i.e. the independent cohort. Charlson comorbidity index (CCI; low, moderate or high), previous hospital admissions within the previous six months and heart failure were the strongest prognostic factors and were included in the final model. The efficacy of the pharmaceutical intervention did not prove significant in the model. A prognostic index (PI) was constructed to estimate the hazard of readmission or death (low, intermediate or high-risk groups). Overall, the external validation replicated the result. We were unable to identify a subgroup of the multimorbid patients with better efficacy of the intervention. ConclusionsA prognostic model including CCI, previous admissions and heart failure can be used to obtain valid estimates of risk of readmission and death in patients with multimorbidity.

Assessment of a Geriatric Evaluation and Management in the Home (GEMITH) Service at a Quaternary Hospital: A Retrospective Observational Study.

Background: The increasing aging population in Australia has created a higher demand for specialist geriatric services within hospitals. A Geriatric Evaluation and Management in the Home (GEMITH) service was implemented at a quaternary Queensland hospital. The GEMITH service was unique as it incorporated a specialist pharmacist into the multidisciplinary team. Objective: To determine the medication safety and quality impact of the GEMITH service by evaluating the type and clinical significance of specialist pharmacist interventions. Methods: This was retrospective observational study of clinical interventions made by the GEMITH pharmacist for patients admitted to the service between October 2020 to April 2021. All pharmacist interventions were rated for their clinical significance using the Society of Hospital Pharmacists of Australia (SHPA) risk classification system. The ratings were undertaken by a panel of three pharmacists that independently assessed the interventions, coming together for final discussion. A narrative analysis of the interventions were derived through group consensus. Results: There was a total of 119 admissions to the GEMITH service, with 132 clinical interventions made by the specialist geriatric pharmacist. The majority (47%) of interventions were considered as low risk interventions, although high- (21%) and extreme-risk (2%) interventions still occurred. The most common type of intervention (32%) involved medication reconciliation. Other intervention types included monitoring recommendations, dosing interventions, and deprescribing suggestions. Conclusion: Multiple clinical interventions were made by the GEMITH pharmacist, which prevented possible and significant medication-related harm. This demonstrated the quality impact of the specialist pharmacist in improving medication safety for geriatric patients.

Investigating the effect of prescribing status and patient characteristics on the therapeutic outcomes in patients with diabetes using a leftover drug adjustment protocol.

Treatment for diabetes includes anti-diabetic medication in addition to lifestyle improvements through diet and exercise. In Japan, protocol-based pharmacotherapy management allows drug treatment to be provided through cooperation between physicians and pharmacists, based on a protocol that is prepared and agreed upon in advance. However, there are no studies to clarify the relationship between patient characteristics and therapeutic effects after pharmacist intervention in protocol-based pharmacotherapy management for patients with diabetes. Therefore, this study aimed to use protocol-based reports from pharmacies to understand the status of outpatient diabetes medication compliance. We classified patients with diabetes on the basis of patient characteristics that can be collected in pharmacies and investigated the characteristics that impacted diabetes treatment. Patients were prescribed oral anti-diabetic drugs at outpatient clinics of Hitachinaka General Hospital, Hitachi, Ltd., from April 2016 to March 2021. Survey items included patient characteristics (sex, age, number of drugs used, observed number of years of anti-diabetic drug prescription, number of anti-diabetic drug prescription days, and presence or absence of leftover anti-diabetic drugs) and HbA1c levels. Graphical analyses indicated the relationship between each categorised patient characteristic using multiple correspondence analyses. Subsequently, the patients were clustered using K-means cluster analysis based on the coordinates obtained for each patient. Patient characteristics and HbA1c values were compared between the groups for each cluster. A total of 1,910 patients were included and classified into three clusters, with clusters 1, 2, and 3 containing 625, 703, and 582 patients, respectively. Patient characteristics strongly associated with Cluster 1 were ages between 65 and 74years, use of three or more anti-diabetic drugs, use of 3years or more of anti-diabetic drugs, and leftover anti-diabetic drugs. Furthermore, Cluster 1 had the highest number of patients with worsening HbA1c levels compared with other clusters. Using the leftover drug adjustment protocol, we clarified the patient characteristics that affected the treatment course. We anticipate that through targeted interventions in patients exhibiting these characteristics, we can identify those who are irresponsibly continuing with drug treatment, are not responding well to therapy, or both. This could substantially improve the efficacy of their anti-diabetic care.

Optimizing Oral Anticoagulation Therapy: Impact of Pharmacists Intervention in Patient Knowledge and International Normalized Ratio (INR) Control

Optimizing Oral Anticoagulation Therapy: Impact of Pharmacists Intervention in Patient Knowledge and International Normalized Ratio (INR) Control

Costs saved and avoided from pharmacist interventions to address drug-related problems identified from outpatient clinics in Jordan

Costs saved and avoided from pharmacist interventions to address drug-related problems identified from outpatient clinics in Jordan

Using a rule‐based decision tool for medication dose selection to improve patient safety and the need for pharmacist intervention

AbstractIntroductionAn assortment of alerts has been employed to influence provider order entry, yet many medication orders still require dose adjustment by pharmacists upon order verification.ObjectivesThe primary goals of this study were to evaluate the impact of adding rule‐based decision support to the computerized provider order entry system on the need for medication dose adjustment by a pharmacist and the occurrence of acute kidney injury (AKI) among patients.MethodsThis was a retrospective, pre‐ and post‐implementation observational study on the integration of rule‐based logic into the computerized provider order entry system to automatically select default doses and frequencies for weight‐based or renally‐cleared medications in alignment with health system guidelines. The primary end points were the proportion of medication orders that required pharmacist intervention for dose adjustment and the number of times the AKI pop‐up alert was triggered.ResultsAfter inclusion and exclusion criteria were applied to all available orders, there were 47 393 and 45 767 orders included for final analysis in the pre‐ and post‐implementation periods, respectively. The post‐implementation period showed a significant reduction in pharmacist dosing interventions, with a relative risk of 0.42 (95% confidence interval [CI]: 0.40–0.43; p < 0.0001) and a reduction in AKI (relative risk = 0.58 [95% CI: 0.53–0.64; p < 0.0001]).ConclusionThis study demonstrates the potential of rule‐based decision support to improve initial medication dose selection, reduce the occurrence of AKI, and reduce pharmacist workload, all without increasing alert fatigue.

Outcomes of a tele-intensive care unit pharmacist on the management of diabetic ketoacidosis.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. The tele-intensive care unit (tele-ICU) pharmacist facilitates patient-specific diabetic ketoacidosis (DKA) treatment utilizing guideline-directed therapy. This study was designed to determine how patient-specific interventions by a tele-ICU pharmacist affected patients with DKA compared to the standard of care. This retrospective cohort study utilized custom reports and manual chart review to evaluate the electronic health records of patients 18 years or older who received continuous intravenous insulin and were admitted for DKA between January 2019 and December 2020. The primary endpoint was time to DKA resolution, defined by the patient meeting at least 2 of the following criteria: a serum bicarbonate concentration of at least 18 mEq/L, an arterial pH of greater than 7.3, and closure of the anion gap (less than or equal to 12 mEq/L). Patients treated with tele-ICU pharmacist patient-specific interventions reached DKA resolution 7.32 hours earlier than patients treated with the standard of care (22.16 vs 29.48 hours; P = 0.0019). There was no statistically significant difference between the groups for ICU length of stay, time until subcutaneous insulin administration, incidence of hypoglycemia, incidence of severe hypoglycemia, and sodium bicarbonate use. In patients who received a tele-ICU pharmacist intervention, there was a statistically significant increase in the volume for fluid resuscitation and the amount of total continuous insulin infused after ICU admission and a statistically significant reduction in the time between laboratory draws. Treatment of patients with tele-ICU pharmacist patient-specific interventions was associated with faster DKA resolution, more frequent laboratory monitoring, and a higher volume of insulin and fluids infused than in patients treated with protocol-driven therapy.

The impact of clinical pharmacists’ intervention on the rational use of intravenous paracetamol vials in Baghdad Teaching Hospital: A case-control study

Paracetamol has been recognized worldwide as a safe and effective agent for relieving pain and reducing fever in many patients. This study aimed to investigate the role of clinical pharmacist interventions in the rational and appropriate use of intravenous paracetamol in surgical patients and the impact of this rational use on hospital costs. A case-control study was conducted on 794 patients (400 in the intervention group and 394 in the control group). The appropriate and rational use of the drug was compared between baseline and post-intervention in the intervention group and between the two groups. The result showed a significant reduction in dispensed IV paracetamol vials after the pharmaceutical intervention (4,151 vials recovered by the intervention), which led to a reduction in the cost (8,302 USD reduction in the total cost). There was a significant reduction in the dose of IV paracetamol, use with or without adjunctive opioid analgesics, frequency of administration, duration of intravenous paracetamol use, daily max exceeding 4 g, and concomitant use with oral paracetamol after applying the clinical pharmacist intervention. In conclusion, the clinical pharmacist plays a vital role in various aspects of healthcare; clinical pharmacist involvement positively impacts the patient’s management plan by improving the optimal and rational use of intravenous paracetamol and decreasing hospital costs.

Pharmacist-Led Deprescribing of Aspirin in Older People in an Outpatient Setting.

Background In 2019, the American College of Cardiology and American Heart Association updated their joint guidelines stating low-dose aspirin should not be used on a routine basis for primary prevention of atherosclerotic cardiovascular disease (ASCVD) among people older than 70 years of age because of increased bleeding risk.1 In addition to these updated guidelines, a statement released by the US Preventive Services Task Force in April 2022 recommends against the initiation of low-dose aspirin for primary prevention of cardiovascular disease in people 60 years of age or older.² Despite these updated recommendations, aspirin continues to be a common medication older patients take, providing an opportunity for a clinical pharmacist deprescribing intervention. Objective To identify the role of a pharmacist-led aspirin deprescribing intervention within a safety-net health system in the outpatient setting. Methods This project included patients 70 years of age and older who had aspirin listed as an active medication without documented ASCVD. This project assessed aspirin deprescribing rates, time spent on pharmacist outreach, and reasons for patient and/or provider refusal to discontinue aspirin. Results One hundred thirty-one eligible patients were contacted. Of those, 78 (60%) patients discontinued aspirin after speaking with the pharmacist, and 8 patients discontinued aspirin after a clinical pharmacist recommendation to the patient's primary care provider (PCP). The median time spent on outreach was approximately eight minutes. Of the 6 patients who consented to the project but declined to discontinue aspirin therapy based on pharmacist intervention, 5 preferred to discuss the issue with their PCP, while 1 patient was told by an outside provider to take aspirin. Conclusion Results indicate the successful impact a clinical pharmacist may have in deprescribing aspirin in a high-risk population. These data may also suggest that an active and intentional approach to deprescribing is likely to be more effective than a written recommendation to providers.

Rural ambulatory care pharmacists providing in-clinic and home visit services improve adherence to long-acting injectable antipsychotics.

Patients with schizophrenia often experience symptoms such as poor insight and disorganized thought, which limit their ability to seek and receive care consistently. In rural settings, systemic factors, including limited resources and transportation, further contribute to difficulties in health care access. Long-acting injectable antipsychotics (LAIs) can improve medication adherence and reduce hospitalizations from relapse. Opportunities exist for pharmacists to provide individualized care and improved health care access. The pilot service took place in ambulatory care clinics and home care settings. Pharmacists performed weekly reviews of patients with active orders for LAIs, coordinated care with nonadherent patients, and offered follow-up appointments in the Patient Centered Medical Home (PCMH). For patients unable to be reached, outreach pharmacists provided psychiatric assessment and LAI medication administration at home visits. There were 10 patients with LAI prescriptions in the past year selected for review. The period reviewed was 90 days before and after start of service. Pharmacist interventions resulted in 4 patients reestablished with care who were previously lost to follow-up. The percentage of days covered by LAI fills increased from an average 26% to 67% of days covered (P = .06). Total emergency room visits related to mental health episodes decreased from 11 to 2 visits (P = .03). Four patients who did not have metabolic lab monitoring in more than 1 year received lab monitoring as indicated. PCMH pharmacy services, including home visits by outreach pharmacists, may improve access and bridge care gaps for patients on LAIs by providing community-based services in addition to traditional clinic-based care.

Clinical impact and financial feasibility of remote oncology pharmacists' roles in community oncology practices.

1545 Background: The clinical and financial impact of oncology-trained pharmacists in the community oncology setting has not been well documented. The US Oncology Network has introduced a novel remote oncology pharmacist model which provides clinical services to oncology community practices to alleviate the burden on oncologists, enhance patient care, and improve workflows. Methods: Oncology-trained pharmacists remotely reviewed chemotherapy regimens across 12 community oncology practices. Pharmacists identified opportunities to modify therapy based on clinical criteria, waste reduction, and/or financial stewardship. These modifications were discussed with the treatment team or implemented in accordance with practice-approved policies. Clinical and financial metrics were tracked to assess the overall impact of the pharmacist interventions and provider time saved. Results: From January 1, 2023, through December 31, 2023, 27,938 reviews were documented for 19,962 patients. Among these reviews, the majority (14,572, 73%) required modification by the pharmacist, and many (3,005, 21%) were deemed clinically significant by the intervening pharmacist. The most common clinically significant interventions included changes to anticancer drug doses (1155, 38%), modifications to supportive care (742, 25%) and recommendations for additional monitoring (426, 14%). Across 12 practices, 63 drug-related workflow policies were implemented allowing pharmacists to autonomously auto-substitute products, order laboratory tests and adjust chemotherapy doses. These policies saved over 600 hours of physician time. Pharmacist involvement resulted in medication-related margin improvements totaling $9.3M. Practices also experienced a $4.3M reduction in the total cost of care in medication expenses. The cost of the pharmacists during this period was $1.4M, equating to a 560% return on investment compared to margin improvement. Conclusions: Community oncology practices operate within a resource-constrained model with limited access to oncology pharmacists. As invaluable members of the care team, pharmacists identified opportunities to significantly enhance clinical care by focusing on medication safety, dosing, and regimen optimization, while demonstrating a tremendous financial impact on small-scale budgets. Oncology-trained pharmacists play a vital role in alleviating care burden of the clinical team by collaboratively developing practice-approved policies and reviewing clinical orders in a high-risk patient population.

Epilepsy patients’ satisfaction with pharmacist interventions: The impact of specialized pharmaceutical care services

Objectives: Patient satisfaction evaluations are necessary to understand patient needs and their impression of the services received. The aim of this study was to determine the impact of specialized pharmaceutical care (PC) services on epilepsy patients’ satisfaction with pharmacist interventions. Materials and Methods: An open, prospective, and longitudinal randomized controlled study was conducted among epilepsy patients recruited from two epilepsy referral centers in Nigeria. The patients were randomized into one of two study groups: Intervention group (IG) or control group (CG). Patients in the IG received specialized PC services in addition to the usual care offered at the hospitals. The effect of PC on patients’ satisfaction with pharmacists’ interventions was evaluated using a validated instrument. Data was analyzed using the IBM Statistical Products and Services Solutions version 25.0 with statistical significance set at P < 0.05. Results: Patients in the CG had a significantly lower PC satisfaction score than those in the IG at three months and six months − pre-intervention: 2.505 vs. 2.559; t = −0.803; P = 0.423, three months: 2.483 vs. 3.811; t = −19.618; P = 0.0001, six months: 2.506 vs. 3.969; t = −24.393; P = 0.0001, indicating a significant improvement in patient satisfaction with PC services among those in the IG over time. Conclusion: Specialized PC services improve patients’ satisfaction with pharmacists’ interventions.

The Role of a Clinical Pharmacist in the Identification of Potentially Inadequate Drugs Prescribed to the Geriatric Population in Low-Resource Settings Using the Beers Criteria: A Pilot Study.

Population aging is a global phenomenon. Each country in the world faces an increased number of older persons in the total population. With aging, a high prevalence of multiple chronic diseases occurs, leading to the use of complex therapeutic regimens and often to polypharmacy. Potentially inappropriate medication (PIM) is a medicine prescribed to a patient for whom the risks outweigh the benefits. Today, several tools are used to evaluate the use of pharmacotherapy in older adults, one of them is the 2019 AGS Beers Criteria. In this prospective, pilot study, we aimed to investigate if the number of PIMs in elderly patients would be significantly reduced if a clinical pharmacist performed a pharmacotherapy review. The study included 66 patients over 65 years of age who were hospitalized at the 1200-bed university hospital. The intervention was conducted by a clinical pharmacist who reviewed the patients' pharmacotherapy and provided written suggestions to physicians. The pharmacotherapy was again reviewed at the patients' discharge from the hospital. A total number of 204 PIMs were identified in the pharmacotherapy of the study population. At discharge, the number of PIMs decreased to 67. A total of 67% of the pharmacist's suggestions were accepted by the physicians. The pharmacist's intervention led to significant decrease in the number of PIMs on patients' discharge letters.

Ambulatory care hematology/oncology pharmacy services: A comprehensive review by the Saudi Oncology Pharmacy Assembly

AbstractSaudi Vision 2030 has driven significant changes in ambulatory care pharmacy services in the Kingdom of Saudi Arabia (KSA), transitioning pharmaceutical care from inpatient to outpatient settings. With a growing need to address non‐communicable diseases, particularly cancer, ambulatory care oncology pharmacy services are of paramount importance. This study aims to evaluate the potential benefits and challenges of establishing such services in the KSA and offers recommendations for clinical pharmacists. A comprehensive literature search was conducted using PubMed, MEDLINE, EMBASE, and Google Scholar, encompassing research from inception to September 2023. The search focused on English language studies related to ambulatory care oncology/hematology pharmacy services. Among the 1351 studies found, those assessing the impact of clinical pharmacists on patient outcomes in outpatient oncology clinics were included. The review of the literature highlights the substantial impact of clinical pharmacists in outpatient hematology/oncology settings. A selection of several studies revealed their role in improving patient care, reducing health care costs, and enhancing treatment outcomes. Notable findings include a high acceptance rate of pharmacist interventions with significant cost savings, increased pharmacist involvement in patient encounters, and reduced emergency department visits and inpatient admissions due to pharmacist interventions. These results showed the valuable contributions of clinical pharmacists in the international outpatient oncology setting. Establishing ambulatory care hematology/oncology pharmacy services in Saudi Arabia is critical, considering the rising cancer burden. The value of specialized oncology clinical pharmacists in the outpatient setting is emphasized by various studies conducted in the United States. This review proposes a framework for patient‐centered oncology practices, serving as a valuable resource for the strategic development of ambulatory care oncology pharmacy services in Saudi Arabia. These efforts align with Saudi Vision 2030's broader goals of enhancing health care quality and patient care.

Embodiment of Pharmacist Intervention in Palliative Care and Augmentation of a Curriculum for its Assessment

Background Palliative care is the care of patients who have progressive, life-threatening illnesses and who are facing death in the foreseeable future. Since there is a growing need for pharmacist’s intervention in palliative care and there is a gap in the education of palliative care for pharmacy students, this study aims to identify roles and services that have to be performed by palliative care pharmacists in medication-related areas and also to formulate an add-on course to train pharmacy graduates. Materials and Methods A prospective interventional study was done in the palliative care centre in Perinthalmanna, Kerala, India. Relevant data were pooled and analysed for drug-related problems. Necessary interventions were made. Results were interpreted and an add-on course for the training of pharmacy graduates was formulated. Results A total of 88 patients were included in the study. The most prevalent conditions in our palliative setting were kidney disease, liver disease, cancer and stroke. Notably, 38 and 10 cases were found to have drug interactions and drug duplications, respectively. Four patients required dosage adjustments. Fifty cases involved pharmacist intervention which improved the outcome by 80%. At the end of the study, a curriculum was formulated to implement a 3-month add-on course entitled ‘PALLIATIVE PHARMACY’ under the guidance of an Expert committee for training pharmacists and pharmacy students. Conclusion The study identified that there are various roles a pharmacist must undertake in a palliative setup. The involvement of pharmacists in patients’ treatment helps to prevent drug-related problems to a greater extent. The addition of an integrated course for the management of palliative care patients will help to improve the learning as well as practical skills of pharmacists. Incorporating basic and clinical sciences in the therapeutic course is an effective learning plan.

Diabetes Care in A Safety Net Hospital: Impact of a Pharmacist Transitional Care Service.

Diabetes is associated with increased risk of hospital readmission and imposes a significant economic burden on patients and healthcare systems. Literature suggests that pharmacist-led transitions-of-care (TOC) services reduce hospital readmissions and improve patient outcomes and data within safety-net hospitals is limited. This was a single-center evaluation to assess the impact of pharmacist-led diabetes TOC services on hospital readmissions among diabetes patients vs standard care (SC). The evaluation included patients admitted from 11/1/2021-2/28/2022 and 10/19/2022-2/28/2023 who had a primary diagnosis of diabetes mellitus, were admitted for a diabetes-related reason, or were seen by the endocrine consult service during admission. The primary outcome was 30-day readmissions. Secondary outcomes included time to readmission, readmission diagnosis, changes in HbA1c, completion of follow-up visits, and number of pharmacist interventions at follow-up. There were 109 patients included (TOC n = 65; SC n = 44) and 13.8% (9/65) of TOC and 18.2% (8/44) of SC patients readmitted within 30 days (P = .235). Average time to readmission was 15.3days in the TOC and 10.4 days in the SC cohorts. There were no diabetes-related readmissions in the TOC cohort. Over 60% (5/8) of readmissions in the SC cohort were diabetes-related. The average change in HbA1c was -2.5% in the TOC cohort and -1.2% in the SC cohort, P = .046. Approximately 51% of TOC patients completed an outpatient follow-up visit and nearly 70% of those patients had an intervention made at that time. Pharmacist-led diabetes TOC services within a safety-net hospital may reduce hospital readmissions and improve clinical outcomes.

Enhancing medication management in hemodialysis patients: Exploring the impact of patient-centered pharmacist care and motivational interviewing.

Patients on hemodialysis (HD) often uses several medications, making them highly susceptible to medication-related problems (MRP) thereby leading to medication nonadherence. Therefore, an innovative pharmaceutical care strategy incorporating drug therapy optimization (DTO) and motivational interviewing (MI) can mitigate medication-related problems and optimize patient care. The objective of this study is to assess the efficacy of pharmacist led interventions in utilizing DTO and MI techniques in managing medication related problems among patients undergoing hemodialysis. A12-months, cross sectional prospective study was conducted among 63 End Stage Renal Disease (ESRD) patients on HD. DTO was conducted by the pharmacist to identify the MRP by reviewing complete medication list gathered from patient interview and medical records. All MRPs was classified using the PCNE classification version 9.00 and medication issues, that require patient involvement were categorized as patient-related, while those that necessitate physician intervention were classified as physician-related. The DTO was performed at the baseline, 6-month and at the final month of the study. Identified medication issues were communicated to the site nephrologist and was tracked during next follow up. Whereas MI was conducted physically at Month-3 and via telephone on month-6 and month-9 to address patient related medication issues. Mean age of the study population was 48.5±14 years. While the mean number of prescribed medications was 8.1±2 with 57% of the patients taking more than 5 types of medication. After 12 months of pharmacist intervention using DTO and MI, a mean reduction in MRP was observed for both patient-related and physician-related MRPs across three time series. However, further analysis using repeated measure ANOVA revealed that the reduction in patient-related MRPs was statistically significant [F(1.491, 92.412) = 60.921, p < 0.05], while no statistically significant difference was detected in physician-related MRPs [F(2, 124) = 2.216, P = 0.113]. Pharmaceutical care service through DTO and MI can effectively reduce and prevent drug-related issues to optimize medication therapy among HD patients.

Antibiotic regimens tailored by clinical pharmacist supported by intensivist enhance rational use of antibiotics

ABSTRACT Background High antibiotics utility rates have been observed in surgical intensive care units (SICU). The present study was performed to evaluate the effect of engaging a clinical pharmacist in SICU on rational use of antibiotic treatment. Methods This retrospective quasi-experimental experiment involved 505 patients, over a period of one year, admitted to emergency department surgical/trauma ICU of a large tertiary care hospital. Before and during pharmacist participation periods of six months, 226 and 153 patients, respectively, are compared. Results Antibiotics consumption pattern changed with a decrease in total antibiotic consumption from 101.42 to 94.1 Defined Daily Dose/100 patients’ days after the clinical pharmacist participation, in addition to, a statistically significant rise (p = 0.001) in percentage of appropriateness of the prescribed antibiotic therapy from 72.1% to 86.3%. Time to control infection (days) was not statistically different (p = 0.825) in both periods. The average ICU days of stay was statistically significant longer (p = 0.046) during pharmacist attendance (4.42 ± 5.61) in comparison with period without pharmacist attendance (3.31 ± 3.66). The difference in ICU mortality rate was not statistically significance (p = 0.217). Cost per stay increased by 65% during pharmacist intervention period. Conclusions Antibiotic management with pharmacist participation as a part of multidisciplinary team with intensivist can promote rate of the appropriateness of the prescribed antibiotic therapy, lower utility of antibiotic consumption, but with a longer ICU stay, no mortality reduction, and higher expenses per stay. Trial Registry ClinicalTrials.gov: NCT04931914.

Pharmacist intervention is associated with fewer serious falls over 3 months among older fallers at a day hospital: A quasi-experimental study

ObjectivesSome drugs increase the risk of falls, including serious falls. The objective of this quasi-experimental study was to determine whether the intervention of a clinical pharmacist among older outpatients receiving a multifactorial fall prevention program at a geriatric day hospital dedicated to older patients with a recent history of falls was effective in preventing serious falls over a 3-month follow-up, compared with usual care. Study designQuasi-experimental study in 296 consecutive older outpatients, including 85 with pharmacist intervention (the intervention group) and 148 without (the control group). Main outcome measuresThe main outcome was the occurrence of at least one serious fall within 3 months of follow-up. Covariates included age, sex, body mass index, grip strength, history of falls, Mini-Mental State Examination score, use of ≥3 drugs associated with risk of falls, frailty, and disability. ResultsFewer participants in the intervention group experienced at least one serious fall than in the control group (5 (5.9 %) versus 23 (15.5 %), P = 0.029), which persisted after adjustment for potential confounding factors (OR = 0.30 [95CI:0.11–0.84], P = 0.022). No significant effect was found on the indicence of all falls. Pharmacist intervention allowed more frequent therapeutic optimizations of antithrombotics (OR = 3.69 [95CI: 1.66–8.20]), proton pump inhibitors (OR = 3.34 [95CI: 1.31–8.50]), benzodiazepines (OR = 3.15 [95CI: 1.06–9.36]) and antidepressants (OR = 3.87 [95CI: 1.21–12.35]). ConclusionsAmong older fallers receiving a multifactorial fall prevention program at a day hospital, a clinical pharmacist intervention was associated with fewer incident serious falls over 3 months of follow-up.