Community pharmacists' attitudes towards checking prescriptions: a cross-sectional survey.

BACKGROUND: The final prescription check is a mandatory but time-consuming process in Dutch community pharmacies. A safer dispensing process may have made the final prescription check obsolete. OBJECTIVE: To describe the final prescription check in Dutch community pharmacies and explore pharmacists' attitudes towards changing this. METHODS: A cross-sectional survey among Dutch community pharmacists. The online questionnaire was based on literature and previous qualitative research, piloted in three pharmacies, and took 10 min to complete. Results were analysed descriptively. RESULTS: A total of 409 pharmacists participated. They saw the final prescription check as an important quality assurance of the dispensing process. Nevertheless, most pharmacists agreed that the final prescription check could be optimized as they thought that the time invested outweighed the benefits. Automation of the dispensing process, only checking selected high-risk prescriptions, and more in-process checks could reduce the need for an extensive final prescription check, rather than delegating the task to assistants. To implement changes, most pharmacists felt current dispensing guidelines needed to be adapted. CONCLUSION: There was a widespread consensus that optimizing the final prescription check could enhance efficiency and allow more time for person-centred care. Most pharmacists expressed a preference for updated guidelines before implementing such changes.

Effects of a multicomponent communication training to involve older people in decisions to DEPRESCRIBE cardiometabolic medication in primary care (CO-DEPRESCRIBE): protocol for a cluster randomized controlled trial with embedded process and economic evaluation.

BACKGROUND: Deprescribing of medication for cardiovascular risk factors and diabetes has been incorporated in clinical guidelines but proves to be difficult to implement in primary care. Training of healthcare providers is needed to enhance deprescribing in eligible patients. This study will examine the effects of a blended training program aimed at initiating and conducting constructive deprescribing consultations with patients. METHODS: A cluster-randomized trial will be conducted in which local pharmacy-general practice teams in the Netherlands will be randomized to conducting clinical medication reviews with patients as usual (control) or after receiving the CO-DEPRESCRIBE training program (intervention). People of 75 years and older using specific cardiometabolic medication (diabetes drugs, antihypertensives, statins) and eligible for a medication review will be included. The CO-DEPRESCRIBE intervention is based on previous work and applies models for patient-centered communication and shared decision making. It consists of 5 training modules with supportive tools. The primary outcome is the percentage of patients with at least 1 cardiometabolic medication deintensified. Secondary outcomes include patient involvement in decision making, healthcare provider communication skills, health/medication-related outcomes, attitudes towards deprescribing, medication regimen complexity and health-related quality of life. Additional safety and cost parameters will be collected. It is estimated that 167 patients per study arm are needed in the final intention-to-treat analysis using a mixed effects model. Taking loss to follow-up into account, 40 teams are asked to recruit 10 patients each. A baseline and 6-months follow-up assessment, a process evaluation, and a cost-effectiveness analysis will be conducted. DISCUSSION: The hypothesis is that the training program will lead to more proactive and patient-centered deprescribing of cardiometabolic medication. By a comprehensive evaluation, an increase in knowledge needed for sustainable implementation of deprescribing in primary care is expected. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov (identifier: NCT05507177).

The prevalence of polypharmacy in older Europeans: A multi-national database study of general practitioner prescribing.

AIMS: The aims of this study were to measure the prevalence of polypharmacy and describe the prescribing of selected medications known for overuse in older people with polypharmacy in primary care. METHODS: This was a multinational retrospective cohort study across six countries: Belgium, France, Germany, Italy, Spain and the UK. We used anonymized longitudinal patient-level information from general practice databases hosted by IQVIA. Patients ≥65 years were included. Polypharmacy was defined as having 5-9 and ≥10 distinct drug classes (ATC Level 3) prescribed during a 6-month period. Selected medications were: opioids, antipsychotics, proton pump inhibitors (PPI), benzodiazepines (ATC Level 5). We included country experts on the healthcare context to interpret findings. RESULTS: Age and gender distribution was similar across the six countries (mean age 75-76 years; 54-56% female). The prevalence of polypharmacy of 5-9 drugs was 22.8% (UK) to 58.3% (Germany); ≥10 drugs from 11.3% (UK) to 28.5% (Germany). In the polypharmacy population prescribed ≥5 drugs, opioid prescribing ranged from 11.5% (France) to 27.5% (Spain). Prescribing of PPI was highest with almost half of patients receiving a PPI, 42.3% (Germany) to 65.5% (Spain). Benzodiazepine prescribing showed a marked variation between countries, 2.7% (UK) to 34.9% (Spain). The healthcare context information explained possible underreporting for selected medications. CONCLUSIONS: We have found a high prevalence of polypharmacy with more than half of the older population being prescribed ≥5 drugs in four of the six countries. Whilst polypharmacy may be appropriate in many patients, worryingly high usage of PPIs and benzodiazepines supports current efforts to improve polypharmacy management across Europe.

Pharmacists combating antimicrobial resistance: A Delphi study on antibiotic dispensing.

BACKGROUND: The daily work of community pharmacists includes dispensing antibiotics, but little is known about how this should be done to ensure quality use of antibiotics. OBJECTIVE: To define specific tasks of the community pharmacist when dispensing antibiotics and to assess to what extent these tasks can be implemented in practice in Europe. METHODS: A Delphi study with community pharmacist experts in the European Economic Area. Statements on potential tasks for pharmacists during the antibiotic dispensing process were based on a systematic literature review. Participants rated the statements for importance and feasibility of implementation in practice in 3 rounds on a scale from 1 to 9. Consensus of importance was defined as ≥ 80 % of experts rating a statement between 7 and 9. An online expert meeting was conducted between rounds 1 and 2. Scores for all statements were analysed descriptively. RESULTS: Overall, 38 experts from 21 countries participated in the study. Experts reached consensus on 108 statements within 5 themes: 1) collaboration with prescribers, 2) checking prescriptions and dispensing, 3) counselling, 4) education, and 5) pharmacy services. Potential tasks included advising and collaborating with prescribers, performing safety checks, and having access to specific prescription information. Additionally, pharmacists should counsel patients related to the dispensed antibiotic and on antimicrobial resistance and infectious diseases. With few exceptions, pharmacists should not dispense antibiotics without prescriptions or prescribe antibiotics. Consensus on feasibility of implementation was only reached for statements in the categories "counselling patients" and "education". Barriers to changing practice included structure of the healthcare system, resistance to change from prescribers or pharmacy staff, lack of time and finances, legal barriers, and patient expectations. CONCLUSION: Community pharmacists have an important role when dispensing antibiotics. This study provides important steps towards better community pharmacy antibiotic dispensing practices throughout the EEA.

Maternal diabetes and risk of attention-deficit/hyperactivity disorder in offspring in a multinational cohort of 3.6 million mother-child pairs.

Previous studies report an association between maternal diabetes mellitus (MDM) and attention-deficit/hyperactivity disorder (ADHD), often overlooking unmeasured confounders such as shared genetics and environmental factors. We therefore conducted a multinational cohort study with linked mother-child pairs data in Hong Kong, New Zealand, Taiwan, Finland, Iceland, Norway and Sweden to evaluate associations between different MDM (any MDM, gestational diabetes mellitus (GDM) and pregestational diabetes mellitus (PGDM)) and ADHD using Cox proportional hazards regression. We included over 3.6 million mother-child pairs between 2001 and 2014 with follow-up until 2020. Children who were born to mothers with any type of diabetes during pregnancy had a higher risk of ADHD than unexposed children (pooled hazard ratio (HR) = 1.16, 95% confidence interval (CI) = 1.08-1.24). Higher risks of ADHD were also observed for both GDM (pooled HR = 1.10, 95% CI = 1.04-1.17) and PGDM (pooled HR = 1.39, 95% CI = 1.25-1.55). However, siblings with discordant exposure to GDM in pregnancy had similar risks of ADHD (pooled HR = 1.05, 95% CI = 0.94-1.17), suggesting potential confounding by unmeasured, shared familial factors. Our findings indicate that there is a small-to-moderate association between MDM and ADHD, whereas the association between GDM and ADHD is unlikely to be causal. This finding contrast with previous studies, which reported substantially higher risk estimates, and underscores the need to reevaluate the precise roles of hyperglycemia and genetic factors in the relationship between MDM and ADHD.

Recommendations for the safe use of direct oral anticoagulants in patients with cirrhosis based on a systematic review of pharmacokinetic, pharmacodynamic and safety data.

PURPOSE: The popularity of direct oral anticoagulants (DOACs) is increasing among patients with cirrhosis. Cirrhosis has a major impact on the pharmacokinetics of drugs, potentially increasing adverse events. Safe use of drugs in cirrhosis requires a diligent risk-benefit analysis. The aim of this study is to develop practice recommendations for safe use of DOACs in cirrhosis based on a systematic review of pharmacokinetic, pharmacodynamic and safety data. METHODS: We conducted a systematic literature search to identify studies on pharmacokinetics, pharmacodynamics and safety of DOACs in cirrhosis. Data were collected and presented in summary tables by severity of cirrhosis using the Child-Turcotte-Pugh (CTP) classification. A multidisciplinary expert panel evaluated the results and classified the DOACs according to safety. RESULTS: Fifty four studies were included. All DOACs were classified as 'no additional risks known' for CTP A. For CTP B, apixaban, dabigatran and edoxaban were classified as 'no additional risks known'. Apixaban and edoxaban showed fewer adverse events in patients with cirrhosis, while dabigatran may be less impacted by severity of cirrhosis based on its pharmacokinetic profile. Rivaroxaban was classified as 'unsafe' in CTP B and C based on significant pharmacokinetic alterations. Due to lack of data, apixaban, dabigatran and edoxaban were classified as 'unknown' for CTP C. CONCLUSION: DOACs can be used in patients with CTP A cirrhosis, and apixaban, dabigatran and edoxaban can also be used in CTP B. It is recommended to avoid rivaroxaban in CTP B and C. There is insufficient evidence to support safe use of other DOACs in CTP C cirrhosis.

Reducing Pharmaceuticals in Water, a New Module Integrated in the Pharmacy Game: Evaluating the Module's Effects on Students' Knowledge and Attitudes.

Pharmaceutical residues end up in surface waters, impacting drinking water sources and contaminating the aquatic ecosystem. Pharmacists can play a role in reducing pharmaceutical residues, yet this is often not addressed in pharmacy undergraduate education. Therefore, we developed the educational module "Reducing Pharmaceuticals in Water" for pharmacy students; this was integrated in our pharmacy simulation game for third year Master of Pharmacy students at the University of Groningen. In this study, we aim to evaluate the effects of the module on students' knowledge of pharmaceutical residues in water, to describe students' experiences in taking the module, and to explore their attitudes towards green pharmacy education in general. This mixed-methods study included quantitative measurements, before and after students took the module (intervention group) and in a control group which did not receive the module. Data were collected between February 2023 and June 2023. Overall, 29 students took the module and 36 students were in the control group. The knowledge score of students in the intervention group (N = 29) increased significantly from 9.3 to 12.9 out of 22 (p < 0.001). The knowledge score of the students in the control group was (8.9 out of 22). Students found the e-learning and the patient cases the most exciting part of this module. Students also recognized the need to including environmental issues in pharmacy education. In conclusion, the module contributes towards improved knowledge and increased awareness of the impact of pharmaceuticals found in water. It represents a promising strategy to strengthen pharmacist's role in mitigating the amount and the effect of pharmaceuticals on water and the environment in the future.

Medication errors by caregivers in the homes of children discharged from a pediatric department in Ghana.

Background: Medication errors (MEs) by caregivers at home are a cause of morbidity and mortality, shortly after discharge from the hospital. Objectives: The objective of this study was to determine the rate and types of MEs at the homes of children discharged from a hospital in Ghana and to explore the factors associated with these errors. Design: This was a cross-sectional study of infants and children discharged from the hospital to review medication administration practices. Methods: Caregivers of children discharged from the hospital after at least 24 hours of admission were interviewed at their homes about medication administration practices. The study assessed potential harm associated with MEs made by caregivers using the Harm Associated with Medication Error Classification tool. The Least Absolute Shrinkage and Selection Operator regression were used to identify the variables associated with MEs. Results: A total of 95 children (mean age: 28.6 months, 52.6% female) and their caregivers were included. Overall, 65 (68.4%) children experienced one or more MEs. Out of a total of 232 medications reviewed, 102 (44.0%) (95% CI: 37.6-50.4) were associated with a ME. The top two errors, wrong time errors and errors in the frequency of dosing were, 45.1% and 21.6%, respectively. Understanding the information on the disease condition being treated and the medicines dispensed was associated with committing fewer MEs. The number of medicines prescribed was associated with a higher likelihood of MEs. Out of 102 MEs, 48 (47.1%) were assessed as posing potentially no harm, 26 (25.5%) minor harm, 15 (14.7%) moderate harm, and 13 (12.8%) serious harm to the patients. Importantly, none of the MEs were assessed as posing potentially severe or life-threatening harm to the patients. Conclusion: MEs in children following discharge are high, and systems should be developed to prevent these errors.

Mistakes by caregivers at home in giving medicine after children leave a Ghanaian children's hospital Why was this study done? Medication error in the home occurs when there is a mistake in how a person's medicine is taken or given. Examples of medication errors in the home could involve taking the wrong medication, taking the wrong dose, taking the medicine at the wrong time, or giving the medicine more or less often. Sometimes, when caregivers take care of children at home after they leave the hospital, they make mistakes with how medicines are given to the children. These mistakes can make the children sick or cause some of them to die. This research wanted to find out how often these mistakes happen in the homes of children who are discharged from a hospital in Ghana, what kinds of mistakes are made, and why they happen. What did the researchers do? We talked to caregivers of children within 7 days after they were discharged from the hospital. We asked them questions about how they give medicines to the children at home. We also used a special technique to find out which things might be responsible for the mistakes while they give the medicines to their children. What did the researchers find? We visited the homes of 95 children (average age 28.6 months, 52.6% girls, the rest were boys). In general, 65 out of the 95 children (about 68%) had at least one mistake made by their caregivers while giving them their medicines. In the homes we visited, 232 medicines were given to the 95 children with 102 out of the 232 (about 44%) having a mistake. The two most common mistakes made by the caregivers were giving medicines at the wrong time (45.1%) and mistakes with how often the medicine is given (21.6%). Caregivers who understood more about the sickness of their children and the medicines made fewer mistakes. Also, in cases where the doctors prescribed more medicines to the children, the caregivers made more mistakes when giving the medicines to the children. What do the findings mean? A lot of mistakes happen with medicines when children leave the hospital to their homes. Governments and regulatory authorities need to create better systems so that patients or their caregivers can report these errors. This will lead to actions being taken to prevent these errors from happening in order to keep children safe.

One Health Determinants of Escherichia coli Antimicrobial Resistance in Humans in the Community: An Umbrella Review.

To date, the scientific literature on health variables for Escherichia coli antimicrobial resistance (AMR) has been investigated throughout several systematic reviews, often with a focus on only one aspect of the One Health variables: human, animal, or environment. The aim of this umbrella review is to conduct a systematic synthesis of existing evidence on Escherichia coli AMR in humans in the community from a One Health perspective. PubMed, EMBASE, and CINAHL were searched on "antibiotic resistance" and "systematic review" from inception until 25 March 2022 (PROSPERO: CRD42022316431). The methodological quality was assessed, and the importance of identified variables was tabulated across all included reviews. Twenty-three reviews were included in this study, covering 860 primary studies. All reviews were of (critically) low quality. Most reviews focused on humans (20), 3 on animals, and 1 on both human and environmental variables. Antibiotic use, urinary tract infections, diabetes, and international travel were identified as the most important human variables. Poultry farms and swimming in freshwater were identified as potential sources for AMR transmission from the animal and environmental perspectives. This umbrella review highlights a gap in high-quality literature investigating the time between variable exposure, AMR testing, and animal and environmental AMR variables.

[Audit of Antibiotic Dispensing in Community Pharmacy (Happy Patient Project)]. / Auditoría de la dispensación de antibióticos en la farmacia comunitaria (proyecto 'Happy Patient').

Background: Dispensing and prescribing antibiotics is inappropriate in many of the countries in the European Union, including Spain, and a threat to the population's health. To tackle the growth of antimicrobial resistance, the Happy Patient project was set up under the sponsorship of the European Commission. Aim: O ascertain the characteristics of dispensing antibiotic therapy in Spanish community pharmacies.To compare the variability between different Spanish community pharmacies. Methods: The Audit Project Odense® methodology was used to find out how antibiotics were dispensed in community pharmacies. Pharmacists taking part were asked to record for five consecutive days between the months of February and April 2022 the actions performed during the dispensing of oral antibiotics for human use and for the treatment of acute infections. Results: A total population of 573 patients (59.9% female) of all age groups were interviewed. The patients were 83.6% aware of the purpose for which the antibiotic was prescribed and the most requested antibiotic was amoxicillin followed by amoxicillin with clavulanic acid.In 15% of dispensations, a triple safety check was completed: interactions, contraindications and allergies. The pharmacist rarely contacted the prescriber but when she did, the prescriber altered the prescription.In 62.3% of cases, information about the duration of treatment was provided and amoxicillin with and without clavulanic acid was the antibiotic dispensed for which most warnings about side effects were issued. In 24.6% of dispensations there was no advice given at all. In 81.7% the pharmacist agreed with the prescribed treatment. Conclusions: This audit can be a starting point to improve clinical practice and reduce antibiotic resistance. It highlights the need for safety checks in regard to the use of antimicrobials and suggests verifying dispensing to correct errors that may jeopardize the safety and effectiveness of antimicrobial therapy.