Effectiveness of an Interprofessional Program (Siscare) for Supporting Patients With Type 2 Diabetes.

Objective: To assess the effectiveness of an interprofessional support program (Siscare) that includes motivational interviews (patient-pharmacist), electronic monitoring (EM) of medications, patient-reported and clinical outcomes monitoring, and interactions with physicians for patients with type 2 diabetes in French-speaking Switzerland. Methods: This was a prospective, multicenter, observational cohort study using a hybrid implementation-effectiveness design. Individual daily adherence to at least one oral antidiabetic medication was measured by EM. A global adherence score was estimated by the product of a model-estimated implementation and a nonparametric estimate of persistence over time. Clinical outcomes (A1C, blood glucose, BMI, blood pressure, heart rate, and cholesterol levels) and quality of life (QoL) were analyzed over time using linear mixed-effect models. Results: A total of 212 patients were included from 27 pharmacies; 120 patients (57%) were followed up for at least 15 months. In total, 140 patients (66%) were male, the mean age was 64 ± 11 years, and the mean number of chronic medications per patient at baseline was 5 ± 3. Of 178 patients who used EM, 95% (95% CI 92-99%) remained persistent at the end of the follow-up period. The percentage of persistent patients taking their medications appropriately (implementation) was stable during follow-up and was estimated to be 90% (95% CI 87-92%) at baseline and 88% (95% CI 84-91%) at month 15. At baseline, the mean A1C and BMI were 7.5% and 31 kg/m2, respectively, which decreased by 0.5% (P = 0.012) and 0.6 kg/m2 (P = 0.017), respectively, after 15 months. QoL remained stable during follow-up. Conclusion: The program supports medication adherence and improves clinical outcomes, illustrating the overall preventive effect of coordinated care.

Random forest machine learning algorithm predicts virologic outcomes among HIV infected adults in Lausanne, Switzerland using electronically monitored combined antiretroviral treatment adherence.

Machine Learning (ML) can improve the analysis of complex and interrelated factors that place adherent people at risk of viral rebound. Our aim was to build ML model to predict RNA viral rebound from medication adherence and clinical data. Patients were followed up at the Swiss interprofessional medication adherence program (IMAP). Sociodemographic and clinical variables were retrieved from the Swiss HIV Cohort Study (SHCS). Daily electronic medication adherence between 2008-2016 were analyzed retrospectively. Predictor variables included: RNA viral load (VL), CD4 count, duration of ART, and adherence. Random Forest, was used with 10 fold cross validation to predict the RNA class for each data observation. Classification accuracy metrics were calculated for each of the 10-fold cross validation holdout datasets. The values for each range from 0 to 1 (better accuracy). 383 HIV+ patients, 56% male, 52% white, median (Q1, Q3): age 43 (36, 50), duration of electronic monitoring of adherence 564 (200, 1333) days, CD4 count 406 (209, 533) cells/mm3, time since HIV diagnosis was 8.4 (4, 13.5) years, were included. Average model classification accuracy metrics (AUC and F1) for RNA VL were 0.6465 and 0.7772, respectively. In conclusion, combining adherence with other clinical predictors improve predictions of RNA.

Interest in and use of person-centred pharmacy services - a Swiss study of people with diabetes.

BACKGROUND: Diabetes is one of the most important chronic diseases and affects 9% of the world's population. To support these people in the day-to-day management of their treatments, pharmacies can offer professional pharmacy services. These are defined as one or more actions organized or provided in a pharmacy to optimize the process of care, with the goal of improving health outcomes and the value of healthcare. Such services have to be tailored to the needs and interests of patients. This study aimed to evaluate interest in and use of pharmacy services among people with diabetes in the canton of Vaud, Switzerland. METHODS: This cross-sectional study analysed self-reported data from 790 people with diabetes included in the CoDiab-VD cohort. Questions focused on sociodemographic and economic characteristics, diabetes and its management, and interest in and use of pharmacy services related to (1) medication intake and adherence and (2) diabetes and general health. Descriptive analyses were first conducted. Logistic regression analyses were then performed for pharmacy services that were of interest to ≥50% of respondents. RESULTS: The mean age of participants was 66 years, and the sample included more males (59%) than females. The pharmacy services that interested the most respondents were individual interview, pill boxes or weekly pill boxes, treatment plans, checks of all medications, first medical opinions from pharmacists and counselling on devices. Factors significantly associated with interest in pharmacy services were being older, having a lower self-efficacy score, taking more than three medications and having a positive opinion about pharmacists. CONCLUSIONS: This study provides key information on interest in and use of pharmacy services among patients with diabetes in Switzerland; it should help pharmacists individualize their services for patients.

Satisfaction and experiences of patients taking fingolimod and involved in a pharmacy-based patient support program in Switzerland - a qualitative study.

BACKGROUND: Fingolimod is an oral multiple sclerosis drug that is considered a specialty drug due to its high cost and safety issues. The Fingolimod Patient Support Program (F-PSP) is a specialty pharmacy service developed to ensure the responsible use of fingolimod by promoting patient safety and medication adherence. This study aims to explore the satisfaction, experiences and perceptions regarding the F-PSP among patients currently involved in this program or recently withdrawn. METHODS: A qualitative study was conducted via individual, face-to-face semistructured interviews with patients involved in the F-PSP. The interviews were audio-recorded, transcribed verbatim, coded and analyzed via thematic content analysis. RESULTS: The main themes identified from the interviews (n = 17) were overall perception of the F-PSP, perception of the pharmacist-led consultations, perception of the tools (electronic monitor and drug intake graph), reasons to participate or potentially withdraw, and suggestions for improvements. Participants perceived the F-PSP as a reassuring support that complemented their medical care, providing a more human, personalized and person-centered approach than usual pharmacy care. Pharmacist-led consultations were valued for the medication-related and holistic support they provided. The importance of the pharmacist's attitude was emphasized. The electronic monitor was valued for promoting daily medication adherence and allowing the involvement of relatives, which reassured participants and their relatives. The participants appreciated the drug intake graph because it provided an objective overview of medication adherence, thereby reassuring, rewarding, and motivating them. The main reason to join the program was to be supported, especially with respect to medication adherence. CONCLUSIONS: Participants were satisfied with the F-PSP, each for different reasons. Their feedback enabled the identification of measures for the optimization of the F-PSP and should facilitate its dissemination and transfer to other drugs/diseases/populations. Essential elements of generic pharmacist-led patient support programs considered valuable from the patients' perspective were identified.

Implementation of an interprofessional medication adherence program for chronic patients in community pharmacies: how much does it cost for the provider?

BACKGROUND: The implementation of an innovative and sustainable professional pharmacy service in routine care requires substantial resources borne by the pharmacy owner. Although a community pharmacy is a business setting, few studies have examined cost as a potential barrier to widespread implementation. Implementation costs, as the cost impact of an implementation effort, can be significant and hamper the decision to invest from the provider perspective. Traditional financial planning tools can be used to analyse and support business decision to implement a service by assessing the net impact of a new service on the provider's budget. This study aimed to estimate the implementation costs and the break-even point of an interprofessional medication adherence program for chronic patients in Switzerland. The program combines motivational interviews, medication adherence electronic monitoring and feedback reports to patient and physicians. METHODS: We used a 3-step approach: (i) micro-costing analysis: identification of implementation activities, quantification and valuation of required resources. Implementation costs, including service support costs and direct delivery costs, were analysed according to the implementation phase (installation, initial implementation, and full operation); (ii) break-even analysis: estimation of the required number of patients to follow up with to ensure that the generated revenue exceeded the total cost; and (iii) univariate sensitivity analyses. RESULTS: The estimated total cost of the installation phase was 8481 CHF, more than half of which represented the cost of the equipment. Direct delivery costs were 666 CHF per patient per year, with 68% of this value associated with the cost of workforce time. According to the Swiss national reimbursement system, a minimal of 16 [10-27] patients was required to cover the implementation costs of the installation phase. This break-even point decreased to 13 patients in the initial and full operation phases. CONCLUSIONS: These estimates lead to a better understanding of the real cost of implementing a professional pharmacy service in routine care. In a Swiss context, the current medication adherence support fee-for-service system allows pharmacists to reach the break-even point. Such information is important for community pharmacists to guide their implementation strategies. The replication of similar analyses in other settings and countries is paramount.

[Interprofessional physicians-pharmacists collaboration in ambulatory care†: a potential to be exploited]. / L'interprofessionnalité médecins-pharmaciens dans les soins ambulatoires†: un potentiel à exploiter.

In ambulatory care, the community pharmacist and the general practitioner most often interact through the dispensing of medicines in pharmacies following a prescription from the physician. However, this interaction can be reinforced by other practices that can increase the quality and safety of care. Interprofessional collaboration is possible through the development of increasing interrelationships, particularly in the sharing of information through dialogue on common objectives that integrate the perspectives of patients and professionals, and through joint decision-making. In this article, interprofessional collaboration between pharmacists and general practitioners is described, as well as data from the literature and some concrete examples from the regular practice of pharmacists and physicians in Unisanté.

Dans les soins ambulatoires, le pharmacien communautaire et le médecin généraliste interagissent le plus souvent par la remise de médicaments en pharmacie suite à une ordonnance rédigée par le médecin. Cette interaction peut néanmoins être renforcée par d'autres pratiques qui peuvent augmenter la qualité et la sécurité des soins. La collaboration interprofessionnelle est possible par le développement d'interrelations croissantes comme le partage d'informations, la concertation sur des objectifs intégrant l'avis du patient et des professionnels, ou encore la prise de décision conjointe. Dans cet article, nous décrivons la collaboration interprofessionnelle entre pharmaciens et médecins généralistes telle que présentée dans la littérature, et quelques exemples concrets issus de la pratique régulière des pharmaciens et médecins d'Unisanté.

Evaluation of compliance with isotretinoin PPP recommendations and exploration of reasons for non-compliance: Survey among French-speaking health care professionals and patients in Belgium.

PURPOSE: To evaluate awareness of and compliance in Belgium by French-speaking health care professionals and patients with the isotretinoin safety recommendations regarding its teratogenic risk. METHOD: Survey using online questionnaires, delivered from December 2014 to March 2015 for patients, pharmacists, dermatologists, and GPs and delivered again from September 2015 to October 2015 for GPs. RESULTS: Questionnaires were completed by 24 dermatologists, 24 GPs, 58 pharmacists, and 33 female patients. The pregnancy prevention programme was poorly known by health care professionals (23.6%) and patients (15.2%). Health care professionals informed women of childbearing age in depth about the teratogenic risk (98.3% of pharmacists and 100.0% of GPs and dermatologists) and the importance of an effective contraceptive method (87.9% and 100.0%, respectively). Patients were less informed about the pregnancy test (25.9% and 14.6%) and the need to use a second contraceptive method (29.3% and 27.1%). The low compliance with the last 2 recommendations was due to a lack of adoption by health care professionals regarding the need for these recommendations if female patients have an effective contraceptive method and the pregnancy risk is discussed in detail with them. CONCLUSION: The effectiveness of the pregnancy prevention programme recommendations should be reconsidered by an expert committee. Justifications should be added to effective recommendations to increase their adoption by health care professionals and patients.

Implementation of an interprofessional medication adherence program for HIV patients: description of the process using the framework for the implementation of services in pharmacy.

BACKGROUND: The community pharmacy center of the Department of Ambulatory Care and Community Medicine of the Policlinique Médicale Universitaire (PMU), Lausanne, Switzerland developed and implemented an interprofessional medication adherence program for chronic patients (IMAP). In 2014, a project was launched to implement the IMAP for HIV patients in a public non-academic hospital with the collaboration of community pharmacists in the Neuchâtel area (Switzerland). This article aims to describe the different implementation stages and strategies of the project. METHODS: A posteriori description of the implementation process, including the conceptualization strategies and stages (exploration, preparation, operation, sustainability) using the Framework for the Implementation of Services in Pharmacy (FISpH). RESULTS: In 2014, an attending infectious disease physician and a nurse at a public hospital (Neuchâtel, Switzerland) contacted the PMU to implement the IMAP in their setting in collaboration with community pharmacies. Five volunteer community pharmacies in Neuchâtel were trained to deliver the program. Three factors were found to be essential to the successful launch and progress of the implementation project: the experience of the community pharmacy center of the PMU with the IMAP, the involvement of the PMU research team, and collaboration with an external start up (SISPha) to train and support pharmacists. During the operation stage, the most important strategy developed was that of regular meetings between all stakeholders. These allowed healthcare professionals to discuss the implementation progress, to address each stakeholder's expectations, and to exchange experiences to facilitate interprofessional collaboration and program delivery. Structural changes allowed the formalization of the activities at the hospital and in a community pharmacy. This formalization was identified as the transition step between the operation and the sustainability stages. CONCLUSIONS: The transfer of the IMAP for HIV patients to a non-academic setting and its implementation are feasible. However, implementation of a new model of pharmacy service such as IMAP implies a deep change in practice. A transitional external support and the allocation of sufficient resources to carry out the IMAP are essential for its long-term sustainability.

Implementation study of an interprofessional medication adherence program for HIV patients in Switzerland: quantitative and qualitative implementation results.

BACKGROUND: An interprofessional medication adherence program (IMAP) for chronic patients was developed and successfully implemented in the community pharmacy of the Department of ambulatory care and community medicine (Lausanne, Switzerland). This study assesses the capacity of a physician and a nurse at the infectious diseases service of a public hospital and of community pharmacists in the Neuchâtel area (Switzerland) to implement the IMAP in their practice. METHODS: Mixed method, prospective, observational study. Quantitative and qualitative analyses of the implementation process were conducted following the RE-AIM model (reach, effectiveness, adoption, implementation and maintenance). RESULTS: Implementation started in November 2014. One physician, one nurse, and five pharmacists agreed to participate. Healthcare professionals perceived the benefits of the program and were motivated to implement it in their practice (adoption). Seventeen patients were included in the program; 13 refused to participate. The inclusion of naïve HIV patients was easier than the inclusion of experienced patients with difficult psychosocial issues (reach). Pharmacists were engaged in reinforcing patient medication adherence in 25% of interviews (effectiveness). Key facilitators expressed by healthcare professionals were patient inclusion by the physician and the nurse instead of the pharmacist and the organisation of regular meetings between all stakeholders. In contrast, the encountered barriers were the lack of time and resources, the lack of team uptake, and the lack of adoption by senior managers (implementation). Interviewed patients were all satisfied with this new program, encouraging healthcare professionals to scale it up. Structural changes allowed the hospital and one pharmacy to enter the maintenance stage (maintenance). CONCLUSION: The research team and collaboration between all professionals involved played an important role in this implementation. However, the dissemination of such a program to a larger scale and for the long term requires financial and structural resources as well as transitional external support.

Switching Patients to Home-Based Subcutaneous Immunoglobulin: an Economic Evaluation of an Interprofessional Drug Therapy Management Program.

PURPOSE: Home-based subcutaneous immunoglobulin (SCIg) therapy is an alternative to hospital-based intravenous infusions (IVIg). However, SCIg requires patient training and long-term support to ensure proper adherence, optimal efficacy and safety. We evaluated if switching patients to home-based SCIg including an interprofessional drug therapy management program (physician, community pharmacist and nurse) would be cost-effective within the Swiss healthcare system. METHODS: A 3-year cost-minimization analysis was performed from a societal perspective comparing monthly IVIg in an outpatient clinic and home-based weekly SCIg including an interprofessional program. Healthcare costs (immunoglobulin, professional time, infusion pump and disposables) were derived from administrative data. Transportation and productivity loss were estimated by expert opinion. The results were expressed in Swiss francs (CHF) and converted to Euros and US dollars (1 CHF = 0.92€, 1 CHF = $1.02; www.xe.com , 12/14/2015). RESULTS: Under base case assumptions, SCIg was estimated to cost 35,862 CHF (33,134€; $36,595) per patient during the first year and 30,309 CHF (28,004€; $30,929) in subsequent years versus 35,370 CHF (32,679€; $36,095) per year for IVIg. The total savings from switching to SCIg with the interprofessional program were 9630 CHF (8897€; $9828) per patient over 3 years. The results were relatively sensitive to the cost per gram of IgG, the cost of equipment and the annual number of infusions. CONCLUSION: Home-based SCIg including an interprofessional therapy management program may be an efficient alternative for patients. The program provides long-term support from self-administration training to the responsible use of therapy (proper adherence, optimal efficacy and safety). Over the short term, additional costs from purchasing equipment and the drug therapy management program were offset by avoiding hospital costs.

Comparison of Population Pharmacokinetics Based on Steady-State Assumption Versus Electronically Monitored Adherence to Lopinavir, Atazanavir, Efavirenz, and Etravirine: A Retrospective Study.

BACKGROUND: Population pharmacokinetic (PopPK) analyses often rely on steady state and full adherence to prescribed dosage regimen assumptions from data gathered during therapeutic drug monitoring (TDM). Nonadherence is common in chronic diseases such as HIV. This study evaluates the impact of adherence measurement by electronic monitoring on PopPK parameter estimation and individual concentration profile predictions, and also the influence of adherence issues on the clinical interpretation of a concentration measurement. METHODS: Published PopPK models for lopinavir, atazanavir, efavirenz, and etravirine were applied to estimate PK parameters and individual concentrations in 140 HIV patients taking part in a medication adherence program using 2 dosing data sets. The first set included the last dose reported by the patient with steady-state and full adherence assumptions; the second set used detailed electronic dosing history. PopPK parameter estimates and individual predictions were compared between the 2 dosing entries. RESULTS: Clearance estimates and likewise predicted concentrations did not markedly differ between the 2 dosing histories. However, certain patterns of nonadherence such as sparse missed doses or consecutive missed doses lead to suboptimal drug exposure. The interpretation based on self-reported information would have concluded on a wrongly appropriate individual exposure. CONCLUSIONS: PopPK analysis assuming steady state with full adherence produced similar results to those based on detailed electronic dosing history reconciled with patients' allegations. Self-reported last dose intake appeared reliable for concentration predictions and therapeutic drug monitoring interpretation for most patients followed at the medication adherence program. Yet, clinicians should be aware that concentration predictions based on self-reported last dose intake might be overestimated in case of undetected patterns of nonadherence, increasing the risk of forthcoming therapeutic failure.

[Interprofessional pill box management in an ambulatory care setting]. / Gérer un semainier a plusieurs chez un patient bénéficiaire de soins a domicile.

Complex multimorbid patients are now more common in ambulatory care and the management of their medication more frequently needs interprofessional collaboration. This qualitative study explored health professional's main challenges when introducing, preparing and sharing the use of a pill box for a patient. Another objective of this study was to explore options for improving care in these situations.

[Medication adherence in chronic patients: from its concepts to its management in primary care]. / Adhésion thérapeutique du patient chronique: des concepts a la prise en charge ambulatoire.

Medication nonadherence is common and its determinants are diverse. Adherence is influenced by many parameters, such as patient's self-efficacy, knowledge of health risk, outcome expectations, benefits of change, and barriers and facilitators. The sociocognitive theory helps professionals to structure their approach and to support patients in managing their treatment. Professionals need skills and time, and benefit from coordination in care, in particular between physicians and pharmacists. This article presents the key elements of a medication adherence program as well as tools and some useful questions.

[Hospital's discharge prescription: a challenge for continuity of care and the interprofessional collaboration]. / Ordonnance de sortie d'hôpital: un défi pour la continuité des soins et la collaboration interprofessionnelle.

The transition between hospital and community is an interface at high risk for medication. "The Association of Family Doctors" committee in the canton of Vaud (MFVaud), together with community pharmacists' and Homecare representatives, have begun to consider the following improvements: fast and co-ordinated care providers' information; arrangements for family doctors appointments as soon as possible; awareness and education for interprofessional collaboration; more secured preparation of pill boxes; development of interprofessional means such as medication use reviews and reconciliations. In the opinion of all the experts, there is an urgent public health need to act in an interprofessional manner, even if the solutions required (especially change in professional culture and technologies) are not immediate.

New roles for community pharmacists in modern health care systems: a challenge for pharmacy education and research.

The academic activities led by the Unit of Community Pharmacy can be classified as translational. Our group is interested in person-centered pharmaceutical services aimed at a more responsible use of drugs (effectiveness, safety, efficiency) in collaboration with physicians and other health care professionals in a primary care setting. The following domains of education and research are high priorities for our group: medication therapy management, medication adherence, integrated care, individualization of therapies, care management for the elderly and e-health.

An interdisciplinary HIV-adherence program combining motivational interviewing and electronic antiretroviral drug monitoring.

To ensure successful treatment, HIV patients must maintain a high degree of medication adherence over time. Since August 2004, patients who are (or are at risk of) experiencing problems with their HIV antiretroviral therapy (ART) have been referred by their physicians to an interdisciplinary HIV-adherence program. The program consists of a multifactorial intervention along with electronic drug monitoring (MEMS(TM)). The pharmacists organize individualized semi-structured motivational interviews based on cognitive, emotional, behavioral, and social issues. At the end of each session, the patient brings an adherence report to the physician. This enables the physician to use the adherence results to evaluate the treatment plan. The aim of this study was to retrospectively analyze this on-going interdisciplinary HIV-adherence program. All patients who were included between August 2004 and the end of April 2008 were analyzed. One hundred and four patients were included (59% women, median age 39 (31.0, 46.0) years, 42% black ethnicity). Eighty (77%) patients were ART-experienced patients and 59% had a protease inhibitor-based treatment. The retention rate was high (92%) in the program. Patient inclusion in this HIV-adherence program was determined by patient issues for naive patients and by nonadherence or suboptimal clinical outcomes for ART-experienced patients. The median time spent by a subject at the pharmacy was 35 (25.0, 48.0) minutes, half for the medication handling and half for the interview. The adherence results showed a persistence of 87% and an execution of 88%. Proportion of undetectable subjects increased during study. In conclusion, retention and persistence rates were high in this highly selected problematic population.

Evolution of potentially inappropriate medication use in nursing homes: Retrospective analysis of drug consumption data.

BACKGROUND: The use of potentially inappropriate medication (PIMs) is frequent in nursing homes (NHs), and leads to worsened health outcomes for their residents. Numerous initiatives to curb their use have been launched. Most studies of PIMs use in NHs, however, focused on their prevalence, and provide few insights on the evolution of their use. OBJECTIVE: The objective of this analysis is to measure the evolution of PIMs use in the nursing NHs of western Switzerland taking part in an integrated pharmacy service (IPS). METHODS: Drug consumption data from 166 NHs were collected for 2014 to 2018, through the monitoring of the IPS. These data were cross-referenced with validated PIMs lists (Beers' list and Norwegian General Practice-Nursing Home, NORGEP-NH) to compute the number of potentially inappropriate defined daily doses per average resident (DDD/res) in each NH. Linear mixed-effects models were used to assess the evolution of PIMs use over time, following the NORGEP-NH classification of PIMs and the drug classes involved. RESULTS: In 2018, the number of DDD/res was 7.3 (SD 1.9); of those, 2.2 (SD 0.8) were potentially inappropriate. Psycholeptics, psychoanaleptics and antihypertenseives were the most-used PIMs. Between 2014 and 2018, the number of potentially inappropriate DDD/res decreased by 0.03 per year (CI95 [-0.05; -0.01]). CONCLUSIONS: This study complements others that focused on the prevalence of PIMs use in NHs. The statistically significant reduction in the use of PIMs is an encouraging sign, but is probably not clinically meaningful for NH residents. With the growing concerns of the potential harms of these drugs, more specific interventions and implementation strategies need to be developed to help clinicians further reduce their use in NHs.

Implementation Evaluation of an Interprofessional Programme (Siscare) for Supporting Patients with Type 2 Diabetes in a primary care setting.

BACKGROUND: In 2016, the Swiss government decided to back the implementation of an interprofessional patient support programme to redefine and extent the pharmacist's role in primary care. The programme, called Siscare, includes regular motivational interviews by pharmacists; medication adherence, patient-reported, and clinical outcomes monitoring; and pharmacist-physician interactions. OBJECTIVE: To assess, from a pharmacy team's perspective, the implementation of Siscare for patients with type 2 diabetes taking at least one oral antidiabetic treatment, followed for 15 months, in a primary care setting of the French-speaking part of Switzerland. METHODS: This prospective, multicentre, observational, cohort study used a hybrid implementation-effectiveness design and the Framework for the Implementation of Services in Pharmacy (FISpH). Quantitative and qualitative methods assessed outcomes at three levels (process, outcomes and impact) at each stage of the implementation process (exploration, preparation, operation, sustainability). RESULTS: An advisory board with 10 representatives of key national stakeholders committed to supporting the study and 41 pharmacies were trained for Siscare. Of these, 33 (80%) had at least one of five implementation strategies in place 12 weeks after the start of patient inclusion and 27 (66%) have included ≥1 patient; mean inclusion per pharmacy: 8 (SD 6) patients [range: 1-29] with a total of 212 patients. Nine pharmacies (22%) met the target of 10 patients. An ordered three-step process of the implementation was observed in pharmacies: internal organisation, preparation of interprofessional practice, and relationship building with patients. Influencing factors were pharmacists' skills in motivational interviewing, support from pharmacy owners, pre-existing local interprofessional networks, and profitability of the programme. CONCLUSIONS: This implementation evaluation supports the feasibility and acceptability from the pharmacy team's perspective of Siscare. The programme's implementation on a wider scale is still difficult due to the inertia inherent in any fundamental change in practices and the economic-political uncertainties influencing the actors in primary care.

Deprescribing in nursing homes: Protocol for nested, randomised controlled hybrid trials of deprescribing interventions.

INTRODUCTION: Polypharmacy and the use of potentially inappropriate medication (PIMs) are frequent among nursing home (NH) residents, and are associated with adverse health outcomes like falls, hospitalisation and death. Deprescribing has been proposed as a way to curtail both problems; however, the best way to implement deprescribing and its real impact are still unclear. This article describes nested trials of two consecutive deprescribing interventions, the first at the NH level, and the second at the resident level. METHODS AND ANALYSIS: The first intervention (QC-DeMo) will be a deprescribing module to be carried out in existing interprofessional quality circles in NHs, with the goal to develop a NH-wide deprescribing consensus. Its effects will be evaluated on the use of PIMs and on patient safety outcomes such as death, hospitalisation and falls. All NHs in the cantons of Vaud and Fribourg with an integrated pharmacy service will be eligible. The second intervention (IDeI), at the resident level, will be a deprescribing-focused medication review, resulting in the implementation of a deprescribing plan. Its effects will be evaluated on the use of PIMs and chronic medications, and on quality of life. This second trial will take place in the NHs allocated to the intervention group of the first trial. All residents of these NHs over 65 years old, living in the NH for at least 4 months, and taking 5 or more medications will be eligible to participate. Both trials will be hybrid effectiveness and implementation trials, aiming to understand the implementation process for the interventions, and to identify barriers and facilitators. ETHICS, REGISTRATION AND FUNDING: Both trials were approved by the relevant ethics committee, registered on ClinicalTrials.gov (QC-DeMo: NCT03688542; IDeI: NCT03655405), and funded by the Swiss National Fund for Scientific Research.

Longitudinal analysis of safety and medication adherence of patients in the Fingolimod patient support program: a real-world observational study.

The Fingolimod Patient Support Program (F-PSP) is an interprofessional specialty pharmacy service designed to ensure responsible use of fingolimod by promoting patient safety and medication adherence. This study aims to evaluate the safety and medication adherence of patients who joined the F-PSP between 2013 and 2016. Sociodemographic and medical characteristics, patient safety data (patient-reported symptoms, discontinuations due to adverse events (AEs), repeated first-dose monitoring), and medication adherence (implementation, persistence, reasons for discontinuation, influence of covariates, barriers and facilitators) were described. Sixty-seven patients joined the F-PSP. Patients reported a high frequency of symptoms. Due to AEs, 7 patients discontinued fingolimod, 3 took therapeutic breaks, and 1 reduced the regimen temporarily. Three patients repeated the first-dose monitoring. Patients had a high medication adherence over the 18-month analysis period: implementation decreased from 98.8 to 93.7%, and fingolimod persistence was 83.2% at 18 months. The patients' level of education, professional situation, and living with child(ren) influenced implementation. Patients reported more facilitators of medication adherence than barriers. The F-PSP seems valuable for supporting individual patients (ensuring responsible use of fingolimod and inviting patients for shared-decision making) and public health (indirectly gathering real-world evidence).