Improving the outcomes of anticoagulation in rural Australia: an evaluation of pharmacist-assisted monitoring of warfarin therapy.

OBJECTIVE: The aim of this project was to assess whether rural pharmacist involvement in the management of patients receiving warfarin has the potential to lead to safer and more effective anticoagulation, and is valued and welcomed by patients and their general practitioners (GPs). METHODS: A convenience sample of rural pharmacists was trained in the use of the CoaguChek S International Normalized Ratio (INR) monitor and then conducted pharmacy-based testing for approximately 3 months. Two types of testing were performed in the pharmacy: (i) comparison testing was defined as pharmacy-based tests taken within 4 h of conventional laboratory testing or (ii) additional testing, which was a pharmacy-based test with no direct comparison laboratory test taken. Pharmacists, GPs and patients completed anonymous satisfaction surveys after the completion of the pharmacy-based testing. RESULTS: Pharmacists from 16 rural pharmacies were trained to use the CoaguChek S monitor. During the trial period, 518 INR tests were performed in the pharmacies on 137 different patients. A total of 120 tests were evaluated against results from laboratory testing. The pharmacy-based INR values were significantly correlated with the laboratory INR values (mean of 2.32+/-0.77 and 2.32+/-0.59 respectively; r=0.88, P<0.0001). A total of 398 additional pharmacy-based tests were conducted in the pharmacy and 8.5% of the additional tests resulted in a subsequent dosage change. The monitoring was well received by pharmacists, GPs and patients. CONCLUSIONS: The results of the trial were very positive. The CoaguChek S monitor in pharmacy-based testing performed accurately compared with conventional laboratory testing. Further research needs to be conducted on the impact of community pharmacy-conducted INR monitoring on patient care and outcomes.

The Australian Medicines Handbook and its controlling vocabularies.

The Australian Medicines Handbook is intended to serve as an independent peer-reviewed knowledge resource for health care providers. A printed handbook is planned first, followed by electronic products. Information about medication will be dissected and entered into a detailed database, whose elemental nature should make it "computer understandable." The terms used in the database will be cross-referenced to preferred terms. Thus, the vocabulary will be controlled. The handbook will be printed directly from the database with use of database publishing techniques.

Cephalosporin utilisation review and evaluation.

The clinical misuse of drugs may result in preventable patient morbidity and mortality, costly remedial care, additional costs for diagnosis and management of iatrogenic disease and unnecessary wastage of healthcare resources. In recognition of this problem, drug utilisation evaluation (DUE) has been recommended as a method for identifying inappropriate or unnecessary drug use and for promoting rational therapy. Growing concern over the widespread misuse of antibiotics, together with the emergence of antimicrobial resistance and escalating expenditures, has resulted in antibiotics being the drugs most frequently chosen for DUE projects. Cephalosporin DUE is well documented as being successful for modifying cephalosporin use and for containing drug expenditure. Studies range from isolated projects to ongoing programmes that comprehensively evaluate cephalosporin use and the impact of corrective strategies. Sensible use of antibiotics requires a clear understanding of the infectious process, the clinical pharmacology of anti-infective agents and an appreciation of clinical and microbiological monitoring and assessment. Audit criteria that incorporate the above principles, and which are described in the studies reviewed in this article, will be useful for other investigators. Through its DUE programme, the Royal Adelaide Hospital has investigated the use of cephalosporins, including ceftriaxone, ceftazidime and cefoxitin. These reviews have resulted in improvements in cephalosporin use and significant cost savings. Alterations to cephalosporin use that were recommended following these reviews have not resulted in adverse changes to post-operative infection rates, clinical outcomes or adverse drug reactions. This experience, combined with that of other investigators, serves as a useful model for the promotion of rational and economical therapy with cephalosporins and other drug groups.

Drug utilization review in a teaching hospital: experience with vancomycin.

A prospective, two-phase, drug utilization review (DUR) was performed at the Royal Adelaide Hospital (RAH) to determine the extent and pattern of vancomycin use. For all patients commencing oral or parenteral vancomycin, treatment indication, route of administration, duration of therapy, results of culture and sensitivity tests, adverse drug reactions and results of therapeutic drug level monitoring were recorded. Vancomycin courses were classified as being for therapy or prophylaxis and compared with predetermined audit criteria to assess appropriateness of use. During the 8 week initial phase, data on 62 treatment courses in 59 patients were recorded, 50% for therapy and 50% for prophylaxis. Sixty four percent were classified as inappropriate, occurring in 32% of therapeutic courses and 97% of those for prophylaxis. During the 10 week re-evaluation, conducted 10 months later, data for 43 treatment courses in 43 patients were reviewed, 42% for therapy and 58% for prophylaxis. Sixty five percent were inappropriate occurring in 17% of therapeutic courses and 100% of the prophylactic courses. When compared with the initial phase, the re-evaluation demonstrated a decrease in the empirical use of vancomycin in the combination treatment of neutropaenic fever and also in the duration of vancomycin use for surgical prophylaxis. During both study phases, criteria contraventions were mostly due to inappropriate indication or duration of therapy. The cost of inappropriate vancomycin use was reduced by over 50% between survey phases, from $Aus11,500 or 55% of total vancomycin cost during the initial phase to $Aus3,600 or 25.7% during the re-evaluation. The most effective of the remedial strategies implemented after the initial phase was direct consultation with prescriber groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Nifedipine hepatitis.

An 80-year-old woman developed acute hepatitis following her first exposure to nifedipine. This adverse effect was characterised by fever, chills, anorexia, nausea, liver tenderness, hepatitic liver function tests and peripheral blood eosinophilia. On liver biopsy the portal tracts were expanded with a mixed inflammatory cell infiltrate rich in eosinophils. The potential for the occurrence of this adverse effect must increase with the current expansion of indications for the use of nifedipine.