Types Of Drug Therapy Problems Research Articles

Evaluation of quality measure attainment with pharmacist-delivered Medicare annual wellness visits

BackgroundMedicare is required to fully cover annual wellness visits (AWVs) to increase access to preventive care. As health care converts to pay for performance models, clinical quality measures have increasing importance. Few studies have investigated the effect of pharmacist-delivered AWVs on clinical quality measure attainment in a rural family medicine (FM) clinic setting. ObjectivesThe primary objective of this study was to evaluate attainment of clinical quality measures for pharmacist-delivered AWVs compared with physician-delivered AWVs (usual care). Secondary objectives included assessment of the number and type of drug therapy problems (DTPs) identified by pharmacists during AWVs. MethodsThis single-center retrospective cohort study was conducted within an FM clinic located in southwest Georgia. Two cohorts were created according to the provider of AWVs during 2017: pharmacist or physician-usual care. Data on quality measure eligibility, attainment, and DTPs (for the pharmacist group only) were collected through electronic chart review. Descriptive statistics were used to characterize variables, and chi-square (or Fisher exact where appropriate) tests to compare the proportion of clinical quality measures attained between groups. ResultsAmong 334 delivered AWVs, pharmacists performed 68.6%. Approximately 62% of pharmacist and usual care visits were female with mean ages of 72 (SD +/− 9.1) and 62 (SD +/− 13.9) years, respectively. Pharmacist-delivered AWVs had statistically significant greater quality measure attainment in the following categories: advance care planning, osteoporosis cardiovascular screenings, and Tdap vaccinations compared with usual care (P < 0.05). Usual care had statistically significant greater quality measure attainment for diabetes screening. Seventy-five DTPs were identified in the pharmacist group, with the majority being related to adherence (39%). ConclusionPharmacist-delivered AWVs had greater quality measure attainment in several areas than usual care. Furthermore, increased quality measure attainment may assist in meeting benchmarks set by payers to ensure ongoing reimbursement of these services.

Impact Analysis of a Pharmacist-Led Home-Medication Review Service Within an interprofessional Outreach Team

To describe the demographic and clinical characteristics of frail and homebound communitydwelling older patients receiving a home medication review (HMR) conducted by a home-visiting pharmacist; the types of drug therapy problems (DTPs) that were identified; the types of clinical interventions being recommended and their implementation rate. Retrospective, cross-sectional chart-review study using data from patient records. Homes of patients receiving a HMR by a community pharmacy-based consulting home-visiting pharmacist. 171 patients received a HMR between January 1, 2016, and May 31, 2018. Patients received a comprehensive HMR by a home-visiting pharmacist working as a member of an interprofessional geriatrics team. Charlson Comorbidity Index (CCI) score, comorbidities, use of potentially inappropriate medications, DTPs identified, number and type of clinical interventions being recommended and successfully implemented. Patients had a mean age of 81 years (range: 54-100 years), majority were 65 years of age or older (95%), and female (59%). Fifty-three percent of patients had a CCI score of 1 to 2, and 93.6% were experiencing multi-morbidity and polypharmacy. Patients used an average of 13.0 medications, and 76.1% were found to be using at least 1 potentially inappropriate medication. In total, the home-visiting pharmacist identified 827 DTPs and made 1088 recommendations with a successful implementation rate of 74%. Frail and homebound communitydwelling older adults referred for a HMR were observed to be using a high number of medications with a significant number of DTPs identified. Offering HMRs was an effective method for a community-based pharmacist to make acceptable recommendations to optimize medication therapy management for frail older patients.

Impact Analysis of a Pharmacist-Led Home-Medication Review Service Within an interprofessional Outreach Team.

To describe the demographic and clinical characteristics of frail and homebound communitydwelling older patients receiving a home medication review (HMR) conducted by a home-visiting pharmacist; the types of drug therapy problems (DTPs) that were identified; the types of clinical interventions being recommended and their implementation rate. Retrospective, cross-sectional chart-review study using data from patient records. Homes of patients receiving a HMR by a community pharmacy-based consulting home-visiting pharmacist. 171 patients received a HMR between January 1, 2016, and May 31, 2018. Patients received a comprehensive HMR by a home-visiting pharmacist working as a member of an interprofessional geriatrics team. Charlson Comorbidity Index (CCI) score, comorbidities, use of potentially inappropriate medications, DTPs identified, number and type of clinical interventions being recommended and successfully implemented. Patients had a mean age of 81 years (range: 54-100 years), majority were 65 years of age or older (95%), and female (59%). Fifty-three percent of patients had a CCI score of 1 to 2, and 93.6% were experiencing multi-morbidity and polypharmacy. Patients used an average of 13.0 medications, and 76.1% were found to be using at least 1 potentially inappropriate medication. In total, the home-visiting pharmacist identified 827 DTPs and made 1088 recommendations with a successful implementation rate of 74%. Frail and homebound communitydwelling older adults referred for a HMR were observed to be using a high number of medications with a significant number of DTPs identified. Offering HMRs was an effective method for a community-based pharmacist to make acceptable recommendations to optimize medication therapy management for frail older patients.

Drug therapy problems identified among older adults placed in a nursing home: the Croatian experience.

ObjectiveThe aim of this study was to determine the frequency and type of drug therapy problems (DTPs) in older institutionalized adults.MethodWe conducted a cross-sectional observational study from February to June 2016 at a 150-bed public nursing home in Croatia, where comprehensive medication management (CMM) services were provided. A rational decision-making process, referred to as the Pharmacotherapy Workup method, was used to classify DTPs.ResultsData were prospectively collected from 73 residents, among which 71% were age 75 years or older. The median number of prescribed medications per patient was 7 (2–16) and polypharmacy (> 4) was recorded for 54 (74.0%) patients. A total 313 DTPs were identified, with an average of 4.3 ± 2 DTPs per patient. The most frequent DTP was needing additional drug therapy (n = 118; 37.7%), followed by adverse drug reaction (n = 55; 17.6%). Lactulose (14.4%), tramadol (6.7%), and potassium (6.4%) were the medications most frequently related to DTPs.ConclusionThe high prevalence of DTPs identified among older institutionalized adults strongly suggests the need to incorporate new pharmacist-led CMM services within existing institutional care facilities, to improve the care provided to nursing home residents.

Evaluation of drug therapy problems among outpatient hypertensive and type-2-diabetic patients at a Tertiary Hospital, South-West Nigeria

Background: Health-related burden and poor outcomes due to drug therapy problems (DTPs) is a major concern in healthcare delivery especially in resource-poor countries.Objective: To evaluate extent and types of DTPs as well as disease-specific clinical parameters in outpatient hypertensive and type-2-diabetic (T2D) patients attending a tertiary hospital in Nigeria.Materials and Methods: This entailed questionnaire-guided interaction with 205-adult hypertensive and 198-T2D patients who were purposively enrolled, followed by a retrospective review of their medical records from September - November 2018. Domains of DTP explored included drug and dose selection, drug form, treatment duration, patients’ adherence and drug interactions. Data were summarised using descriptive statistics, while categorical variables were evaluated with Chi-square test at p&lt;0.05 level of significance.Results: Overall, 840 DTPs were identified among participants. This comprised 422(50.2 %) DTPs among T2D (average = 2.13 DTPs per patient), and 418(49.8 %) DTPs in the hypertensive (average = 2.04 DTPs per patient). The order of occurrence of DTPs among T2D was non-adherence [intentional, 173 (41.0 %) and unintentional, 69 (16.4 %)]&gt;drug interactions, 155 (36.7 %)&gt;drug selection, 25 (5.9 %); while for hypertensive patients, the order was non-adherence [intentional, 156 (37.3 %); unintentional, 57 (13.6 %)]&gt;drug interactions, 157 (37.6 %)&gt;dose selection, 25 (6.0 %)&gt;drug selection, 23 (5.5 %). A total of 133(65.5 %) hypertensive patients had good blood pressure (≤140/90 mmHg) control, while the mean glycosilated haemoglobin was 7.5 (SD=2.6 %).Conclusion: Extent of DTPs among participants is high, with non-adherence and drug interactions constituting the highest DTPs burden. There is generally a need for prescribers and pharmacists in particular to be wary of potential or actual DTPs during patient encounters, as this may ensure better therapeutic outcomes.Keywords: Drug therapy problems, Hypertensive and type-2-diabetic patients, Outpatient, Nigeria

Magnitude and determinants of drug therapy problems among type 2 diabetes mellitus patients with hypertension in Ethiopia.

Introduction:Type 2 diabetes mellitus patients with hypertension are at high risk of drug therapy problems since they are subject to receive multiple drug therapies due to comorbidities.Objectives:To determine the magnitude of drug therapy problems and its determinants among Type 2 diabetes mellitus patients with hypertension.Methods:A cross-sectional study was employed among 423 randomly selected participants based on the inclusion criteria. A structured questionnaire and review of patients’ medical record were employed in the data collection. The classification system used by Cipolle was used to classify and evaluate drug therapy problems. Data were analyzed using Statistical Package for the social sciences version 25.0 software. Multivariate logistic regression analysis was used to identify determinants of drug therapy problems with a statistical significance of p ⩽ 0.05.Results:A total of 491 drug therapy problems with a mean of 1.86 ± 0.53 drug therapy problems per patient were identified, and 62.4% (264) of them experienced at least one drug therapy problem. Non-compliance (197, 40.1%), needs of additional drug therapy (119, 24.2%), and dosage too low (91, 18.5%) were the most frequently observed drug therapy problems in the study setting. Anti-diabetic medications (88.4%), statins (44.5%), and aspirin (33.5%) were the most commonly involved drugs in drug therapy problems. The determinants of drug therapy problems were very low family income (adjusted odds ratio = 4.64, p = 0.010), age (45–65 years old) (adjusted odds ratio = 2.55, p = 0.008), presence of comorbidity (adjusted odds ratio = 9.19, p < 0.001), and taking ⩾5 medications (adjusted odds ratio = 2.84, p = 0.001).Conclusion:Approximately three out of five patients had one or more drug therapy problems encountered. In this study, the most common types of drug therapy problems were non-compliance, needs additional drug therapy, and dosage too low. Family monthly income, age, comorbidities, and number of medications were the significant determinants of drug therapy problems. Therefore, patient education regarding medication adherence, routine medication review, and strengthening clinical pharmacy services should be promoted.

Non-dispensing pharmacists' actions and solutions of drug therapy problems among elderly polypharmacy patients in primary care.

To evaluate the process of clinical medication review for elderly patients with polypharmacy performed by non-dispensing pharmacists embedded in general practice. The aim was to identify the number and type of drug therapy problems and to assess how and to what extent drug therapy problems were actually solved. An observational cross-sectional study, conducted in nine general practices in the Netherlands between June 2014 and June 2015. On three pre-set dates, the non-dispensing pharmacists completed an online data form about the last 10 patients who completed all stages of clinical medication review. Outcomes were the type and number of drug therapy problems, the extent to which recommendations were implemented and the percentage of drug therapy problems that were eventually solved. Interventions were divided as either preventive (aimed at following prophylactic guidelines) or corrective (aimed at active patient problems). In total, 1292 drug therapy problems were identified among 270 patients, with a median of 5 (interquartile range 3) drug therapy problems per patient, mainly related to overtreatment (24%) and undertreatment (21%). The non-dispensing pharmacists most frequently recommended to stop medication (32%). Overall, 83% of the proposed recommendations were implemented; 57% were preventive, and 35% were corrective interventions (8% could not be assessed). Almost two-third (64%) of the corrective interventions actually solved the drug therapy problem. Non-dispensing pharmacists integrated in general practice identified a large number of drug therapy problems and successfully implemented a proportionally high number of recommendations that solved the majority of drug therapy problems.

Pharmaceutical Care at the primary care clinic in Garðabær - number and type of drug therapy problems identified among elderly clients

Elderly people are a rising population in Iceland. With higher age the likelihood of drug consumption increases and thus drug therapy problems. Pharmaceutical care has been established abroad, where the pharmacist works in collaboration with other healthcare professionals to reduce patients' drug therapy problems. The aim of this research was to study the number and types of drug therapy problems of older individuals in primary care in Garðabær, by providing pharmacist-led pharmaceutical care in collaboration with general practitioners. Five general practitioners selected patients, 65 years and older, and asked the pharmacist to provide them with pharmaceutical care service. The pharmacist provided pharmaceutical care using a well-defined process. A total of 100 patients participated in the research, 44 men and 56 women. On average the pharmacist identified two drug therapy problems per patient. The most frequent drug therapy problem was related to noncompliance (30.1%), next was adverse drug reaction (26.7%) and the third was unnecessary drug therapy (18.2%). Almost all pharmacist comments were accepted by the general practitioners (90.3%). Our results reveal that a pharmacist providing pharmaceutical care makes, on average, two comments regarding each drug therapy. In almost all cases the general practitioners accept the comments.

A Pilot Project for Clinical Pharmacy Services in a Clinic for Children With Medical Complexity.

The primary objective of the project was to assess the impact of clinical pharmacy services in a clinic for children with medical complexity. Secondary objectives were to identify and characterize the drug-related needs of these patients and to describe and develop the role of a pharmacist in the clinic. This was a prospective descriptive study in which a clinical pharmacist staffed the clinic for children with medical complexity for 11 weeks, from January to March 2011. This allowed for the collection of baseline data, such as patient characteristics and measurements of pharmacist workload and assessment (eg, types of drug therapy problems, medication reconciliation, medication teaching). A pharmacist participated in 46 clinic visits with 43 patients, identifying a total of 42 drug therapy problems. Of the 42 problems, 35 actual and 7 potential drug problems were identified, resulting in approximately 1 problem per patient. The most common actual problems included "dose too small" (37.1%) and "patient requires a medication for untreated condition" (20%). Common potential problems included "drug interactions" (43%) and "adverse effects" (57%). The pilot study demonstrates that children with medical complexity are at high risk for drug therapy problems and the presence of a clinic pharmacist is beneficial in the identification, prevention, and resolution of drug therapy problems, while helping ensure continuity of care in this population.

Drug therapy problems and medication discrepancies during care transitions in super-utilizers

ObjectivesFirst, to investigate the prevalence and types of drug therapy problems and medication discrepancies among super-utilizers, and associated patient characteristics. Second, to examine the outcomes of pharmacist recommendations and estimated cost avoidance through care transitions support focused on medication management. DesignRetrospective analysis of the pharmacist-led interventions as part of the SafeMed Program. SettingA large nonprofit health care system serving the major medically underserved areas in Memphis, Tennessee. ParticipantsThree hundred seventy-four super-utilizing SafeMed participants with multiple chronic conditions and polypharmacy. InterventionComprehensive medication review, medication therapy management, enhanced discharge planning, home visits, telephone follow-up, postdischarge medication reconciliation, and care coordination with physicians. Main outcome measuresTypes of drug therapy problems, outcomes of pharmacist recommendations, estimated cost avoided, medication discrepancies, and self-reported medication adherence. ResultsPrevalence of drug therapy problems and postdischarge medication discrepancies was 80.7% and 75.4%, respectively. The most frequently occurring drug therapy problems were enrollee not receiving needed medications (33.4%), underuse of medications (16.9%), and insufficient dose or duration (11.2%). Overall 50.8% of the pharmacist recommendations were accepted by physicians and patients, resulting in an estimated cost avoidance of $293.30 per drug therapy problem identified. Multivariate analysis indicated that participants with a higher number of comorbidities were more likely to have medication discrepancies (odds ratio 1.23 [95% CI 1.05–1.44]). Additional contributors to postdischarge medication discrepancies were difficulty picking up and paying for medications and not being given necessary prescriptions before discharge. ConclusionDrug therapy problems and medication discrepancies are common in super-utilizers with multiple chronic conditions and polypharmacy during transitions of care, and greater levels of comorbidity magnify risk. Pharmacist-led interventions in the SafeMed Program have demonstrated success in resolving enrollees' medication-related issues, resulting in substantial estimated cost savings. Preliminary evidence suggests that the SafeMed model's focus on medication management has great potential to improve outcomes while reducing costs for vulnerable super-utilizing populations nationwide.

Evaluation of Eligibility Criteria Used to Identify Patients for Medication Therapy Management Services: A Retrospective Cohort Study in a Medicare Advantage Part D Population.

General eligibility criteria used by the Centers for Medicare & Medicaid Services (CMS) to identify patients for medication therapy management (MTM) services include having multiple chronic conditions, taking multiple Part D drugs, and being likely to incur annual drug costs that exceed a predetermined threshold. The performance of these criteria in identifying patients in greatest need of MTM services is unknown. Although there are numerous possible versions of MTM identification algorithms that satisfy these criteria, there are limited data that evaluate the performance of MTM services using eligibility thresholds representative of those used by the majority of Part D sponsors. To (a) evaluate the performance of the 2013 CMS MTM eligibility criteria thresholds in identifying Medicare Advantage Prescription Drug (MAPD) plan patients with at least 2 drug therapy problems (DTPs) relative to alternative criteria threshold levels and (b) identify additional patient risk factors significantly associated with the number of DTPs for consideration as potential future MTM eligibility criteria. All patients in the Medicare Advantage Part D population who had pharmacy eligibility as of December 31, 2013, were included in this retrospective cohort study. Study outcomes included 7 different types of DTPs: use of high-risk medications in the elderly, gaps in medication therapy, medication nonadherence, drug-drug interactions, duplicate therapy, drug-disease interactions, and brand-to-generic conversion opportunities. DTPs were identified for each member based on 6 months of most recent pharmacy claims data and 14 months of most recent medical claims data. Risk factors examined in this study included patient demographics and prior health care utilization in the most recent 6 months. Descriptive statistics were used to summarize patient characteristics and to evaluate unadjusted relationships between the average number of DTPs identified per patient and each risk factor. Quartile values identified in the study population for number of diseases, number of drugs, and annual spend were used as potential new criteria thresholds, resulting in 27 new MTM criteria combinations. The performance of each eligibility criterion was evaluated using sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs). Patients identified with at least 2 DTPs were defined as those who would benefit from MTM services and were used as the gold standard. As part of a sensitivity analysis, patients identified with at least 1 DTP were used as the gold standard. Lastly, a multivariable negative binomial regression model was used to evaluate the relationship between each risk factor and the number of identified DTPs per patient while controlling for the patients' number of drugs, number of chronic diseases, and annual drug spend. A total of 2,578,336 patients were included in the study. The sensitivity, specificity, PPV, and NPV of CMS MTM criteria for the 2013 plan year were 15.3%, 95.6%, 51.3%, and 78.8%, respectively. Sensitivity and PPV improved when the drug count threshold increased from 8 to 10, and when the annual drug cost decreased from $3,144 to $2,239 or less. Results were consistent when at least 1 DTP was used as the gold standard. The adjusted rate of DTPs was significantly greater among patients identified with higher drug and disease counts, annual drug spend, and prior ER or outpatient or hospital visits. Patients with higher median household incomes who were male, younger, or white had significantly lower rates of DTPs. The performance of MTM eligibility criteria can be improved by increasing the threshold values for drug count while decreasing the threshold value for annual drug spend. Furthermore, additional risk factors, such as a recent ER or hospital visit, may be considered as potential MTM eligibility criteria.

Identifying Drug Therapy Problems Through Patient Consultation at Community Pharmacies: A Quality Improvement Project.

This study aimed to identify drug therapy problems during patient counseling at prescription pickup in the community pharmacy setting. This descriptive quality improvement project assessed the number of drug therapy problems identified during patient consultation. Data were collected for 2 months at 6 community pharmacies in Arizona. The criterion for inclusion was any patient new or transferred prescription consultation provided by a pharmacist or pharmacy intern. Three doctor of pharmacy candidates collected data on a standardized form. The percentage and type of drug therapy problems identified during patient consultation were calculated. Data collectors counseled patients on 1305 prescriptions, and of those, 29 drug therapy problems (2.2%) were identified after the pharmacists' final check. The most common problems involved patient drug allergy or sensitivity (20.7%). This project suggests that drug therapy problems in a community pharmacy setting can be identified via patient counseling at the time of prescription pickup.

Pattern of drug therapy problems and interventions in ambulatory patients receiving antiretroviral therapy in Nigeria.

We describe the frequency and types of drug therapy problems (DTPs), and interventions carried out to resolve them, among a cohort of HIV-infected patients on ART in Jos, Nigeria. A prospective pharmacists' intervention study was conducted between January and August 2012 at the outpatient HIV clinic of the Jos University Teaching Hospital (JUTH). Pharmacists identified DTPs and made recommendations to resolve them. The main outcome measures were number of DTPs encountered, interventions proposed and acceptance rate of recommendations. A total of 42,416 prescriptions were dispensed to 9339 patients during the eight months study. A total of 420 interventions (Intervention rate of 1 per 100 prescriptions) were made to resolve DTPs in 401 (4.3%) patients with a mean age of 41 (SD=10) years, and made up of 73% females. DTPs encountered were drug omission (n=89, 21.2%), unnecessary drug (n=55, 13.1%) and wrong drug indication (n=55, 13.1%). Recommendations offered included; Addition of another drug to the therapy (n=87, 20.7%), rectification of incomplete prescriptions (n=85, 20.2%), change of drug or dosage (n=67, 16.0%), and discontinuation of the offending drug (n=59, 14.0%). A total of 389 (93%) out of 420 of the recommendations were accepted. In all, 50.4% (212) of the problematic prescriptions were changed and dispensed, 22.2% (89) were clarified and dispensed, while wrong identities were corrected in 11.7% (49). However, 7.5% (30) prescriptions were dispensed as prescribed, 5.2% (21) were not dispensed, and 3% (12) were unresolved. Our findings suggest that pharmacists-initiated interventions can ameliorate DTPs in patients receiving ART given the high intervention acceptance rate recorded. The implication of this finding is that pharmacists with requisite training in HIV pharmacotherapy are an excellent resource in detecting and minimizing the effect of antiretroviral drug-related errors.

Access to patients’ health records for drug therapy problem determination by pharmacists

To evaluate differences in the number and type of drug therapy problems (DTPs) identified by pharmacists with and without access to patients' primary care health records; determine the confidence level of pharmacists in their assessment of DTPs with and without access to health records; and determinethe type of information pharmacistsneed to confirm their assessment. The study design was an exploratory and comparative evaluation of comprehensive medication management assessments. Pharmacists initially completed patient assessments without access to the patient's primary care health record. Pharmacists documented the visit according to the standard of care and documented the assessment in a standardized study form. Pharmacists then reviewed the patient's primary care health record and documented a revised assessment in the standardized study form. The standardized form included sections about the number of DTPs, the classification of DTPs, the pharmacist's confidence level in identifying DTPs, and the information needed to increase the pharmacist's confidence level in identifying DTPs. Pharmacists evaluated 24 patients and identified 132 DTPs. After reviewing patients' primary care health records, 31 DTPs were deemed "false DTPs," 3DTPs were recategorized, and 9 new DTPs were identified. Practitioner confidence levels in DTP determination improved after reviewing patients' primary care health records. The health information most frequently identified as desirable after the initial review was laboratory tests. Pharmacists identified more DTPs with lower confidence levels without access to patients' primary care health records. Fewer DTPs were deemed "confirmed DTPs" and confidence in the practitioners' assessments improved after review of the primary care health records. Access to primary care health records can help community pharmacists build an efficient and comprehensive medication management practice.

Pharmaceutical care outcomes in an outpatient human immunodeficiency virus treatment center in Jos, Nigeria

Rationale:Pharmacotherapy for patients infected with human immunodeficiency virus (HIV) is complex and increases the potential for drug therapy problems (DTPs). We described the frequency and type of DTPs in a Nigerian cohort of HIV infected patients on antiretroviral therapy (ART), as well as the changes in HIV clinical outcomes after pharmacists’ intervention.Methods:A prospective 1-year descriptive study was conducted from July 2010 to June 2011, at the adult HIV clinic of Jos University Teaching Hospital, Nigeria. DTPs and the associated pharmacist-initiated interventions were documented. Chi-square and Wilcoxon signed ranks test was used as appropriate, to compare the main outcome measures of pre- and post-intervention levels of viral load and CD+ cell count.Results:A total of 64,839 prescriptions were dispensed to 9320 patients. Interventions were documented for 85 unique patients (incidence of 1.31 interventions/1000 prescriptions), of which 62 (73%) and 3 (3.5%) were on first- and second-line ART, respectively, while 20 (23.5%) were yet to commence ART. Reasons for pharmacist intervention included failure to initiate therapy for HIV or hepatitis B infection; therapeutic failure (25.9%); and drug toxicity (24.7%). After intervention, the percentage of patients with HIV ribonucleic acid level <400 copies/mL rose from 29.4% to 67.1% (P < 0.001), while median (interquartile range) CD4+ cell count increased from 200 (123–351) to 361 (221–470) cells/mm3 (P < 0.001).Conclusion:Pharmacist intervention resulted in clinically significant improvements in patients HIV virological and immunological outcomes. This highlights an important role for the pharmacist in the treatment and care of HIV-infected patients, in a multidisciplinary team.

Medication error reporting in rural critical access hospitals in the North Dakota Telepharmacy Project

Results of a study of medication "quality-related events" (QREs) at critical access hospitals (CAHs) participating in a telepharmacy project are reported. Rates and types of medication QREs (i.e., all types of drug therapy problems requiring pharmacist intervention) were evaluated at 17 CAHs receiving telepharmacy services from a central order-entry site in the North Dakota Telepharmacy Project (NDTP). During the 17-month study, remote pharmacists used telepharmacy technology to review medication orders prepared at the CAH sites, identify and address QREs, and code clinical interventions. The collected data were analyzed via chi-square testing. Cumulative monthly medication orders at the CAH study sites ranged from a low of 12,535 in the first month of the study to a high of 18,257. Monthly rates of visual medication verification and clinical intervention ranged from 8.0% to 14.2% and from 1.3% to 3.1%, respectively. Overall, the most frequently identified QREs were transcription errors, which accounted for 2,389 interventions (43.3%); 2,078 interventions (37.7%) targeted prescribing-related QREs. The most frequently cited intervention codes were for dosage adjustments (n = 547), deep venous thrombosis prophylaxis (n = 437), pharmacokinetic consultation (n = 268), renal dosing (n = 182), and the prevention of minor (n = 148) and major (n = 94) adverse drug events. The study results indicate that the NDTP telepharmacy model is effective in identifying and resolving QREs in CAHs. The use of the telepharmacy services increased over the study period, suggesting that CAH practitioners became more comfortable using the technology on a regular basis to enhance patient safety.

Application of system-level root cause analysis for drug quality and safety problems: A case study

BackgroundAutomated surveillance indicators are used to identify problems with drug therapy. A previous study automated 39 indicators of possible drug-related emergency department visits and hospitalizations. These indicators were used to investigate the quality and safety of drug use in a large health care coalition in Florida. This study describes a method of capturing this input with an aim of applying it to a root cause analysis (RCA), which may be useful for improving system-level flaws and weaknesses in medication use. ObjectiveTo apply results of a computerized surveillance system containing selected indicators of potential drug-related emergency department and hospital admissions to an RCA for evaluation. Such evaluation might prove effective in determining criteria useful in improving the quality and safety of systemic responses to individual types of drug therapy problems. MethodsThis was a case study that brought together a study group of 6 coalition stakeholders to evaluate findings from 4 indicators. The indicators represented problems in the prescribing, adherence, and monitoring steps in the ambulatory care medication use system. The RCA included the following procedures: brainstorming of possible system failures, organizing proposed system failures into groups and corresponding system levels, voting to prioritize proposed system failures, tree diagramming to illustrate how the system failures are interconnected among system levels, and determining whether system conditions or failure sequences are common among indicator types. ResultsThe group judged 3 themes to be important contributors to drug-related problems identified by the 4 indicators, including lack of patient knowledge, patient nonadherence to medical recommendations, and lack of medication management systems. The group believed that these barriers were interconnected and the result of subsystem influences. ConclusionDrug therapy problems represented by the indicators have certain system failures, flaws, or defects in common, allowing them to occur and persist. RCA may be a useful method for evaluating population-level indicator findings to identify potential failures with the medication use system and develop interventions.

Role of a Psychiatric Pharmacist in a Los Angeles “Skid-Row” safety-net clinic

Limited access to a psychiatrist prompted a collaborative practice agreement between a psychiatric pharmacist, a psychiatric pharmacy resident, and primary care physicians at the Center for Community Health, a safety-net clinic providing comprehensive care to the homeless in Skid Row, Los Angeles, CA, USA. From July 2009 to February 2010, 36 (75%) of the 48 patients referred to the psychiatric pharmacy resident met the criteria for the chart review. Twenty-six (54%) were seen for regular follow-up care over 7months. Most referrals were for depression, bipolar disorder, and posttraumatic stress disorder. The types of drug therapy problems, pharmacist interventions, and clinical mental health outcomes are discussed.

Drug Therapy Management: An Empirical Report of Drug Therapy Problems, Pharmacists' Interventions, and Results of Pharmacists' Actions

To determine the number and types of drug therapy problems identified by pharmacists at six community pharmacies, identify the interventions made by these pharmacists in their attempts to resolve drug therapy problems, and determine the results of the pharmacists' actions taken to resolve drug therapy problems. Retrospective review of patient records from pharmacies. Six community pharmacies that had participated in Project ImPACT: Hyperlipidemia. One hundred sixteen patients from Project ImPACT: Hyperlipidemia. Drug therapy problems, pharmacists' interventions, and results of pharmacists' actions were identified and categorized. Drug therapy problems were classified into seven categories, pharmacists' interventions into six categories, and results were categorized into eight types. Frequencies and descriptive statistics were calculated for the measures. A total of 512 initial drug therapy problems were reported for 116 patients in the 6 pharmacies. In addition to the initial interventions, pharmacists documented another 545 times in which they intervened on the original problems. There were 354 (69.1%) drug therapy problems associated with hyperlipidemia and 158 (30.9%) with other conditions. Overall, most common types of drug therapy problems were needs additional therapy (39.8%) and nonadherence to therapy (31.1%). The most common discretionary pharmacist interventions were patient education and physician communication, which occurred on average 4.63 and 3.30 times during the project period. The most common consequence of a pharmacist intervention was an increase in patient adherence, which was reported for almost half of the patients. Drug therapy management (DTM) for patients with dyslipidemias identified frequent drug therapy problems associated with both hyperlipidemia and other conditions. Pharmacists used interventions that included laboratory testing, patient monitoring, patient education, and physician communication to influence patient adherence and optimize drug therapy. Although further research is needed, the findings of this analysis are promising for the more widespread adoption of a DTM role by community pharmacists.

Identification and clarification of drug therapy problems by Indian health service pharmacists.

To describe drug therapy problem intervention activities of Indian Health Service (IHS) pharmacists and to characterize the types of drug therapy problems encountered. Longitudinal descriptive study of documented potential drug therapy problems detected by pharmacists during the conduct of routine dispensing activities during a 6-month period. All 18 IHS hospitals and ambulatory care facilities in one geographic area. Potential drug therapy problem detection rates by pharmacists and problem detection rates per 100 dispensed prescriptions are reported. Problems are characterized as to type, nature of intervention activities undertaken, and results of interventions. Changes in problem detection rate across clinics and over time are reported. Pharmacists detected and reported problems at a rate of slightly less than one per 100 prescriptions dispensed; however, drug therapy changes occurred 78% of the time as a result of the interventions. The types of drug therapy problems occurring most frequently were incorrect information (40.7%), prescription clarification (39.6%), clinical problems (10.4%), and inappropriate drug (9.3%). Physician acceptance of pharmacist interventions varied by type of drug therapy problem. Drug therapy changes occurred 77.7% of the time as a result of the interventions. Pharmacists at several sites used records of the drug therapy problems to make changes in policy or procedures as a part of continuous quality improvement activities. As a result, the problem detection rate declined over time in several settings. In comparison with other settings where cognitive services have been reported, IHS pharmacists detected fewer problems, but their interventions resulted in a higher percentage of drug therapy changes.