Drug-related emergency department visits: external validation of an assessment tool in a general emergency department population.

BACKGROUND: The process of identifying drug-related hospitalisations is subjective and time-consuming. Assessment tool for identifying hospital admissions related to medications (AT-HARM10) was developed to simplify and objectify this process. AT-HARM10 has not previously been externally validated, thus the predictive precision of the tool is uncertain. AIM: To externally validate AT-HARM10 in adult patients admitted to the emergency department (ED). METHOD: This retrospective cross-sectional study investigated 402 patients admitted to the ED, Diakonhjemmet Hospital, Oslo, Norway. A trained 5th-year pharmacy student used AT-HARM10 to assess all patients and to classify their ED visits as possibly or unlikely drug-related. Assessment of the same patients by an interdisciplinary expert panel acted as the gold standard. The external validation was conducted by comparing AT-HARM10 classifications with the gold standard. RESULTS: According to AT-HARM10 assessments, 169 (42%) patients had a possible drug-related ED visit. Calculated sensitivity and specificity values were 95% and 71%, respectively. Further, positive and negative predictive values were 46% and 98%, respectively. Adverse effects/over-treatment and suboptimal treatment were the issues most frequently overestimated by AT-HARM10 compared with the gold standard. CONCLUSION: AT-HARM10 identifies drug-related ED visits with high sensitivity. However, the low positive predictive value indicates that further review of ED visits classified as possible drug-related by AT-HARM10 is necessary. AT-HARM10 can serve as a useful first-step screening that efficiently identifies unlikely drug-related ED visits, thus only a smaller proportion of the patients need to be reviewed by an interdisciplinary expert panel.

Impact of systematic medication review in emergency department on patients' post-discharge outcomes-A randomized controlled clinical trial.

INTRODUCTION: The main objective of this study was to investigate whether systematic medication review conducted by clinical pharmacists can impact clinical outcomes and post-discharge outcomes for patients admitted to the emergency department. METHOD: This parallel group, non-blinded, randomized controlled trial was conducted in the emergency department, Diakonhjemmet Hospital, Oslo, Norway. The study was registered in ClinicalTrials.gov, Identifier: NCT03123640 in April 2017. From April 2017 to May 2018, patients ≥18 years were included and randomized (1:1) to intervention- or control group. The control group received standard care from emergency department physicians and nurses. In addition to standard care, the intervention group received systematic medication review including medication reconciliation conducted by pharmacists, during the emergency department stay. The primary outcome was proportion of patients with an unplanned contact with hospital within 12 months from inclusion stay discharge. RESULTS: In total, 807 patients were included and randomized, 1:1, to intervention or control group. After excluding 8 patients dying during hospital stay and 10 patients lacking Norwegian personal identification number, the primary analysis comprised 789 patients: 394 intervention group patients and 395 control group patients. Regarding the primary outcome, there was no significant difference in proportion of patients with an unplanned contact with hospital within 12 months after inclusion stay discharge between groups (51.0% of intervention group patients vs. 53.2% of control group patients, p = 0.546). CONCLUSION: As currently designed, emergency department pharmacist-led medication review did not significantly influence clinical- or post-discharge outcomes. This study did, however pinpoint important practical implementations, which can be used to design tailored pharmacist-led interventions and workflow regarding drug-related issues in the emergency department setting.

Drug-related emergency department visits: prevalence and risk factors.

The study aimed to investigate the prevalence of drug-related emergency department (ED) visits and associated risk factors. This retrospective cohort study was conducted in the ED, Diakonhjemmet Hospital, Oslo, Norway. From April 2017 to May 2018, 402 patients allocated to the intervention group in a randomized controlled trial were included in this sub-study. During their ED visit, these patients received medication reconciliation and medication review conducted by study pharmacists, in addition to standard care. Retrospectively, an interdisciplinary team assessed the reconciled drug list and identified drug-related issues alongside demographics, final diagnosis, and laboratory tests for all patients to determine whether their ED visit was drug-related. The study population's median age was 67 years (IQR 27, range 19-96), and patients used a median of 4 regular drugs (IQR 6, range 0-19). In total, 79 (19.7%) patients had a drug-related ED visits, and identified risk factors were increasing age, increasing number of regular drugs and medical referral reason. Adverse effects (72.2%) and non-adherence (16.5%) were the most common causes of drug-related ED visits. Antithrombotic agents were most frequently involved in drug-related ED visits, while immunosuppressants had the highest relative frequency. Only 11.4% of the identified drug-related ED visits were documented by physicians during ED/hospital stay. In the investigated population, 19.7% had a drug-related ED visit, indicating that drug-related ED visits are a major concern. If not recognized and handled, this could be a threat against patient safety. Identified risk factors can be used to identify patients in need of additional attention regarding their drug list during the ED visit.

Effect of high-intensity exercise on cardiorespiratory fitness, cardiovascular disease risk and disease activity in patients with inflammatory joint disease: protocol for the ExeHeart randomised controlled trial.

INTRODUCTION: Inflammatory joint disease (IJD) is associated with increased risk of cardiovascular disease (CVD) fostered by systemic inflammation and a high prevalence of CVD risk factors. Cardiorespiratory fitness (CRF) is an important health parameter and CRF-measures are advocated in routine health evaluations. CRF associates with CVD risk, and exercise modalities such as high intensity interval training (HIIT) can increase CRF and mitigate CVD risk factors. In IJD, exercise is rarely used in CVD risk management and the cardioprotective effect of HIIT is unclear. Furthermore, the clinical applicability of HIIT to primary care settings is largely unknown and warrants investigation. The primary aim is to assess the effect of a HIIT programme on CRF in patients with IJD. Second, we will evaluate the effect of HIIT on CVD risk and disease activity in patients with IJD, feasibility of HIIT in primary care and validity of non-exercise algorithms to detect change in CRF. METHODS AND ANALYSIS: ExeHeart is a single-blinded, randomised controlled trial. Sixty patients with IJD will be recruited from the Preventive Cardio-Rheuma clinic at Diakonhjemmet Hospital, Norway. Patients will be assigned to receive standard care (relevant lifestyle advice and cardio-preventive medication) or standard care plus a 12-week HIIT intervention by physiotherapists in primary care. HIIT sessions will be prescribed at 90%-95% of peak heart rate. Outcomes include CRF (primary outcome), CVD risk factors, anthropometric measures, disease activity and patient-reported outcomes related to pain, fatigue, disease, physical activity and exercise and will be assessed at baseline, 3 months (primary endpoint) and 6 months postbaseline. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Regional Committee for Medical and Health Research Ethics (201227). Participants are required to sign a written informed consent form. Results will be discussed with patient representatives, submitted to peer-reviewed journals and presented at relevant platforms. TRIAL REGISTRATION NUMBER: NCT04922840.

Emergency department physicians' distribution of time in the fast paced-workflow-a novel time-motion study of drug-related activities.

Background In the emergency department physicians are forced to distribute their time to ensure that all admitted patients receive appropriate emergency care. Previous studies have raised concerns about medication discrepancies in patient's drug lists at admission to the emergency department. Thus, it is important to study how emergency department physicians distribute their time, to highlight where workflow redesign can be needed.Aim to quantify how emergency department physicians distribute their time between various task categories, with particular focus on drug-related tasks.Method Direct observation, time-motion study of emergency department physicians at Diakonhjemmet Hospital, Oslo, Norway. Physicians' activities were categorized in discrete categories and data were collected with the validated method of Work Observation Method By Activity Timing between October 2018 to January 2019. Bootstrap analysis determined 95% confidence intervals for proportions and interruption rates.Results During the observation time of 91.4 h, 31 emergency department physicians were observed. In total, physicians spent majority of their time gathering information (36.5%), communicating (26.3%), and documenting (24.2%). Further, physicians spent 17.8% (95% CI 16.8%, 19.3%) of their time on drug-related tasks. On average, physicians spent 7.8 min (95% CI 7.2, 8.6) per hour to obtain and document patients' drug lists.Conclusion Emergency department physicians are required to conduct numerous essential tasks and distributes a minor proportion of their time on drug-related tasks. More efficient information flow regarding drugs should be facilitated at transitions of care. The presence of healthcare personnel dedicated to obtaining drug lists in the emergency department should be considered.

2020 EULAR points to consider for the prevention, screening, assessment and management of non-adherence to treatment in people with rheumatic and musculoskeletal diseases for use in clinical practice.

BACKGROUND: Non-adherence to treatment could preclude reaching an optimal outcome. Thirty to 80% of patients with rheumatic and musculoskeletal diseases (RMDs) do not adhere to the agreed treatment. OBJECTIVES: The objective was to establish points to consider (PtCs) for the prevention, screening, assessment and management of non-adherence to (non-)pharmacological treatments in people with RMDs. METHODS: An EULAR task force (TF) was established, and the EULAR standardised operating procedures for the development of PtCs were followed. The TF included healthcare providers (HCPs), comprising rheumatologists, nurses, pharmacists, psychologists, physiotherapists, occupational therapists and patient-representatives from 12 European countries. A review of systematic reviews was conducted in advance to support the TF in formulating the PtCs. The level of agreement among the TF was established by anonymous online voting. RESULTS: Four overarching principles and nine PtCs were formulated. The PtCs reflect the phases of action on non-adherence. HCPs should assess and discuss adherence with patients on a regular basis and support patients to treatment adherence. As adherence is an agreed behaviour, the treatment has to be tailored to the patients' needs. The level of agreement ranged from 9.5 to 9.9 out of 10. CONCLUSIONS: These PtCs can help HCPs to support people with RMDs to be more adherent to the agreed treatment plan. The basic scheme being prevent non-adherence by bonding with the patient and building trust, overcoming structural barriers, assessing in a blame-free environment and tailoring the solution to the problem.

Prevention, screening, assessing and managing of non-adherent behaviour in people with rheumatic and musculoskeletal diseases: systematic reviews informing the 2020 EULAR points to consider.

OBJECTIVE: To analyse how non-adherence to prescribed treatments might be prevented, screened, assessed and managed in people with rheumatic and musculoskeletal diseases (RMDs). METHODS: An overview of systematic reviews (SR) was performed in four bibliographic databases. Research questions focused on: (1) effective interventions or strategies, (2) associated factors, (3) impact of shared decision making and effective communication, (4) practical things to prevent non-adherence, (5) effect of non-adherence on outcome, (6) screening and assessment tools and (7) responsible healthcare providers. The methodological quality of the reviews was assessed using AMSTAR-2. The qualitative synthesis focused on results and on the level of evidence attained from the studies included in the reviews. RESULTS: After reviewing 9908 titles, the overview included 38 SR on medication, 29 on non-pharmacological interventions and 28 on assessment. Content and quality of the included SR was very heterogeneous. The number of factors that may influence adherence exceed 700. Among 53 intervention studies, 54.7% showed a small statistically significant effect on adherence, and all three multicomponent interventions, including different modes of patient education and delivered by a variety of healthcare providers, showed a positive result in adherence to medication. No single assessment provided a comprehensive measure of adherence to either medication or exercise. CONCLUSIONS: The results underscore the complexity of non-adherence, its changing pattern and dependence on multi-level factors, the need to involve all stakeholders in all steps, the absence of a gold standard for screening and the requirement of multi-component interventions to manage it.

Serum Concentrations and Elimination Rates of Direct-Acting Oral Anticoagulants (DOACs) in Older Hip Fracture Patients Hospitalized for Surgery: A Pilot Study.

BACKGROUND: Use of direct-acting oral anticoagulants (DOACs) is increasing, but knowledge about pharmacokinetics and safety in frail patients is lacking. OBJECTIVE: The aim was to determine serum concentrations and elimination rates of DOACs in older hip fracture patients hospitalized for surgery. METHODS: The study included patients ≥ 65 years of age hospitalized for acute hip fracture surgery over a period of 6 months. Use of antithrombotic drugs was registered and serum samples collected for analysis of DOACs (apixaban, dabigatran and rivaroxaban) at admission and surgery. Measured concentrations were assessed in relation to reference (therapeutic) ranges of the respective drugs and applied for half-life calculations. Furthermore, waiting time for surgery was compared between DOAC and warfarin users. RESULTS: Of 167 patients included (median age 84 years), 11 and 14 used DOACs and warfarin, respectively. Seven of the DOAC-treated patients had concentrations above the upper reference range (> 300 nM) at admission, and concentrations were still in the reference range for five of these at surgery. Elimination half-lives could be estimated in eight patients and ranged between 14.6 and 59.7 h (median 21.6). The observed waiting time for surgery was longer for patients using DOACs than warfarin (median 44 vs. 25 h). CONCLUSION: This pilot study indicates that older patients prone to hip fracture are at risk of being exposed to therapeutic serum concentrations of DOACs during surgery due to reduced drug elimination rates. The observation that almost 50% of the patients had therapeutic concentrations at surgery should be investigated further regarding safety of DOAC use in this frail elderly population.

Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (IMMENSE study): study protocol for a randomised controlled trial.

INTRODUCTION: Drug-related problems (DRPs) are common in the elderly, leading to suboptimal therapy, hospitalisations and increased mortality. The integrated medicines management (IMM) model is a multifactorial interdisciplinary methodology aiming to optimise individual medication therapy throughout the hospital stay. IMM has been shown to reduce readmissions and drug-related hospital readmissions. Using the IMM model as a template, we have designed an intervention aiming both to improve medication safety in hospitals, and communication across the secondary and primary care interface. This paper presents the study protocol to explore the effects of the intervention with regard to healthcare use, health-related quality of life (HRQoL) and medication appropriateness in elderly patients. METHODS AND ANALYSIS: A total of 500 patients aged ≥70 years will be included and randomised to control (standard care) or intervention group (1:1). The intervention comprises five steps mainly performed by pharmacists: (1) medication reconciliation at admission, (2) medication review during hospital stay, (3) patient counselling about the use of medicines, (4) a comprehensible and patient-friendly medication list with explanations in discharge summary and (5) postdischarge phone calls to the primary care level. The primary outcome is the difference between intervention and control patients in the rate of emergency medical visits (acute readmissions and visits to emergency department) 12 months after discharge. Secondary outcomes include length of index hospital stay, time to first readmission, mortality, hip fractures, strokes, medication changes, HRQoL and medication appropriateness. Patient inclusion started in September 2016. ETHICS AND DISSEMINATION: The trial was approved by the Norwegian Centre for Research Data and the Norwegian Data Protection Authority. We aim to publish the results in international peer-reviewed open access journals, at national and international conferences, and as part of two PhD theses. TRIAL REGISTRATION NUMBER: NCT02816086.

Drug safety at admission to emergency department: an innovative model for PRIOritizing patients for MEdication Reconciliation (PRIOMER).

OBJECTIVE: This study aimed to develop an innovative prioritizing model for conducting medication reconciliation (MR) at a fast-paced workflow emergency department (ED) and to implement an efficient working model for MR. PATIENTS AND METHODS: A total of 276 patients were included at the ED, Diakonhjemmet Hospital, Norway, and medication discrepancies (MDs) between hospital admission records and information on prehospital medication use were recorded. Clinically relevant medication discrepancies (crMDs) were assessed by a multidisciplinary panel. Binary logistic regression was used to construct the prioritizing model from patient characteristics correlated to crMDs, and patient characteristics included in the model should be easily available in the acute situation. A survey among the physicians made up the basis for the working model for conducting MR. RESULTS: In total, 62% of the patients had one or more crMD. The following turned out to be risk factors for having a crMD suitable for inclusion in the model: sex (woman), age (≥60), one or more admission to hospital in the last 12 months and admission causes: surgical, malfunction, cancer. The prioritizing model correctly classified 76.1% of the patients as high-risk patients for having a crMD. In the new working model, in which clinical pharmacists/trained nurses perform MR before the physician did the medication history, was perceived to be more time efficient and also clarified questions related to the medication history early in the admission process. CONCLUSION: This innovative prioritizing model is designed to be practical in the fast-paced workflow at the ED and can identify what patients are at increased risk of having crMDs. The multidisciplinary working model was proven time efficient and could contribute towards increased patient safety.

Should nurses or clinical pharmacists perform medication reconciliation? A randomized controlled trial.

PURPOSE: To study differences in outcomes of medication reconciliation (MR) when performed by clinical pharmacists compared to nurses. METHODS: 201 patients (21-92 years) admitted to the Department of Cardiology at the University Hospital of North Norway, autumn 2012, were randomized into a pharmacist group (PG) and a nurse group (NG). The nurses and the pharmacists were trained for performing the MR process by an independent clinical pharmacist. Medication discrepancies (MDs) were discussed with the physicians. Time spent during the MR was recorded. An independent expert group rated clinical relevance of the MDs retrospectively. RESULTS: At least one MD was identified in 78 % and 84 % of patients in PG and NG, respectively (P = 0.269) with a mean number of MDs per patient 3.1 (SD 2.1) and 2.8 (SD 2.2), respectively (P = 0.528). Mean time spent/patient on the MR process was 22.9 min (SD 11.6) in the PG and 32.2 min (SD 20.3) in the NG (P < 0,001). Physicians agreed significantly more often to act upon the MDs presented by pharmacists compared to nurses (P = 0.001). The expert group finally assessed 48 % and 49 % of the MDs to be of the clinical relevance in the PG and the NG, respectively. CONCLUSIONS: By applying a structured method for MR, a small however not statistically significant difference in identified MDs between nurses and clinical pharmacists was revealed. The pharmacists spent significantly less time than the nurses, and physicians agreed significantly more often with the pharmacist that action should be taken on the MDs. This is important in the discussion of who to perform MR.

Beliefs about medicines among Norwegian outpatients with chronic cardiovascular disease.

OBJECTIVE: To investigate the beliefs of Norwegian outpatients about medicines, and to explore if some patient-specific factors and drug use are associated with the beliefs. METHODS: Patients from an outpatient clinic for chronic cardiovascular diseases were referred by physicians to a pharmacist-led medication outpatient clinic. Here the patients were asked to complete the Beliefs about Medicines Questionnaire. RESULTS: 150 patients were included (mean age 70.0 years (range 31-91), 50 (33.3%) women), using a total of 1061 drugs. 91.2% strongly believed in the necessity of their medicines and 29.7% had strong concerns. Multivariate regression analyses showed that with an increasing number of drugs, the score for necessity was significantly increased (p<0.01). Women were significantly more concerned than men (p=0.03). The older the patient, the higher the score for general harm of medicines (p=0.01). CONCLUSIONS: Although the majority of the patients in this study believed in the necessity of their medication, one-third had strong concerns.

Use of antibiotics in nursing homes--surveillance with different methods.

BACKGROUND: Residents in nursing homes have a heightened risk of developing infections that should be treated with antibiotics. Inappropriate use of antibiotics may generate drug-related problems and increase resistance. In this study, we describe the use of antibiotics in nursing homes on the basis of prevalence surveys and drug sales statistics. MATERIAL AND METHODS: Five nursing homes in Oslo participated in two one-day surveys in 2009. All use of systemic antibiotics was registered. The data collection was undertaken according to a protocol developed by the European Surveillance of Antimicrobial Consumption (ESAC) Network and was part of a European study. The nursing homes' drug sales statistics for systemic antibiotics during 2009, distributed by the number of bed days for each nursing home, were estimated. Information on indications for each antibiotic from the prevalence surveys was collated with sales data to achieve an estimate of how the purchased antibiotics were used. RESULTS: The prevalence surveys showed that more than 8% of the residents received antibiotics. Prophylactic treatment accounted for 33% of the prescriptions. A prevalence of antibiotic use of 10% was estimated from the drug sales statistics. Urinary tract infection was the most frequently registered indication. Pivmecillinam and methenamine were most frequently prescribed and most frequently purchased. Most courses of treatment were prescribed in accordance with the national guidelines for antibiotic use. INTERPRETATION: The results from the drug sales statistics concurred well with the prevalence surveys, and the methods can thus be relevant for purposes of monitoring the use of antibiotics.

How are drug regimen changes during hospitalisation handled after discharge: a cohort study.

OBJECTIVES: To investigate drug regimen changes during hospitalisation and explore how these changes are handled after patients are transferred back into the care of their general practitioners (GPs). DESIGN: Cohort study. SETTING: Patients in this multicentre study had undergone at least one change in their drug regimens at discharge from the general medicine departments at six hospitals in Norway. These changes were altered doses, discontinuation of drugs or start of new drugs. Clinical pharmacists visited the patients' GPs 4-5 months after patient discharge and recorded any additional drug regimen changes. RESULTS: In total, 105 patients (mean age 76.1 years, 54.3% women) completed the study. On average, they used 5.6 drugs at admission (range 0-16) and 7.6 drugs at discharge (range 1-17). On average, 4.4 drug changes per patient (SD 2.7, range 1-16) were made at the hospital, and 3.4 drug changes per patient (SD 2.9, range 0-14) within 4-5 months of discharge. Of the 465 drug changes made in hospital, 153 were changed again after discharge (mean 1.5 per patient, SD 1.8, range 0-13). The drug regimens of 90 of these 105 patients were changed after discharge. The OR for extensive drug changes after discharge (≥ 4 changes) increased significantly with the number of drugs used at discharge from hospital (OR=1.29, 95% CI 1.04 to 1.59). Only 68 of 105 discharge notes contained complete drug lists, and only 24 of the discharge notes were received by the GPs within 7 days. CONCLUSIONS: In addition to the extensive changes in drug regimens during hospitalisation, almost equally extensive changes were made in the initial months after discharge. Surveillance of drug regimens is particularly necessary in the period immediately after hospital discharge.

Multidisciplinary intervention to identify and resolve drug-related problems in Norwegian nursing homes.

OBJECTIVE: To describe an innovative team intervention to identify and resolve DRPs (drug-related problems) in Norwegian nursing homes. DESIGN: Descriptive intervention study. Setting. Three nursing homes in Bergen, Norway. SUBJECTS: A total of 142 long-term care patients (106 women, mean age 86.9 years). RESULTS: Systematic medication reviews performed by pharmacists in 142 patients revealed altogether 719 DRPs, of which 504 were acknowledged by the patients' physician and nurses, and 476 interventions were completed. "Unnecessary drug" and "Monitoring required" were the most frequently identified DRPs. Drugs for treating the nervous system and the alimentary tract and metabolism were most commonly questioned. CONCLUSIONS: The multidisciplinary team intervention was suitable to identify and resolve drug-related problems in nursing home settings. Systematic medication reviews and involvement of pharmacists in clinical teams should therefore be implemented on a regular basis to achieve and maintain high-quality drug therapy.

Evaluating categorisation and clinical relevance of drug-related problems in medication reviews.

OBJECTIVES: We aimed to evaluate the categorisation and clinical relevance of DRPs identified by community pharmacists, and further, to assess the quality of interventions with the patients and the physicians as documented by the pharmacists. SETTING: 23 Norwegian community pharmacies. METHOD: Patients with type 2 diabetes were recruited by 24 community pharmacists who performed structured medication reviews based on the patients' drug profiles and patient interviews. The DRPs identified were subsequently categorised. An evaluation group (EG) retrospectively evaluated the reviews. Clinical/practical relevance of each DRP and quality of community pharmacists' intervention with patients and physician were scored. Average agreement between the EG and the community pharmacists was calculated. Internal agreement in the EG was calculated using a modified version of Fleiss' Kappa coefficient. RESULTS: A total of 73 patients were included (mean age 62 years, 52% female, on average prescribed 8.7 drugs). The pharmacists identified 88 DRPs in 43 of the patients. The most common DRPs were adverse drug reactions (22%) and wrong drug or dose used by patient (14%). Anti-diabetic drugs and lipid modifying drugs were associated with the most DRPs. The EG agreed with detection and categorisation of DRPs in more than 80% of the cases. The clinical/practical relevance of the detected DRPs was scored by the EG to be high or medium in 87% of the cases. The quality of the follow-up with patients and physicians was scored to be good or satisfactory in 93 and 98% of the cases, respectively. CONCLUSIONS: Pre-defined categories of DRPs supported by structured forms were reliable and valid tools for identifying DRPs. The evaluation demonstrated that community pharmacists were able to identify DRPs of high to medium clinical/practical relevance, and to perform follow-ups of the DRPs with the patients and the physicians with a good or satisfactory quality.

Drugs with narrow therapeutic index as indicators in the risk management of hospitalised patients.

UNLABELLED: Drugs with narrow therapeutic index (NTI-drugs) are drugs with small differences between therapeutic and toxic doses. The pattern of drug-related problems (DRPs) associated with these drugs has not been explored. OBJECTIVE: To investigate how, and to what extent drugs, with a narrow therapeutic index (NTI-drugs), as compared with other drugs, relate to different types of drug-related problems (DRPs) in hospitalised patients. METHODS: Patients from internal medicine and rheumatology departments in five Norwegian hospitals were prospectively included in 2002. Clinical pharmacists recorded demographic data, drugs used, medical history and laboratory data. Patients who used NTI-drugs (aminoglycosides, ciclosporin, carbamazepine, digoxin, digitoxin, flecainide, lithium, phenytoin, phenobarbital, rifampicin, theophylline, warfarin) were compared with patients not using NTI-drugs. Occurrences of eight different types of DRPs were registered after reviews of medical records and assessment by multidisciplinary hospital teams. The drug risk ratio, defined as number of DRPs divided by number of times the drug was used, was calculated for the various drugs. RESULTS: Of the 827 patients included, 292 patients (35%) used NTI-drugs. The NTI-drugs were significantly more often associated with DRPs than the non-NTI-drugs, 40% versus 19% of the times they were used. The drug risk ratio was 0.50 for NTI-drugs and 0.20 for non-NTI-drugs. Three categories of DRPs were significantly more frequently found for NTI-drugs: non-optimal dose, drug interaction, and need for monitoring. CONCLUSION: DRPs were more frequently associated with NTI-drugs than with non-NTI-drugs, but the excess occurrence was solely related to three of the eight DRP categories recorded. The drug risk ratio is a well-suited tool for characterising the risk attributed to various drugs.

Use of antirheumatic drugs in mothers and fathers before and during pregnancy-a population-based cohort study.

PURPOSE: Exploring the use of antirheumatic drugs in pregnant women and expectant fathers. METHODS: Population-based cohort study, based on linkage of two nationwide databases: the Norwegian Prescription Database was linked to data on 106 000 pregnancies during 2004-2006 from the Medical Birth Registry of Norway. Antirheumatic drugs dispensed to mothers 3 months prior to conception, during pregnancy, and up to 6 months after delivery, and prescriptions to fathers 3 months prior to conception were identified. RESULTS: During the 18-month observation period for each pregnancy, 1411 women (1.3% of the women) redeemed at least one antirheumatic drug. Of these, 45% received at least one drug during 3 months prior to conception and 28% in the first trimester. Four women redeemed prescriptions for methotrexate during the 3 months prior to conception, and two women did so during the pregnancy. One of the four women on leflunomide, received the drug 3 months before conception, and two of them during the first trimester. Among the women using etanercept, 19 women redeemed the prescription 3 months before pregnancy, 11 during the first trimester, one in both the second and third trimesters. Three months prior to conception, 837 expecting fathers (0.8%) redeemed at least one prescription: 40 had sulfasalazin, 36 methotrexate and 28 had biological drugs. CONCLUSION: Three women redeemed leflunomide or methotrexate, which have known teratogenic effects, during their first trimester. While there are high levels of awareness about maternal drug use in pregnancy, drug exposure in fathers shortly before conception should be further explored.

Risk of drug-related problems for various antibiotics in hospital: assessment by use of a novel method.

PURPOSE: To investigate the use of antibiotics in hospitals, to explore drug-related problems (DRPs) linked to antibiotics and to introduce a novel way of expressing the risks accompanying use of various antibiotics. METHODS: Patients from internal medicine departments in four Norwegian hospitals were prospectively included in 2002. Demographics, drugs used, medical history, laboratory data and clinical/pharmacological risk factors were recorded. DRPs were identified by clinical pharmacists and assessed in multidisciplinary hospital teams. A new term, the drug risk ratio, was established and defined as the number of times the antibiotic was associated with DRPs in relation to the number of times it was used. RESULTS: Out of the 668 patients included, 283 patients (42%) used antibiotics (AB users). AB users were older (76.2 vs. 73.9), used more drugs on admission (5.1 vs. 4.4) and had more DRPs (3.0 vs. 2.2) than non-users. The DRP categories no further need for drug, non-optimal drug and non-optimal dose were most frequently observed. The drug risk ratio, calculated for 12 antibiotic groups, was highest for aminoglycosides (0.77), beta-lactamase-resistant penicillins (0.56), macrolides (0.54) and quinolones (0.48) and lowest for first- and third-generation cephalosporins, 0.17 and 0.13, respectively. CONCLUSIONS: Nearly half of the hospitalised patients were prescribed antibiotics and antibiotic associated DRPs occurred frequently. The drug risk ratio for the different antibiotic groups varied with a factor of six from the lowest to the highest. A high drug risk ratio would alert of antibiotics which require heightened awareness when going to be used in clinical practice.

The impact of clinical pharmacists on drug-related problems and clinical outcomes.

Drug-related problems are frequent and may result in reduced quality of life, and even morbidity and mortality. Many studies have shown that clinical pharmacists can effectively identify and prevent clinically significant drug-related problems and that physicians acknowledge and act on the clinical pharmacist's suggestions for interventions to the drug-related problems. A pro-active rather than a reactive approach on the part of the pharmacists seems prudent for obtaining most benefit. This includes participation of pharmacists in the multidisciplinary team discussions - at the stage of ordering and prescribing - where all types of drug-related problems, including also potential problems, should be discussed. In addition, counselling by pharmacists about medication on discharge and follow-up after discharge resulted in better outcomes. Furthermore, clinical pharmacists can positively influence other outcomes, such as improvement of levels of markers for drug use (e.g. optimization of lipid levels, anticoagulation levels and blood pressure). Some studies have reported positive effects on hard clinical outcomes, such as reduced length of stay, fewer re-admissions and fewer disease events (e.g. heart failure events and thromboembolism). However, more studies should be undertaken with larger patient populations, including patients from multiple sites. More knowledge about patient-specific factors that predict improved care is also needed. In conclusion, there is increasing evidence that participation and interventions of clinical pharmacists in health care positively influence clinical practice.