Drug-Associated Risk Tool: development and validation of a self-assessment questionnaire to screen for hospitalised patients at risk for drug-related problems.

INTRODUCTION: Identifying patients with a high risk for drug-related problems (DRPs) might optimise the allocation of targeted pharmaceutical care during the hospital stay and on discharge. OBJECTIVE: To develop a self-assessment screening tool to identify patients at risk for DRPs and validate the tool regarding feasibility, acceptability and the reliability of the patients' answers. DESIGN: Prospective validation study. SETTING: Two mid-sized hospitals (300-400 beds). PARTICIPANTS: 195 patients, exclusion criteria: under 18 years old, patients with a health status not allowing a meaningful communication (eg, delirium, acute psychosis, advanced dementia, aphasia, clouded consciousness state), palliative or terminally ill patients. METHODS: Twenty-seven risk factors for the development of DRPs, identified in a previous study, provided the basis of the self-assessment questionnaire, the Drug-Associated Risk Tool (DART). Consenting patients filled in DART, and we compared their answers with objective patient data from medical records and laboratory data. RESULTS: One hundred and sixty-four patients filled in DART V.1.0 in an average time of 7 min. After a first validation, we identified statements with a low sensitivity and revised the wording of the questions related to heart insufficiency, renal impairment or liver impairment. The revised DART (V.2.0) was validated in 31 patients presenting heart insufficiency, renal impairment or liver impairment as comorbidity and reached an average specificity of 88% (range 27-100) and an average sensitivity of 67% (range 21-100). CONCLUSIONS: DART showed a satisfying feasibility and reliability. The specificity of the statements was mostly high. The sensitivity varied and was higher in statements concerning diseases that require regular disease control and attention to self-care and drug management. Asking patients about their conditions, medications and related problems can facilitate getting a first, broad picture of the risk for DRPs and possible pharmaceutical needs.

Demonstrating the clinical pharmacist's activity: validation of an intervention oriented classification system.

BACKGROUND: Clinical pharmacists are increasingly involved in detecting and solving drug-related problems. To document their performance, a convenient tool to code pharmaceutical interventions in daily practice is desirable. The Swiss Society of Public Health Administration and Hospital Pharmacists (GSASA) proposed to implement a new classification system for pharmaceutical interventions. OBJECTIVES: To develop and validate a classification system for pharmaceutical interventions and to compare it with the well-established Pharmaceutical Care Network Europe (PCNE) system. SETTING: Rehabilitation clinic, geriatric and orthopaedic wards of a 427-bed teaching hospital. METHODS: Development of the GSASA classification started with expert panel discussions and the validation of the first version (GSASA V1). To assess appropriateness, interpretability, and validity, clinical pharmacists documented during a 6-week period all interventions using GSASA V1 and PCNE version 6.2 (V6.2). Acceptability and feasibility were tested by an 8-item questionnaire with 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), and inter-rater reliability (Fleiss-Kappa coefficients κ) was determined. After revision, the second version (V2) was assessed again for reliability. MEAN OUTCOME MEASURES: User's agreement/satisfaction, comprehensiveness/reliability of the classification system. RESULTS: The GSASA V1 includes 4 categories and 35 subcategories. Of 115 interventions classified with GSASA V1, 93 (80.9 %) could be completely classified in all categories. This explains that 3 of 6 users could be not satisfied with the comprehensiveness of GSASA V1 (mean user agreement 2.7 ± 0.8). The questionnaire showed that all users could find GSASA V1 (4.0 ± 0.0) easier to use than PCNE V6.2 (3.0 ± 0.9). Users were generally satisfied with the GSASA V1 (3.5 ± 0.8), especially with the adequate time expenditure (4.0 ± 0.7). Inter-rater reliability and acceptability of GSASA V1 were comparable to those of the PCNE V6.2. The agreement among the GSASA V1 users was substantial for the categories 'problem' (κ = 0.66), 'intervention' (κ = 0.74), and 'outcome' (κ = 0.63), while moderate agreement for the category 'cause' was obtained (κ = 0.53). The final system GSASA V2 includes 5 categories (addition of 'type of problem') and 41 subcategories. Total inter-rater reliability was moderate (κ = 0.52). CONCLUSION: The GSASA classification system appeared to be reliable and promising for documentation of pharmaceutical interventions in daily practice (practical and less time-consuming). The system is validated in terms of appropriateness, interpretability, validity, acceptability, feasibility, and reliability.

Inappropriate prescribing: a systematic overview of published assessment tools.

BACKGROUND: Criteria to assess the appropriateness of prescriptions might serve as a helpful guideline during professional training and in daily practice, with the aim to improve a patient's pharmacotherapy. OBJECTIVE: To create a comprehensive and structured overview of existing tools to assess inappropriate prescribing. METHOD: Systematic literature search in Pubmed (1991-2013). The following properties of the tools were extracted and mapped in a structured way: approach (explicit, implicit), development method (consensus technique, expert panel, literature based), focused patient group, health care setting, and covered aspects of inappropriate prescribing. RESULTS: The literature search resulted in 46 tools to assess inappropriate prescribing.Twenty-eight (61%) of 46 tools were explicit, 8 (17%) were implicit and 10 (22%) used a mixed approach. Thirty-six (78%) tools named older people as target patients and 10 (22%) tools did not specify the target age group. Four (8.5%) tools were designed to detect inappropriate prescribing in hospitalised patients, 9 (19.5%) focused on patients in ambulatory care and 6 (13%) were developed for use in long-term care. Twenty-seven (59%) tools did not specify the health care setting. Consensus methods were applied in the development of 19 tools (41%), the others were based on either simple expert panels (13; 28%) or on a literature search (11; 24%). For three tools (7%) the development method was not described. CONCLUSION: This overview reveals the characteristics of 46 assessment tools and can serve as a summary to assist readers in choosing a tool, either for research purposes or for daily practice use.

Drug-related problems in diabetes and transplant patients: an observational study with home visits.

OBJECTIVES: To get insight into the medication management of diabetes type 2 (DM) as well as solid organ transplant (Tx) patients and to analyse drug-related problems (DRPs) in order to explore opportunities for the provision of pharmaceutical care. SETTING: Seventy-nine Swiss community pharmacies offering internships for pharmacy students. METHODS: Diabetes and transplant patients were recruited in community pharmacies and were interviewed at home by fifth-year pharmacy students who were supervised by a trained investigator, using a specific interview guide developed for this study. MAIN OUTCOME MEASURE: Pattern and frequency of DRPs and pattern of medication management. RESULTS: In total, 22 (Tx patients) and 54 (DM patients) home visits were carried out. Mean age of visited patients was 71.4 ± 8.1 years (DM) and 52.6 ± 13.8 years (Tx). Overall, 37.0% (DM) and 50.0% (Tx) of participants were female. We identified 7.4 ± 2.4 (mean ± SD) DRPs per visited patient, with considerable differences between Tx and DM patients (6.3 ± 1.7 vs. 7.8 ± 2.5). The most frequent DRPs were risk for non-adherence (DM: 61.1%; Tx: 77.3%), confusion of generic and trade names (DM: 74.1%; Tx: 27.3%), hoarding of over-the-counter medicines (DM: 48.1%; Tx: 4.5%) and prescription-only medicines (DM: 37.0%; Tx: 36.4%), gaps in knowledge about potential interactions (DM: 61.1%; Tx: 18.2%) and purpose of drugs (DM: 48.1%; Tx: 36.4%). Mean (SD) duration of the visits was 51.7 ± 21.4 min. CONCLUSION: Visiting Tx and DM patients in their homes allowed the identification of a wide range of opportunities for pharmaceutical care as well as specific DRPs which most probably would have escaped a medication review in the pharmacy.

Outcomes of early switching from intravenous to oral antibiotics on medical wards.

OBJECTIVES: To evaluate outcomes following implementation of a checklist with criteria for switching from intravenous (iv) to oral antibiotics on unselected patients on two general medical wards. METHODS: During a 12 month intervention study, a printed checklist of criteria for switching on the third day of iv treatment was placed in the medical charts. The decision to switch was left to the discretion of the attending physician. Outcome parameters of a 4 month control phase before intervention were compared with the equivalent 4 month period during the intervention phase to control for seasonal confounding (before-after study; April to July of 2006 and 2007, respectively): 250 episodes (215 patients) during the intervention period were compared with the control group of 176 episodes (162 patients). The main outcome measure was the duration of iv therapy. Additionally, safety, adherence to the checklist, reasons against switching patients and antibiotic cost were analysed during the whole year of the intervention (n = 698 episodes). RESULTS: In 38% (246/646) of episodes of continued iv antibiotic therapy, patients met all criteria for switching to oral antibiotics on the third day, and 151/246 (61.4%) were switched. The number of days of iv antibiotic treatment were reduced by 19% (95% confidence interval 9%-29%, P = 0.001; 6.0-5.0 days in median) with no increase in complications. The main reasons against switching were persisting fever (41%, n = 187) and absence of clinical improvement (41%, n = 185). CONCLUSIONS: On general medical wards, a checklist with bedside criteria for switching to oral antibiotics can shorten the duration of iv therapy without any negative effect on treatment outcome. The criteria were successfully applied to all patients on the wards, independently of the indication (empirical or directed treatment), the type of (presumed) infection, the underlying disease or the group of antibiotics being used.

Drug-related problems: evaluation of a classification system in the daily practice of a Swiss University Hospital.

AIM: To evaluate the Pharmaceutical Care Network Europe (PCNE) classification system as a tool for documenting the impact of a hospital clinical pharmacology service. SETTING: Two medical wards comprising totally 85 beds in a university hospital. MAIN OUTCOME MEASURE: Number of events classified with the PCNE-system, their acceptance by the medical staff and cost implications. METHODS: Clinical pharmacy review of pharmacotherapy on ward rounds and from case notes were documented, and identified drug-related problems (DRPs) were classified using the PCNE system version 5.00. RESULTS: During 70 observation days 216 interventions were registered of which 213 (98.6%) could be classified: 128 (60.1%) were detected by reviewing the case notes, 33 (15.5%) on ward rounds, 32 (15.0%) by direct reporting to the clinical pharmacist (CP), and 20 (9.4%) on non-formulary prescriptions. Of 148 suggested interventions by the CP 123 (83.0%) were approved by the responsible physician, 12 ADR reports (8.1%) were submitted to the local pharmacovigilance centre and 31 (20.9%) specific information given without further need for action. An evaluation of the DRPs showed that direct drug costs of 2,058 within the study period or 10,731 per year could be avoided. CONCLUSION: We consider the PCNE system to be a practical tool in the hospital setting, which demonstrates the values of a clinical pharmacy service in terms of identifying and reducing DRPs and also has the potential to reduce prescribing costs.