Oral anticoagulant switching in patients with atrial fibrillation: a scoping review.

INTRODUCTION: Oral anticoagulants (OACs) prevent stroke in patients with atrial fibrillation (AF). Several factors may cause OAC switching. OBJECTIVES: To examine the phenomenon of OAC switching in patients with AF, including all available evidence; frequency and patterns of switch, clinical outcomes, adherence, patient-reported outcomes, reasons for switch, factors associated with switch and evidence gaps. DESIGN: Scoping review. DATA SOURCES: MEDLINE, Embase and Web of Science, up to January 2022. RESULTS: Of the 116 included studies, 2/3 examined vitamin K antagonist (VKA) to direct-acting OAC (DOAC) switching. Overall, OAC switching was common and the definition of an OAC switch varied across. Switching from VKA to dabigatran was the most prevalent switch type, but VKA to apixaban has increased in recent years. Patients on DOAC switched more to warfarin than to other DOACs. OAC doses involved in the switches were hardly reported and patients were often censored after the first switch. Switching back to a previously taken OAC (frequently warfarin) occurred in 5%-21% of switchers.The risk of ischaemic stroke and gastrointestinal bleeding in VKA to DOAC switchers compared with non-switchers was conflicting, while there was no difference in the risk of other types of bleeding. The risk of ischaemic stroke in switchers from DOAC versus non-switchers was conflicting. Studies evaluating adherence found no significant changes in adherence after switching from VKA to DOAC, however, an increase in satisfaction with therapy were reported. Reasons for OAC switch, and factors associated with OAC switch were mostly risk factors for stroke and bleeding. Clinical outcomes, adherence and patient-reported outcomes were sparse for switches from DOACs. CONCLUSIONS: OAC switching is common in patients with AF and patients often switch back to an OAC they have previously been on. There are aspects of OAC switching that have received little study, especially in switches from DOACs.

A taxonomy of risk-associated alternative health practices: A Delphi study.

Defining alternative health care and the recording of associated adverse events and harm remains problematic. This Canadian study aimed to establish and classify risk-associated alternative health practices in a Delphi study undertaken with an interdisciplinary panel of 17 health experts in 2020. It provides a new functional definition of alternative health care and an initial taxonomy of risk-associated alternative health care practices. A number of risk-associated practices were identified and categorized into general practices that conflict with biomedical care or largely untested therapies, alternative beliefs systems, physical manipulative alternative therapies, and herbal and nutritional supplements. Some risk significant harms including major physical injuries or even death. The lack of systematic methods for recording adverse events in alternative health care makes establishing the frequency of such events challenging. However, it is important that people engaging with alternative health care understand they are not necessarily risk-free endeavours, and what those risks are.

Adherence to oral anticoagulants among patients with atrial fibrillation: a systematic review and meta-analysis of observational studies.

INTRODUCTION: Medications cannot exert their effect if not taken as prescribed by patients. Our objective was to summarise the observational evidence on adherence to oral anticoagulants (OACs) among patients with atrial fibrillation (AF). METHODS: In March 2019, we systematically searched PubMed/Medline, Embase, CINAHL and PsycINFO (from inception) for observational studies measuring adherence, its determinants and impacts in patients with AF. Mean adherence measures and corresponding proportions of adherent patients were pooled using random effects models. Factors shown to be independently associated with adherence were extracted as well as the clinical and economic outcomes of adherence. RESULTS: We included 30 studies. Pooled mean adherence scores of over half a million patients with AF 6 months and 1 year after therapy initiation were 77 (95% CI: 74-79) and 74 (68-79) out of 100, respectively. Drug-specific pooled mean adherence score at 6 months and 1 year were as follows: rivaroxaban: 78 (73-84) and 77 (69-86); apixaban: 77 (75-79) and 82 (74-89); dabigatran: 74 (69-79) and 75 (68-82), respectively. There was inadequate information on warfarin for inclusion in meta-analysis.Factors associated with increased adherence included: older age, higher stroke risk, once-daily regimen, history of hypertension, diabetes or stroke, concomitant cardiovascular medications, living in rural areas and being an experienced OAC user. Non-adherent patients were more likely to experience stroke and death, and incurred higher medical costs compared with patients with poor adherence. CONCLUSIONS: Our findings show that up to 30% of patients with AF are non-adherent, suggesting an important therapeutic challenge in this patient population.

Health Authority Pharmacists' Perceptions of Independent Pharmacist Prescribing.

BACKGROUND: In many jurisdictions, the pharmacist's role continues to evolve from drug distribution-based service delivery to expanded scopes of practice, including independent prescribing of medications. OBJECTIVES: To assess health authority-based pharmacists' attitudes, beliefs, and perceptions about independent prescribing, to determine how independent prescribing may affect their behaviour, and to identify perceived barriers and enablers to incorporating it into their practice. METHODS: An anonymous, cross-sectional online survey of 677 health authority-based pharmacists employed by Lower Mainland Pharmacy Services in British Columbia collected information in the following domains: demographic characteristics; attitudes, beliefs, and perceptions regarding pharmacist prescribing; anticipated effect of pharmacist prescribing on behaviour; likelihood of applying for this authority, if granted; and barriers and enablers to applying for prescribing authority and incorporating prescribing into their practice. A multivariate regression analysis was performed. RESULTS: A total of 266 pharmacists (39.3%) responded to the survey. Most respondents agreed that prescribing is important to the profession and relevant to their practice, and that it might enhance job satisfaction. Additionally, respondents agreed that they had the expertise to prescribe. Respondents perceived prescribing as having the potential to positively affect behaviour, including deprescribing, prescribing at time of discharge or transfer, and renewing medications. Enablers to applying for pharmacist prescribing authority included perceived positive impact on patient care and the profession, level of support from management and coworkers, and personal ability. No barriers were identified. About two-thirds of pharmacists indicated they would likely apply for prescribing authority if it were granted through legislation. Pharmacists with a clinical practice or research role were significantly more likely to apply to be a prescriber, whereas those with more than 10 years of experience were less likely to apply. CONCLUSIONS: In this study, health authority-based pharmacists held positive attitudes and beliefs about the value and impact of independent prescribing of medications on their practice and the profession. There were no perceived barriers to applying for prescribing authority or to incorporating prescribing into practice.

CONTEXTE: Dans bien des provinces, le rôle du pharmacien ne cesse d'évoluer, depuis la prestation de services fondée sur la distribution de médicaments à des champs de pratique élargis, comprenant le droit de prescription autonome des médicaments. OBJECTIFS: Évaluer les attitudes, les croyances et les opinions des pharmaciens rattachés à des régies de santé concernant le droit de prescription autonome, déterminer l'influence de ce droit sur leurs habitudes et recenser les éléments qui, selon eux, entravent ou facilitent l'intégration de ce droit dans leur pratique. MÉTHODES: Une enquête transversale anonyme en ligne s'adressant à 677 pharmaciens rattachés à une régie de santé et employés par les services de pharmacie des basses-terres continentales en Colombie-Britannique a permis de recueillir de l'information sur les domaines suivants : caractéristiques démographiques; attitudes, croyances et opinions concernant le droit de prescrire des pharmaciens; effets envisagés sur les habitudes du droit de prescrire accordé aux pharmaciens; probabilité de demander ce droit, s'il existe; et les éléments entravant ou facilitant la demande du droit de prescrire et l'intégration de ce droit dans leur pratique. Une analyse de régression multivariée a été réalisée. RÉSULTATS: Au total, 266 pharmaciens (39,3 %) ont répondu au sondage. La plupart d'entre eux ont affirmé que le droit de prescrire est important pour la profession et pertinent dans le cadre de leur pratique et que cet acte pourrait accroître leur satisfaction au travail. De plus, les répondants affirmaient qu'ils possédaient l'expertise requise pour prescrire. Selon eux, le droit de prescrire pouvait influencer positivement leurs habitudes, notamment en ce qui concerne l'interruption de la prescription, la prescription au moment du congé ou d'un transfert et le renouvellement de médicaments. Parmi les éléments incitant les pharmaciens à solliciter le droit de prescrire, on comptait les effets positifs présumés sur les soins offerts aux patients et sur la profession, le soutien de la part de la direction et des collègues et les capacités personnelles. Aucun obstacle n'a été recensé. Environ deux tiers des pharmaciens ont indiqué qu'ils solliciteraient probablement le droit de prescrire s'il était accordé par la loi. Les pharmaciens en pratique clinique et ceux en recherche étaient beaucoup plus enclins à faire la demande pour devenir prescripteurs alors que ceux comptabilisant plus de dix ans d'expérience étaient moins enclins à faire la demande. CONCLUSIONS: Dans la présente étude, les pharmaciens rattachés à une régie de santé affichaient une attitude et des croyances positives à propos de la valeur du droit de prescription autonome des médicaments et des effets qu'il aurait sur leur pratique et la profession. On n'a recensé aucun élément perçu comme un obstacle à la formulation d'une demande du droit de prescrire ou à l'inclusion de ce rôle dans la pratique.

Assessment of Condition and Medication Knowledge Gaps Among Atrial Fibrillation Patients: A Systematic Review and Meta-analysis.

Background: Patient education facilitates construction of a correct illness representation, improves beliefs about medications, and improves knowledge, factors that have been associated with better adherence. Objective: Our objective was to characterize the published literature about atrial fibrillation (AF) patients' disease and medication knowledge to identify knowledge gaps and misconceptions to inform AF patient education strategies. Methods: Following PRISMA guidelines, we searched PubMed, EMBASE, CINAHL, and PsychINFO from inception to May 2018 for studies that assessed AF patients' knowledge about their condition and medications. For quantitative studies, we extracted the proportion of participants who provided correct answers to the questions asked about their condition, medications, or risk of stroke. We classified data for related questions into knowledge domains. A random-effects meta-analysis was conducted for each knowledge domain. A domain was considered a knowledge gap if the pooled mean proportion of participants who demonstrated knowledge of it was ≤50%, regardless of CI. Qualitative data were summarized narratively. Results: A total of 21 studies were included. AF- and stroke-related knowledge gaps and misconceptions included the following: AF can be asymptomatic, AF can predispose to heart failure, women are at a higher risk of stroke, the definition of ischemic stroke, and patients' awareness of their diagnosis. Medication-related knowledge gaps were antithrombotic-drug interactions, antithrombotic-food interactions, vitamin K content of foods, the term INR (international normalized ratio) and its interpretation, and the required actions in case of a missed dose. Conclusion and Relevance: This systematic review identified several AF patient knowledge gaps about their condition and its treatment that can inform the development of AF patient education programs.

Evaluating the Effect of a Patient Decision Aid for Atrial Fibrillation Stroke Prevention Therapy.

BACKGROUND: Stroke prevention therapy decisions for patients with atrial fibrillation (AF) are complex and require trade-offs, but few validated patient decision aids (PDAs) are available to facilitate shared decision making. OBJECTIVE: To evaluate the effects of a novel PDA on decision-making parameters for AF patients choosing stroke prevention therapy. METHODS: We developed an evidence-based individualized online AF PDA for stroke prevention therapy and evaluated it in a prospective observational pilot study. The primary outcome was decisional conflict. Secondary outcomes were knowledge, usability/acceptability, patient preferences, effects on therapy choices, and participant feedback. RESULTS: 37 participants completed the PDA. The PDA could be completed independently and was well accepted. It significantly decreased the mean decisional conflict score ( P < 0.001) and all its subscales and increased participant AF knowledge ( P = 0.02). 76% of participants indicated that their individualized therapy attribute ranking was congruent with their values. The PDA-generated best-match therapy was chosen by 70% of participants in decision 1 (no therapy, aspirin, or oral anticoagulant), and 17% for decision 2 (choice of anticoagulant). Among AF patients, 60% chose a different drug than that currently prescribed to them. Conclusion and Relevance: Our PDA was effective for reducing decisional conflict, increasing patient knowledge, eliciting patients' values, and presenting therapy options that aligned with patients' values and preferences. Using the PDA revealed that many patients have therapy preferences different from their currently prescribed treatment. The PDA is a practical and potentially valuable tool to facilitate decision making about stroke prevention therapy for AF.

Patient values and preferences for antithrombotic therapy in atrial fibrillation. A Narrative Systematic Review.

Guidelines recommend that patients' values and preferences should be considered when selecting stroke prevention therapy for atrial fibrillation (SPAF). However, doing so is difficult, and tools to assist clinicians are sparse. We performed a narrative systematic review to provide clinicians with insights into the values and preferences of AF patients for SPAF antithrombotic therapy. Narrative systematic review of published literature from database inception. RESEARCH QUESTIONS: 1) What are patients' AF and SPAF therapy values and preferences? 2) How are SPAF therapy values and preferences affected by patient factors? 3) How does conveying risk information affect SPAF therapy preferences? and 4) What is known about patient values and preferences regarding novel oral anticoagulants (NOACs) for SPAF? Twenty-five studies were included. Overall study quality was moderate. Severe stroke was associated with the greatest disutility among AF outcomes and most patients value the stroke prevention efficacy of therapy more than other attributes. Utilities, values, and preferences about other outcomes and attributes of therapy are heterogeneous and unpredictable. Patients' therapy preferences usually align with their values when individualised risk information is presented, although divergence from this is common. Patients value the attributes of NOACs but frequently do not prefer NOACs over warfarin when all therapy-related attributes are considered. In conclusion, patients' values and preferences for SPAF antithrombotic therapy are heterogeneous and there is no substitute for directly clarifying patients' individual values and preferences. Research using choice modelling and tools to help clinicians and patients clarify their SPAF therapy values and preferences are needed.

Patient preferences regarding atrial fibrillation stroke prophylaxis in patients at potential risk of atrial fibrillation.

Background With an increasing number of options for atrial fibrillation (AF) stroke prophylaxis, there are several medication-related factors to consider. This study aimed to gain a better understanding of which preference factors influence patient decisions when selecting AF stroke prophylaxis. Objective To determine the factors that influence patient stroke prophylaxis decisions and preferred therapeutic options. Methods A questionnaire about AF stroke prophylaxis medication options was distributed to participants at risk of AF. Preferences were elicited through ranking and rating medication preference factor statements, then selecting most and least preferred treatment options. Results Reduced stroke risk and lowest risk of an intracranial haemorrhage (ICH) had the highest median preference factor ranking of 2 (IQR, 1-3.5 for stroke reduction; 2-4 for ICH risk). Reducing stroke risk, availability of a lab test to assess drug effect, and availability of an antidote were the preference factors with the highest ratings. Apixaban was the most preferred treatment option (44% blinded to drug name, 37% unblinded) while 'No treatment' was the least preferred option (48% blinded, 52% unblinded). Conclusions Reducing stroke risk and limiting ICH risk were the most important medication factors to participants. High inter-participant preference variability suggests the importance of including the patient in decision-making when selecting AF stroke prophylaxis.

Probiotics for preventing urinary tract infections in adults and children.

BACKGROUND: Urinary tract infection (UTI) is a common bacterial infection that can lead to significant morbidity including stricture, abscess formation, fistula, bacteraemia, sepsis, pyelonephritis and kidney dysfunction. Mortality rates are reported to be as high as 1% in men and 3% in women due to development of pyelonephritis. Because probiotic therapy is readily available without a prescription, a review of their efficacy in the prevention of UTI may aid consumers in making informed decisions about potential prophylactic therapy. Institutions and caregivers also need evidence-based synopses of current evidence to make informed patient care decisions. OBJECTIVES: Compared to placebo or no therapy, did probiotics (any formulation) provide a therapeutic advantage in terms of morbidity and mortality, when used to prevent UTI in susceptible patient populations?Compared to other prophylactic interventions, including drug and non-drug measures (e.g. continuous antibiotic prophylaxis, topical oestrogen, cranberry juice), did probiotics (any formulation) provide a therapeutic advantage in terms of morbidity and mortality when used to prevent UTIs in susceptible patient populations? SEARCH METHODS: We searched the Cochrane Kidney and Transplant Specialised Register to 21 September 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA: Randomised controlled trials (RCTs) of susceptible patients (e.g. past history of UTI) or healthy people in which any strain, formulation, dose or frequency of probiotic was compared to placebo or active comparators were included. DATA COLLECTION AND ANALYSIS: All RCTs and quasi-RCTs (RCTs in which allocation to treatment was obtained by alternation, use of alternate medical records, date of birth or other predictable methods) looking at comparing probiotics to no therapy, placebo, or other prophylactic interventions were included. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes. MAIN RESULTS: We included nine studies that involved 735 people in this review. Four studies compared probiotic with placebo, two compared probiotic with no treatment, two compared probiotics with antibiotics in patients with UTI, and one study compared probiotic with placebo in healthy women. All studies aimed to measure differences in rates of recurrent UTI.Our risk of bias assessment found that most studies had small sample sizes and reported insufficient methodological detail to enable robust assessment. Overall, there was a high risk of bias in the included studies which lead to inability to draw firm conclusions and suggesting that any reported treatment effects may be misleading or represent overestimates.We found no significant reduction in the risk of recurrent symptomatic bacterial UTI between patients treated with probiotics and placebo (6 studies, 352 participants: RR 0.82, 95% CI 0.60 to 1.12; I(2) = 23%) with wide confidence intervals, and statistical heterogeneity was low. No significant reduction in the risk of recurrent symptomatic bacterial UTI was found between probiotic and antibiotic treated patients (1 study, 223 participants: RR 1.12, 95% CI 0.95 to 1.33).The most commonly reported adverse effects were diarrhoea, nausea, vomiting, constipation and vaginal symptoms. None of the included studies reported numbers of participants with at least one asymptomatic bacterial UTI, all-cause mortality or those with at least one confirmed case of bacteraemia or fungaemia. Two studies reported study withdrawal due to adverse events and the number of participants who experienced at least one adverse event. One study reported withdrawal occurred in six probiotic participants (5.2%), 15 antibiotic participants (12.2%), while the second study noted one placebo group participant discontinued treatment due to an adverse event. AUTHORS' CONCLUSIONS: No significant benefit was demonstrated for probiotics compared with placebo or no treatment, but a benefit cannot be ruled out as the data were few, and derived from small studies with poor methodological reporting.There was limited information on harm and mortality with probiotics and no evidence on the impact of probiotics on serious adverse events. Current evidence cannot rule out a reduction or increase in recurrent UTI in women with recurrent UTI who use prophylactic probiotics. There was insufficient evidence from one RCT to comment on the effect of probiotics versus antibiotics.

The effect of transitioning from residency to pharmacy practice on learning style.

OBJECTIVE: To describe the evolution of learning styles of pharmacy residents as they transition from residency to practice. METHODS: Cross-sectional survey and interview-based study. A complete provincial cohort of former pharmacy residents (N=28), who had their learning styles characterized with the Pharmacists' Inventory of Learning Styles (PILS) at the beginning of their residency and, 1 year post-residency, were invited to repeat the PILS. Interviews were administered to consenting participants to gain additional insight. RESULTS: Twenty-seven of the former residents (96%) completed the PILS survey and 16 (59%) completed the post-PILS interview. Thirteen (48%) changed their dominant learning style and 20 (74%) changed their secondary learning style. Six (22%) participants did not change either learning style. The overall proportion of dominant assimilators (59%) and convergers (26%) remained similar to baseline (52% and 26%, respectively), meaning participants had adopted and abandoned different learning style in similar numbers. Change in learning style was associated with being a preceptor (p<0.05), as 58% of the 12 former residents who became preceptors stated in the interview they had adjusted their teaching practices based on knowledge of their learning styles gained during their residency. CONCLUSION: Changing learning style is common for former residents after 1 year in postresidency practice. There is no overall direction to the change; former residents transition into and out of various learning styles with similar frequency and retain preferences for passive/abstract learning approaches over active/concrete ones. The early-career lability in learning style the study demonstrated may reveal an opportunity to guide pharmacists toward more active learning preferences through residency curricula, preceptorship, and mentorship.

Learning styles and teaching perspectives of Canadian pharmacy practice residents and faculty preceptors.

OBJECTIVE: To characterize and compare learning styles of pharmacy practice residents and their faculty preceptors, and identify teaching perspectives of faculty preceptors. METHODS: Twenty-nine pharmacy residents and 306 pharmacy faculty members in British Columbia were invited to complete the Pharmacists' Inventory of Learning Styles (PILS). Faculty preceptors also were asked to complete the Teaching Perspectives Inventory (TPI). RESULTS: One hundred percent of residents and 61% of faculty members completed the PILS, and 31% of faculty members completed the TPI. The most common dominant learning style among residents and faculty preceptors was assimilator, and 93% were assimilators, convergers, or both. The distribution of dominant learning styles between residents and faculty members was not different (p=0.77). The most common dominant teaching perspective among faculty members was apprenticeship. CONCLUSION: Residents and preceptors mostly exhibited learning styles associated with abstract over concrete thinking or watching over doing. Residency programs should steer residents more toward active learning and doing, and maximize interactions with patients and other caregivers.

Reasons for non-use of proven pharmacotherapeutic interventions: systematic review and framework development.

RATIONALE, AIMS AND OBJECTIVES: The quality of patient care and safety is dependent on addressing both errors of commission (e.g. overuse of medications) and errors of omission (e.g. patients receiving too little care). Despite guidelines recommending the use of certain proven pharmacotherapeutic interventions, a large gap exists between the patients that have an indication for, and those that actually receive such interventions. To address how the rate of implementation of proven interventions can be improved is dependent on a comprehensive knowledge of the factors contributing to their underuse. The aim of the review is to create an evidence-based framework of reasons why eligible patients do not receive proven pharmacotherapeutic interventions. METHODS: A systemic review of the published reasons for non-use based on the Cochrane methodology. RESULTS: The systematic review identified 67 articles meeting the inclusion criteria. The reasons for non-use were extracted from the studies and a framework was created from the results. CONCLUSIONS: The factors associated with lack of implementation of proven pharmacotherapeutic interventions are complex and heterogeneous but can be understood from the perspectives of clinicians, patients and health care delivery systems. Efforts to increase the utilization of proven interventions should focus on disease/intervention-specific programmes that take into account the identified modifiable clinician, patient and system factors.

Survey of graduates of the british columbia pharmacy practice residency programs, 1973-2009.

BACKGROUND: The Canadian Hospital Pharmacy Residency Board (CHPRB) first introduced accreditation standards to guide the development and maintenance of pharmacy residency programs in the 1970s. These standards have evolved over the years, including a comprehensive revision in 1998. Ongoing quality assessment of residency training is necessary to identify areas for improvement and to ensure that residency training keeps pace with continual changes in pharmacists' roles. OBJECTIVE: To characterize the practices of graduates of the British Columbia Pharmacy Practice Residency Programs (BCPPRPs), to review the effect of residency training on their careers, and to assess whether the BCPPRPs achieved their educational goals with respect to the 2010 CHPRB accreditation standards. METHODS: An 18-question electronic survey was sent by e-mail to all graduates of the BCPPRPs from inception in 1973 to 2009. Both quantitative and qualitative data were collected, so descriptive, narrative, and formal mixed-methods approaches were used for the analysis. RESULTS: Of the estimated 490 graduates, 144 (29%) completed the survey. About 95% of respondents (125 of 131) agreed that the BCPPRPs had adequately prepared them for a career in hospital pharmacy practice. A majority strongly or somewhat agreed that their respective programs had allowed them to aquire all core competencies. There was less agreement about the achievement of project management and leadership skills. Analysis of these results by eras (specifically, before and after the 1998 revision of the CHPRB accreditation standards) showed statistically significant improvements in achievement for 2 of the educational outcomes, "providing evidence-based direct patient care as a member of an inter-professional team" (p = 0.001) and "adequate training in literature appraisal" (p = 0.005). CONCLUSIONS: A majority of respondents recognized that their residency program had a substantial impact on their hospital pharmacy careers, especially in terms of developing direct patient care skills. The 2010 standards have introduced a specific outcome related to leadership skills. These results indicate that both the CHPRB and specific residency programs would benefit from discussions clarifying outcomes related to project management skills.

Quality and usability of common drug information databases.

BACKGROUND: Pharmacists' access to user-friendly electronic drug information databases that can quickly provide accurate, up-to-date information has become increasingly important. Unfortunately, decisions about purchasing subscriptions to such services are not always made objectively. Previously published studies have compared drug information databases, but there are no recent analyses from the perspective of Canadian hospital pharmacists. OBJECTIVE: To determine overall preferences among the most commonly used online drug information databases, based on an appraisal of the quality, performance, and usability of the databases and users' preferences. METHODS: Qualitative and quantitative analyses with descriptive and inferential statistics were used to compare the Clinical Pharmacology, Lexi-Comp Online, and Micromedex databases. Quality scores were determined from investigators' consensus ratings across 5 categories of quality indicators. Performance scores were determined according to the ability of a database to answer 15 clinical drug information questions. Usability scores were determined from user ratings in 7 domains. Users' preferences were assessed through rankings of the databases by 26 practising pharmacists. RESULTS: The highest quality and performance scores were awarded to Lexi-Comp Online, whereas Micromedex received the lowest overall usability score, attributable to poor scores for layout, navigation, and speed. Lack of Canadian content was identified as a major disadvantage of the Clinical Pharmacology database. Users ranked Micromedex significantly lower than the other databases, whereas the majority of users ranked Lexi-Comp Online as the most preferred database. CONCLUSIONS: Lexi-Comp Online appeared to be the most preferred database, whereas Micromedex was clearly the least preferred database. These findings should be considered in future decisions about purchasing database subscriptions.

Do emergency physicians attribute drug-related emergency department visits to medication-related problems?

STUDY OBJECTIVE: Adverse drug events represent the most common cause of preventable nonsurgical adverse events in medicine but may remain undetected. Our objective is to determine the proportion of drug-related visits emergency physicians attribute to medication-related problems. METHODS: This prospective observational study enrolled adults presenting to a tertiary care emergency department (ED) during 12 weeks. Drug-related visits were defined as ED visits caused by adverse drug events. The definition of adverse drug event was varied to examine both narrow and broad adverse drug event classification systems. Clinical pharmacists evaluated all patients for drug-related visits, using standardized assessment algorithms, and then followed patients until hospital discharge. Interrater agreement for the clinical pharmacist diagnosis of drug-related visit was assessed. Emergency physicians, blinded to the clinical pharmacist opinion, were interviewed at the end of each shift to determine whether they attributed the visit to a medication-related problem. An independent committee reviewed and adjudicated all cases in which the emergency physicians' and clinical pharmacists' assessments were discordant, or either the emergency physician or clinical pharmacist was uncertain. The primary outcome was the proportion of drug-related visits attributed to a medication-related problem by emergency physicians. RESULTS: Nine hundred forty-four patients were enrolled, of whom 44 patients received a diagnosis of the narrowest definition of an adverse drug event, an adverse drug reaction (4.7%; 95% confidence interval [CI] 3.5% to 6.2%). Twenty-seven of these were categorized as medication-related by emergency physicians (61.4%; 95% CI 46.5% to 74.3%), 10 were categorized as uncertain (22.7%; 95% CI 12.9% to 37.1%), and 7 categorized as a non-medication-related problem (15.9%; 95% CI 8.0% to 29.5%). Seventy-eight patients (8.3%; 95% CI 6.7% to 10.2%) received a diagnosis of an adverse drug event caused by an adverse drug reaction, a drug interaction, drug withdrawal, a medication error, or noncompliance. Emergency physicians attributed 49 of these to a medication-related problem (62.8%; 95% CI 51.7% to 72.7%), were uncertain about 15 (19.2%; 95% CI 12.0% to 29.4%), and attributed 14 to non-medication-related problems (17.9%; 95% CI 11.0% to 27.9%). Twenty-five of 29 (86.2%; 95% CI 69.3% to 94.4%) adverse drug events not considered medication related by emergency physicians were rated at least moderate in severity. CONCLUSION: A significant proportion of drug-related visits are not deemed medication related by emergency physicians. Drug-related visits not attributed to medication-related problems by emergency physicians may be missed in ongoing outpatient adverse drug event surveillance programs intended to develop strategies to enhance drug safety. Further research is needed to determine what the effect may be of not attributing adverse drug events to medication-related problems.

Incidence, severity and preventability of medication-related visits to the emergency department: a prospective study.

BACKGROUND: Medication-related visits to the emergency department are an important but poorly understood phenomenon. We sought to evaluate the frequency, severity and preventability of drug-related visits to the emergency department. METHODS: We performed a prospective observational study of randomly selected adults presenting to the emergency department over a 12-week period. Emergency department visits were identified as drug-related on the basis of assessment by a pharmacist research assistant and an emergency physician; discrepancies were adjudicated by 2 independent reviewers. RESULTS: Among the 1017 patients included in the study, the emergency department visit was identified as drug-related for 122 patients (12.0%, 95% confidence interval [CI] 10.1%-14.2%); of these, 83 visits (68.0%, 95% CI 59.0%-76.2%) were deemed preventable. Severity was classified as mild in 15.6% of the 122 cases, moderate in 74.6% and severe in 9.8%. The most common reasons for drug-related visits were adverse drug reactions (39.3%), nonadherence (27.9%) and use of the wrong or suboptimal drug (11.5%). The probability of admission was significantly higher among patients who had a drug-related visit than among those whose visit was not drug-related (OR 2.18, 95% CI 1.46-3.27, p < 0.001), and among those admitted, the median length of stay was longer (8.0 [interquartile range 23.5] v. 5.5 [interquartile range 10.0] days, p = 0.06). INTERPRETATION: More than 1 in 9 emergency department visits are due to drug-related adverse events, a potentially preventable problem in our health care system.

Selection of atypical antipsychotics for the management of schizophrenia.

OBJECTIVE: To review the evidence for selecting one atypical antipsychotic agent over another for management of schizophrenia. DATA SOURCES: A literature search of MEDLINE (1966-June 2003), EMBASE (1998-June 2003), and the Cochrane Library was conducted using the following terms: schizophrenia, quetiapine, ziprasidone, olanzapine, aripiprazole, and risperidone. Bibliographies of relevant articles were hand-searched for additional references. STUDY SELECTION AND DATA EXTRACTION: Prospective, randomized, blinded trials and meta-analyses that directly or indirectly compared > or =2 atypical antipsychotic agents in the management of schizophrenia are included in this review. Studies comparing an atypical agent with clozapine are not included. DATA SYNTHESIS: A small number of prospective, randomized, blinded trials that compare efficacy and tolerability of olanzapine and risperidone have been published. These trials did not reveal clinically meaningful differences in efficacy but did confirm that their adverse effect profiles are slightly different (more weight gain with olanzapine and more extrapyramidal reactions with risperidone). Direct comparisons between other atypical antipsychotics are not available. Systematic reviews (indirect comparisons) of placebo-controlled or traditional antipsychotic-controlled trials suggest similar efficacy for quetiapine, olanzapine, and risperidone when placebo is the comparator and inferior efficacy of quetiapine compared to olanzapine and risperidone when haloperidol is the comparator. The few available economic analyses are difficult to interpret in light of current practice. CONCLUSIONS: Additional randomized, blinded clinical trials directly comparing efficacy, tolerability, and cost-effectiveness are needed to confirm the proposed differences among atypical antipsychotic agents before recommendations can be made with confidence.

Systematic reviews in emergency medicine: Part II. Critical appraisal of review quality, data synthesis and result interpretation.

Reviews of the medical literature have always been an important resource for physicians. Increasingly, qualitative and quantitative systematic reviews (SRs) have replaced the traditional "narrative review" as a means of capturing and summarizing current evidence on a topic or, when possible, answering a specific clinical question. This paper is Part II of a 2-part series designed to provide emergency physicians with the background necessary to locate, critically evaluate and interpret SRs. The paper expands on the critical appraisal principles discussed in Part I by focusing on quality assessment, data synthesis and interpretation of results. To illustrate key points and facilitate readability, examples from the emergency medicine literature have been included and technical details have been kept to a minimum. The references, however, are comprehensive and provide a resource for readers seeking further information.

Systematic reviews in emergency medicine: Part I. Background and general principles for locating and critically appraising reviews.

Reviews of the medical literature have always been an important resource for physicians. Increasingly, qualitative and quantitative "systematic reviews" have replaced the traditional "narrative review" as a means of capturing and summarizing current evidence on a topic or, when possible, answering a specific clinical question. This paper is part one of a two-part series designed to provide emergency physicians with the background necessary to locate, critically evaluate and interpret systematic reviews. The paper provides a brief background on systematic reviews and general principles on locating and critically appraising them. To facilitate readability, examples from the emergency medicine literature have been included for illustrative purposes and technical details have been kept to a minimum. The references, however, are comprehensive and provide a resource for readers seeking further information.