Multifaceted pharmacist-led interventions in secondary care settings between countries of various income levels: a scoping review protocol.

INTRODUCTION: Clinical pharmacy services often involve multifaceted pharmacist-led interventions. However, current pharmacy practice models vary across different countries. Despite the documented benefits of clinical pharmacy services, the characteristics of pharmacist-led interventions in different countries have not yet been adequately explored and described. Therefore, this protocol outlines the methodology for a proposed scoping review aiming to investigate various types of multifaceted pharmacist-led interventions and the outcomes used to evaluate their effectiveness within secondary care settings. Additionally, the scoping review will map the current evidence surrounding the characteristics of interventions and outcomes reported across various countries of socioeconomic status. METHODS AND ANALYSIS: The scoping review will be conducted according to the JBI Methodology for Scoping Reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews. We will systematically search the following electronic databases: MEDLINE (Ovid), CINAHL (EbscoHost), Embase (embase.com), Scopus (scopus.com), Cochrane Library (cochranelibrary.com) and APA PsycInfo (Ovid). Additionally, the reference lists of identified reviews and included full texts will be searched for relevant papers. Grey literature sources, such as International Pharmaceutical Abstracts and the International Pharmaceutical Federation (FIP) website, will be searched. We will include primary studies published in the English language from January 2013 to December 2023, involving secondary care multifaceted pharmacist-led interventions. Two independent reviewers will screen studies against eligibility criteria and use a piloted data extraction form to extract relevant information. We will extract relevant data, complete a tabular summary from each included publication and analyse it. ETHICS AND DISSEMINATION: Ethical approval is not required as we will be using data from publicly available literature sources. Findings will be disseminated in publications and presentations with relevant stakeholders. We aim to map available evidence across the breadth of studies that have reported multifaceted pharmacist-led interventions and their outcomes.

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, 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 1564 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 (CKD) (p=0.046), chronic obstructive pulmonary disease (COPD) (p=0.037) and a prior history of ischaemic heart disease (p=0.005). Gastrointestinal (GI) bleeding, acute kidney injury (AKI) 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 (ACEi) were the most commonly implicated medications. The median time to medication harm rehospitalisation was 79 days (interquartile range [IQR]: 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.

Defining quality indicators, pharmaceutical care bundles and outcomes of clinical pharmacy service delivery using a Delphi consensus approach.

BACKGROUND: Clinical pharmacy quality indicators are often non-uniform and measure individual activities not linked to outcomes. AIM: To define a consensus agreed pharmaceutical care bundle and patient outcome measures across an entire state health service. METHOD: A four-round modified-Delphi approach with state Directors of Pharmacy was performed (n = 25). They were asked to rate on a 5-point Likert scale the relevance and measurability of 32 inpatient clinical pharmacy quality indicators and outcome measures. They also ranked clinical pharmacy activities in order from perceived most to least beneficial. Based upon these results, pharmaceutical care bundles consisting of multiple clinical pharmacy activities were formed, and relevance and measurability assessed. RESULTS: Response rate ranged from 40 to 60%. Twenty-six individual clinical pharmacy quality indicators reached consensus. The top ranked clinical pharmacy quality indicator was 'proportion of patients where a pharmacist documents an accurate list of medicines during admission'. There were nine pharmaceutical care bundles formed consisting between 3 and 7 activities. Only one pharmaceutical care bundle reached consensus: medication history, adverse drug reaction/allergy documentation, admission and discharge medication reconciliation, medication review, provision of medicines education and provision of a medication list on discharge. Sixteen outcome measures reached consensus. The top ranked were hospital acquired complications, readmission due to medication misadventure and unplanned readmission within 10 days. CONCLUSION: Consensus has been reached on one pharmaceutical care bundle and sixteen outcomes to monitor clinical pharmacy service delivery. The next step is to measure the extent of pharmaceutical care bundle delivery and the link to patient outcomes.

Can a novel constructivist theory-informed feedback intervention reduce prescribing errors ? A pre-post study.

CONTEXT: Medical interns (interns) find prescribing challenging and many report lacking readiness when commencing work. Errors in prescribing puts patients' safety at risk. Yet error rates remain high, despite education, supervision and pharmacists' contributions. Feedback on prescribing may improve performance. Yet, work-based prescribing feedback practices focus on rectifying errors. We aimed to explore if prescribing can be improved using a theory-informed feedback intervention. METHODS: In this pre-post study, we designed and implemented a constructivist-theory informed prescribing feedback intervention, informed by Feedback-Mark 2 Theory. Interns commencing internal medicine terms in two Australian teaching hospitals were invited to engage in the feedback intervention. Their prescribing was evaluated by comparing errors per medication order of at least 30 orders per intern. Pre/baseline (weeks 1-3) were compared with post intervention (weeks 8-9). Interns' baseline prescribing audit findings were analysed and discussed at individualised feedback sessions. These sessions were with a clinical pharmacologist (Site 1) and a pharmacist educator (Site 2). RESULTS: Eighty eight intern's prescribing over five 10-week terms was analysed from two hospitals. The frequency of prescribing errors significantly reduced at both sites after the intervention, across all five terms (p < 0.001).There were initially 1598 errors in 2750 orders (median [IQR] 0.48 [0.35-0.67] errors per order) and after the intervention 1113 errors in 2694 orders (median [IQR] 0.30 [0.17-0.50] errors per order). CONCLUSION: Our findings suggest interns' prescribing practices may improve as a result of constructivist -theory learner centred, informed feedback with an agreed plan. This novel intervention, contributed, to a reduction in interns' prescribing errors. This study suggests new strategies for improving prescribing safety should include the design and implementation of theory-informed feedback interventions.

Impact of a clinical pharmacist on optimising the quality use of medicines according to the acute coronary syndrome (ACS) secondary prevention guidelines and medication adherence following discharge in patients with ACS in Sri Lanka: a prospective non-randomised controlled trial study protocol.

OBJECTIVES: Ensuring quality use of medicines (QUM) through clinical pharmacy services can improve therapeutic outcomes of patients diagnosed with acute coronary syndrome (ACS). The major objective of this study is to demonstrate the added value of a clinical pharmacist to the medical and nursing team providing care to patients with ACS on the continuation of quality use of the patients' medicine after discharge. STUDY DESIGN: This protocol outlines a prospective, non-blinded, non-randomised, controlled interventional study. STUDY SETTING: The study will be conducted at the professorial medical wards of a tertiary care teaching hospital in Sri Lanka. PARTICIPANTS: Sample size will be 746 patients in both control and intervention arms. Patients diagnosed with ACS who are 18 years old or above and expected to visit the hospital for their routine clinic follow-ups after discharge will be recruited and randomised 1:1 to either the intervention group or the control group. Patients who are diagnosed and suffering from psychological disorders will be excluded from this study. INTERVENTIONS: The planned interventions that will be delivered at discharge include review and optimisation of medications, assessing patient adherence and providing discharge medication counselling. Data will be collected at recruitment, 1 month, 3 months and 6 months' time intervals in both groups. Improvement of patients' medication adherence, reduction of hospital readmissions, reduction of drug-related problems, the attitude of doctors and nurses towards clinical pharmacy services and the cost-effectiveness of the clinical pharmacy services will be the major outcomes of this study. ETHICS AND DISSEMINATION: Ethical approval for this study has been obtained from the ethics review committee, Faculty of Medicine, University of Peradeniya (2019/EC/26) and the trial is registered at the Sri Lanka Clinical Trials Registry. The results of this study will be disseminated via conference proceedings, journal publications and thesis presentations. TRIAL REGISTRATION NUMBER: SLCTR/2019/039.

The effect of Computerised Physician Order Entry on prescribing errors: An interrupted time-series study at a secondary referral hospital in Australia.

BACKGROUND: Computerised Physician Order Entry (CPOE) software is increasingly used across the world to improve medication safety. However, few high-quality studies have reviewed the impact of CPOE on prescribing errors and patient harm. OBJECTIVE: To investigate the effect of a hybrid CPOE-paper prescribing system on prescribing errors at a secondary hospital site. DESIGN: An interrupted time-series study was conducted by identifying prescribing errors via prospective medical chart review before and after the implementation of CPOE across three medical wards. PARTICIPANTS: The medication orders of all patients admitted to the medical wards during the study period were reviewed. INTERVENTION: Implementation of a CPOE across three medical wards. MEASURES: A blinded expert panel risk stratified the errors according to level of severity, preventability and potential for harm. Pearson's chi square and segmented regressions were used to determine if there were differences in prescribing errors pre- and post-CPOE implementation. KEY RESULTS: A total of 10,535 medication orders were reviewed pre-CPOE and 13,841 medication orders reviewed post-CPOE. Analysis demonstrated that after implementation of CPOE there were reductions in the proportion of orders with one or more of any error (-30.1%, 95 %CI: -36.5%, -23.7%, p < 0.001). Reductions in the proportion of orders with one or more errors were seen across the error categories of dosing errors (-20.1%, 95 %CI: -25.1%, -15%, p < 0.001), procedural/administrative errors (-18.9%, 95 %CI: -22.8%, -15%, p < 0.001), and therapeutic errors (-2.6%, 95 %CI: -4.1%, -1%, p = 0.002). Post-CPOE there were reductions in the proportion of orders with at least one non-intercepted serious error (-12.6%, 95 %CI: -16.4%, -8.8%, p < 0.001). CONCLUSION: The introduction of CPOE was associated with reductions in prescribing errors. There is also evidence that this translated into a reduced risk of harm to patients post-CPOE implementation through the reduction in actual adverse drug events.

Retrospective study of the prevalence and characteristics of adverse drug events in adults who present to an Australian emergency department.

OBJECTIVE: To determine the burden, on the ED, of harm from unintentional adverse drug events (ADEs) in the community. METHODS: A retrospective, observational study of 936 randomly selected presentations to a level 6 ED at a principal referral hospital in Brisbane, Australia, in November 2017. Clinical records were screened by a pharmacist, who identified suspected ADEs. All suspected ADEs and a random selection of presentations without ADEs were reviewed by an expert panel, which classified, by consensus: occurrence and type of ADE, contribution of ADE to presentation, severity of harm and preventability of presentation. Medication-related ED presentations (ADE-Ps) and potential ADEs were, respectively, defined as presentations directly attributable to an ADE, and medication events that occurred but did not cause the ED presentation. Descriptive data analysis was performed. RESULTS: The median (interquartile range) age of patients was 40 (27-58) years, with 49.7% (95% confidence interval [CI] 46.5-52.9) being male. The prevalences of ADE-Ps and potential ADEs were 9.2% (95% CI 7.5-11.3) and 5.0% (95% CI 3.8-6.6), respectively. The severity of harm was classified as 'death or likely permanent harm' in 4.7% (95% CI 0.2-9.1) of ADE-Ps, 'temporary harm' (89.5%, 95% CI 83.1-96.0) and 'minimal or no harm' (5.8%, 95% CI 0.9-10.8). Most (79.1%, 95% CI 70.5-87.7) ADE-Ps were preventable. CONCLUSIONS: There is a high burden on emergency care because of unintended medication harm in the community. Interventions to reduce such harm are likely to require a co-ordinated primary, acute and public healthcare response. The high proportion of presentations with potential ADEs indicates opportunity for harm mitigation in the ED.

Medication Utilisation Program, Quality Improvement and Research Pharmacist-Implementation Strategies and Preliminary Findings.

Judicious use of medicines that considers evidence-based practice, together with cost-effectiveness, is a priority for all health care organisations. We describe an initiative to lead a Medication Utilisation Program, incorporating medication quality improvement and research activities. In August 2020 an advanced pharmacist position was implemented to lead the Program. The purpose was to provide oversight and facilitate initiatives promoting medication optimisation to create sustainable change in practice. A strategic plan was developed with key performance indicators. A governance structure was implemented with relevant reporting mechanisms. Strategic planning and collaboration with medical, nursing and allied health professionals has seen the successful implementation of seven codesigned medication-use evaluations and eight quality improvement projects centred around patient safety, quality and value-based care. Several research studies have been designed with subsequent commencement of pharmacists enrolled in university Research Higher Degree programs. Cost containment initiatives have realised potential savings approximating AUD 250,000. Educational programs included protocol design, ethics approvals and report writing. Key success criteria for a Medication Utilisation Program include dedicated pharmacist resources, structured governance and reporting mechanisms. Alignment of study complexity with staff experience and interdisciplinary collaboration are also critical.

Patient harm from cardiovascular medications.

BACKGROUND: Medication harm can lead to hospital admission, prolonged hospital stay and poor patient outcomes. Reducing medication harm is a priority for healthcare organisations worldwide. Recent Australian studies demonstrate cardiovascular (CV) medications are a leading cause of harm. However, they appear to receive less recognition as 'high risk' medications compared with those classified by the medication safety acronym, 'APINCH' (antimicrobials, potassium, insulin, narcotics, chemotherapeutics, heparin). Our aim was to determine the scale and type of medication harm caused by CV medications in healthcare. METHODS: A narrative review of adult (>16 years) medication harm literature identified from PubMed and CINAHL databases was undertaken. Studies with the primary outcome of measuring the incidence of medication harm were included. Harm caused by CV medications was described and ranked against other medication classes at four key stages of a patient's healthcare journey. Where specified, the implicated medications and type of harm were investigated. RESULTS: A total of 75 studies were identified, including seven systematic reviews and three meta-analyses, with most focussing on harm causing hospital admission. CV medications were responsible for approximately 20% of medication harm; however, this proportion increased to 50% in older populations. CV medications were consistently ranked in the top five medication categories causing harm and were often listed as the leading cause. CONCLUSION: CV medications are a leading cause of medication harm, particularly in older adults, and should be the focus of harm mitigation strategies. A practical approach to generate awareness among health professionals is to incorporate 'C' (for CV medications) into the 'APINCH' acronym. PLAIN LANGUAGE SUMMARY: Patient harm from cardiovascular medications: Background: • Harm from medications can cause poor patient outcomes.• Certain medications have been identified as 'high risk' and are known to cause high rates of harm.• 'High risk' medications are included in medication guidelines used by health professionals.• Cardiovascular medications (e.g. blood pressure and cholesterol medications) are important and have many benefits.• Recent studies have found cardiovascular medications to cause high rates of harm.• Cardiovascular medication harm is often under-recognised in clinical practice.• Some guidelines do not consider cardiovascular medications to be 'high risk'.Method: • This review investigated the extent of harm caused by cardiovascular medications in adults across four healthcare settings:(1) at the time of hospital admission;(2) during hospital admission;(3) after hospital; and(4) readmission to hospital.• Harm caused by cardiovascular medications was ranked against other medication classes.• We investigated the type of cardiovascular medications to cause harm and the type of harm caused.Results: • Seventy-five studies were reviewed across 41 countries.• Cardiovascular medications were ranked within the top five medications to cause harm.• Cardiovascular medications were a leading cause of harm in each healthcare setting investigated.• Harm caused by cardiovascular medications was common in older adults (>65 years).• Cardiovascular medications often caused preventable harm.• Medications to treat high blood pressure and abnormal heart rhythms were the most common causes of harm.• We reported kidney injury, electrolyte changes and low blood pressure as common types of harm.Conclusion: • Increased focus on cardiovascular medications in clinical practice is needed.• Health professionals need to carefully prescribe and frequently review cardiovascular medications, especially in older adults.• Patient and health professional discussions should be based on both the benefits and harms of cardiovascular medications.• Cardiovascular medications should be included in all 'high risk' medication guidelines.

Reducing Medical Admissions and Presentations Into Hospital through Optimising Medicines (REMAIN HOME): a stepped wedge, cluster randomised controlled trial.

OBJECTIVE: To investigate whether integrating pharmacists into general practices reduces the number of unplanned re-admissions of patients recently discharged from hospital. DESIGN, SETTING: Stepped wedge, cluster randomised trial in 14 general practices in southeast Queensland. PARTICIPANTS: Adults discharged from one of seven study hospitals during the seven days preceding recruitment (22 May 2017 - 14 March 2018) and prescribed five or more long term medicines, or having a primary discharge diagnosis of congestive heart failure or exacerbation of chronic obstructive pulmonary disease. INTERVENTION: Comprehensive face-to-face medicine management consultation with an integrated practice pharmacist within seven days of discharge, followed by a consultation with their general practitioner and further pharmacist consultations as needed. MAJOR OUTCOMES: Rates of unplanned, all-cause hospital re-admissions and emergency department (ED) presentations 12 months after hospital discharge; incremental net difference in overall costs. RESULTS: By 12 months, there had been 282 re-admissions among 177 control patients (incidence rate [IR], 1.65 per person-year) and 136 among 129 intervention patients (IR, 1.09 per person-year; fully adjusted IR ratio [IRR], 0.79; 95% CI, 0.52-1.18). ED presentation incidence (fully adjusted IRR, 0.46; 95% CI, 0.22-0.94) and combined re-admission and ED presentation incidence (fully adjusted IRR, 0.69; 95% CI, 0.48-0.99) were significantly lower for intervention patients. The estimated incremental net cost benefit of the intervention was $5072 per patient, with a benefit-cost ratio of 31:1. CONCLUSION: A collaborative pharmacist-GP model of post-hospital discharge medicines management can reduce the incidence of hospital re-admissions and ED presentations, achieving substantial cost savings to the health system. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12616001627448 (prospective).

The impact of a Post-Take Ward Round Pharmacist on the Risk Score and Enactment of Medication-Related Recommendations.

There is a scarcity of published research describing the impact of a pharmacist on the post-take ward round (PTWR) in addition to ward-based pharmacy services. The aim of this paper was to evaluate the impact of clinical pharmacists' participation on the PTWR on the risk assessment scores of medication-related recommendations with and without a pharmacist. This includes medication-related recommendations occurring on the PTWR and those recommendations made by the ward-based pharmacist on the inpatient ward. A pre-post intervention study was undertaken that compared the impact of adding a pharmacist to the PTWR compared with ward-based pharmacist services alone. A panel reviewed the risk of not acting on medication recommendations that was made on the PTWR and those recorded by the ward-based pharmacist. The relationship between the risk scores and the number and proportion of recommendations that led to action were compared between study groups. There were more medication-related recommendations on the PTWR in the intervention group when a pharmacist was present. Proportionately fewer were in the 'very high and extreme' risk category. Although there was no difference in the number of ward pharmacist recommendations between groups, there was a significantly higher proportion of ward pharmacist recommendations in the "very high and extreme" category in those patients who had been seen on a PTWR attended by a pharmacist than when a pharmacist was not present. There were a greater proportion of "low and medium" risk actionable medication recommendations actioned on the PTWR in the intervention group; and no difference in the risk scores in ward pharmacist recommendations actioned between groups. Overall, the proportion of recommendations that were actioned was higher for those made on the PTWR compared with the ward. The addition of a pharmacist to the PTWR resulted in an increase in low, medium, and high risk recommendations on the PTWR, more very high and extreme risk recommendations made by the ward-based pharmacist, plus an increased number of recommendations being actioned during the patients' admission.

Accuracy checking of dispensed medications by a pharmacy technician: a hospital case study.

Medication order accuracy checking is an integral and time-consuming component of the current Australian pharmacist's role. However, the pharmacy profession internationally has moved towards separating the checking task into two parts: a clinical check performed by the registered pharmacist and a technical accuracy check delegated to an appropriately trained pharmacy technician. This case study demonstrates that in an Australian hospital pharmacy context, appropriately trained pharmacy technicians have the potential to be more proficient and time efficient than pharmacists when undertaking accuracy checking of dispensed medications.

A systematic review of the costs and cost-effectiveness of clinical pharmacists on hospital ward rounds.

Introduction: There is a lack of good quality economic evidence for the inclusion of pharmacists on hospital ward rounds in addition to, or as an alternative to, traditional ward-based clinical pharmacy services. There has been no systematic review of the cost or cost-effectiveness of pharmacists attending and contributing on ward rounds. Areas covered: A literature search was conducted in Medline, Embase, Cochrane, and CINAHL and reported in accordance with the PRISMA guidelines in May 2019. As well, a search using Google Scholar and a targeted hand search were undertaken. Studies that reported any estimate of the cost or cost-effectiveness were included if pharmacist participation on inpatient hospital ward rounds was the predominant focus of the intervention. The identified studies were subsequently screened by three reviewers who extracted data on their clinical and economic design. A bias assessment was completed using the ROBINS-I tool. Expert opinion: Seven studies were identified investigating a clinical pharmacist's inclusion on hospital ward rounds where there was a cost estimated. However, none were deemed to be a full economic evaluation and all were found to be open to a serious risk of bias. Future evaluations should include a comparator group and investigate the cost and cost savings of the service, alongside their clinical outcomes.

Clozapine and shared care: the consumer experience.

Clozapine is a high-risk medication with restrictions that may increase consumer treatment burden. Shared care may improve access, reduce burden and promote primary care management. However, knowledge about the consumer experience of clozapine treatment within a shared-care setting has not been previously reported to the authors' knowledge. The aim of this study was to explore the consumer experience within the shared-care setting. This mixed-methods study examined consumers' experiences with a clozapine shared-care program in an urban setting in Queensland, Australia. Eligible consumers (n=35) participated in a semi-structured interview, including a survey. Analysis was descriptive and thematic. Ten (28.6%) consumers participated. Survey results found a strong belief in the necessity for clozapine, with a low level of reported treatment burden and minimal adverse effects. Four themes were identified from the interviews: (i) understanding of illness and recovery; (ii) positive outcomes of treatment; (iii) acceptance of treatment burden; and (iv) communication pathways. Participants reported positive experiences in the clozapine shared-care program, citing clozapine's efficacy and the GP relationship as key benefits, however communication between clinicians and consumers must be enhanced to reduce risk of suboptimal treatment and adverse drug events.

Cost-effectiveness analysis of doctor-pharmacist collaborative prescribing for venous thromboembolism in high risk surgical patients.

BACKGROUND: Current evidence to support cost effectiveness of doctor- pharmacist collaborative prescribing is limited. Our aim was to evaluate inpatient prescribing of venous thromboembolism (VTE) prophylaxis by a pharmacist in an elective surgery pre-admission clinic against usual care, to measure any benefits in cost to the healthcare system and quality adjusted life years (QALYs) of patients. METHOD: A decision tree model was developed to assess cost effectiveness of pharmacist prescribing compared with usual care for VTE prophylaxis in high risk surgical patients. Data from the literature was used to inform decision-tree probabilities, utility, and cost outcomes. In the intervention arm, a pharmacist prescribed patient's regular medications, documented a VTE risk assessment and prescribed VTE prophylaxis. In the usual care arm, resident medical officers were responsible for prescribing regular medications, and for risk assessment and prescribing of VTE prophylaxis. The base scenario assessed the cost effectiveness of a pre-existing pre-admission clinic pharmacy service that takes on a collaborative prescribing role. The alternative scenario assessed the benefits of introducing a pre-admission clinic pharmacy service where previously there had not been one. Probabilistic sensitivity analysis was conducted to explore uncertainty in the model. RESULTS: In both the base-case scenario and the alternative scenario pharmacist prescribing resulted in an increase in the proportion of patients adequately treated and a decrease in the incidence of VTE resulting in cost savings and improvement in quality of life. The cost savings were $31 (95% CI: -$97, $160) per patient in the base scenario and $12 (95% CI: -$131, $155) per patient in the alternative scenario. In both scenarios the pharmacist-doctor prescribing resulted in an increase in QALYs of 0.02 (95% CI: -0.01, 0.005) per patient. The probability of being cost effective at a willingness to pay off $40,000 was 95% in the base scenario and 94% in the alternative scenario. CONCLUSION: Delegation of the prescribing of VTE prophylaxis for high risk surgical patients to a pharmacist prescriber in PAC, as part of a designated scope of practice, would result in fewer cases of VTE and associated lower costs to the healthcare system and increased QALYs gained by patients. TRIAL REGISTRATION: Pre admission clinic study registered with ANZCTR-ACTR Number ACTRN12609000426280 .

Ward-based clinical pharmacists and hospital readmission: a non-randomized controlled trial in Sri Lanka.

OBJECTIVE: To assess if a ward-based clinical pharmacy service resolving drug-related problems improved medication appropriateness at discharge and prevented drug-related hospital readmissions. METHOD: Between March and September 2013, we recruited patients with noncommunicable diseases in a Sri Lankan tertiary-care hospital, for a non-randomized controlled clinical trial. The intervention group received usual care and clinical pharmacy service. The intervention pharmacist made prospective medication reviews, identified drug-related problems and discussed recommendations with the health-care team and patients. At discharge, the patients received oral and written medication information. The control group received usual care. We used the medication appropriateness index to assess appropriateness of prescribing at discharge. During a six-month follow-up period, a pharmacist interviewed patients to identify drug-related hospital readmissions. RESULTS: Data from 361 patients in the intervention group and 354 patients in the control group were available for analysis. Resolutions of drug-related problems were higher in the intervention group than in the control group (57.6%; 592/1027, versus 13.2%; 161/1217; P < 0.001) and the medication was more appropriate in the intervention group. Mean score of medication appropriateness index per patient was 1.25 versus 4.3 in the control group (P < 0.001). Patients in the intervention group were less likely to be readmitted due to drug-related problems (44 patients of 311 versus 93 of 311 in the control group; P < 0.001). CONCLUSION: A ward-based clinical pharmacy service improved appropriate prescribing, reduced drug-related problems and readmissions for patients with noncommunicable diseases. Implementation of such a service could improve health care in Sri Lanka and similar settings.