Unplanned Rehospitalisation due to Medication Harm following an Acute Myocardial Infarction.

INTRODUCTION: The contribution of medication harm to rehospitalisation and adverse patient outcomes after an acute myocardial infarction (AMI) needs exploration. Rehospitalisation is costly to both patients and the healthcare facility. Following an AMI, patients are at risk of medication harm as they are often older and have multiple comorbidities and polypharmacy. This study aimed to quantify and evaluate medication harm causing unplanned rehospitalisation after an AMI. METHODS: This was a retrospective cohort study of patients discharged from a quaternary hospital post-AMI. All rehospitalisations within 18 months were identified using medical record review and coding data. The primary outcome measure was medication harm rehospitalisation. Preventability, causality, and severity assessments of medication harm were conducted. RESULTS: A total of 1,564 patients experienced an AMI, and 415 (26.5%) were rehospitalised. Eighty-nine patients (5.7% of total population; 6.0% of those discharged) experienced a total of 101 medication harm events. Those with medication harm were older (p = 0.007) and had higher rates of heart failure (p = 0.005), chronic kidney disease (p = 0.046), chronic obstructive pulmonary disease (p = 0.037), and a prior history of ischaemic heart disease (p = 0.005). Gastrointestinal bleeding, acute kidney injury, and hypotension were the most common medication harm events. Forty percent of events were avoidable, and 84% were classed as "serious." Furosemide, antiplatelets, and angiotensin-converting enzyme inhibitors were the most commonly implicated medications. The median time to medication harm rehospitalisation was 79 days (interquartile range: 16-200 days). CONCLUSION: Medication harm causes unplanned rehospitalisation in 5.7% of all AMI patients (1 in 17 patients; 6.0% of those discharged). The majority of harm was serious and occurred within the first 200 days of discharge. This study highlights that measures to attenuate the risk of medication harm rehospitalisation are essential, including post-discharge medication management.

Individualised medicine: why we need Bayesian dosing.

Individualised drug dosing has been shown to improve patient outcomes and reduce adverse drug events. One method of individualised medicine is the Bayesian approach, which uses prior information about how the population responds to therapy, to inform clinicians about how a specific individual is responding to their current therapy. This information is then used to make changes to the dose. Studies using a Bayesian approach to adjust drug dosing have shown that clinicians are able to achieve a therapeutic range quicker than standard practice. If concentration is related to a pharmacodynamic end-point, this means that the drug will be more effective, and the side-effects will be minimised. Unfortunately, the software options to assist with Bayesian dosing in Australia are limited. The aims of this article are to demystify the concepts of Bayesian dosing, set the context of the Bayesian approach using reference to other dosing strategies and discuss its benefits over current dosing methods for a number of drugs. The article is targeted to medical and pharmacy clinicians, and there is a practical clinical case to demonstrate how this method could be used in everyday clinical practice.

Investigating strategies used by hospital pharmacists to effectively communicate with patients during medication counselling.

BACKGROUND: Medication counselling opportunities are key times for pharmacists and patients to discuss medications and patients' concerns about their therapy. Communication Accommodation Theory (CAT) describes behavioural, motivational and emotional processes underlying communication exchanges. Five CAT strategies (approximation, interpretability, discourse management, emotional expression and interpersonal control) permit identification of effective communication. OBJECTIVE: To invoke CAT to investigate communication strategies used by hospital pharmacists during patient medication counselling. DESIGN: This was a theory-based, qualitative study using transcribed audiorecordings of patients and hospital pharmacists engaged in medication counselling. SETTING AND PARTICIPANTS: Recruited pharmacists practised in inpatient or outpatient settings. Eligible patients within participating pharmacists' practice sites were prescribed at least three medications to manage chronic disease(s). MAIN OUTCOME MEASURES: The extent to which pharmacists accommodate, or not, to patients' conversational needs based on accommodative behaviour described within CAT strategies. RESULTS: Twelve pharmacists engaged four patients (48 total interactions). Exemplars provided robust examples of pharmacists effectively accommodating or meeting patients' conversational needs. Non-accommodation mainly occurred when pharmacists spoke too quickly, used terms not understood by patients and did not include patients in the agenda-setting phase. Multiple strategy use resulted in communication patterns such as "information-reassurance-rationale" sandwiches. DISCUSSION AND CONCLUSIONS: Most pharmacists effectively employed all five CAT strategies to engage patients in discussions. Pharmacists' communication could be improved at the initial agenda-setting phase by asking open-ended questions to invite patients' input and allow patients to identify any medication-related concerns or issues.

Bayesian Estimation of Tobramycin Exposure in Patients with Cystic Fibrosis.

Fixed tobramycin (mg/kg) dosing is often inappropriate in patients with cystic fibrosis (CF), as pharmacokinetics are highly variable. The area under the concentration-time curve (AUC) is an exposure metric suited to monitoring in this population. Bayesian strategies to estimate AUC have been available for over 20 years but are not standard practice in the clinical setting. To assess their suitability for use in clinical practice, three AUC estimation methods using limited sampling were compared to measured true exposure by using intensive sampling tobramycin data. Adults prescribed once daily intravenous tobramycin had eight concentrations taken over 24 h. An estimate of true exposure within one dosing interval was calculated using the trapezoidal method and compared to three alternate estimates determined using (i) a two-sample log-linear regression (LLR) method (local hospital practice); (ii) a Bayesian estimate using one concentration (AUC1); and (iii) a Bayesian estimate using two concentrations (AUC2). Each method was evaluated against the true measured exposure by a Bland-Altman analysis. Twelve patients with a median (range) age and weight of 25 (18 to 36) years and 66.5 (51 to 76) kg, respectively, were recruited. There was good agreement between the true exposure and the three alternate estimates of AUC, with a mean AUC bias of <10 mg/liter · h in each case, i.e., -8.2 (LLR), 3.8 (AUC1), and 1.0 (AUC2). Bayesian analysis-based and LLR estimation methods of tobramycin AUC are equivalent to true exposure estimation. All three methods may be suitable for use in the clinical setting; however, a one-sample Bayesian method may be most useful in ambulatory patients for which coordinating blood samples is difficult. Suitably powered, randomized clinical trials are required to assess patient outcomes.

Compliance With Enoxaparin Dosing and Monitoring Guidelines and the Impact on Patient Length of Stay: A Pilot Study.

BACKGROUND: To investigate the compliance of prescribers with the state-wide Queensland Health (QH) guidelines for dosing and monitoring of enoxaparin, and to examine the effect that compliance has on the patients' length of stay (LOS) in hospital. METHODS: A 4-week retrospective study of consecutive inpatients who were administered enoxaparin for the treatment of an embolic disease. Data collected included influential patient demographics such as weight, renal function; details of antifactor Xa (aXa) monitoring, and patient LOS. All dosing and monitoring for each patient was compared to the current QH guidelines for enoxaparin usage; a multidisciplinary consensus document. The reasons for noncompliance were quantified and explored. RESULTS: A total of 67 inpatients were recruited. The median (range) age, weight, and creatinine clearance of patients were 66 years (18-92), 78.5 kg (47.6-182), and 64 mL/min (16-180), respectively. Only 20 (30%) patients received enoxaparin in compliance with QH guidelines, leaving 47 (70%) noncompliant. The median (range) LOS was 7 (2-58) days for the compliant group versus 15 days (2-101) for the noncompliant (P = 0.06, Mann-Whitney U test). A total of 10 (15%) patients were monitored for aXa; none of whom were monitored correctly. Twenty-eight patients did not receive monitoring when indicated (moderate or severe renal impairment, weight >105 kg, or extended duration of therapy). In these patients, the median (range) LOS was 16.5 days (2-101). CONCLUSIONS: Current prescribing of enoxaparin does not match state guidelines. Although not significant, there was a trend toward noncompliant patients having a greater LOS in hospital. The quality of aXa monitoring is suboptimal and barriers need to be explored. Larger studies are warranted.

Direct oral anticoagulants: New drugs with practical problems. How can nurses help prevent patient harm?

The safe use of anticoagulants requires a delicate balance between the risk of bleeding and the risk of thrombosis, particularly in drug-sensitive patients, such as older people. Recently-marketed "direct oral anticoagulants" are now being increasingly prescribed and administered in the hospital setting. Direct oral anticoagulants have pharmacological properties that are often unpredictable, and inter-patient variability in drug response is high. Therefore, people often require meticulous review and planning to ensure they receive optimal dosing and monitoring. The multidisciplinary medication management of those receiving these drugs needs to be effectively coordinated to reduce the risk of patient harm. All clinical staff, including nurses, doctors, and pharmacists, should be competent in the pharmacology of these drugs, and know which people require individualized care plans. In this study, we introduced important concepts via the use of case studies developed from commonly-seen scenarios at our quaternary hospital. In particular, the important role of nurses in ensuring patient safety in the periprocedural setting is highlighted.

The Effect of Digitization on the Safe Management of Anticoagulants.

BACKGROUND: Anticoagulants are high-risk medications and are a common cause of adverse events of hospitalized inpatients. The incidence of adverse events involving anticoagulants has remained relatively unchanged over the past two decades, suggesting that novel approaches are required to address this persistent issue. Electronic medication management systems (eMMSs) offer strategies to help reduce medication incidents and adverse drug events, yet poor system design can introduce new error types. OBJECTIVE: Our objective was to evaluate the effect of the introduction of an electronic medical record (EMR) on the quality and safety of therapeutic anticoagulation management. METHODS: A retrospective, observational pre-/poststudy was conducted, analyzing real-world data across five hospital sites in a single health service. Four metrics were compared 1-year pre- and 1-year post-EMR implementation. They included clinician-reported medication incidents, toxic pathology results, hospital-acquired bleeding complications (HACs), and rate of heparin-induced thrombocytopenia. Further subanalyses of patients experiencing HACs in the post-EMR period identified key opportunities for intervention to maximize safety and quality of anticoagulation within an eMMS. RESULTS: A significant reduction in HACs was observed in the post-EMR implementation period (mean [standard deviation [SD]] =12.1 [4.4]/month vs. mean [SD] = 7.8 [3.5]/month; p = 0.01). The categorization of potential EMR design enhancements found that new automated clinical decision support or improved pathology result integration would be suitable to mitigate future HACs in an eMMS. There was no significant difference in the mean monthly clinician-reported incident rates for anticoagulants or the rate of toxic pathology results in the pre- versus post-EMR implementation period. A 62.5% reduction in the cases of heparin-induced thrombocytopenia was observed in the post-EMR implementation period. CONCLUSION: The implementation of an EMR improves clinical care outcomes for patients receiving anticoagulation. System design plays a significant role in mitigating the risks associated with anticoagulants and consideration must be given to optimizing eMMSs.

Toward a Learning Health Care System: A Systematic Review and Evidence-Based Conceptual Framework for Implementation of Clinical Analytics in a Digital Hospital.

OBJECTIVE: A learning health care system (LHS) uses routinely collected data to continuously monitor and improve health care outcomes. Little is reported on the challenges and methods used to implement the analytics underpinning an LHS. Our aim was to systematically review the literature for reports of real-time clinical analytics implementation in digital hospitals and to use these findings to synthesize a conceptual framework for LHS implementation. METHODS: Embase, PubMed, and Web of Science databases were searched for clinical analytics derived from electronic health records in adult inpatient and emergency department settings between 2015 and 2021. Evidence was coded from the final study selection that related to (1) dashboard implementation challenges, (2) methods to overcome implementation challenges, and (3) dashboard assessment and impact. The evidences obtained, together with evidence extracted from relevant prior reviews, were mapped to an existing digital health transformation model to derive a conceptual framework for LHS analytics implementation. RESULTS: A total of 238 candidate articles were reviewed and 14 met inclusion criteria. From the selected studies, we extracted 37 implementation challenges and 64 methods employed to overcome such challenges. We identified common approaches for evaluating the implementation of clinical dashboards. Six studies assessed clinical process outcomes and only four studies evaluated patient health outcomes. A conceptual framework for implementing the analytics of an LHS was developed. CONCLUSION: Health care organizations face diverse challenges when trying to implement real-time data analytics. These challenges have shifted over the past decade. While prior reviews identified fundamental information problems, such as data size and complexity, our review uncovered more postpilot challenges, such as supporting diverse users, workflows, and user-interface screens. Our review identified practical methods to overcome these challenges which have been incorporated into a conceptual framework. It is hoped this framework will support health care organizations deploying near-real-time clinical dashboards and progress toward an LHS.

Current dosing of low-molecular-weight heparins does not reflect licensed product labels: an international survey.

AIMS: Low-molecular-weight heparins (LMWHs) are used globally to treat thromboembolic diseases; however, there is much debate on how to prescribe effectively for patients who have renal impairment and/or obesity. We aimed to investigate the strategies used to dose-individualize LMWH therapy. METHODS: We conducted an online survey of selected hospitals in Australia, New Zealand (NZ), United Kingdom (UK) and the United States (US). Outcome measures included: the percentage of hospitals which recommended that LMWHs were prescribed according to the product label (PL), the percentage of hospitals that dose-individualized LMWHs outside the PL based on renal function, body weight and anti-Xa activity and a summary of methods used to dose-individualize therapy. RESULTS: A total of 257 surveys were suitable for analysis: 84 (33%) from Australia, 79 (31%) from the UK, 73 (28%) from the US and 21 (8%) from NZ. Formal dosing protocols were used in 207 (81%) hospitals, of which 198 (96%) did not adhere to the PL. Of these 198 hospitals, 175 (87%) preferred to dose-individualize based on renal function, 128 (62%) on body weight and 48 (23%) by monitoring anti-Xa activity. All three of these variables were used in 29 (14%) hospitals, 98 (47%) used two variables and 71 (34%) used only one variable. CONCLUSIONS: Dose-individualization strategies for LMWHs, which contravene the PL, were present in 96% of surveyed hospitals. Common individualization methods included dose-capping, use of lean body size descriptors to calculate renal function and the starting dose, followed by post dose anti-Xa monitoring.

Individualized dosing of enoxaparin for subjects with renal impairment is superior to conventional dosing at achieving therapeutic concentrations.

INTRODUCTION: Enoxaparin is an anticoagulant used in the treatment of thromboembolic diseases. It is a hydrophilic molecule that is, predominantly, eliminated renally with few data to support dosing for subjects with renal impairment and/or obesity. A recently conducted randomized controlled clinical trial compared individualized enoxaparin doses based on lean body weight and renal function to conventional dosing. During this trial, anti-Xa concentrations were collected using a sparse sampling design and a population pharmacokinetic model was developed to describe the data. METHODS: The current study evaluated the ability of the individualized dose to achieve and maintain anti-Xa concentrations within the therapeutic range (0.5-1.0 IU/mL) in subjects with renal impairment and/or obesity. A matched comparison of the two dosing strategies was undertaken using individual model predicted anti-Xa concentrations generated every 30 minutes to 120 hours post initiation of therapy. Concentration-time curves were generated for each subject and the proportion of time in the therapeutic, supratherapeutic, and subtherapeutic ranges were determined. RESULTS: When compared with conventional dosing, individualized dosing in subjects with renal impairment resulted in a significantly greater proportion of time in the therapeutic range (median [range] = 69.9% (11.3-91.8) versus 42.6% [13.9-71.4], P = 0.02) and a significantly reduced proportion of time in the supratherapeutic range (median [range] = 9.3% (0%-67.0%) versus 37.1% (0%-85.7%), P = 0.02). Although there was a trend toward a greater proportion of time in the therapeutic range in obese subjects, this did not achieve statistical significance. CONCLUSIONS: Individualized dosing in subjects with renal impairment is more effective than conventional dosing at achieving and maintaining therapeutic anti-Xa concentrations, which could decrease the risk of bleeding events and mortality in these subjects.

Modelling the occurrence and severity of enoxaparin-induced bleeding and bruising events.

AIMS: To develop a population pharmacokinetic-pharmacodynamic model to describe the occurrence and severity of bleeding or bruising as a function of enoxaparin exposure. METHODS: Data were obtained from a randomized controlled trial (n = 118) that compared conventional dosing of enoxaparin (product label) with an individualized dosing regimen. Anti-Xa concentrations were sampled using a sparse design and the size, location and type of bruising and bleeding event, during enoxaparin therapy, were collected daily. A population pharmacokinetic-pharmacodynamic analysis was performed using nonlinear mixed effects techniques. The final model was used to explore how the probability of events in patients with obesity and/or renal impairment varied under differing dosing strategies. RESULTS: Three hundred and forty-nine anti-Xa concentrations were available for analysis. A two-compartment first-order absorption and elimination model best fit the data, with lean body weight describing between-subject variability in clearance and central volume of distribution. A three-category proportional-odds model described the occurrence and severity of events as a function of both cumulative enoxaparin AUC (cAUC) and subject age. Simulations showed that individualized dosing decreased the probability of a bleeding or major bruising event when compared with conventional dosing, which was most noticeable in subjects with obesity and renal impairment. CONCLUSIONS: The occurrence and severity of a bleeding or major bruising event to enoxaparin, administered for the treatment of a thromboembolic disease, can be described as a function of both cAUC and subject age. Individualized dosing of enoxaparin will reduce the probability of an event.

Developing Preliminary Steps in a Pharmacist Communication - Patient Outcome Pathway.

BACKGROUND: Nonadherence to medication therapy has been associated with poor health outcomes and increased health care costs. The literature describes pharmacists as key health care professionals in identifying and addressing nonadherence issues but does not explain how and why effective pharmacist-patient communication affects patients' medication adherence. Previously published pathways used in linking effective physician-patient communication to patient outcomes are proposed for the context of pharmacist-patient communication. OBJECTIVES: To develop preliminary steps in a pharmacist communication - patient outcome pathway, adapted from a physician-patient communication pathway. METHODS: This longitudinal descriptive study, which took place in a large quaternary hospital, involved hospital pharmacists and patients. Patients' assessment of pharmacist communication behaviours and reporting of patient satisfaction occurred after the pharmacist-patient consultation. Medication-taking behaviour questionnaires were administered before the consultation and again 4 weeks after discharge. Developing the preliminary pathway (based on previously established physician communication pathways) involved 2 steps, with investigation of the following associations: (1) between patient-reported effective communication by pharmacists, as per the Communication Accommodation Theory (CAT), and patient satisfaction; and (2) between patient-reported pharmacist communication and satisfaction and patients' medication-taking behaviour. RESULTS: Twelve pharmacists and 48 patients participated. For step 1, almost all patient-reported pharmacist communication behaviours were positively correlated with patient satisfaction statements. Strong associations between CAT-related pharmacist communication behaviours and patient satisfaction highlighted the pharmacists' behaviours that are important to patients and necessary for effective conversations to take place. In step 2, there were fewer correlations of medication-taking behaviour indices with pharmacist communication behaviours and patient satisfaction. CONCLUSIONS: This study showed how a preliminary pharmacist communication - patient outcome pathway could be successfully adapted from existing physician communication pathways. Such pathways provide an initial platform upon which future pharmacist communication - patient outcome research can be built.

CONTEXTE: Le non-respect de la pharmacothérapie a été associé à de mauvais résultats sur la santé et à une augmentation des coûts des soins de santé. La documentation actuelle décrit les pharmaciens comme étant les professionnels de la santé les mieux placés pour déceler les problèmes de non-respect de la prise de médicaments et pour y répondre. Toutefois, elle n'explique pas comment ni pourquoi une communication efficace entre le pharmacien et le patient incite le patient à respecter sa médication. Les parcours qui ont aidé les médecins à améliorer l'efficacité de la communication avec leurs patients sont désormais proposés aux pharmaciens dans le contexte de leur relation avec le patient. OBJECTIFS: Développer les étapes préliminaires d'un parcours de communication entre le pharmacien et le patient adapté à partir des résultats tirés du parcours de communication entre le médecin et le patient. MÉTHODES: Cette étude descriptive longitudinale, qui s'est déroulée dans un important hôpital de soins quaternaires, portait sur les pharmaciens d'hôpitaux et les patients. L'évaluation par les patients des comportements de communication des pharmaciens et le rapport sur la satisfaction du patient se sont déroulés après la consultation qui a eu lieu entre le pharmacien et le patient. Les questionnaires relatifs à la prise de médicaments ont été administrés avant la consultation et à nouveau quatre semaines après le congé hospitalier. L'élaboration du parcours préliminaire (basée sur les parcours de communication du médecin déjà établis) comportait deux étapes servant à examiner les associations suivantes : (1) le rapport qu'ont fait les patients sur l'efficacité de la communication des pharmaciens conformément à la théorie de l'accommodation de la communication (TAC) et la satisfaction du patient et (2) le rapport qu'ont fait les patients sur la communication des pharmaciens ainsi que leur satisfaction et la prise de médicaments des par les patients. RÉSULTATS: Douze pharmaciens et 48 patients ont participé à l'étude. Concernant la première étape, presque tous les patients ont rapporté que les comportements de communication des pharmaciens étaient positivement corrélés aux énoncés de satisfaction des patients. Les fortes associations entre les comportements de communication liés à la TAC du pharmacien et la satisfaction des patients mettaient en exergue les comportements des pharmaciens qui sont importants pour les patients et nécessaires pour accroître l'efficacité des conversations. Concernant la deuxième étape, les corrélations étaient moindres entre les indices de comportement liés à la prise de médicaments et les comportements de communication du pharmacien ainsi que la satisfaction du patient. CONCLUSIONS: Cette étude a démontré comment un parcours de communication préliminaire entre le pharmacien et le patient peut être adapté avec succès à partir des résultats tirés des parcours de communication existants destinés au médecin. De tels parcours fournissent une plateforme initiale sur laquelle peuvent se développer les recherches futures servant à démontrer les résultats sur les patients de la communication du pharmacien.

Hospital pharmacists' and patients' views about what constitutes effective communication between pharmacists and patients.

OBJECTIVES: The study's objective was to explore hospital pharmacists' and patients' views about what constitutes effective communication exchanges between pharmacists and patients. METHODS: This was a novel theory-based qualitative study using semi-structured interviews to elicit patients' and pharmacists' perspectives. Pharmacists providing clinical pharmacy services in either inpatient or outpatient settings were recruited first. Eligible patients had been admitted to a study pharmacist's practice area and were prescribed three or more medications to manage a chronic disease(s). Following each pharmacist-patient medication counselling session, semi-structured interviews were held separately with patients and pharmacists. Participants were asked questions intended to explore their views about what constitutes an effective pharmacist-patient conversation. Audio recordings were transcribed verbatim, analysed using a process of inductive thematic analysis and then mapped to Communication Accommodation Theory strategies. Observational notes and reflexive note taking were conducted throughout. KEY FINDINGS: Twelve pharmacists each engaged four individual patients for a total of 48 pharmacist-patient conversations (resulting in 48 separate interviews with pharmacists and patients). An overall shared goal was the assurance of patients' confidence in managing their medications at home. Themes included shared colloquialisms/slang, well-explained information, engagement, established rapport and empowerment. Participants provided rich exemplars for each of the themes. CONCLUSIONS: Pharmacists and patients provided valuable insights about what makes pharmacist-patient interactions effective. Patient-identified preferences for pharmacist-patient exchanges may help guide pharmacy students and practitioners to engage patients in effective conversations.

Using Discursis to enhance the qualitative analysis of hospital pharmacist-patient interactions.

INTRODUCTION: Pharmacist-patient communication during medication counselling has been successfully investigated using Communication Accommodation Theory (CAT). Communication researchers in other healthcare professions have utilised Discursis software as an adjunct to their manual qualitative analysis processes. Discursis provides a visual, chronological representation of communication exchanges and identifies patterns of interactant engagement. AIM: The aim of this study was to describe how Discursis software was used to enhance previously conducted qualitative analysis of pharmacist-patient interactions (by visualising pharmacist-patient speech patterns, episodes of engagement, and identifying CAT strategies employed by pharmacists within these episodes). METHODS: Visual plots from 48 transcribed audio recordings of pharmacist-patient exchanges were generated by Discursis. Representative plots were selected to show moderate-high and low- level speaker engagement. Details of engagement were investigated for pharmacist application of CAT strategies (approximation, interpretability, discourse management, emotional expression, and interpersonal control). RESULTS: Discursis plots allowed for identification of distinct patterns occurring within pharmacist-patient exchanges. Moderate-high pharmacist-patient engagement was characterised by multiple off-diagonal squares while alternating single coloured squares depicted low engagement. Engagement episodes were associated with multiple CAT strategies such as discourse management (open-ended questions). Patterns reflecting pharmacist or patient speaker dominance were dependant on clinical setting. DISCUSSION AND CONCLUSIONS: Discursis analysis of pharmacist-patient interactions, a novel application of the technology in health communication, was found to be an effective visualisation tool to pin-point episodes for CAT analysis. Discursis has numerous practical and theoretical applications for future health communication research and training. Researchers can use the software to support qualitative analysis where large data sets can be quickly reviewed to identify key areas for concentrated analysis. Because Discursis plots are easily generated from audio recorded transcripts, they are conducive as teaching tools for both students and practitioners to assess and develop their communication skills.

Hospital pharmacists' perceptions of medication counseling: A focus group study.

BACKGROUND: Medication counseling sessions are key times for a pharmacist to speak to patients about their medications and the changes made to their therapies during their hospital stay. OBJECTIVES: To explore hospital pharmacists' perceptions of their roles and goals in patient medication counseling, and perceived barriers and facilitators to achieving their goals. METHODS: Hospital pharmacist focus groups were held in two tertiary referral hospitals. Eligible pharmacists had provided medication counseling within the previous six months in inpatient and/or outpatient settings. Interested pharmacists attended a focus group designed to elicit their opinions and perceptions of patient medication counseling. Focus groups were audio recorded and transcribed verbatim. Inductive thematic analysis was applied to the data to identify initial patterns (codes) which were then organized into common overarching themes using NVivo(®) software. The codes were reviewed for reliability by pharmacists independent of the focus groups. RESULTS: Six, 1-h focus groups were conducted with a total of 24 pharmacists participating. Saturation of information was determined after four focus groups. Greater than 80% consensus was achieved for reliability of the identified codes. A number of themes emerged from these codes around the goals, roles, and the barriers and facilitators to meeting these goals. Pharmacists' patient-centered goals in medication counseling were to build rapport, to empower patients and to improve patients' experience, health and safety. These goals would be accomplished through specific roles such as being an assessor, educator and problem-solver. Pharmacists frequently cited time pressures caused by systemic (hospital), and pharmacy specific processes as key challenges to achieving their goals. Factors that enabled pharmacists to meet their goals were those related to effective interprofessional collaboration and the quality of professional practice (such as training, expanded roles and advanced planning for discharge). CONCLUSIONS: Hospital pharmacists emphasized patient-centered goals in medication counseling and outlined the challenges to meet those goals. The findings from this study will be used to develop strategies for effective communication and inform pharmacy practice changes to improve patient care.

Examining hospital pharmacists' goals for medication counseling within the communication accommodation theoretical framework.

BACKGROUND: Medication counseling opportunities are key times for pharmacists to speak to patients about their medications and any changes made during their hospital stay. Communication Accommodation Theory (CAT) posits that an individual's goals drive their communication behavior. The way in which pharmacists communicate with patients may be determined by the goals they set for these medication counseling sessions. OBJECTIVES: To examine hospital pharmacists' goals in patient medication counseling within the CAT framework. METHODS: Hospital pharmacist focus groups were held in two teaching hospitals. Interested pharmacists attended a focus group designed to elicit their goals in patient medication counseling. Focus groups were audio recorded and transcribed verbatim. NVivo(®) software was used to assist in coding and organization. The codes were reviewed for reliability by pharmacists independent of the focus groups. An inductive thematic analysis was applied to the data. RESULTS: Six 1 h focus groups were conducted with a total of 24 pharmacists participating. Saturation of information was achieved after four focus groups. Greater than 80% consensus was achieved for reliability of the identified codes. Patient-centered themes constructed from these codes were to build rapport, to empower patients and to improve patients' experience, health and safety. Exemplars provided by pharmacists for the goals of building rapport and empowering patients were aligned with five CAT communication behaviors (approximation, interpretability, discourse management, emotional expression and interpersonal control). CONCLUSIONS: Patient-centered goals described by hospital pharmacists for medication counseling aligned well with CAT behaviors necessary for effective communication. Further research using the CAT framework to examine the effectiveness of hospital pharmacist-patient exchanges that include both participants' perspectives is required to better understand how well pharmacists communicate with patients.

Reporting a population pharmacokinetic-pharmacodynamic study: a journal's perspective.

The key purpose of performing pharmacometric research is to aid optimization of drug dosing strategies. The statistical techniques required for this research are advanced, which can make interpretation of results difficult to convey to the target audience if they are unfamiliar with pharmacometric concepts. This article provides a basic guide for authors who wish to publish pharmacometric analyses in peer-reviewed journals. This guide is intended to enhance the readability, reproducibility and understanding of the work for a general readership, which may include clinicians, pharmacists and pharmacometricians. Presentation techniques and examples are offered, as well as a checklist of suggested contents for the manuscript.

Recurrent readmissions in medical patients: a prospective study.

BACKGROUND: Hospital readmissions are common and costly. A recent previous hospitalization preceding the index admission is a marker of increased risk of future readmission. OBJECTIVES: To identify factors associated with an increased risk of recurrent readmission in medical patients with 2 or more hospitalizations in the past 6 months. DESIGN: Prospective cohort study. SETTING: Australian teaching hospital acute medical wards, February 2006-February 2007. PARTICIPANTS: 142 inpatients aged ≥ 50 years with a previous hospitalization ≤ 6 months preceding the index admission. Patients from residential care, with terminal illness, or with serious cognitive or language difficulties were excluded. VARIABLES OF INTEREST: Demographics, previous hospitalizations, diagnosis, comorbidities and nutritional status were recorded in hospital. Participants were assessed at home within 2 weeks of hospital discharge using validated questionnaires for cognition, literacy, activities of daily living (ADL)/instrumental activities of daily living (IADL) function, depression, anxiety, alcohol use, medication adherence, social support, and financial status. MAIN OUTCOME MEASURE: Unplanned readmission to the study hospital within 6 months. RESULTS: A total of 55 participants (38.7%) had a further unplanned hospital admission within 6 months. In multivariate analysis, chronic disease (adjusted odds ratio [OR] 3.4; 95% confidence interval [CI], 1.3-9.3, P = 0.002), depressive symptoms (adjusted OR, 3.0; 95% CI, 1.3-6.8, P = 0.01), and underweight (adjusted OR, 12.7; 95% CI, 2.3-70.7, P = 0.004) were significant predictors of readmission after adjusting for age, length of stay and functional status. CONCLUSIONS: In this high-risk patient group, multiple chronic conditions are common and predict increased risk of readmission. Post-hospital interventions should consider targeting nutritional and mood status in this population.

Routine plasma anti-Xa monitoring is required for low-molecular-weight heparins.

Low-molecular-weight heparins are anticoagulants used in the treatment of thrombosis. They have effectiveness and safety profiles similar to those of unfractionated heparin but are considered an attractive alternative because of their predictable pharmacokinetic characteristics. In this article, we demonstrate the need for therapeutic monitoring of low-molecular-weight heparins by addressing evidence arising from the literature and from modelling and simulation. First, treatment targets for unfractionated heparin and enoxaparin sodium were identified. Then, 10 000 virtual patients were simulated and the rate of treatment success was calculated. Treatment success was found to be similar between the two drugs (48% with unfractionated heparin and 54% with enoxaparin sodium). These results are consistent with empirical evidence from the literature and reflect the inadequacy of current dosing strategies in achieving desired biomarker targets. These results, along with recent advances in Bayesian forecasting techniques, support the need for routine monitoring and dose individualization of enoxaparin sodium in order to improve treatment success.