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Effects of Clinical Pharmacists' Interventions: on Drug-Related Hospitalisation and Appropriateness of Prescribing in Elderly Patients
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Pharmacy, Department of Pharmaceutical Biosciences.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The overall aim of this thesis was to evaluate clinical pharmacist interventions with the focus on methods aiming to improve the quality of drug therapy and increase patient safety. Adverse drug events caused by medication errors, suboptimal dosages and inappropriate prescribing are common causes of drug-related morbidity and mortality. Clinical pharmacists integrated in multi-professional health-care teams are increasingly addressing these issues. A randomised controlled trial (RCT) was conducted to investigate the effectiveness of clinical pharmacists’ interventions in reducing morbidity and use of hospital care for patients 80 years or older. The results showed that the intervention group had fewer visits to hospital and that the intervention was cost-effective. In a subsequent study based on the population in the RCT, the appropriateness of prescribing was assessed using three validated tools. The results indicated improved appropriateness of prescribing for the intervention group as a result of the intervention. The tools and the number of drugs at discharge were then tested for validity in terms of causal links between the scores at discharge and hospitalisation. No clear correlations between high scores for the tools or a high number of drugs and increased risk of hospitalisation could be detected. During the inclusion period of the RCT a survey based study was conducted where the perceived value of ward-based clinical pharmacists, from the perspective of hospital-based physicians and nurses as well as from general practitioners (GPs) was evaluated. The respondents were positive to the new collaboration to a high degree and stated increased patient safety and improvements in patients’ drug therapy as the main advantages. In the last study the frequency and severity of prescription and transcription errors, when patients enrolled in the multidose-dispensed medications (MDD) system are discharged from hospital, was investigated. The results showed that errors frequently occur when MDD patients are hospitalised.

 

 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2012. , 58 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Pharmacy, ISSN 1651-6192 ; 154
Keyword [en]
Drug-related problems, medication review, appropriateness of prescribing, quality of prescribing, hospitalisation, pharmacist, clinical pharmacy, inter-professional relationships, collaboration, medication error, medication reconciliation, multidose-dispensed medications, prescription errors, transition of care
National Category
Social and Clinical Pharmacy
Research subject
Pharmaceutical Science
Identifiers
URN: urn:nbn:se:uu:diva-167343ISBN: 978-91-554-8262-6 (print)OAI: oai:DiVA.org:uu-167343DiVA: diva2:483737
Public defence
2012-03-09, B:8, BMC, Husargatan 3, Uppsala, 09:00 (English)
Opponent
Supervisors
Available from: 2012-02-17 Created: 2012-01-25 Last updated: 2012-03-01Bibliographically approved
List of papers
1. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial
Open this publication in new window or tab >>A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial
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2009 (English)In: Archives of Internal Medicine, ISSN 0003-9926, E-ISSN 1538-3679, Vol. 169, no 9, 894-900 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND

Patients 80 years or older are underrepresented in scientific studies. The objective of this study was to investigate the effectiveness of interventions performed by ward-based pharmacists in reducing morbidity and use of hospital care among older patients.

METHODS

A randomized controlled study of patients 80 years or older was conducted at the University Hospital of Uppsala, Uppsala, Sweden. Four hundred patients were recruited consecutively between October 1, 2005, and June 30, 2006, and were randomized to control (n = 201) and intervention (n = 199) groups. The interventions were performed by ward-based pharmacists. The control group received standard care without direct involvement of pharmacists at the ward level. The primary outcome measure was the frequency of hospital visits (emergency department and readmissions [total and drug-related]) during the 12-month follow-up period.

RESULTS

Three hundred sixty-eight patients (182 in the intervention group and 186 in the control group) were analyzed. For the intervention group, there was a 16% reduction in all visits to the hospital (quotient, 1.88 vs 2.24; estimate, 0.84; 95% confidence interval [CI], 0.72-0.99) and a 47% reduction in visits to the emergency department (quotient, 0.35 vs 0.66; estimate, 0.53; 95% CI, 0.37-0.75). Drug-related readmissions were reduced by 80% (quotient, 0.06 vs 0.32; estimate, 0.20; 95% CI, 0.10-0.41). After inclusion of the intervention costs, the total cost per patient in the intervention group was $230 lower than that in the control group.

CONCLUSION

If implemented on a population basis, the addition of pharmacists to health care teams would lead to major reductions in morbidity and health care costs.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-103205 (URN)10.1001/archinternmed.2009.71 (DOI)000265994000011 ()19433702 (PubMedID)
Note

De 2 första författarna delar förstaförfattarskapet.

De 2 sista författarna delar sistaförfattarskapet.

Available from: 2009-05-15 Created: 2009-05-15 Last updated: 2017-12-13Bibliographically approved
2. Effects of pharmacists’ interventions on appropriateness of prescribing for elderly and exploration of a possible correlation between scores for appropriateness and clinical outcomes: analyses from a randomized controlled trial
Open this publication in new window or tab >>Effects of pharmacists’ interventions on appropriateness of prescribing for elderly and exploration of a possible correlation between scores for appropriateness and clinical outcomes: analyses from a randomized controlled trial
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background:

Inappropriate prescribing can cause substantial morbidity and represents a clinical and economic burden for patients and society. Appropriateness of prescribing can be assessed by various measures and screening tools, however, for a tool to be valid there should be casual links to important clinical health outcomes. The aim of this study was to investigate the effect of a pharmacist intervention on appropriateness of prescribing, and to explore the relationship between these results and clinical health outcomes defined as re-visits to hospital.

Methods:

The study population from a previous randomized controlled study, in which the effects of a comprehensive pharmacist intervention on re-hospitalisation was investigated, was used. The criteria from the validated instruments STOPP, START and MAI were applied retrospectively to the study patients (368 patients; intervention group n=182, control group n=186). The quality assessments were done on admission and at discharge to detect differences over time between the control- and the intervention group. Hospital care consumption one year after admission was recorded and the correlation between scores for appropriateness, as well as number of drugs at discharge, and hospital visits was analysed.

Results:

The number of Potentially Inappropriate Medicines (PIMs) per patient as identified by STOPP was reduced for the intervention group but not for the control group (1.42 and 0.93 vs. 1.46 and 1.66 respectively, p<0.01) The number of Potential Prescription Omissions (PPOs) per patient as identified by START was reduced for the intervention group but not for the control group (0.36 and 0.09 vs. 0.42 and 0.45 respectively, p<0.001). The summated score for MAI was reduced for the intervention group but not for the control group (8.5 to 5.0 and 8.7 to 10.0 respectively, p< 0.001). There was no correlation between the scores of the tools and total visits to hospital. Number of drugs (unadjusted) correlated with visits to hospital and the rate ratio was 4%. For readmissions to hospital, MAI (unadjusted) and the number of drugs showed a positive correlation. There was a correlation between MAI and STOPP and drug-related readmissions (RR 8-9% and 30-34% respectively).

Conclusion:

The addition of a comprehensive pharmacist service to standard care significantly improved the appropriateness of prescribing for patients in the intervention group that participated in the randomized controlled trial, as evaluated by all three instruments used; STOPP, START and MAI. However, the results on correlation between the tools and re-visits to hospital were inconclusive.

Keyword
appropriateness, quality of prescribing, hospitalisation, pharmacist intervention
National Category
Social and Clinical Pharmacy
Identifiers
urn:nbn:se:uu:diva-167138 (URN)
Available from: 2012-01-22 Created: 2012-01-22 Last updated: 2012-08-24Bibliographically approved
3. Perceived value of ward-based pharmacists from the perspective of physicians and nurses
Open this publication in new window or tab >>Perceived value of ward-based pharmacists from the perspective of physicians and nurses
2012 (English)In: International Journal of Clinical Pharmacy, ISSN 2210-7703, E-ISSN 2210-7711, Vol. 34, no 1, 127-135 p.Article in journal (Refereed) Published
Abstract [en]

Background

Clinical pharmacy in a hospital setting is relatively new in Sweden. Its recent introduction at the University Hospital in Uppsala has provided an opportunity for evaluation by other relevant professionals of the integration of clinical pharmacists into the health-care team.

Objectives

The objectives of this descriptive study were to evaluate the perceived value of wardbased clinical pharmacists from the perspective of hospital based physicians and nurses and to identify potential advantages and disadvantages related to the new inter professional collaboration. Another objective was to evaluate the experiences of general practitioners on receiving medication reports from wardbased clinical pharmacists.

Setting

Two acute internal medicine wards at the University Hospital in Uppsala, where a previously reported randomized controlled trial investigating the effects of ward based clinical pharmacists on re-visits to hospital was undertaken.

Methods

Data were collected by questionnaires containing closed- and openended questions. The questionnaires were distributed during the nine-month study period of the randomized controlled trial by an independent researcher to 29 hospital-based physicians and 44 nurses on the study wards and to 21 general practitioners who had received two or more medication reports. Answers were analysed descriptively for the closedended questions and by content analysis for the open-ended questions.

Main outcome measure

The main outcome measure was the physicians’ and nurses’ level of satisfaction with the new collaboration with clinical pharmacists, from a hospital and primary care perspective.

Results

Seventy-six percent of the hospital-based physicians and 81% of the nurses completed the questionnaire. Ninety-five percent of the physicians and 93% of the nurses were very satisfied with the collaboration. Out of the 17 general practitioners (81%) that completed the questionnaire 71% wanted to continue to receive medication reports in a similar way in the future. Increased patient safety and improvements in patients’ drug therapy were the main advantages stated by all three groups of respondents. Eighteen percent of the hospital-based physicians and 21% of the nurses thought that the collaboration had been time-consuming to certain or to a high extent.

Conclusions

The majority of the respondents, both GPs and hospital based physicians and nurses, were satisfied with the new collaboration with the ward based pharmacists and perceived that the quality of the patients’ drug therapy and drug-related patient safety had increased.

Place, publisher, year, edition, pages
Springer, 2012
Keyword
Clinical pharmacy, Collaboration, Inter-professional relationships, Multidisciplinary team, nurses, physicians, Sweden
National Category
Social and Clinical Pharmacy
Research subject
Pharmacokinetics and Drug Therapy
Identifiers
urn:nbn:se:uu:diva-167133 (URN)10.1007/s11096-011-9603-1 (DOI)000299329300019 ()
Available from: 2012-01-22 Created: 2012-01-22 Last updated: 2017-12-08Bibliographically approved
4. Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: an observationaland interventional study
Open this publication in new window or tab >>Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: an observationaland interventional study
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2013 (English)In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 19, no 1, 185-191 p.Article in journal (Refereed) Published
Abstract [en]

Background 

Medication errors frequently occur when patients are transferred between health care settings. The main objective of this study was to investigate the frequency, type and severity of prescribing and transcribing errors for drugs dispensed in multidose plastic packs when patients are discharged from the hospital. The secondary objective was to correct identified errors and suggest measures to promote safe prescribing.

Methods 

The drugs on the patients' multidose drug dispensing (MDD) order sheets and the medication administration records were reconciled prior to the MDD orders being sent to the pharmacy for dispensing. Discrepancies were recorded and the prescribing physician was notified and given the opportunity to change the order. Discrepancies categorized as unintentional and related to the discharge process were subject to further analysis.

Results 

Seventy-two (25%) of the 290 reviewed MDD orders had at least one discharge error. In total, 120 discharge errors were identified, of which 49 (41%) were assessed as being of moderate and three (3%) of major severity. Orders with a higher number of medications and orders from the orthopaedic wards had a significantly higher error rate.

Conclusion 

The main purpose of the MDD system is to increase patient safety by reducing medication errors. However, this study shows that prescribing and transcribing errors frequently occur when patients are hospitalized. Because the population enrolled in the MDD system is an elderly, physically vulnerable group with a high number of prescribed drugs, preventive measures to ensure safe prescribing of MDD drugs are warranted.

Keyword
medication error, medication reconciliation, multi-dose dispensed medications, patient safety, prescription error, transition of care
National Category
Social and Clinical Pharmacy
Research subject
Pharmaceutical Science; Pharmacokinetics and Drug Therapy
Identifiers
urn:nbn:se:uu:diva-167137 (URN)10.1111/j.1365-2753.2011.01798.x (DOI)000314114400026 ()
Available from: 2012-01-22 Created: 2012-01-22 Last updated: 2017-12-08

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