Effect of training and structured medication review on medication appropriateness in nursing home residents and on cooperation between health care professionals: the InTherAKT study protocol.

BACKGROUND: Pharmacotherapy in residents of nursing homes is critical due to the special vulnerability of this population. Medical care and interprofessional communication in nursing homes are often uncoordinated. As a consequence, polypharmacy and inappropriate medication use are common and may lead to hospitalizations and health hazards. The aim of this study is to optimize communication between the involved professional groups by specific training and by establishing a structured medication review process, and to improve medication appropriateness and patient-relevant health outcomes for residents of nursing homes. METHODS/DESIGN: The trial is designed as single-arm study. It involves 300 nursing home residents aged ≥ 65 years and the members of the different professional groups practising in nursing home care (15-20 general practitioners, nurses, pharmacists). The intervention consists of interprofessional education on safe medication use in geriatric patients, and a systematic interprofessional therapy check (recording, reviewing and adapting the medication of the participating residents by means of a specific online platform). The intervention period is divided into two phases; total project period is 3 years. Primary outcome measure is the change in medication appropriateness according to the Medication Appropriateness Index. Secondary outcomes are cognitive performance, occurrence of delirium, agitation, tendency of falls, total number of drugs, number of potentially dangerous drug-drug interactions and appropriateness of recorded analgesic therapy regimens according to the Medication Appropriateness Index. Data are collected at t0 (before the start of the intervention), t1 (after the first intervention period) and t2 (after the second intervention period). Cooperation and communication between the professional groups are investigated twice by qualitative interviews. DISCUSSION: The project aims to establish a structured system for monitoring of drug therapy in nursing home residents. The newly developed online platform is designed to systematize and to improve the communication between the professional groups and, thus, to enhance quality and safety of drug therapy. Limitations of the study are the lack of a control group and the non-randomly recruited study sample. TRIAL REGISTRATION: DRKS Data Management, DRKS-ID: DRKS00007900.

Identification of factors for a successful implementation of medication reviews in community pharmacies: Using Positive Deviance in pharmaceutical care.

Background Pharmacists in community pharmacies worldwide successfully conduct an increasing number of medication reviews (MR). Since June 2012 MR are incorporated in the German ordinance on the operation of pharmacies as pharmaceutical service. In November 2014, a German guideline for MR was established. Different teaching programmes for MR were implemented since. Despite these favorable conditions, only few pharmacies conduct MR regularly. OBJECTIVE: Identification of factors necessary for a successful implementation of MR in community pharmacies. SETTING: Community pharmacies located in the area of the Pharmacists'  Chamber Westphalia-Lippe (Part of Northrhine-Westphalia, Germany). METHOD: Following a Positive-Deviance approach, telephone interviews were conducted in community pharmacies with pharmacy-owners, MR-trained employed pharmacists, and technicians. Data evaluation was performed using qualitative content analysis. MAIN OUTCOME RESULTS: Successful strategies for implementing MR in community pharmacies. RESULTS: Forty-four interviews were conducted and analysed. Thirty-three success factors were identified. Data analysis revealed two groups of success-factors important for implementation of MR; organisational (n = 25) and individual factors (n = 8). Relevant organisational success-factor were involvement of the entire team with active involvement of technicians, documentation of results in the pharmacy software and training in patient-identification and communication. Restructuring of workflows increased time-periods for MR. Important individual success-factors were: motivation and identification with the service, routine in execution to enhance self-esteem, and specialisation in pharmacotherapy of particular diseases. Pharmacy-owners play a pivotal role as motivators. Professional healthcare attitude, exhibited in daily routine, leads to increased acceptance by patients and practitioners and thus increases implementation-rates considerably. CONCLUSION: We were able to define strategies for successful implementation of MR in community pharmacies.

Enhancing medication therapy in Parkinson's disease by establishing an interprofessional network including pharmacists.

Background Optimizing therapy regimens through collaboration and combination of available resources is a promising approach to improve quality of life for patients with Parkinson's disease (PD). Aim The aim of this project was to enhance patient-oriented therapy and interprofessional collaboration by establishing a regional PD network. Setting The network is located in a rural area in Germany. It covers primary, secondary and tertiary care facilities across professional boundaries. Development Recruitment of PD specialists and patient support groups was done by the local newspaper to spread the word. The network was initially open to all healthcare professionals, who stated a focus or special interest in PD. A working group for medication was founded within the network by asking for interested participants. Problems in the medication process were discussed within the group. As a consequence, therapy recommendations (quickcards) and a specific medication plan were developed and a certified education curriculum for pharmacists was developed. Implementation The network grew to > 150 participants across all disciplines and sectors. Quickcards were adjusted, approved and implemented by the network during interquartile meetings. Certified education was implemented and became a requirement for participating pharmacists. Evaluation The quickcards on medication plan and drug-drug-interactions were approved to be useful and feasible by the network by unanimous assent. Overall satisfaction with certified education was high (mean of 1.4 on a scale between 1 = high and 6 = low). Conclusion A regional interprofessional PD network with pharmacists was established and new standards were established. Future research needs to measure the effects on patient outcomes.

Compliance assessment of ambulatory Alzheimer patients to aid therapeutic decisions by healthcare professionals.

BACKGROUND: Compliance represents a major determinant for the effectiveness of pharmacotherapy. Compliance reports summarising electronically compiled compliance data qualify healthcare needs and can be utilised as part of a compliance enhancing intervention. Nevertheless, evidence-based information on a sufficient level of compliance is scarce complicating the interpretation of compliance reports. The purpose of our pilot study was to determine the compliance of ambulatory Alzheimer patients to antidementia drugs under routine therapeutic use using electronic monitoring. In addition, the forgiveness of donepezil (i.e. its ability to sustain adequate pharmacological response despite suboptimal compliance) was characterised and evidence-based guidance for the interpretation of compliance reports was intended to be developed. METHODS: We determined the compliance of four different antidementia drugs by electronic monitoring in 31 patients over six months. All patients were recruited from the gerontopsychiatric clinic of a university hospital as part of a pilot study. The so called medication event monitoring system (MEMS) was employed, consisting of a vial with a microprocessor in the lid which records the time (date, hour, minute) of every opening. Daily compliance served as primary outcome measure, defined as percentage of days with correctly administered doses of medication. In addition, pharmacokinetics and pharmacodynamics of donepezil were simulated to systematically assess therapeutic undersupply also incorporating study compliance patterns. Statistical analyses were performed with SPSS and Microsoft Excel. RESULTS: Median daily compliance was 94% (range 48%-99%). Ten patients (32%) were non-compliant at least for one month. One-sixth of patients taking donepezil displayed periods of therapeutic undersupply. For 10 mg and 5 mg donepezil once-daily dosing, the estimated forgiveness of donepezil was 80% and 90% daily compliance or two and one dosage omissions at steady state, respectively. Based on the simulation findings we developed rules for the evidence-based interpretation of donepezil compliance reports. CONCLUSIONS: Compliance in ambulatory Alzheimer patients was for the first time assessed under routine conditions using electronic monitoring: On average compliance was relatively high but variable between patients. The approach of pharmacokinetic/pharmacodynamic in silico simulations was suitable to characterise the forgiveness of donepezil suggesting evidence-based recommendations for the interpretation of compliance reports.

[Assuring the quality of continuous professional development: An analysis of accreditation documents of the chambers of pharmacists in Germany]. / Qualitätssicherung in der pharmazeutischen Fortbildung: Eine Analyse der Akkreditierungsunterlagen der deutschen Apothekerkammern.

Accreditation of continuous professional training events is an important means to ensure quality. In Germany, the chambers of pharmacists accredit these events, i. e., they check the documents that the organizers of these events provide. The aim of this investigation was to compare the accreditation documents that the chambers of pharmacists publish on their websites. We developed explicit rating criteria concerning the categories quality of content, conflict of interest and sponsoring. The analysis revealed a huge discrepancy between the individual chambers of pharmacists and also in the way they addressed different items. The Federal Chamber of Pharmacists revised its accreditation requirements in early 2019, which raised the rating. However, there is still room for improvement. To ensure the quality of pharmaceutical continuous accreditation, the chambers of pharmacists should work towards establishing more stringent and uniform accreditation requirements.

[The beers criteria--an instrument to optimise the pharmacotherapy of geriatric patients]. / Die Beers-Liste. Ein Instrument zur Optimierung der Arzneimitteltherapie geriatrischer Patienten.

Geriatric patients represent an important population group in counselling and care of pharmacists. Despite this high need, there are only few investigations in this special patient population and derived aids for competent and practice-oriented pharmaceutical care. The Beers criteria developed in the US represent an instrument to detect potentially inappropriate medication in older adults. In order to propagate in Germany a translation and adaptation to the German drug market was performed. Systematic consensus building by an expert panel will be necessary for wide acceptability. Applying the Beers criteria presents an opportunity of pharmacist to optimise the pharmacotherapy of geriatric patients.

Urea as an endogenous surrogate in human microdialysis to determine relative recovery of drugs: analytics and applications.

During in vivo microdialysis studies time-consuming and laborious bedside calibration methods, e.g. retrodialysis, have to be performed. To reduce the burden on the patient it would be desirable to establish a reliable, time-saving calibration technique to obtain the in vivo recovery describing the relative drug transfer across the membrane of the microdialysis probe. The performed study aimed to evaluate and validate the use of urea as an endogenous reference compound to determine relative in vivo recovery of anti-infectives, e.g. linezolid used herein as model drug. In order to meet the special requirements imposed by microdialysis to measure urea concentrations in very small sample volumes ( approximately 10 microL) a photometric assay in 96-well microtiter plates was established based on the method of Berthelot. Subsequently, concentration- and flow rate-dependence were evaluated in vitro to determine the relative recovery (RR) of urea. Finally, urea and linezolid concentrations in human microdialysis samples were measured. The developed assay was validated according to international guidelines and met all requirements. Relative in vitro recovery was found to be independent from concentration and dependent on flow rate. Subsequently, relative in vivo recovery of urea was correlated with relative in vivo recovery of linezolid obtained by the traditional retrodialysis method. In healthy volunteers, the mean ratio of the relative recovery of linezolid to the relative recovery of urea was 0.6 for the subcutaneous (s.c.: CV 33.4%, n = 48) and 0.7 for the intramuscular probe (i.m.: CV 18.8%, n = 40), respectively. In critically ill patients this ratio was 0.7 for both tissues (s.c.: CV 32.8%, n = 18; i.m.: CV 22.1%, n = 17). Successful calibration of the urea reference technique without the need to use in vitro data will further promote the application of microdialysis in clinical studies especially in critically ill patients, as it reduces the imposed burden to a minimum.

[Pharmacotherapy of a patient with Alzheimer's disease: interactions with the antidementive galantamine]. / Pharmakotherapie einer Patientin mit Alzheimer-Demenz. Interaktionen mit dem Antidementivum Galantamin.

Based on a case-report, drug-related problems of the therapy of a female patient with Alzheimer's disease are discussed. According to the SOAP scheme options for optimizing the pharmacotherapy are discussed.

[Information content of medication schedules prior to the implementation of the federal standard medication plan]. / Informationsgehalt von Medikationsplänen vor dem Hintergrund der Einführung des einheitlichen patientenbezogenen Medikationsplans.

BACKGROUND: Polypharmacy and complex medication regimens are challenging in patient care. Written information like a medication schedule is the main component in this context. To exchange these data the federal medication plan is an adequate medium. However there is insufficient knowledge of whether structures for implementation exist and which categories are already used in daily practice. It is also unknown how often an update for these schedules is necessary. METHODS: During a medication review including a brown-bag analysis the current medication from 500 patients was assessed and compared to the medication schedule available. In this way we established both the categories of the federal medication plan that are already in use and the age of the plan. Age and frequency of data within the different categories were compared to the number of deviations. In addition, these data were analyzed for different authorships. RESULTS: None of the 399 medication schedules fully complied with the draft. The brand name was listed in only 33.8 %, but with large deviations (41 %) from the currently used brand. Brand names and the name of the active component were used in a mixed manner. Dosage was missing in 34.6 % of the medications, and in 80.2 % the formulations were not provided. Indication was lacking in 95.2 % of the medications and intake recommendations in 96.7 %. Large differences were seen with different authors. The average age of the plans was 4.5 months [range 0-12 months]. The number of discrepancies increased by 50 % after two months, statistical significance was reached after 4.5 months (p=0.039). CONCLUSION: The complete categories of the federal medication plan are not commonly used in everday practice. Essential information such as the correct brand name, dosages and intake recommendations as well as medication relevant safety data concerning galenic form and indication is not fully provided. To achieve implementation and completeness of medication plans, interprofessional collaboration of all healthcare professions with the involvement of patients is reasonable. Updating is necessary after each change in medication but should also be routinely conducted every 3 months.

Discrepancies on Medication Plans detected in German Community Pharmacies.

RATIONALE, AIMS AND OBJECTIVES: A current medication plan was identified as important patient safety factor. Information is needed on how many patients possess such a plan and what problems can be identified with its use. This study tried to define factors that influence accuracy of medication plans and to detect discrepancies from planned and actually administered medication in polypharmacy patients. METHODS: Participants of the 'Apo-AMTS' course in Germany evaluated medication plans from their patients during performing medication reviews in community pharmacies. Discrepancies were defined as additional or missing drugs and deviations in dosage and drug names for Rx drugs and missing or additional self-medication. RESULTS: Eighty per cent of the patients possessed a medication plan mainly written by general practitioners. Only 6.5% of the plans showed no discrepancies. Most discrepancies were seen on medication plans written by medical specialists and general practitioners, mainly name aberrations (41%) followed by additional drugs taken (30%) and prescribed drugs no longer taken (18%). Dosage variance was seen in 11% of all discrepancies. Deviations from the plan were observed frequently with antihypertensives (31.4%), analgesics (11.3%) and antidepressants/hypnotics as well as lipid-lowering drugs (6.7%). Four hundred thirty-three OTC drugs were not listed, mainly analgesics, mineral supplements and laxatives. CONCLUSION: Many patients possess a medication plan but most of these plans showed discrepancies which limits the use as patient safety indicator. Community pharmacies offering medication reviews have an essential position to use the medication plan as a central link between patients and their prescribers, and therefore improve patient safety.

Task allocation in cancer medication management - integrating the pharmacist.

OBJECTIVE: This study was conducted to define the task allocation in multiprofessional cancer medication management (MCMM) with a special focus on the role of the pharmacist as well as patient education and counseling. The acceptance of the proposed task allocation and the perceptions on multiprofessional teamwork were explored on a national level. METHODS: We held local focus group meetings (University of Bonn with collaboration partners) to identify MCMM tasks. With the Delphi technique the tasks were allocated to physicians, pharmacists and nurses. Professionals (members of the German Cancer Society) were approached nationwide via an online questionnaire to evaluate the acceptance of the MCMM model and explore their perceptions on multiprofessional teamwork. RESULTS: The MCMM model comprised 38 tasks including 11 on patient education and counseling. It was rated to be reasonable (79%) and feasible (68%). Barriers and benefits of multiprofessional teamwork stated were patient-, team-, therapy-, structure-, and resources-related. CONCLUSIONS: The MCMM model integrates the pharmacist with responsibilities in patient education and counseling as well as prevention of drug-related problems. The approach was generally appreciated nationwide by the professions. PRACTICE IMPLICATIONS: The proposed model can serve as a tool to trigger changes in cancer medication management.