Herbal supplements in Jordan: a cross-sectional survey of pharmacists' perspectives and knowledge.

OBJECTIVES: Pharmacists are ideal partners for engaging with the needs and expectations of patients. They can play a vital role by providing information and supplying herbal medicines. In some community settings, pharmacists are also the main first point of care. This study explored Jordanian community pharmacists' perspectives and knowledge of herbal medicines available in pharmacies. DESIGN: A cross-sectional study using an online survey was developed, and it was distributed via social media platforms. The one-way analysis of variance (ANOVA) test was used to compare the mean knowledge scores between different demographic groups. Multiple linear regression analysis was used to identify predictors of herbal medicines knowledge. SETTING: Jordanian community pharmacies. PARTICIPANTS: 401 Jordanian community pharmacists. RESULTS: Herbal supplements are sold in practically all pharmacies (98.5%). Slimming aids (14.7%), followed by sexual and sports enhancements (14%) and maintaining general health (12.1%) were most requested by Jordanian customers. While supplements for maintaining general health (12%), followed by slimming aids (11.4%) and skin conditions (9.3%) were most recommended by Jordanian pharmacists. 63.1% were not aware of potential herb-drug interactions, 95.6% did not receive complaints from customers about herbal medicines and 41.2% would not report adverse reactions to the national pharmacovigilance services. The mean knowledge score for knowledge of use, regulation, adverse reactions, and drug interactions was 3.7 (SD: 0.7), 3.5 (SD: 0.8), 3.6 (SD: 0.8), and 3.6 (SD: 0.8) (out of 5), respectively. ANOVA test showed that total pharmacists' knowledge scores significantly differed based on the length of time practising pharmacy (p<0.05). CONCLUSION: This study highlights some key concerns relating to recommendations, awareness and reporting of herbal medicines among Jordanian community pharmacists. Pharmacists need enhanced education to provide objective and evidence-based information on the benefits-risks of herbal medicines. Future studies need to be carried out to confirm whether our findings are transferable to other Middle Eastern countries.

Survey of Pharmacists' Knowledge of Connecticut's Medical Cannabis Program.

Introduction: Over the last few years, a growth in research and interest in medical cannabis (most often referred to as medical marijuana) use have occurred nationally. Medical cannabis has become a treatment option for disease conditions, such as epilepsy, wasting syndrome associated with AIDs, and post-traumatic stress disorder, when traditional medication is ineffective. Objectives: The objectives were to identify knowledge deficits of the medical cannabis program (MCP) in Connecticut among Connecticut pharmacists and the impact of MCP on Connecticut pharmacy practice and concerns Connecticut pharmacists have regarding medical cannabis use. Methods: A cross-sectional survey through an online platform, Google forms, was administered for 2 months (October 15, 2017-December 15, 2017). An e-mail containing the link to the survey was e-mailed to all pharmacists whose e-mail addresses were available from the State of Connecticut's Commission of Pharmacy database (n = 6182). Of those with available e-mail addresses, only 5653 pharmacists received the e-mail; the others were rejected upon receipt of our e-mail. Our survey consists of 16 items related to pharmacist demo- graphic information, knowledge assessment, impact on pharmacists' practice, and concerns stemming from medical cannabis. Results: Only 51 (15.2%) respondents believed that Connecticut MCP would impact their practice. Only 39 (11.6%) respondents selected the two correct requirements for patient registration and correctly identified the wrong choices. Only 81 (24.2%) respondents identified the correct approved dose (maximum allowable monthly amount of 2.5 ounces) of medical cannabis. Sixty-eight (20.2%) respondents correctly identified all three approved conditions and all other incorrect conditions. Sixty-five (19.40%) respondents correctly identified all roles of dispensary pharmacists. Majority of respondents, 243 (72.5%), expressed their concern about federal laws regarding cannabis. A total of 98 (29.3%) respondents thought that they were knowledgeable enough about the side effects of medical cannabis to provide appropriate counseling to patients. Conclusion: Overall, the results of our survey found that Connecticut licensed pharmacists had lack of complete and accurate knowledge regarding the state's MCP. As more states legalize medical cannabis, it will be imperative that education of pharmacists and other health care professionals about the MCP and the clinical use of cannabis occur.

Engaging community pharmacists in quality improvement (QI): a qualitative case study of a partnership between a Higher Education Institute and Local Pharmaceutical Committees.

BACKGROUND: Quality improvement (QI) involves the use of systematic tools and methods to improve the quality of care and outcomes for patients. However, awareness and application of QI among healthcare professionals is poor and new strategies are needed to engage them in this area. OBJECTIVES: This study describes an innovative collaboration between one Higher Educational Institute (HEI) and Local Pharmaceutical Committees (LPCs) to develop a postgraduate QI module aimed to upskill community pharmacists in QI methods. The study explores pharmacist engagement with the learning and investigates the impact on their practice. METHODS: Details of the HEI-LPCs collaboration and communication with pharmacist were recorded. Focus groups were held with community pharmacists who enrolled onto the module to explore their motivation for undertaking the learning, how their knowledge of QI had changed and how they applied this learning in practice. A constructivist qualitative methodology was used to analyse the data. RESULTS: The study found that a HEI-LPC partnership was feasible in developing and delivering the QI module. Fifteen pharmacists enrolled and following its completion, eight took part in one of two focus groups. Pharmacists reported a desire to extend and acquire new skills. The HEI-LPC partnership signalled a vote of confidence that gave pharmacists reassurance to sign up for the training. Some found returning to academia challenging and reported a lack of time and organisational support. Despite this, pharmacists demonstrated an enhanced understanding of QI, were more analytical in their day-to-day problem-solving and viewed the learning as having a positive impact on their team's organisational culture with potential to improve service quality for patients. CONCLUSIONS: With the increased adoption of new pharmacist's roles and recent changes to governance associated with the COVID-19 pandemic, a HEI-LPC collaborative approach could upskill pharmacists and help them acquire skills to accommodate new working practices.

Perceptions of the Value of Clinical Pharmacy Medication Review for Women During Early Pregnancy.

BACKGROUND: The benefit of continuing medications to prevent or treat illness is often overlooked, since pregnant women tend to overestimate the teratogenic risk of medications. Pharmacists can serve as a resource to prescribers and pregnant women with their knowledge of the appropriate use and management of medications during pregnancy. Little information exists on the value women place on pharmacists' medication management during pregnancy. OBJECTIVE: To assess pregnant women's perceptions of an ambulatory care clinical pharmacist (CP) medication review service during early pregnancy that provided education regarding the risks and benefits of medication use during pregnancy. METHODS: This was a qualitative study of pregnant women using semistructured telephone interviews performed between December 12, 2018, and January 18, 2019, and conducted in an integrated health care delivery system. Potential participants were identified from CP encounter records. Consented English-speaking women aged ≥ 18 years participated in an up to 30-minute interview within 1 week of the CP encounter. Interviews were professionally transcribed and coded line by line using the constant comparison method with grounded theory used to gain insight into participants' perspectives. RESULTS: 62 women were invited to participate in semistructured telephone interviews of whom 24 (39%) completed the interview. Three main themes emerged from the qualitative analysis: satisfaction with the service, comfort with medication use during pregnancy, and connectedness to the health care team. Overall, the CP medication review and education service was perceived positively by the participants. Participants reported satisfaction in the quality, timeliness, and convenience of the service and found it beneficial to have their medications reviewed early during pregnancy to assist in medication use decisions before their first obstetric visit. CONCLUSIONS: CP medication review provided a comforting, valuable service for women during early pregnancy when medication-taking decisions can feel exigent. DISCLOSURES: This study was funded by Kaiser Permanente. The authors have nothing to disclose. Preliminary results were presented at the Mountain States Conference for Residents and Preceptors, May 2019, in Salt Lake City, UT.

Evaluation of a Pharmacist-Managed Nonsteroidal Anti-Inflammatory Drugs Deprescribing Program in an Integrated Health Care System.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat symptoms of chronic inflammatory diseases such as osteoarthritis and rheumatoid arthritis; however, they are also associated with various adverse effects, including gastrointestinal (GI) bleeding and renal harm. As patients get older, some medications may no longer be beneficial or may even cause harm. Deprescribing is defined as the planned and supervised process of dose reduction or discontinuation of medications. While there are studies showing that deprescribing strategies with several classes of medications positively affects outcomes in elderly patients, there is a lack of strong evidence and guidance to deprescribe NSAIDs. OBJECTIVE: To evaluate the effectiveness, safety, and economic impact of pharmacists deprescribing NSAIDs under the guidance of a standardized deprescribing program compared with usual care within an integrated health care system. METHODS: This retrospective, propensity score-matched cohort study included patients aged ≥ 65 years who were eligible for the NSAID deprescribing program from July 2016 to June 2018. Those patients in the deprescribing group were assessed by pharmacists and had their medications deprescribed. Patients who were eligible for the deprescribing program but did not receive any interventions were matched to the deprescribed group using propensity score matching at a 4:1 ratio and became the usual care group. Patients were followed for 6 months, until end of membership, or until death, whichever occurred first. The effectiveness and safety outcomes included rates of 3 adverse events: GI bleeds, acute kidney injuries (AKI), and exacerbation of pain triggering a hospitalization or emergency room visit. The economic outcome was the change in monthly NSAID cost. Descriptive statistics, t-tests, chi-square tests, and conditional logistic regression models were used for analysis. RESULTS: There were 431 patients in the deprescribed group and 1,724 patients in the usual care group, with similar baseline characteristics after propensity score matching. The adjusted results showed no significant difference between the deprescribed and usual care groups for GI bleed events (OR = 0.65, 95% CI = 0.36-1.16, P = 0.15) and AKI (OR = 0.53, 95% CI = 0.24-1.16, P = 0.11). The deprescribed group experienced a significant 2-fold decrease in the odds of exacerbation of pain versus the deprescribed group (OR = 0.50, 95% CI = 0.33-0.77, P < 0.01). Finally, there was no significant difference in the change in monthly NSAIDs costs between the 2 groups (median change, IQR: -$0.29, -$2.37 to -$0.11 for deprescribed group; -$0.23, -2.59 to 0.00 for usual care group, P = 0.054). CONCLUSIONS: Although this study did not find any difference in the rate of GI bleed or AKI, we found a significant decrease in the rate of exacerbation of pain in the deprescribed group versus the usual care group. This result suggests that deprescribing NSAIDs did not cause harm during the 6-month follow-up. Further long-term studies are necessary to validate these outcomes. DISCLOSURES: No funding was provided to support this research study. The authors of this study have no actual or potential conflicts of interest to report. Parts of this study were presented in a nonreviewed resident poster at the AMCP Managed Care and Specialty Pharmacy Annual Meeting; March 25-28, 2019; San Diego, CA.

Attitudes and knowledge about cannabis and cannabis-based therapies among US neurologists, nurses, and pharmacists.

Use of cannabinoid therapies is on the rise in the United States, but responses of healthcare professionals and their knowledge of these therapies have been mixed. More information is needed about factors associated with healthcare professionals' attitudes and knowledge about medical cannabis. We conducted an online survey of US-based neurologists, nurse practitioners (NPs)/nurses, and pharmacists in August-September of 2018 (n = 451). We constructed perceived knowledge and attitudes scales and a knowledge index from multiple items and assessed state cannabis laws, participant's sociodemographics, workplace type and policies, and patient population. We used ordinary least-squares regression to examine associations among study variables. Over 80% of participants supported use and legalization of medical cannabis, especially cannabidiol (CBD) for epilepsy and when prescribed by a medical provider, but 40-50% (depending on item) felt unfamiliar with cannabinoid pharmacology and clinical applications. A total of 43% favored legal recreational cannabis. Pharmacists scored higher on the knowledge test than neurologists and NPs/nurses, but NPs/nurses had more favorable attitudes than neurologists and higher perceived knowledge than pharmacists. Both knowledge indicators predicted attitudes. State cannabis access and favorable workplace policies were associated with higher knowledge and more favorable attitudes. Healthcare professionals see potential in cannabis therapies but report significant knowledge gaps. Professional cannabinoid education is needed to address growing patient and provider demand for knowledge about cannabinoid therapies.

Pharmacy Competencies for Interprofessional Integrative Health Care Education.

Objective. To address the gap in evidence-based knowledge among pharmacy students and practicing pharmacists regarding complementary and integrative health approaches due to insufficient education and a lack of standardized training. Methods. The National Center for Integrative Primary Healthcare (NCIPH) developed 22 pharmacy competencies linked to a set of 10 interprofessional "metacompetencies" in integrative health care. Results. The NCIPH pharmacy competencies are well-aligned with the current educational standards and Center for the Advancement of Pharmacy Education (CAPE) outcomes for pharmacy programs. Therefore, the NCIPH competencies may provide a foundation for the incorporation of interprofessional integrative health care education into pharmacy curricula. Conclusion. The NCIPH pharmacy competencies in integrative health care, linked to the interprofessional "metacompetencies," are aligned with educational standards and outcomes, and may serve as a basis for pharmacy curriculum.

New Models of Care: How Pharmacists Can Provide Better Care at Lower Costs.

Pharmacists, highly trained and accessible health care professionals, continue to be underused in American communities. Helping pharmacists to make the best use of their extensive clinical education and skills is a primary focus for the discipline's leaders. The University of Connecticut School of Pharmacy's PRISM initiative ( PeRformance I mprovement for Safe Medication Management) creates opportunities to partner with other health professionals or programs to advance the pharmacist's role in the community. All stakeholders must understand the evolving health care climate as society moves toward "health care without walls" (i. e., health care that is innovative, convenient, and likely to be entirely different than previous models). This article discusses progress made in Connecticut to advance pharmacy practice and describes programs that, if replicated in other areas of the country, could significantly improve care for vulnerable populations, especially the elderly. Programs that have been especially useful have emphasized the difference between needing medical versus pharmacy services, and approached provision of care in entirely new ways.

Advancement of clinical pharmacy practice through intervention capture.

PURPOSE: The methods and processes utilized to deploy the Pharmacists Achieve Results with Medications Documentation (PhARMD) Project intervention template across the largest integrated healthcare system in the United States are described. SUMMARY: The PhARMD Project team at the Department of Veterans Affairs (VA) designed, developed, and deployed a standardized template within VA's electronic health record (EHR) that allows the clinical pharmacy specialist (CPS) to efficiently document select interventions made during patient care encounters that specifically contribute to the overall care provided and patient outcomes. The template is completed by the CPSs as part of progress note documentation within the EHR. Using point-and-click functionality, a CPS selects the check boxes corresponding to specific interventions made during that patient care encounter. This improves workflow and negates the need to document interventions in a separate software system, streamlining documentation. The implementation and use of the PhARMD template at each VA facility are voluntary. From October 1, 2016, to September 30, 2017, 4,728 CPSs documented 3,805,323 interventions during 2,384,771 patient care encounters. These interventions were documented across 592,126 unique patients, with a mean of 6.4 interventions per patient during this period. Most interventions (95%) were performed by CPSs functioning as advanced practice providers and with autonomous prescriptive authority authorized under their scope of practice. CONCLUSION: The PhARMD template demonstrated that the capture of clinical pharmacy interventions and outcomes can be achieved across a large integrated healthcare system by thousands of CPSs in numerous practice settings.

Documenting Stage 1 and 2 Meaningful Use criteria: A comparison of clinical pharmacists with other healthcare providers.

PURPOSE: Documentation of Stage 1 and Stage 2 Meaningful Use (MU) criteria for patients with type 2 diabetes mellitus between clinical pharmacists and other healthcare providers was compared. METHODS: Patients seen at 8 clinics in a federally qualified health center who had type 2 diabetes mellitus and were seen by clinical pharmacists or other healthcare providers were randomly selected for inclusion in this retrospective study. Approximately half of the encounters were evaluated for Stage 1 MU compliance (encounters from October through December 2014), and half were evaluated for Stage 2 MU compliance (encounters from January through March 2015). Categorical and descriptive variables were analyzed by calculating frequencies and percentages. Chi-square tests were used to compare groups with an a priori level of significance set at 0.05. RESULTS: A total of 790 patients were seen by 46 providers, 8 (18%) of whom were clinical pharmacists. The study also included 24 medical doctors, 8 family nurse practitioners, 1 physician assistant, and 5 doctors of osteopathic medicine. Other healthcare providers more consistently documented 5 Stage 1 MU criteria than did clinical pharmacists. Clinical pharmacists more consistently documented 2 core objectives than did other healthcare providers. Otherwise, no significant differences in documentation were detected. CONCLUSION: Other healthcare providers more consistently documented 5 Stage 1 MU criteria than did clinical pharmacists. Clinical pharmacists more consistently documented 2 core objectives than did other healthcare providers.

Practice of community pharmacists related to multivitamin supplements: a simulated patient study in Iran.

Background Multivitamin supplements are a subset of dietary supplements sold in pharmacies as over-the-counter medicines. Community pharmacists are regarded as responsible professionals and relied on for their safe practice and efficacy. Objective The aim of this study was to evaluate the counselling practices of community pharmacists relating to typical use, interactions, contraindications, and side effects of multivitamin supplements using simulated patients. Setting Ninety-seven community pharmacies in Kerman, Iran. Method Two male students acted as simulated patients who role-played a scenario in the community pharmacies in two steps. In step 1, they spontaneously mentioned they were a student and did not eat properly through lack of time and requested a multivitamin supplement. In Step 2, if the pharmacists did not request a drug history, they would explain that they had severe acne and had been taking oral isotretinoin for a month. The counselling practice of the pharmacists was audio recorded. Main outcome measure The number of pharmacists who provided information about multivitamin use and identified isotretinoin-vitamin A interaction. Results Thirteen pharmacists in charge were absent at the time of the purchases. None of the pharmacists provided information about contraindications and side effects of multivitamin products. Twenty pharmacists provided instruction for multivitamin use, and two pharmacists took a drug history. In Step 1, only two pharmacists identified isotretinoin-vitamin A interaction, but in Step 2, this number increased to 15. Conclusion The counselling practice of pharmacists should be improved to promote effective and safe use of multivitamin supplements.

Impact of clinical pharmacists in outpatient oncology practices: A review.

PURPOSE: Published literature describing the effectiveness of outpatient oncology services delivered by clinical pharmacists is summarized. METHODS: Peer-reviewed articles on studies evaluating the provision of outpatient oncology services by licensed clinical pharmacists in the United States were identified and screened according to a study-specific protocol. Only research publications focused on the care of oncology patients and indicating the evaluation of measurable services and outcomes were selected for review. Data from eligible studies were extracted using a standardized tool, and agreement by a majority of the investigators was required for inclusion of articles in the final review. RESULTS: Eight publications were included in the review; nearly all were published since 2010. All of the included articles reported on results of observational studies in which data sourced from surveys, existing medical or prescription records, or medical cost information were analyzed to measure patient or provider satisfaction (or both) or patient-reported health outcomes. The evaluated evidence indicated that pharmacists were effective in identifying treatment issues and medication misuse, delivering satisfactory and valued services, and finding mechanisms to reduce medical costs or generate revenue to justify continuation or support expansion of clinical pharmacy services. Moreover, in two instances, pharmacists' services were associated with improvements in symptoms reported by oncology patients. CONCLUSION: Available evidence suggests that outpatient oncology practices may benefit from integrating pharmacists into care models in order to more effectively, efficiently, and holistically address the needs of patients with cancer.

Design and implementation of population-based specialty care programs.

PURPOSE: The development, implementation, and scaling of 3 population-based specialty care programs in a large integrated healthcare system are reviewed, and the role of clinical pharmacy services in ensuring safe, effective, and affordable care is highlighted. SUMMARY: The Kaiser Permanente (KP) integrated healthcare delivery model allows for rapid development and expansion of innovative population management programs involving pharmacy services. Clinical pharmacists have assumed integral roles in improving the safety and effectiveness of high-complexity, high-cost care for specialty populations. These roles require an appropriate practice scope and are supported by an advanced electronic health record with disease registries and electronic surveillance tools for care-gap identification. The 3 specialty population programs described were implemented to address variation or unrecognized gaps in care for at-risk specialty populations. The Home Phototherapy Program has leveraged internal partnerships with clinical pharmacists to improve access to cost-effective nonpharmacologic interventions for psoriasis and other skin disorders. The Multiple Sclerosis Care Program has incorporated clinical pharmacists into neurology care in order to apply clinical guidelines in a systematic manner. The KP SureNet program has used clinical pharmacists and data analytics to identify opportunities to prevent drug-related adverse outcomes and ensure timely follow-up. CONCLUSION: Specialty care programs improve quality, cost outcomes, and the patient experience by appropriating resources to provide systematic and targeted care to high-risk patients. KP leverages an integration of people, processes, and technology to develop and scale population-based specialty care.

Creation of a certification requirement for pharmacists in direct patient care roles.

PURPOSE: Steps taken by a large health system to require certification for all pharmacists in direct patient care roles are detailed. SUMMARY: Major supply chain changes and rising payer expectations are reshaping pharmacy practice, resulting in expanded responsibilities for pharmacists and a heightened need for certification in specialized practice areas. In response, the pharmacy leadership team at UW Health, the integrated health system of the University of Wisconsin-Madison, used an iterative process and a "rolling" FAQ format to develop and implement a certification requirement. Key decisions during the process included decisions to accept only rigorous certifications (mainly those offered by the Board of Pharmacy Specialties), to provide institutional support for continuing education-based recertification, and to use an accepted definition of direct patient care in determining which pharmacists need to be certified. The team obtained the support of the UW Health human relations department by drafting a policy and rewriting all pharmacist position descriptions to incorporate the certification requirement. An all-pharmacist forum was held to build staff commitment. As a result of the requirement, 73 pharmacists were required to obtain certification by 2018 at a total cost to UW Health of $44,000; ongoing support of certification maintenance will cost an estimated $40,000 per year. CONCLUSION: Health systems can be successful in establishing uniform certification expectations for pharmacists in direct patient care roles, even across diverse practice settings, by aligning expectations with organizational goals.

Developing a dashboard for benchmarking the productivity of a medication therapy management program.

OBJECTIVES: To describe a method for internal benchmarking of medication therapy management (MTM) pharmacist activities. SETTING: Multisite MTM pharmacist practices within an integrated health care system. PRACTICE DESCRIPTION: MTM pharmacists are located within primary care clinics and provide medication management through collaborative practice. MTM pharmacist activity is grouped into 3 categories: direct patient care, nonvisit patient care, and professional activities. PRACTICE INNOVATION: MTM pharmacist activities were tracked with the use of the computer-based application Pharmacist Ambulatory Resource Management System (PhARMS) over a 12-month period to measure growth during a time of expansion. RESULTS: A total of 81% of MTM pharmacist time was recorded. A total of 1655.1 hours (41%) was nonvisit patient care, 1185.2 hours (29%) was direct patient care, and 1190.4 hours (30%) was professional activities. The number of patient visits per month increased during the study period. There were 1496 direct patient care encounters documented. Of those, 1051 (70.2%) were face-to-face visits, 257 (17.2%) were by telephone, and 188 (12.6%) were chart reviews. Nonvisit patient care and professional activities also increased during the period. IMPACT: PhARMS reported MTM pharmacist activities and captured nonvisit patient care work not tracked elsewhere. Internal benchmarking data proved to be useful for justifying increases in MTM pharmacist personnel resources. Reviewing data helped to identify best practices from high-performing sites. Limitations include potential for self-reporting bias and lack of patient outcomes data. CONCLUSION: Implementing PhARMS facilitated internal benchmarking of patient care and nonpatient care activities in a regional MTM program.

Pharmacist prescribing within an integrated health system in Washington.

PURPOSE: Pharmacist prescribing as part of a collaborative drug therapy agreement (CDTA) within an integrated health system in Washington is described. SUMMARY: Virginia Mason Medical Center (VMMC) in Seattle, Washington, uses a team-based care model with broad-based CDTAs to provide quality patient care. The majority of patients are referred to the pharmacist after a diagnosis has been made and a clinical care plan has been started. The pharmacist manages the patient's care within his or her scope of practice as defined by state laws and further detailed by VMMC internal protocols. The pharmacist then documents in the electronic medical record the medication plan of care and other standard elements based on provider note templates. Medication prescribing and laboratory test ordering are the responsibilities of the pharmacist, as are any dosage adjustments or interpretations of laboratory test results. For some chronic diseases, the pharmacist may continue to see the patient indefinitely, replacing physician visits (e.g., for warfarin management). In more episodic care, the pharmacist may see the patient, optimize drug therapy, and then transition the patient back to the referring provider (e.g., for hypertension management). Integrating the pharmacist into the team has helped achieve optimal medication outcomes and increased patient satisfaction scores. CONCLUSION: The addition of the pharmacist into a team-based care model using a CDTA helped achieve optimal medication outcomes and increased patient satisfaction scores in an integrated health system. Integration was successful due to the collaborative support from physician leadership and ongoing physician involvement. Hands-on leadership by the pharmacy department and clinic directors and the health system's adoption of Lean methodology fostered an environment for developing innovative care models.

Pharmacists counselling of pregnant women: Web-based, comparative study between Serbia and Norway.

OBJECTIVES: To describe, compare and evaluate whether pharmacists in two European countries, Serbia and Norway, give appropriate counselling for common ailments in pregnancy. DESIGN: A cross sectional, web-based study. PARTICIPANTS AND SETTINGS: A study was conducted among Serbian and Norwegian pharmacists during two four-month study periods in 2012 respectively 2014. Participants were recruited through postal and electronic invitation facilitated by several pharmacy chains. Participation in the study was anonymous and voluntary. MEASUREMENT INSTRUMENT: Pharmacists were presented with the questionnaire that included five scenarios (back pain, heavy legs, nausea, cold and constipation in pregnancy) and were asked to give their advice about use of medicines, supplements (e.g. herbal products, vitamins, minerals), non-pharmacological treatment and referral to physician in each condition. FINDINGS: In total, 276 pharmacists, 119 in Serbia and 157 in Norway, accepted to participate in the study. Recommendation about medicines use ranged from 32% (heavy legs) to 71% (back pain) in Serbia and from 3% (heavy legs) to 92% (constipation) in Norway. Several pharmacists' recommendations on medicines and supplements use were inappropriate. Recommendation about non-pharmacological treatments ranged from 11% (nausea) to 50% (heavy legs) in Serbia and from 12% (constipation) to 63% (cold) in Norway. Approximately 12% of the Norwegian and Serbian pharmacists offered referral to a physician as only advice for nausea in pregnancy, indicating a lack of confidence in or knowledge about this common ailment in pregnancy. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Large differences in counselling of pregnant women by pharmacists in Serbia and Norway were observed. Enhancement of pharmacists' knowledge about treatment of common ailments in pregnancy is needed and will enhance pharmacists' role in improving maternal health.

Pharmacist-driven antimicrobial optimization in the emergency department.

PURPOSE: A pharmacist-driven antimicrobial optimization service in the non-trauma emergency department (ED) of an 864-bed non-profit tertiary care teaching hospital was reviewed to assess its value. Local antimicrobial resistance patterns of urine, wound, stool, and blood cultures were also studied to determine whether or not empiric prescribing practices should be modified. METHODS: A retrospective electronic chart review was performed for ED patients with positive cultures during two different three-month periods. During Period 1, ED nursing management performed positive culture follow-up. During Period 2, ED clinical pharmacists performed this role. The primary objective was to determine the value of the pharmacist-driven antimicrobial optimization service as measured by the number of clinical interventions made when indicated. The secondary objective was to examine resistance patterns of urine and wound isolates in order to determine if empiric prescribing patterns in the ED should be modified. RESULTS: During Period 1, there were 499 patient visits with subsequent positive cultures. Of those, 76 patients (15%) were discharged home. Nursing management intervened on 21 of 42 (50%) positive cultures that required an intervention; in Period 2, there were 473 patient visits with subsequent positive cultures, and 64 (14%) were discharged home. Pharmacists intervened on 24 of 30 (80%) cultures where an intervention was indicated resulting in a 30% increase in interventions for inappropriate therapy (p = 0.01). A review of the secondary objective revealed a 38% fluoroquinolone resistance rate of E. coli, the most frequently isolated urinary organism. CONCLUSION: Pharmacist-driven antimicrobial stewardship program resulted in a 30% absolute increase in interventions for inappropriate therapy as compared to the nursing-driven model. This stewardship program has further demonstrated the value of ED pharmacists. Pharmacist interventions should help to ensure that infections are resolved through modification of antimicrobial therapies for patients with bug-drug mismatches. The fluoroquinolone resistance rate indicates a need to consider alternative therapies for uncomplicated urinary tract infections. Nitrofurantoin remains with good coverage against E. coli and Enterococcus species but should be used in uncomplicated patients with normal renal function.

Improving the appropriateness of prescribing in older patients: a systematic review and meta-analysis of pharmacists' interventions in secondary care.

INTRODUCTION: potentially inappropriate prescribing (PIP) in older hospitalised patients, and in particular those with dementia, is associated with poorer health outcomes. PIP reduction is therefore essential in this population. METHODS: a comprehensive electronic literature search was conducted using 12 databases from inception up to and including September 2014. Inclusion criteria were controlled trials (randomised or non-randomised) of interventions involving pharmacists conducted in hospitals, with an objective of the study being PIP reduction in patients 65 years or older or patients with dementia of any age, using any validated PIP tool as an outcome measure. Risk of bias assessments were conducted utilising the Cochrane Collaboration's tool. RESULTS: a total of 1,752 records were found after duplicates were removed. Four trials (n = 1,164 patients; two randomised, two non-randomised) from three countries were included in the quantitative analysis. All studies were at moderate risk of bias. No study focused specifically on dementia patients. Three trials reported statistically significant reductions in the Medication Appropriateness Index score in the intervention group (mean difference from admission to discharge = -7.45, 95% CI: -11.14, -3.76) and other PIP tools such as Beers Criteria. One trial reported reduced drug-related readmissions and another reported increased adverse drug reactions. CONCLUSION: multi-disciplinary teams involving pharmacists may improve prescribing appropriateness in older inpatients, though the clinical significance of observed reductions is unclear. More research is required into the effectiveness of pharmacists' interventions in reducing PIP in dementia patients. Additionally, easily assessed and clinically relevant measures of PIP need to be developed.