Implementing a newly prescribed cardiovascular medicine in daily routine: The patient perspective at readmission to primary care.

BACKGROUND: Readmission to primary care is challenging for patients due to involvement of multiple healthcare providers across different settings and implementing new medicines into their daily routine. Elucidating patients' needs is crucial to tailor counseling support. OBJECTIVE: To explore the patient perspectives on implementing a newly prescribed cardiovascular medicine into their daily routine at readmission to primary care. METHODS: A qualitative study was performed within the outpatient pharmacy. Adult patients who were prescribed a new cardiovascular medicine by their treating hospital physician at hospital discharge or during an outpatient clinic visit were eligible to participate. Purposive sampling was applied to equally distribute adherence-influencing factors. Patients were interviewed by telephone and inclusion continued until theoretical data saturation. An adapted Greenhalgh framework for implementation research was used for a thematic content analysis by conceptualizing the new medicine as an innovation that requires implementation by a patient (adopter). RESULTS: Data saturation was reached at 44 patients of which 19 discontinued their new medicine at the time of the interview. Reasons for discontinuing included: side-effects, insufficient efficacy or negligence. Patients considered a lack of basic knowledge on their newly prescribed cardiovascular medicine as a major barrier for adopting it into their daily routine. They were in need of information on risks and benefits of their new medicine. A noticeable effect and tailored counseling facilitated patients in taking their medicine as prescribed. Patients mentioned personalized organizing tools and routinization of medication intake as important success factors for addressing their practical challenges with their new medicine. CONCLUSIONS: By applying the adapted Greenhalgh framework, this study provided a unique and structured insight in patients' barriers and facilitators that could influence their ability to implement a new cardiovascular medicine at readmission to primary care. This knowledge enables pharmacists to tailor their patient support and provide individualized patient counseling.

Immunity to the bacteriocin sublancin 168 Is determined by the SunI (YolF) protein of Bacillus subtilis.

Bacillus subtilis strain 168 produces the extremely stable lantibiotic sublancin 168, which has a broad spectrum of bactericidal activity. Both sublancin 168 production and producer immunity are determined by the SPbeta prophage. While the sunA and sunT genes for sublancin 168 production have been known for several years, the genetic basis for sublancin 168 producer immunity has remained elusive. Therefore, the present studies were aimed at identifying an SPbeta gene(s) for sublancin 168 immunity. By systematic deletion analysis, we were able to pinpoint one gene, named yolF, as the sublancin 168 producer immunity gene. Growth inhibition assays performed using plates and liquid cultures revealed that YolF is both required and sufficient for sublancin 168 immunity even when heterologously produced in the sublancin-sensitive bacterium Staphylococcus aureus. Accordingly, we propose to rename yolF to sunI (for sublancin immunity). Subcellular localization studies indicate that the SunI protein is anchored to the membrane with a single N-terminal membrane-spanning domain that has an N(out)-C(in) topology. Thus, the bulk of the protein faces the cytoplasm of B. subtilis. This topology has not yet been reported for known bacteriocin producer immunity proteins, which implies that SunI belongs to a novel class of bacteriocin antagonists.

Collaboration between hospital and community pharmacists to address drug-related problems: The HomeCoMe-program.

BACKGROUND: Hospital discharge poses a significant threat to the continuity of medication therapy and frequently results in drug-related problems post-discharge. Therefore, establishing continuity of care by realizing optimal collaboration between hospital and community pharmacists is of utmost importance. OBJECTIVE: To evaluate the collaboration between hospital and community pharmacists on addressing drug-related problems after hospital discharge. METHODS: A prospective follow-up study was conducted between November 2013-December 2014 in a general hospital and all affiliated community pharmacies. Adult patients, admitted for ≥48 h to the neurology or pulmonology ward were eligible if they used ≥3 chronic prescription drugs and lived in the community pharmacies' service area. The HomeCoMe intervention program was comprised of medication verification and counseling at admission, medication screening by the hospital pharmacist during admission, outpatient pharmacy discharge consultation and support, and a community pharmacist home visit within one week post-discharge. RESULTS: The mean age of the 152 included patients was 67.0 ±â€¯12.6 years and 56.6% were female. A total of 745 DRPs (4.9 ±â€¯2.2 DRPs per patient, range: 0-11) were identified with the need for additional "Education or information" (36.1%) and "Compliance" (16.4%) issues as most common DRP-types. This led to a total of 928 recommendations (6.1 ±â€¯3.0 per patient, range: 1-19) to solve the DRP. The majority of DRPs were identified (83.6%, n = 623) and solved (91.6%, n = 682) by the community pharmacist during the home visit. Furthermore, 52.5% (n = 64) of the DRPs identified during hospitalization were solved during the post-discharge home visit. CONCLUSIONS: Collaboration between hospital and community pharmacists from hospital admission to readmission to primary care is crucial to establish continuity of care. A post-discharge community pharmacist home visit is a valuable addition to in-hospital transitional care to identify and solve drug-related problems.

Patient-pharmacist communication during a post-discharge pharmacist home visit.

Background With the shifting role of community pharmacists towards patient education and counselling, they are well-positioned to conduct a post-discharge home visit which could prevent or solve drug-related problems. Gaining insight into the communication during these home visits could be valuable for optimizing and consequently improving patient safety at readmission to primary care. Objective To assess patient-pharmacist communication during a post-discharge home visit. Setting The homes of patients recently discharged from a single general hospital in the Netherlands. Methods Pharmacists used a semi-structured protocol to guide the consultations and audiorecorded them. Sixty audio-recordings were included for a qualitative analysis in this study with the help of NVivo version 11 software. Main outcome measure (1) Initiator and topics under discussion. (2) Frequency of discussion of topics as per coded in themes and subthemes. Results Issues regarding the administration and use of medication, e.g. regimen and actual drug-taking issues, knowledge gaps regarding their medication and patients' health were discussed most frequently, followed by medication logistics and medication effectiveness. Patients' beliefs about their medication and adherence were less frequently discussed. The pharmacist initiated the majority of these topics. Additional non-protocolled topics were scarce and consisted mainly of patient-initiated dissatisfaction regarding the community pharmacy or health insurers. Conclusion Community pharmacists most frequently initiated practical issues, but explored patients' medication beliefs less adequately. Discussing these beliefs might be easier by increasing patient engagement in the consultation and providing training programs for pharmacists.

Pharmacists' barriers and facilitators on implementing a post-discharge home visit.

BACKGROUND: Introducing a post-discharge community pharmacist home visit can secure continuity of care and prevent drug-related problems. Currently, this type of pharmaceutical care is not standard practice and implementation is challenging. Mapping the factors influencing the implementation of this new form of care is crucial to ensure successful embedding. OBJECTIVE: To explore which barriers and facilitators influence community pharmacists' adoption of a post-discharge home visit. METHODS: A mixed methods study was conducted with community pharmacists who had recently participated in a study that evaluated the effectiveness of a post-discharge home visit in identifying drug-related problems. Four focus groups were held guided by a topic guide based on the framework of Greenhalgh et al. After the focus groups, major barriers and facilitators were formulated into statements and presented to all participants in a scoring list to rank for relevance and feasibility in daily practice. RESULTS: Twenty-two of the eligible 26 pharmacists participated in the focus groups. Twenty pharmacists (91%) returned the scoring list containing 21 statements. Most of these statements were perceived as both relevant and feasible by the responding pharmacists. A small number scored high on relevance but low on feasibility, making these potential important barriers to overcome for broad implementation. These were the necessity of dedicated time for performing pharmaceutical care, implementing the home visit in pharmacists' daily routine and an adequate reimbursement fee for the home visit. CONCLUSIONS: The key to successful implementation of a post-discharge home visit may lay in two facilitators which are partly interrelated: changing daily routine and reimbursement. Reimbursement will be a strong incentive, but additional efforts will be needed to reprioritize daily routines.

Identifying the Optimal Role for Pharmacists in Care Transitions: A Systematic Review.

BACKGROUND: A transition from one health care setting to another increases the risk of medication errors. Several strategies have been applied to improve care transitions and reduce adverse clinical outcomes. Pharmacist intervention during and after hospitalization has been frequently studied and show a variable effect on these outcomes. OBJECTIVE: To identify the components of pharmacist intervention that improve clinical outcomes during care transitions. METHODS: MEDLINE, EMBASE, International Pharmaceutical Abstracts, and Web of Science databases were searched for randomized controlled trials (RCTs) that studied pharmacist intervention with regard to hospitalization. Two reviewers independently screened all references published from inception to November 2014, extracted data, and assessed risk of bias. RESULTS: A total of 30 studies met the inclusion criteria. A model was created to categorize and cluster components of pharmacist intervention. The average number of components deployed, stages of hospitalization covered, and intervention targets were equally distributed between effective and ineffective studies. A best evidence synthesis of 15 studies revealed strong evidence for a clinical medication review in multifaceted programs (5 effective vs. 0 ineffective studies). Conflicting evidence was found for an isolated postdischarge intervention, admission medication reconciliation, combining postdischarge interventions with in-hospital interventions, and covering of multiple stages. Closely collaborating with other health care providers enhanced the effectiveness. CONCLUSIONS: Although there is a need for well-designed and well-reported RCTs, the study heterogeneity enabled a best evidence synthesis to elucidate effective components of pharmacist intervention. In isolated postdischarge intervention programs, evidence tends towards collaborating with nurses and tailoring to individual patient needs. In multifaceted intervention programs, performing medication reconciliation alone is insufficient in reducing postdischarge clinical outcomes and should be combined with active patient counseling and a clinical medication review. Furthermore, close collaboration between pharmacists and physicians is beneficial. Finally, it is important to secure continuity of care by integrating pharmacists in these multifaceted programs across health care settings. Ultimately, pharmacists need to know patient clinical background and previous hospital experience.

Bridging the gap between hospital and primary care: the pharmacist home visit.

Bridging the gap between hospital and primary care is important as transition from one healthcare setting to another increases the risk on drug-related problems and consequent readmissions. To reduce those risks, pharmacist interventions during and after hospitalization have been frequently studied, albeit with variable effects. Therefore, in this manuscript we propose a three phase approach to structurally address post-discharge drug-related problems. First, hospitals need to transfer up-todate medication information to community pharmacists. Second, the key phase of this approach consists of adequate follow-up at the patients' home. Pharmacists need to apply their clinical and communication skills to identify and analyze drug-related problems. Finally, to prevent and solve identified drug related problems a close collaboration within the primary care setting between pharmacists and general practitioners is of utmost importance. It is expected that such an approach results in improved quality of care and improved patient safety.