Pharmacist-led Medication Review Research Articles

Core components of pharmacist-led medication reviews and their relationship to outcomes: a systematic review

Abstract Introduction Medication reviews are a recognised intervention undertaken by healthcare professionals to support patients prescribed multiple medicines or with complex medication regimens. Pharmacist-led medication reviews are now an established intervention in policy and practice. There are different types of medication review, each implemented differently. Huiskes et al. demonstrated that medication reviews undertaken by any professional in any setting had minimal effects on clinical outcomes and that evidence is lacking about their effect on economic outcomes.[1] The implementation of medication reviews in practice was recognised as a factor which may impact outcomes, but this has not been explored further. Aim To develop an initial programme theory that links the core components of pharmacist-led medication reviews to outcomes in different contexts. Methods A systematic review was conducted to identify randomised controlled trials of medication reviews in adults (18+). The review updated that by Huiskes et al. and used the same search strategy in the MEDLINE, EMBASE and Web of Science databases.[1] The search terms used were related to ‘medication review’, ‘pharmacist’ and ‘randomised controlled trial’. Medication review was defined as “a consultation between a pharmacist and a patient to review the patient’s total medicines use with a view to improve patient health outcomes and minimise medicines related problems”. Studies reporting any outcomes were included. Papers not published in English or not available as full texts were excluded. The Cochrane Risk of Bias 2.0 tool was used to assess the studies. Data were extracted using a previously piloted bespoke data collection form. Descriptions of the medication reviews’ core components, implementation and outcomes were narratively synthesised to draw out common themes. The GRADE framework informed the overall assessment of the quality of the evidence from the studies.[2] Results Records screened n=10947, total reports of studies included n=68. Of the 50 individual studies that were identified, 66% were assessed as having a high risk of bias. Narrative synthesis of the data extracted relating to the description and implementation of the medication reviews, and where and how this may have affected outcomes, is presented in our programme theory as core components. Collaborative working may help reduce medicines-related problems and number of medicines prescribed. Patient involvement in goal setting and action planning may improve patients’ ability to take medicines as prescribed and help them achieve their treatment goals. Additional support and follow-up may lead to improved blood pressure, diabetes control, quality of life and a reduction of medicines-related problems. Conclusion This is an extensive systematic review that has explored pharmacist-led medication reviews in all settings and resulted in the production of a draft programme theory. It is best practice for stakeholders to be involved in the development of a programme theory. Providers of medication reviews can evaluate their processes and consider if and how these core components are implemented in their service provision. This initial programme theory will be refined and discussed in future research.

Exploring stakeholders’ views of pharmacist-led medication reviews in general practice

Abstract Introduction Medication reviews are a widely implemented intervention to support patients who are prescribed multiple medicines or those with complex medication regimens. The more medicines a patient takes, the higher the chance of them experiencing harmful effects. Despite the extensive use of medication reviews, the proportion of patients who experience poor medicines outcomes such as adverse drug reactions and hospitalisations has not altered significantly in ten years. Pharmacists have been introduced to general practice to help to improve patient access to medication reviews. Aim The aim of this study was to explore pharmacists’, patients’, and general practitioners’ (GPs’) opinions and experience of medication reviews in general practice. Methods We held one focus group with patients and one with pharmacists. As the two GPs were unable to attend the focus group with the pharmacists, they were individually interviewed. Purposive sampling was used to select participants with a range of ethnicity, gender, age, and geographical mix. Reflexive thematic analysis of the focus group and interview transcripts was undertaken by one researcher (MC) to identify themes.[1] Results Seven patients, five pharmacists, and two general practitioners participated in this study. Two main themes were generated. Theme one: preparing for the review. Subtheme one: time to prepare. Patients require advance notice of their review so they can be prepared with queries. Pharmacists need sufficient time to familiarise themselves with the patient’s history and perform the necessary clinical checks. Subtheme two: education about medication reviews. Some patients do not understand the purpose or process of a medication review and can be reticent to engage. Subtheme three: suitability of appointments. Longer face-to-face appointments usually benefit patients with complex medication regimens, or patients with communication difficulties. Patients who have simple regimens or are happy with their medicines may be content with a telephone or online review. Theme two: conducting the medication review. Subtheme one: establish the aim of the review. Patients present for medication reviews for different reasons (e.g., a clinical issue has been identified, patients meet defined criteria or take specific medicines); therefore, the aim of the review should be established at the beginning. Subtheme two: involve and engage the patient. Patients want to feel that they have been listened to and supported during the medication review. Patients want more opportunities to ask questions and/or raise their concerns in the review. Subtheme three: defined but flexible process for the review. Pharmacists and GPs acknowledged the use of templates and guidance to deliver medication reviews, but stressed the importance of tailoring the medication review to meet the needs of the patient. Conclusion Whilst recruitment was challenging, the variety of participants provided a multi-perspective view of medication reviews and a rich source of data. GPs interviews provided a good source of data, but it is possible that different sub-themes may have been generated from integrated discussions. The themes identified provide an outline of the implementation of pharmacist-led medication reviews in general practice. These can be used to support future work to optimise medication reviews in primary care.

A pre-post study of pharmacist-led medication reviews within a hospital-based residential aged care support service.

Hospital-based residential aged-care support service teams typically consist of doctors and nurses who provide hospital substitutive care to aged-care residents. There is limited literature evaluating the pharmacist's role in such aged-care support teams. To analyse the effect of residential aged-care support service pharmacist-led medication reviews on polypharmacy, drug burden index, potentially inappropriate medications, and potential prescribing omissions for aged-care residents. Residents referred to a residential aged-care support service pharmacist for medication review over a 12-month period were included. The pharmacist communicated medication-related problems and recommendations to the resident's general practitioner and residential aged-care support service medical practitioner. Residents' medication histories were obtained at baseline and one-month postintervention. The number of medications and their associated drug burden indices were compared using paired t-tests; potentially inappropriate medications and potential prescribing omissions were compared using Wilcoxon's signed rank test. Of 175 residents (mean age 84 years) referred for pharmacist-led medication review, 146 had postintervention evaluation after one-month (median 29 days). Mean number of medications reduced from 12.47 at baseline to 11.84 postintervention (mean difference (95% CI): 0.63(0.33-0.93), P < .001). Mean drug burden index score reduced from 1.54 at baseline to 1.37 postintervention (mean difference (95% CI): 0.17(0.10-0.24), P < .001). More residents experienced a decrease in inappropriate medications (median (IQR) pre: 2(1-3), post: 1(0-2), P < .001) and prescribing omissions (median (IQR) pre: 0(0-1), post: 0(0-0), P = .003) compared with those that had an increase. Medication reviews performed by pharmacists embedded in hospital-based residential aged-care support services may improve medication prescribing. Further research into such preventative health service models is required.

Medication use among the oldest old in the Faroe Islands-A national cross-sectional study.

Aging is often associated with an increasing number of comorbidities that warrant use of multiple drugs which increases the use of potentially inappropriate medications (PIMs), drug-drug interactions (DDIs) and drug-related problems (DRPs). The aim is to assess the prevalence of polypharmacy, PIMs, DDIs and DRPs among Faroese residents aged ≥90 years. In this population-based cross-sectional study, 494 individuals ≥90 years were invited and 298 (60%) participated. A pharmacist-led medication review was performed based on self-information, electronic patient journal and the Faroese Prescription Registry. The prevalence of polypharmacy was 74% with no sex-difference. Approximately 60% of participants used PIMs, primarily benzodiazepines and proton pump inhibitors, the latter being a frequently implicated medication in DRPs. Opioid use was low compared with other Nordic studies. DRPs were observed for 79% with discrepancies in the medication lists as the most common cause, and DDIs were identified for 47% of participants, mostly moderately clinically relevant DDIs. In conclusion, the medication use among the oldest old Faroese resembled that in other Nordic countries with a high prevalence of polypharmacy and use of PIMs, especially PPIs and benzodiazepines. However, no sex-difference was noted in medication use and the use of opioids was low.

Evaluation of medication safety assessment tools for pharmacist-led medication reviews: the Eastern European pilot project.

Background: Pharmacist-led medication reviews (MR) are one of the key methods to support medication safety in polypharmacy patients. The aims of this study were to pilot MRs in Eastern European community pharmacies, describe medication use in polypharmacy patients, and evaluate the usability of medication safety assessment tools. Methods: The MR pilot was undertaken in Estonia, Latvia, Poland, Hungary, Romania, and Bulgaria. Patients who used at least five medicines were directed to the service by their GPs. Data on drug-related problems (DRPs) and adherence were collected by pharmacists through structured patient interviews. Databases for identification of potential drug-drug interactions (pDDIs) and adverse drug reactions (ADRs) named Inxbase/Riskbase, as well as an integrated tool comprising potentially inappropriate medicines (PIMs) lists EU(7)-PIM and EURO-FORTA, were applied retroactively to the MR pilot data to investigate possibilities for their use and to describe medication use and potential risks in the study population. Results: A total of 318 patients were included in the study, 250 of them elderly (≥65 years). One hundred and eighty (56.6%) participants had a total of 504 pDDIs based on Inxbase analysis. On average, there were 1.6 pDDIs per participant. Twenty-five (5.0%) of the 504 pDDIs were in a high-risk category. A total of 279 (87.7%) participants had a potential ADR in at least one of 10 Riskbase categories. One hundred and fifty-four (20.8%) of the potential ADRs were in a high-risk category. Twenty-seven pDDIs and 68 ADRs documented as DRPs during the service were not included in the databases. Using the integrated EU(7)-PIM/EURO-FORTA PIM list, a total of 816 PIMs were found in 240 (96%) of the 250 elderly participants (on average 3.4 PIMs per elderly participant). Seventy-one (29.6%) of the participants were using high-risk PIMs. Twenty-one percent of high-risk PIMs and 13.8% of medium-risk PIMs were documented as DRPs by the pharmacists during the pilot. Conclusion: Medication safety assessment tools can be useful in guiding decision-making during MRs; however, these tools cannot replace patient interviews and monitoring. Tools that include a thorough explanation of the potential risks and are easy to use are more beneficial for MRs.

Implementation of Pharmacist-Led Medication Review Service for Parkinson's Disease Patients Admitted for Deep Brain Stimulation.

Objective The purpose of this study was to determine the clinical impact of a specialized pharmacist-led medication assessment on the incidence of dopamine antagonists administered for patients with Parkinson's disease after deep brain stimulation (DBS). Methods This was a single-center, Institutional Review Board-approved, two-phase study with pre- and post-implementation cohorts of patients who were 18 years of age or older who underwent DBS for treatment of Parkinson's disease. The primary endpoint was the incidence of dopamine antagonists administered after DBS procedure. Secondary endpoints included the incidence of dopamine antagonists ordered; restarting home Parkinson's disease regimen; rate of tardive dyskinesia; length of hospital stay; and incidence of sitters, restraints, and medications administered for acute agitation. Statistical analysis included Fisher's exact test for categorical data, unpaired t-test for continuous data, and descriptive statistics for all other data. Results The incidence of dopamine antagonists administered was 1 (1.2%) versus 1 (25%) for the pre- and post-implementation groups, respectively (P = 0.09). Restarting of home Parkinson's disease regimen was 30 (36.1%) versus 4 (100%); P = 0.021. The average length of stay was 1.9 days versus 1.3 days. Incidence of sitters was 1 (1.2%) versus 0 (0%), and incidence of restraints was 0 (0%) versus 0 (0%). Incidence of acute agitation medications administered was 9 (10.8%) versus 0 (0%). The secondary endpoints were not significant except for the restarting of home medication regimen. Conclusion The specialized pharmacist-led medication review service identified a single incident of inappropriate medications administered for Parkinson's disease patients status post DBS. However, it did significantly increase the incidence of the restart of Parkinson's disease home regimen.

Clinical Pharmacist-Led Medication Review in Hospitalized Confirmed or Probable Patients with COVID-19 During the First Wave of COVID-19 Pandemic.

Drug-related problems (DRPs) result in serious problems among hospitalized patients, high rates of morbidity and mortality, and increased healthcare costs. This study aimed to identify DRPs by clinical pharmacist-led medication review in hospitalized probable patients with coronavirus disease-2019 (COVID-19) during the first wave of the COVID-19 pandemic. This retrospective cross-sectional study was conducted at the COVID-19 inpatient services of a tertiary university hospital in Türkiye for 3 months (between March 2020 and June 2020) and included hospitalized confirmed or probable COVID-19 patients. The World Health Organization and Turkish Ministry of Health Guidelines case definitions were used to define confirmed and probable COVID-19 patients. Six clinical pharmacy residents provided medication review services during their education and training. DRPs were classified based on the Pharmaceutical Care Network Europe V9.00. The physician's acceptance rate of clinical pharmacists' recommendations was assessed. Among 202 hospitalized patients with probable or confirmed COVID-19, 132 (65.3%) had at least one drug-related problem. Two hundred and sixty-four DRPs were identified. Drug selection (85.6%) and dose selection (9.2%) were the most common causes of these problems. Among the 80 clinical pharmacist interventions, 48.8% were accepted by the physicians. Clinical pharmacists identified a significant number of DRPs during the COVID-19 pandemic, particularly those related to drug interactions and drug safety, such as adverse drug reactions. This study highlights the importance of detecting and responding to DRPs in the COVID-19 pandemic.

PROMOTING PROVIDER ADHERENCE TO THE MEDICATION M OF THE AGE-FRIENDLY 4MS FRAMEWORK

Abstract BACKGROUND The Age Friendly Health Systems (AFHS) initiative promotes use of the 4Ms Framework: We sought to evaluate provider adherence to protocols addressing the medication M of the framework. METHODS The project was conducted among patients &amp;gt; 65years treated in the inpatient (IP), outpatient (OP) and emergency departments (ED) of Grady Memorial Hospital (GMH). We implemented 2 approaches to improve provider prescribing among older adults 1) Using a clinical decision support tool via the electronic health record Epic Systems®, a best practice advisory (BPA) offered individual provider feedback regarding potentially inappropriate medications (PIMs) ordered and offered safer alternative medications. 2)A pharmacist-led daily medication review with provider feedback on PIMs in the Acute Care for Elderly (ACE) Unit. Primary outcome: Percentage of PIMs discontinued. Secondary outcomes: Percentage of BPA vs pharmacist recommendations accepted, discharge PIMs, Length of Stay (LOS), mobility, delirium and Katz scores, 30-day readmission rate. RESULTS: 8270 BPA alerts fired for 3291 patients, mean age 73.7, with 5709 BPAs in IP, 1462 in ED &amp; 1083 in OP settings. Providers responded to alerts by overriding BPA (10.2%), canceling BPA (60.4%), removing alerted PIM (20.6%), ordering alternative medication (3.5%).. With the pharmacist led intervention, ACE Unit providers accepted 47.2% recommendations, discontinued 17.9% PIMs . 19% of ACE and 1.1% of GMU patients were discharged without PIMs. 30-day readmission rate was 19.1% (ACE) vs 27% (GMU) (P = 0.31). Conclusion There was a higher provider acceptance rate with the pharmacist led intervention but no significant difference in PIM discontinuation rate

Primary care pharmacist-led medication review in older adult patients in coordination with general practitioners: an observational retrospective cohorts study

BackgroundPolypharmacy and risk of potentially inappropriate prescribing (PIP) in older adult are being continuously increased. Including a primary care pharmacist (PCP) in the healthcare team is associated with lower rates of medication-related problems (MRPs). ObjectivesTo determine the impact (in terms of variation of PIP, MRPs and polymedication) of treatment reviews (TR) carried out by the PCP by comparing two cohorts: standard TR vs coordinated TR with prescribing General Practitioners (GP). To assess possible health outcomes in both groups 6 months post-TR. MethodsThis is an observational study of two retrospective cohorts (2018 to 2020). All patients who met the inclusion/exclusion criteria were analyzed. Patients ≥65 years, who underwent complete TR by the PCP were included. Patients in a situation of exitus at the time of TR and those who underwent a partial TR were excluded. Control group cohort consisted of patients who underwent standard TR, and intervention group cohort consisted of those who underwent TR coordinated with GP. Sociodemographic, clinical and pharmacological variables were analyzed. Results181 patients were enrolled. Mean age 84.4 ± 7.2 years, 78.5% women. Variables (GP-coordinated vs standard TRs) pre-post: decrease in drugs/patient 1.9 (95%CI: 1.4–2.4) vs 0.6 (95%CI: 0.2–1.3), p < 0.05; decrease in MRPs/patient 3.1 (95%CI: 2.8–3.4) vs 1.0 (95%CI: 0.6–1.4), p < 0.05; decrease in PIP/patient 2.0 (95% CI: 1.6–2.2) vs 0.6 (95% CI: 0.2–0.9), p < 0.05. Health outcomes: there was significant difference in average primary-care visits/patient 1.3 ± 0.5 vs 2.2 ± 1.8, p < 0.05. ConclusionsMultidisciplinary interventions between PCP and GP, together with a systematic approach to TR can improve the quality of pharmacotherapy in the elderly. Prospective large follow-up studies are needed to demonstrate a positive trend in health outcomes.

Effectiveness of community pharmacist-led interventions in osteoarthritis pain management: A cluster-randomized trial

BackgroundCommunity pharmacists contribute in osteoarthritis management via evidence-based pain management services. However, their roles and impacts on osteoarthritis management in low- and middle-income countries have yet to be explored. ObjectiveThis study aims to evaluate the effectiveness of community pharmacist-led educational intervention and medication review among osteoarthritis patients. MethodsA 6-month cluster-randomized controlled study was conducted in 22 community pharmacies of Nepal. Patients clinically diagnosed with osteoarthritis, aged 18 years and above, with a poor knowledge level of osteoarthritis and pain management were enrolled in the study. The intervention groups were educated on osteoarthritis and pain management, and had their medications reviewed while control group received usual care. Primary outcomes evaluated for the study were the change in pain levels, knowledge, and physical functional scores at 3 and 6 months. Repeated analyses of covariance were performed to examine the outcomes. ResultsA total of 158 participants were recruited for the study. The intervention group reported improvements in pain score (mean difference 0.473, 95 % CI 0.047 to 0.900) at 3 months and the end of the study (mean difference 0.469, 95 % CI 0.047 to 0.891) as compared to control. Similarly, improvement in knowledge scores were observed in the intervention group at 3 months (mean difference 5.320, 95 % CI 4.982 to 5.658) and 6 months (mean difference 5.411, 95 % CI 5.086 to 5.735). No differences were observed in other outcomes, including physical functional score, depression, and quality of life. ConclusionCommunity pharmacist-led intervention improved patients’ knowledge of osteoarthritis and pain management. While pain scores improved, physical functional score, depression, and quality of life score remained unchanged. Trial registrationClinicalTrials.gov identifier: NCT05337709.

Medication-related problems identified by community pharmacists: a descriptive case study of two Australian populations

BackgroundMedication-related problems (MRPs) contribute significantly to preventable patient harm and global healthcare expenditure. Vulnerable populations, including Indigenous Australians (please note that the use of the term ‘Indigenous’ in this paper includes all Aboriginal and Torres Strait Islander people and acknowledges their rich traditions and heterogenous cultures.) and people living with severe and persistent mental illness (SPMI), may be at increased risk of MRPs. Pharmacist-led medication reviews can identify MRPs for targeted action.ObjectiveTo characterize MRPs identified and recommendations made by community pharmacists during medication reviews conducted with Indigenous Australians and people living with SPMI.MethodsParticipants were recruited through two Australian trials testing the feasibility and/or effectiveness of novel community pharmacist-led interventions, the Indigenous Medication Review Service (IMeRSe) feasibility study (June 2018–July 2019) and Bridging the Gap between Physical and Mental Illness in Community Pharmacy (PharMIbridge) randomized controlled trial (September 2020–December 2021). Trained community pharmacists conducted medication reviews responsive to the cultural and health needs of participants. MRPs, MRP severity and pharmacist recommendations were documented and classified using an established classification system (DOCUMENT). MRP severity was assessed by pharmacists and an independent assessor. Data were analysed descriptively, and paired t-tests were used to compare severity ratings.ResultsPharmacists identified 795 MRPs with 411 participants across both trials (n = 255 IMeRSe, n = 156 PharMIbridge). Non-adherence to medication was the most common (n = 157, 25.1%) and second-most common (n = 25, 14.7%) MRP in IMeRSe and PharMIbridge, respectively. Undertreatment was the second-most common MRP in the sample of Indigenous Australians (n = 139, 22.2%), and reports of toxicity/adverse reactions were most common in people living with SPMI (n = 41, 24.1%). A change in pharmacotherapy was the most frequent recommendation made by pharmacists (40.2% and 55.0% in IMeRSe and PharMIbridge, respectively). Severity ratings varied, with the majority being ‘Mild’ or ‘Moderate’ in both groups. Significant differences were found in the severity rating assigned by trial pharmacists and the independent assessor.ConclusionsCommunity pharmacists identified a range of MRPs experienced by two at-risk populations, most commonly non-adherence and toxicity or adverse reactions, when conducting medication reviews and proposed diverse strategies to manage these, frequently recommending a change in pharmacotherapy. These findings highlight the opportunity for more targeted approaches to identifying and managing MRPs in primary care and tailored community pharmacist-led interventions may be of value in this space.Trail Registration: Australian and New Zealand Clinical Trial Registry records (IMeRSe ACTRN12618000188235 registered 06/02/2018 & PharMIbridge ACTRN12620000577910 registered 18/05/2020).

Pharmacist-led intervention on potentially inappropriate prescription in patients with polypharmacy: PHARM-PC clinical trial protocol

ObjectivePolypharmacy and potentially inappropriate medications (that is, those associated with an unfavorable risk-benefit ratio) are common concerns in the context of elderly patients treated in primary care as they may increase the risk of morbidity and mortality, as well as healthcare costs. Several studies have assessed the impact of pharmacist-led systematic reviews with respect to prescription appropriateness, health outcomes and/or costs. However, no cluster-randomized controlled trial has been identified that provides an overall assessment of these variables. The objective is to determine the effectiveness of a pharmacist-led systematic medication review in reducing the mean number and proportion of patients on potentially inappropriate medications (primary goal); as well as in decreasing morbidity and mortality and the cost of medications and the use of healthcare resources (secondary goals). MethodAn open-label, cluster-randomized controlled trial will be conducted; where primary care physicians will be randomized either to receive (intervention group) or not to receive pharmacist recommendations to withdraw potentially inappropriate medications detected through the combined use of explicit and implicit criteria (control group). Primary endpoints will be the proportion of patients on potentially inappropriate medications and the mean number of such medications per patient. Secondary endpoints will be healthcare resources used, the proportion of patients who die and the mean number of days survived, as well as the cost of medications and cost of healthcare resources used. ConclusionsIn line with similar reports and based on our stud's design, we hope to obtain statistically significant reductions in the use of potentially inappropriate medications and in medication costs overall. We do not however expect to obtain significant reductions in morbimortality or the cost of health resources employed.

Assessment of potential drug-related problems (PDRP) and clinical outcomes in bacterial meningitis patients admitted to tertiary care hospitals.

Meningitis is an important cause of morbidity and mortality in children and adults. Its treatment strategy varies with age and gender. To assess potential drug-related problems (PDRP) and clinical outcomes in bacterial meningitis patients, a multicenter, clinical, descriptive, cross-sectional prospective observational study in 120 patients admitted to different tertiary care hospitals in Karachi was conducted. It includes both males 48% and females 52% belonging from all age groups i.e. peadiatrics (01 to 12 years), adults (18 to 65 years), and geriatrics (66 to 75 years). Out of these 72 patients were admitted in the public sector and 48 patients were admitted in private sector hospitals. Nosocomial infections were developed in 41% of patients during their stay at the hospital. Potentially nephrotoxic drugs were administered to all BM patients, these drugs should be administered carefully. Majorly Ceftriaxone was administered to 86% of patients, Vancomycin 71%, and meropenem 73% whereas 68% of patients were administered piperacillin-tazobactam. Organisms involved as causative agents in the majority of patients are Neisseria meningitides, Pseudomonas aeruginosa and, Streptococcus pneumoniae. DRPs impacted patient clinical outcomes in presence of many other factors like comorbidities, DDIs, Nis, administration of potentially nephrotoxic drugs, and administration of watch group and reserve group antibiotics without having culture sensitivity test, even after having CST no principles of de-escalation for antibiotics were done, which is a very important factor for hospitalized patients having IV antibiotics. The mortality rate among BM patients was 66%. The majority of patients (87%) stay at the hospital was 1-10 days. The present study helped in the identification of DRPs along with some other factors affecting the clinical outcomes in patients suffering from bacterial meningitis. Healthcare professionals should receive awareness and education on the importance of CST before initiating antibiotic therapy. Pharmacist-led medication review is necessary and should be followed to avoid negative outcomes and serious consequences related to DRPs.

Evaluation of Antibiotics and Clinical Outcomes along with Various Other Factors in Critically Ill Intensive Care Unit Patients

Intensive care units (ICUs) are special hospital wards that provide desired treatment and close monitoring of patients who are critically ill. Drug Utilization Reviews (DUR) is an authorized, structured, ongoing review of patient medication to ensure appropriate and rational medication use to yield positive outcomes. The aim of this study is to evaluate the antibiotics and clinical outcomes in intensive care unit (ICU) patients. This study was cross sectional retrospective (cohort), descriptive and clinical study including patients admitted in ICU of tertiary care hospitals. A total 400 patients (Male 53%) and (Female 47%) were admitted in ICU were analyzed in this study. Majority of patients were from age group between 41 to 60 years i.e., 50.2%. Patients evaluated in this study were suffering from many diseases and comorbidities majorly including respiratory, infectious, nephrology and urology diseases. Antibiotics, majorly penicillins were administered to 185 (46.2%) patients, flouroquinolones 162 (40.5%), cephalosporins 287 (71.8%), carbapenems 102 (25.5%), vancomycin 61 (15.2%) and metronidazole 217 (54.2%) patients. Total 52 (12.5%) patients underwent culture sensitivity test. Significant drug-drug interactions were seen in 64% patients. High mortality rate (72.8%) was seen in this study. It was observed that presence of NI and lack of CST enhanced mortality rate. CST is very important regarding choice of ICU patient’s antibiotic therapy. Current study identified factors affecting the clinical outcomes in terms of morbidity and mortality in the ICU patients. Antibiotics are prescribed in ICU abundantly. Due to presence of drug-drug interactions, nosocomial infections, comorbidities, not having culture sensitivity test (CST) and adverse reactions mortality rate was enhanced. Pharmacist led medication review will help in avoiding all these issues.

Pharmacist-led intervention aimed at deprescribing and appropriate use of cardiometabolic medication among people with type 2 diabetes.

Potential overtreatment with cardiometabolic medication (i.e., glucose lowering medication, antihypertensives and statins) has been observed in 10-40% of older people with type 2 diabetes (T2D). The potential effects of a pharmacist-led clinical medication review targeted at T2D patients who were at high risk of hypoglycaemia will be investigated. A quasi-experimental study was conducted in 14 Dutch community pharmacies. Patients with a high risk of hypoglycaemia were identified using a previously developed algorithm. Pharmacists confirmed eligibility and selected patients for the intervention. Remaining eligible patients were included as controls receiving usual care. The primary outcome was the proportion of intervention patients for whom an action on deprescribing or appropriate use of cardiometabolic medication was implemented. After three months, changes in cardiometabolic medication were compared between the intervention and control group using a Fischer exact test. In total 90 intervention patients and 107 control patients were included. Intervention patients had an average age of 70, used on average 10 medications, five of which were cardiometabolic medication. For half of the intervention patients an action on deprescribing cardiometabolic medication was implemented (n=25) and/or an advice about appropriate use of cardiometabolic medication was given (n=22). In 48% of intervention patients at least one cardiometabolic medication (e.g. insulin, sulfonylurea, diuretic, beta-blocker, statin) was either stopped or reduced in dose compared to 31% of control patients (p=0.018). A pharmacist-led tailored clinical medication review has the potential to increase deprescribing and improve appropriate use of cardiometabolic medication in half of T2D patients at high risk of hypoglycaemia.

Assessment of drug-related problems at the emergency department in older patients living with frailty: pharmacist-led medication reviews within a geriatric care team

BackgroundOlder patients are vulnerable to experiencing drug related problems (DRPs), which may result in emergency department (ED) visits. However, it is not standard practice to conduct medications reviews during ED visit. The aim of this study was to assess the number of DRPs in older patients living with frailty at the ED, identified through pharmacist-led medication reviews within a geriatric care team, and to determine the acceptance rate of pharmacists’ recommendations among hospital physicians and general practitioners or elderly care specialists.MethodsA retrospective observational study was performed in patients ≥ 70 years living with frailty at the ED at Tergooi Medical Center. Pharmacist-led medication reviews were conducted to identify and classify DRPs as part of a larger geriatric assessment. The acceptance rate of given recommendations was determined during follow-up.ResultsA total of 356 ED visits were included. The mean (standard deviation, SD) age of patients was 83 (6.8) years. About 76% of patients had at least one DRP. In total, 548 DRPs were identified with a mean of 1.5 DRP (SD 1.3) per patient. The acceptance rate of medication recommendations in admitted patients was 55%, and 32% among general practitioners/elderly care specialists in discharged patients.ConclusionsPharmacist-led medication reviews as part of a geriatric care team identified DRPs in 76% of older patients living with frailty at the ED. The acceptance rate was substantially higher in admitted patients compared to discharged patients.

Exploring Australian pharmacists' perceptions and practices towards reducing the risk of medicines-related harm in aged care residents.

Background: Older people living in residential aged care facilities frequently experience medicines-related harm. Evidence regarding the perception and practices towards reducing these harms may facilitate the development of customised educational programs for pharmacists providing services in RACFs. Objective: To explore Australian pharmacists' opinions and practices towards reducing the risk of medicines-related harm in aged care residents. Methods: An online survey was developed based on a literature review, expert opinion, and feedback from pharmacists providing services in RACFs. A web link for the survey was shared via professional pharmacy organisations and social media groups with Australian pharmacists providing services in RACFs. Results: A total of 209 pharmacists participated in the survey. Of these, 76% (n = 158) were residential medication management review embedded pharmacists, and 24% (n = 51) were supply pharmacists for RACFs. Most pharmacists believed that medicines-related harm is common in residents (n = 174, 83%), yet few agreed that pharmacists have enough time to participate in medicines-related harm reduction services (n = 60, 28%). There was a high level of agreement regarding the key risk factors (e.g., inappropriate medicines, anticholinergic drug use, and transitions of care) and potential strategies (e.g., embedded pharmacists in RACFs, educating aged care staff, and collaborative pharmacist-led medication reviews) for reducing medicines-related harm in residents. Conclusion: Pharmacists agreed that older residents often experience medicines-related harm, but they did not frequently participate in medicines-related harm reduction services. Initiatives to engage pharmacists in team-based harm reduction services and educate aged care staff regarding safe medication management may improve residents' safety and health outcomes.

A pharmacist-led medication review service with a deprescribing focus guided by implementation science.

Background: Little research addressed deprescribing-focused medication optimization interventions while utilizing implementation science. This study aimed to develop a pharmacist-led medication review service with a deprescribing focus in a care facility serving patients of low income receiving medications for free in Lebanon followed by an assessment of the recommendations' acceptance by prescribing physicians. As a secondary aim, the study evaluates the impact of this intervention on satisfaction compared to satisfaction associated with receiving routine care. Methods: The Consolidated Framework for Implementation Research (CFIR) was used to address implementation barriers and facilitators by mapping its constructs to the intervention implementation determinants at the study site. After filling medications and receiving routine pharmacy service at the facility, patients 65years or older and taking 5 or more medications, were assigned into two groups. Both groups of patients received the intervention. Patient satisfaction was assessed right after receiving the intervention (intervention group) or just before the intervention (control group). The intervention consisted of an assessment of patient medication profiles before addressing recommendations with attending physicians at the facility. Patient satisfaction with the service was assessed using a validated translated version of the Medication Management Patient Satisfaction Survey (MMPSS). Descriptive statistics provided data on drug-related problems, the nature and the number of recommendations as well as physicians' responses to recommendations. Independent sample t-tests were used to assess the intervention's impact on patient satisfaction. Results: Of 157 patients meeting the inclusion criteria, 143 patients were enrolled: 72 in the control group and 71 in the experimental group. Of 143 patients, 83% presented drug-related problems (DRPs). Further, 66% of the screened DRPs met the STOPP/START criteria (77%, and 23% respectively). The intervention pharmacist provided 221 recommendations to physicians, of which 52% were to discontinue one or more medications. Patients in the intervention group showed significantly higher satisfaction compared to the ones in the control group (p < 0.001, effect size = 1.75). Of those recommendations, 30% were accepted by the physicians. Conclusion: Patients showed significantly higher satisfaction with the intervention they received compared to routine care. Future work should assess how specific CFIR constructs contribute to the outcomes of deprescribing-focused interventions.

Pharmacist-led clinical medication review service in primary care: the perspective of general practitioners

BackgroundAn advanced level medication review service (CMR) is systematically reimbursed and available nationwide in Slovenian primary care since 2016. CMR is performed by clinical pharmacists (CP). Close collaboration with general practitioner (GP) is required as they perform patient selection and make clinical decisions regarding patient’s medication.MethodsA prospective observational study was conducted in 2018 aiming to evaluate the perspective of GPs on the implementation of pharmacist-led medication review service in Community Health Care Centre Ljubljana, Slovenia. GPs of the patients, who provided written informed consent were invited for the interviews. The semi-structured interview consisted of 5 open ended questions addressing reasons for referral of the patients, implementation of CP recommendations and the GPs’ perspective of the service in general. Interviews were audio recorded with GPs written consent, transcribed verbatim and inductive content analysis was performed in NVivo11 Pro.ResultsIn total 38 interviews with 24 GPs were performed. The emerged themes were nested under 3 main domains representing Donabedian model of quality healthcare – structure, process, outcomes. The service structure is built on broad pharmacotherapy knowledge as the main CP competency, good accessibility, and complementarity of healthcare professions. Patients are mainly referred to the CMR due to polypharmacotherapy, however in majority there is a more in-depth reason behind (e.g., adverse events, etc.). Lack of time to recognize eligible patients and additional workload to study and implement the recommendations present the major challenges in the service process and therefore low number of referrals. CPs recommendations are mostly accepted, although the implementation time varies. When recommendation addresses medicines prescribed by a clinical specialist, the CMR report is forwarded to them for decision regarding implementation. The empowerment of the patients in medicines use was emphasized as the major benefit of the CMR, which consequently supports and enhances the quality of GP’s patient care. Transferability of recommendations to similar cases and high satisfaction with the service of GPs and patients, were mentioned.ConclusionGPs experiences with CMR are encouraging and supportive and present a base for further growth of the service.

How pharmacist-led medication reviews reduced polypharmacy for patients on a virtual ward

How pharmacist-led medication reviews reduced polypharmacy for patients on a virtual ward