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Clinical pharmacy services within a multiprofessional healthcare team
Linnaeus University, Faculty of Science and Engineering, School of Natural Sciences. (eHälsoinstitutet ; eHealth Institute)
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: The purpose of drug treatment is to reduce morbidity and mortality, and to improve health-related quality of life. However, there are frequent problems associated with drug treatment, especially among the elderly. The aim of this thesis was to investigate the impact of clinical pharmacy services within a multiprofessional healthcare team on quality and safety of patients’ drug therapy, and to study the frequency and nature of medication history errors on admission to hospital.

Methods: A model for clinical pharmacy services within a multiprofessional healthcare team (the Lund Integrated Medicines Management model, LIMM) was introduced in three hospital wards. On admission of patients to hospital, clinical pharmacists conducted medication reconciliation (i.e. identified the most accurate list of a patient’s current medications) to identify any errors in the hospital medication list. To identify, solve and prevent any other drug-related problems, the clinical pharmacists interviewed patients and performed medication reviews and monitoring of drug therapy. Drug-related problems were discussed within the multiprofessional team and the physicians adjusted the drug therapy as appropriate.

Results: On admission to hospital, drug-related problems, such as low adherence to drug therapy and concerns about treatment, were identified. Different statistical approaches to present results from ordinal data on adherence and beliefs about medicines were suggested. Approximately half of the patients were affected by errors in the medication history at admission to hospital; patients who had many prescription drugs had a higher risk for errors. Medication reconciliation and review reduced the number of inappropriate medications and reduced drug-related hospital revisits. No impact on all-cause hospital revisits was demonstrated.

Conclusion: Patients admitted to hospital are at high risk for being affected by medication history errors and there is a high potential to improve their drug therapy. By reducing medication history errors and improving medication appropriateness, clinical pharmacy services within a multiprofessional healthcare team improve the quality and safety of patients’ drug therapy. The impact of routine implementation of medication reconciliation and review on healthcare visits will need further evaluation; the results from this thesis suggest that drug-related hospital revisits could be reduced.

Place, publisher, year, edition, pages
Växjö, Kalmar: Linnaeus University Press, 2012. , 63 p.
Series
Linnaeus University Dissertations, 84/2012
Keyword [en]
Clinical pharmacy services, pharmacist, medication review, medication reconciliation, medication errors, drug-related problems, inappropriate prescribing, elderly, inpatients, patient readmissions, hospitalisation, multiprofessional, patient care team, continuity of patient care
Keyword [sv]
Klinisk farmaci, farmaceut, läkemedelsgenomgång, läkemedelsavstämning, läkemedelsfel, läkemedelsrelaterade problem, olämpliga läkemedel, äldre, återinläggning, sjukhusinläggning, multiprofessionell, vårdteam, kontinuitet i vården
National Category
Social and Clinical Pharmacy
Research subject
Natural Science, Biomedical Sciences
Identifiers
URN: urn:nbn:se:lnu:diva-18293ISBN: 978-91-86983-47-5 (print)OAI: oai:DiVA.org:lnu-18293DiVA: diva2:514898
Public defence
2012-05-16, N2007, Västergård, Smålandsgatan 26E, Kalmar, 13:00 (Swedish)
Opponent
Supervisors
Projects
Läkemedelsgenomgångar och läkemedelsavstämning - LIMM-modellen
Available from: 2012-04-12 Created: 2012-04-11 Last updated: 2017-01-19Bibliographically approved
List of papers
1. Impact of the Lund Integrated Medicines Management (LIMM) model on medication appropriateness and drug-related hospital revisits.
Open this publication in new window or tab >>Impact of the Lund Integrated Medicines Management (LIMM) model on medication appropriateness and drug-related hospital revisits.
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2011 (English)In: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041, Vol. 67, no 7, 741-752 p.Article in journal (Refereed) Published
Abstract [en]

Purpose

To examine the impact of systematic medication reconciliations when admitted to hospital, and medication review while in hospital, on the number of inappropriate medications and unscheduled drug-related hospital revisits in elderly patients.

Methods

A prospective, controlled study in 210 patients, aged 65 years or older, who were admitted to one of three internal medicine wards at a University Hospital in Sweden. Patients received either standard care or care according to the Lund Integrated Medicines Management (LIMM) model. A multi-professional team, including a clinical pharmacist, provided medication reconciliations on admission and medication reviews during the hospital stay for the LIMM group. Blinded reviewers evaluated the appropriateness of the prescribing (using the Medication Appropriateness Index) on admission and discharge, and assessed the probability that a drug-related problem was the reason for any patient readmitted to hospital or visiting the emergency department within three months of discharge (using WHO causality criteria).

Results

There was a greater decrease in the number of inappropriate drugs in the intervention group than in the control group for both the intention-to-treat population (51% [95% CI 43-58%] versus 39% [95% CI 30-48%], p=0.0446) and the per-protocol population (60% [95% CI 51-67%] versus 44% [95% CI 34-52 %], p=0.0106). There were 6 revisits to hospital in the intervention group which were judged as ‘possibly, probably or certainly drug-related’, compared with 12 in the control group (p=0.0469).

Conclusion

In this study, medication reconciliation and reviews provided by a clinical pharmacist in a multi-professional team significantly reduced the number of inappropriate drugs and unscheduled drug-related hospital revisits for elderly patients.

Keyword
Clinical pharmacy services, Medication Appropriateness Index, Medication review, Medication reconciliation, Drug-related problems, Inpatients, Klinisk farmaci, Läkemedelsgenomgång, Läkemedelsavstämning, Läkemedelsrelaterade problem, Slutenvård, Olämpliga läkemedel, Återinläggning
National Category
Pharmaceutical Sciences
Research subject
Natural Science, Biomedical Sciences
Identifiers
urn:nbn:se:lnu:diva-10170 (URN)10.1007/s00228-010-0982-3 (DOI)2-s2.0-79959707163 (Scopus ID)
Available from: 2011-08-22 Created: 2011-01-18 Last updated: 2017-12-11Bibliographically approved
2. A structured questionnaire to assess patient compliance and beliefs about medicines taking into account the ordered categorical structure of data
Open this publication in new window or tab >>A structured questionnaire to assess patient compliance and beliefs about medicines taking into account the ordered categorical structure of data
2009 (English)In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 15, no 4, 713-723 p.Article in journal (Refereed) Published
Abstract [en]

RATIONALE, AIMS AND OBJECTIVE: The objectives were to describe and evaluate the structured medication questionnaire and to improve data handling of results from the Morisky four-item scale for patient compliance and Beliefs about Medicines Questionnaire-specific (BMQ-specific). METHODS: A questionnaire was developed with the purpose of being used when identifying medication errors and assessing patient compliance to and beliefs about medicines. RESULTS: A majority of the respondents (62%; CI 45-77%) had at least one medication error. Assuming that all items are equally important in the Morisky four-item scale we presented four alternative ways to create a unidimensional global scale. A two-dimensional global scale was also constructed. The results from the BMQ-specific were presented in different ways, all taking into account that the scale has ordered verbal categories: at the level addressing each specific question, at the sub-scales 'concern' and 'necessity' level and at the global level. CONCLUSIONS: The structured medication questionnaire can be used in daily practice as a tool to identify drug-related problems. The choice of how to use and present data from those scales in research depends on patient characteristics and how discriminating one would like the scales to be.

Keyword
Aged, Drug Therapy, Health Knowledge, Attitudes, Practice, Medication Errors, Patient Compliance, Questionnaires, Sweden
National Category
Social and Clinical Pharmacy
Research subject
Health and Caring Sciences, Health Informatics; Natural Science, Biomedical Sciences
Identifiers
urn:nbn:se:lnu:diva-18048 (URN)10.1111/j.1365-2753.2008.01088.x (DOI)
Projects
Läkemedelsgenomgångar och läkemedelsintervju - LIMM-modellen
Available from: 2012-03-16 Created: 2012-03-16 Last updated: 2017-12-07Bibliographically approved
3. Errors in medication history at hospital admission: prevalence and predicting factors
Open this publication in new window or tab >>Errors in medication history at hospital admission: prevalence and predicting factors
2012 (English)In: BMC Clinical Pharmacology, ISSN 1472-6904, Vol. 12, Article ID: 9- p.Article in journal (Refereed) Published
Abstract [en]

Background: An accurate medication list at hospital admission is essential for the evaluation and further treatment of patients. The objective of this study was to describe the frequency, type and predictors of errors in medication history, and to evaluate the extent to which standard care corrects these errors.

Methods:A descriptive study was carried out in two medical wards in a Swedish hospital using Lund Integrated Medicines Management (LIMM)-based medication reconciliation. A clinical pharmacist identified each patient's most accurate pre-admission medication list by conducting a medication reconciliation process shortly after admission. This list was then compared with the patient's medication list in the hospital medical records. Addition or withdrawal of a drug or changes to the dose or dosage form in the hospital medication list were considered medication discrepancies. Medication discrepancies for which no clinical reason could be identified (unintentional changes) were considered medication history errors.

Results: The final study population comprised 670 of 818 eligible patients. At least one medication history error was identified by pharmacists conducting medication reconciliations for 313 of these patients (47%; 95% CI 43-51%). The most common medication error was an omitted drug, followed by a wrong dose. Multivariate logistic regression analysis showed that a higher number of drugs at admission (odds ratio [OR] per 1 drug increase = 1.10; 95% CI 1.06 - 1.14; p<0.0001) and the patient living in their own home without any care services (OR1.58; 95% CI 1.02 - 2.45; p = 0.042) were predictors for medication history errors at admission. The results further indicated that standard care by non-pharmacist ward staff had partly corrected the errors in affected patients by four days after admission, but a considerable proportion of the errors made in the initial medication history at admission remained undetected by standard care (OR for medication errors detected by pharmacists' medication reconciliation carried out on days 4 - 11 compared to days 0 - 1 = 0.52; 95% CI 0.30 - 0.91; p = 0.021).

Conclusions: Clinical pharmacists conducting LIMM-based medication reconciliations have a high potential for correcting errors in medication history for all patients. In an older Swedish population, those prescribed many drugs seem to benefit most from admission medication reconciliation.

Keyword
Clinical pharmacy services, pharmacist, medication, drug, medicine, medication reconciliation, medication errors, elderly, inpatients, hospitalisation, multiprofessional, patient care team, continuity of patient care, KLinisk farmaci, farmaceut, läkemedel, läkemedelsavstämning, läkemedelsfel, äldre, sjukhus, vårdteam, kontinuitet i vården
National Category
Social and Clinical Pharmacy
Research subject
Natural Science, Biomedical Sciences
Identifiers
urn:nbn:se:lnu:diva-18295 (URN)10.1186/1472-6904-12-9 (DOI)2-s2.0-84859184890 (Scopus ID)
Projects
Läkemedelsgenomgångar och läkemedelsavstämning - LIMM-modellen
Available from: 2012-04-23 Created: 2012-04-11 Last updated: 2017-12-07Bibliographically approved
4. Clinical implementation of systematic medication reconciliation and review as part of the Lund Integrated Medicines Management model – impact on all cause emergency department revisits
Open this publication in new window or tab >>Clinical implementation of systematic medication reconciliation and review as part of the Lund Integrated Medicines Management model – impact on all cause emergency department revisits
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2012 (English)In: Journal of Clinical Pharmacy and Therapeutics, ISSN 0269-4727, E-ISSN 1365-2710, Vol. 37, no 6, 686-692 p.Article in journal (Refereed) Published
Abstract [en]

What is known and objective: Interventions involving medication reconciliation and review by clinical pharmacists can reduce drug-related problems and improve therapeutic outcomes. The objective of this study was to examine the impact of routine admission medication reconciliation and inpatient medication review on emergency department (ED) revisits after discharge. Secondary outcomes included the combined rate of post-discharge hospital revisits or death.

Methods: This prospective, controlled study included all patients hospitalised in three internal medicine wards in a university hospital, between January 1 2006 and May 31 2008. Medication reconciliation on admission and inpatient medication review, conducted by clinical pharmacists in a multiprofessional team, were implemented in these wards at different times during 2007 and 2008 (intervention periods). A discharge medication reconciliation was undertaken in all the study wards, during both control and intervention periods. Patients were included in the intervention group (n=1216) if they attended a ward with medication reconciliation and review, whether they had received the intervention or not. Control patients (n=2758) attended the wards before implementation of the intervention. 

Results: No impact of medication reconciliation and reviews on ED revisits (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.86-1.04) or event-free survival (HR, 0.96; 95% CI, 0.88-1.04) was demonstrated. In the intervention group, 594 patients (48.8%) visited the ED, compared to 1416 (51.3%) control patients. In total, 716 intervention (58.9%) and 1688 (61.2%) control patients experienced any event (ED visit, hospitalisation or death). Because the time to a subsequent ED visit was longer for the control as well as the intervention groups in 2007 than in 2006 (p<0.05), we re-examined this cohort of patients; the proportion of patients revisiting the ED was similar in both groups in 2007 (p=0.608).

What is new and conclusion: Routine implementation of medication reconciliation and reviews on admission and during the hospital stay did not appear to have any impact on ED revisits, rehospitalisations or mortality over six months' follow-up.  

Keyword
Medications, hospital, medication review, medication reconciliation, pharmacist, clinical pharmacy, multiprofessional team, LIMM-model, readmission, Läkemedel, sjukhus, läkemedelsgenomgångar, läkemedelsavstämning, apotekare, klinisk farmaci, multiprofessionellt team, LIMM-modellen, återinläggning
National Category
Social and Clinical Pharmacy
Research subject
Natural Science, Biomedical Sciences
Identifiers
urn:nbn:se:lnu:diva-21947 (URN)10.1111/jcpt.12001 (DOI)2-s2.0-84868369185 (Scopus ID)
Available from: 2012-10-08 Created: 2012-10-08 Last updated: 2017-12-07Bibliographically approved

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