Development of a computerized intervention to improve health literacy in older Hispanics with type 2 diabetes using a pharmacist supervised comprehensive medication management.

OBJECTIVE: The primary objective was to develop a computerized culturally adapted health literacy intervention for older Hispanics with type 2 diabetes (T2D). Secondary objectives were to assess the usability and acceptability of the intervention by older Hispanics with T2D and clinical pharmacists providing comprehensive medication management (CMM). MATERIALS AND METHODS: The study occurred in three phases. During phase I, an integration approach (i.e., quantitative assessments, qualitative interviews) was used to develop the intervention and ensure cultural suitability. In phase II, the intervention was translated to Spanish and modified based on data obtained in phase I. During phase III, the intervention was tested for usability/acceptability. RESULTS: Thirty participants (25 older Hispanics with T2D, 5 clinical pharmacists) were included in the study. Five major themes emerged from qualitative interviews and were included in the intervention: 1) financial considerations, 2) polypharmacy, 3) social/family support, 4) access to medication/information, and 5) loneliness/sadness. Participants felt the computerized intervention developed was easy to use, culturally appropriate, and relevant to their needs. Pharmacists agreed the computerized intervention streamlined patient counseling, offered a tailored approach when conducting CMM, and could save them time. CONCLUSION: The ability to offer individualized patient counseling based on information gathered from the computerized intervention allows for precision counseling. Future studies are needed to determine the effectiveness of the developed computerized intervention on adherence and health outcomes.

Improving medication adherence and effective prescribing through a patient-centered prescription model in patients with multimorbidity.

PURPOSE: This study aimed to assess the impact of the patient-centered prescription (PCP) model in medication adherence and effective prescribing in patients with multimorbidity. METHODS: Uncontrolled before-after study in an intermediate care facility in a mixed urban-rural district. Inpatients aged ≥ 65 years with multimorbidity exposed to polypharmacy before hospital admission were consecutively enrolled. Every patient's treatment plan was analyzed through the PCP model, which includes interventions aimed at improving medication adherence. The primary endpoint was the change in the proportion of adherent patients between pre-admission and after discharge for all regularly scheduled long-term medications, using the proportion of days covered (PDC). Secondary endpoints included the change on mean PDC for all long-term medications, number of long-term medications, proportion of patients with hyperpolypharmacy, medication regimen complexity index (MRCI) score, drug burden index (DBI) score, number of potential inappropriate prescribing (PIP), and proportion of patients with ≥ 2 PIPs. RESULTS: Ninety-three non-institutionalized patients were included (mean age 83.0 ± SD 6.1 years). The proportion of adherent patients increased from 22.1 to 51.9% (P < 0.001). Intervention also improved mean PDC [mean difference (95% CI) 10.6 (7.7, 13.5)] and effective prescribing through a reduction on the number of long-term medications [- 1.3 (- 1.7, - 0.9)], proportion of patients exposed to hyperpolypharmacy (- 16.1%, P < 0.001), MRCI score [- 2.2 (- 3.4, - 1.0)], DBI score [- 0.16 (- 1.8, - 1.3)], number of PIPs [- 1.6 (- 1.8, - 1.3)], and proportion of patients with ≥ 2 PIPs (- 53.7%, P < 0.001). CONCLUSION: Studied intervention provides significant effective prescribing and medication adherence enhancements in non-institutionalized older patients with multimorbidity and polypharmacy.

Exploring the benefits of structured medication reviews for frail older patients in advanced clinical practice.

Frailty in old age has become synonymous with medication use. As people age, the risk of disease burden increases. Older age is often linked with complex healthcare needs, with a rise in the number of comorbidities. This often results in the need to use multiple medications. Frailty is a global concern and requires early interventions to help people maintain their health as they age. Advanced clinical practitioners have an important role in supporting frail people living in the community. This article will review the literature and explore strategies that advanced practitioners can implement to optimise wellbeing and reduce medicines-related harm for this vulnerable population.

Resident and family engagement in medication management in aged care facilities: a systematic review.

Introduction: Medication-related harms may occur if residents and families are not involved when important medication decisions are made. We examined how residents and families engage in the management of residents' medications in aged care facilities.Areas covered: A systematic review was undertaken, which was registered with PROSPERO (CRD42020152700). Electronic databases were searched from inception until 27 August 2020 using MEDLINE/PubMed, CINAHL, PsycINFO and EMBASE. Data synthesis was undertaken using thematic analysis.Expert opinion: Forty studies were included. Communication tended to be unidirectional comprising consultations where residents and families provided medication information to health care providers or where health care providers provided medication information to residents and families. Many challenges prevailed that prevented effective engagement, including families' hesitation about making decisions, and the lack of adequately-trained health care providers. Testing of interventions often did not include residents or families in developing these interventions or in examining how they participated in medication decisions following implementation of interventions. Areas for improvement comprise actively involving residents and families in planning interventions for resident-centered care. Health care providers need to have greater appreciation of families' ability to detect dynamic changes in residents' behavior, which can be used to enable optimal alterations in medication therapy.

Detrimental effect of antiepileptic drugs dose in pediatric children with epilepsy in Saudi Arabia: A prospective cohort study.

ABSTRACT: This study aims to evaluate the effect of dose titration for different oral antiepileptic medications among children with epilepsy in Riyadh, Saudi Arabia.A single-center prospective pilot, cohort study was undertaken at a tertiary hospital in Riyadh, Saudi Arabia. All medical records of pediatric patients below the age of 14 years of age who has been newly diagnosed with epilepsy by attending a medical specialist or on a new epileptic treatment plans were enrolled in the study.A total of 76 epileptic patients were screened for 3 months' period and 48 patients were included in this study. Out of the 48 patients, 31 patients followed the regular practice in the titration processes and 17 patients were in the British national formulary (BNF) guideline. Fifteen children who were on monotherapy of levetiracetam were in regular practice guideline experienced poor seizure control with a recorded number of seizure incidence (n = 10). The patient in regular practice guidelines using a combination therapy of phenytoin and levetiracetam were experiencing some behavioral disturbance and sedation effect. Seventeen patients followed in the BNF guideline who were on levetiracetam were experienced less adverse effect (n = 2) with no behavioral changes.The group who followed the regular practice found having a greater incidence of documented adverse effects compared to the patients following the BNF guideline. The titrating antiepileptic medication has a detrimental effect on the pediatric population as observed in this study.

Impact of medication therapy management service on selected clinical and humanistic outcomes in the ambulatory diabetes patients of Tikur Anbessa Specialist Hospital, Addis Ababa, Ethiopia.

BACKGROUND: Diabetes mellitus (DM) patients are at increased risk of developing drug therapy problems (DTPs). The patients had a variety of comorbidities and complications, and they were given multiple medications. Medication therapy management (MTM) is a distinct service or group of services that optimize therapeutic outcomes for individual patients. The study assessed the impact of provision of MTM service on selected clinical and humanistic outcomes of diabetes patients at the diabetes mellitus clinic of Tikur Anbessa Specialized Hospital (TASH). METHODS: A pre-post interventional study design was carried out at DM clinic from July 2018 to April 2019. The intervention package included identifying and resolving drug therapy problems, counseling patients in person at the clinic or through telephone calls, and providing educational materials for six months. This was followed by four months of post-intervention assessment of clinical outcomes, DTPs, and treatment satisfaction. The interventions were provided by pharmacist in collaboration with physician and nurse. The study included all adult patients who had been diagnosed for diabetes (both type I & II) and had been taking anti-diabetes medications for at least three months. Patients with gestational diabetes, those who decided to change their follow-up clinic, and those who refused to participate in the study were excluded. Data were analyzed using Statistical Package for the Social Sciences (SPSS). Descriptive statistics, t-test, and logistic regressions were performed for data analyses. RESULTS: Of the 423 enrolled patients, 409 fulfilled the criteria and included in the final data analysis. The intervention showed a decrease in average hemoglobin A1c (HbA1c), fasting blood sugar (FBS), and systolic blood pressure (SBP) by 0.92%, 25.04 mg/dl, and 6.62 mmHg, respectively (p<0.05). The prevalence of DTPs in the pre- and post-intervention of MTM services was found to be 72.9% and 26.2%, respectively (p<0.001). The overall mean score of treatment satisfaction was 90.1(SD, 11.04). Diabetes patients of age below 40 years (92.84 (SD, 9.54)), type-I DM (93.04 (SD, 9.75)) & being on one medication regimen (93.13(SD, 9.17)) had higher satisfaction score (p<0.05). CONCLUSION: Provision of MTM service had a potential to reduce DTPs, improve the clinical parameters, and treatment satisfaction in the post-intervention compared to the pre-intervention phase.

Medication management for complex patients in primary care: application of a remote, asynchronous clinical pharmacist model.

Purpose: Drug therapy problems impact about one-third of US adults, and these issues are likely to continue to worsen as the population of aging Americans increases. The objective of this study is to assess the feasibility of a remotely delivered Comprehensive Medication Management (CMM) for primary practice patients who are polypharmatic and at high risk for drug therapy problems.Methods: Using medical and prescription claims data, a list of Medicare Advantage beneficiaries at high risk for drug therapy problems was identified. Participants were enrolled in a 6-month CMM program from February - November 2020. In the program, their existing drug therapy was assessed by a pharmacist, Drug therapy problems were identified and resolved. A Collaborative Practice Agreement allowed the pharmacists to make prescription changes as needed.Results: Eighty-three percent (202) of contacted individuals agreed to participate in the study. All participants were on five medications or more, and 71% were on more than eight. A clinical pharmacist found that 86% of participants had a drug therapy problem according to classification criteria. Seventy-nine percent of all drug therapy problems identified were resolved upon completion of the study.Conclusion: The findings of this study suggest that engagement of a remote clinical pharmacist can contribute to efficient resolution of most drug therapy problems identified in a primary care population. A service model using remote pharmacist services may be an effective means of improving team-based primary care medication management for this population.

Stepping down asthma treatment.

Overview of: Bloom CL, de Preux L, Sheikh A et al Health and cost impact of stepping down asthma medication for UK patients, 2001-2017: a population-based observational study. PLOS Med 2020;17:e1003145.

Challenges in Chronic Genetic Disorders: Lessons From the COVID-19 Pandemic.

To examine the impact of the COVID-19 pandemic, we interviewed 26 patients with lysosomal storage disorders receiving enzyme replacement therapy. 20 (77 %) had significant interruption in their treatment, with an average of 8 (range 2-28) missed doses. Alternate methods of delivering uninterrupted care including home therapy were used. Vulnerable patients with chronic genetic disorders require organization for their multidisciplinary needs of care.

Impact of Adding Pharmacists and Comprehensive Medication Management to a Medical Group's Transition of Care Services.

OBJECTIVES: Evaluate the impact of pharmacist-provided transition of care (TOC) services on hospital readmissions. METHODS: Starting March 2014, TOC services were provided to all hospitalized patients from an at-risk medical group. Data covering all inpatient and outpatient services and prescription drugs were retrieved for all adult patients discharged between January 2010 and December 2018. The overall impact of TOC was estimated using a generalized estimating equation with logistic regression. Longitudinal TOC effects were estimated using generalized estimating equation in an interrupted time series model. Parallel analyses were conducted using data from an affiliated medical group in a neighboring county without access to the TOC intervention. RESULTS: The study included 13,256 hospital discharges for adult patients for the 30-day readmission analysis and 10,740 discharges for the 180 days analysis. The TOC program reduced 30-day readmission risk by 34.9% [odds ratio (OR)=0.651 (range, 0.590-0.719)] and 180-day readmissions by 33.4% [OR=0.666 (range, 0.604-0.735)]. The interrupted time series results found the 30-day readmission rate to be stable over the pre-TOC period (OR=0.00; not significant) then to decreased by 1.5% per month in the post-TOC period [OR=0.985 (range, 0.980-0.991)]. For 180-day readmissions, risk decreased by 1% per month after TOC implementation [OR=0.990 (range, 0.984-0.996)]. Referral to the medical group's pre-existing Priority Care clinic also reduced readmission risk. Results from the comparison medical group found 180-day readmission declined by 1% per month after March 2014 [OR=0.990 (0.891-1.00)]. CONCLUSIONS: Adding a pharmacist-led TOC program to the medical group's existing outpatient services reduced 30- and 180-day readmissions by "bending the curve" for readmission risk over time.

A retrospective study comparing interventions by oncology and non-oncology pharmacists in outpatient chemotherapy.

BACKGROUND: The differences in the clinical pharmacy services (CPS) provided by oncology and non-oncology pharmacists have not been sufficiently explained. AIM: This study aimed to demonstrate the differences in direct CPS provided by oncology and non-oncology pharmacists for patients and physicians, and to assess the potential impact of these services on medical costs. METHODS: We retrospectively examined CPS provided by oncology and non-oncology pharmacists for outpatients who underwent chemotherapy between January and December 2016. RESULTS: In total, 1177 and 1050 CPS provided by oncology and non-oncology pharmacists, respectively, were investigated. The rates of interventions performed by oncology and non-oncology pharmacists for physicians-determined treatment were 18.5% and 11.3%, respectively (p < .001). The rates of oncology and non-oncology pharmacist interventions accepted by physicians were 84.6 and 78.8%, respectively (p = .12). Level 4 and Level 5 interventions accounted for 64.6% of all oncology pharmacist interventions and 53.0% of all non-oncology pharmacist interventions (p = .03). The rates of improvement in symptoms from adverse drug reactions among patients resulting from interventions by oncology and non-oncology pharmacists were 89.4 and 72.1%, respectively (p = .02). Conservative assessments of medical cost impact showed that a single intervention by an oncology and by a non-oncology pharmacist saved ¥6355 and ¥3604, respectively. CONCLUSION: The results of the present study suggested that CPS by oncology pharmacists enable safer and more effective therapy for patients with cancer and indirectly contribute to reducing health care fees.

Benefits of medicines optimisation for older people living with frailty.

Medicines optimisation involves ensuring that medicines are administered safely and effectively. In the UK, an ageing population and an increasing prevalence of polypharmacy mean that interprofessional medicines reviews and medicines optimisation are vital. This article uses a case study of an older person living with frailty to provide a critical analysis of the medicines optimisation process in optimising health outcomes. The case study focuses on the medicines prescribed, the issues that can arise such as polypharmacy, and the benefits of a medicines-optimisation approach.

Impact of a Pharmacy-Led Fall Prevention Program for Institutionalized Older People.

OBJECTIVE: To evaluate the impact of pharmacy interventions on recurrence of falls in older people. DESIGN: Prospective case-crossover study. SETTING: LECOM Health Nursing and Rehabilitation (LNR) and Senior Living Center (SLC) and Millcreek Community Hospital older adult behavioral health and inpatient rehabilitation units (IRU). PARTICIPANTS: Twenty and 15 residents of the SLC and LNR, respectively, and 5 and 2 patients of the older adult behavioral health unit and IRU, respectively, experienced a fall during the 8-week study period. INTERVENTIONS: Medication reviews were conducted by a pharmacist assessing for fall risk-increasing drugs (FRIDs). Adverse effects, drug interactions, and nonpharmacologic causes were evaluated, and recommendations were made to reduce future fall risk. MAIN OUTCOME MEASURES: Recommendation acceptance rate, FRID use, and incidence of recurrent falls. RESULTS: Eighty percent of fall risk-reduction recommendations were accepted and implemented by the medical team. The mean number of potential FRIDs prescribed per participant was reduced from 3.71 to 3.38. There was a 12.4% reduction in recurrent falls after pharmacy intervention (P = 0.0336; odds ratio [95% confidence interval] = 1.783 [1.045-3.112]). CONCLUSION: Pharmacist interventions for older people who experience a fall were associated with a high acceptance rate by health care providers, a reduction in FRID use, and decreased rate of recurrent falls.

Preoperative Management of Endocrine, Hormonal, and Urologic Medications: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement.

Perioperative medical management is challenging due to the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate management of long-term medications, yet guidelines and consensus statements for perioperative medication management are lacking. Available resources utilize the recommendations derived from individual studies and do not include a multidisciplinary focus or formal consensus. The Society for Perioperative Assessment and Quality Improvement (SPAQI) identified a lack of authoritative clinical guidance as an opportunity to utilize its multidisciplinary membership to improve evidence-based perioperative care. SPAQI seeks to provide guidance on perioperative medication management that synthesizes available literature with expert consensus. The aim of this Consensus Statement is to provide practical guidance on the preoperative management of endocrine, hormonal, and urologic medications. A panel of experts with anesthesiology, perioperative medicine, hospital medicine, general internal medicine, and medical specialty experience was drawn together and identified the common medications in each of these categories. The authors then utilized a modified Delphi approach to critically review the literature and generate consensus recommendations.

The value of the polypill in cardiovascular disease: an Italian multidisciplinary Delphi panel consensus.

The purpose of this work was to reach the consensus of a multidisciplinary and multistakeholder Italian panel on the value of polypill in cardiovascular disease, with respect to the clinical, technological, economic and organizational dimension. A three-step modified Delphi method was used to establish consensus. Eleven experts in the area of cardiology, pharmaceutical technology, general practice, hospital pharmacy, pharmacology, and health economics participated in the expert panel. To identify existing evidence concerning the value of polypill in the prevention of patients with cardiovascular disease, a systematic literature review was carried out according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement guidelines. In the first round, 22 statements were distributed to the panel. Panel members were asked to mark 'agree' or 'disagree' for each statement and provide any comments. The same voting method was again used for the second round. In the first round nine statements met consensus. In the second round, 10 statements reached consensus. Overall, consensus was reached for 19 statements representing five value polypill domains: clinical, technological, economic and organizational. During a final web meeting with all panel members consensus document open points were discussed. Panel members agreed to recognize polypill as effective in reducing cardiovascular events, blood pressure and lipids, cardiovascular risk and the weight of therapy, in therapeutic adherence improvement, in the absence of differences in bioavailability between drugs administered in fixed or free combinations and the better cost-effectiveness profile compared with standard care. This document represents a knowledge framework to inform decision makers of the value of polypill in cardiovascular prevention.

Intervention by clinical pharmacists can improve blood glucose fluctuation in patients with diabetes and acute myocardial infarction: A propensity score-matched analysis.

Acute phase hyperglycemia and exaggerated glucose fluctuation may be associated with poor outcomes in diabetic patients after acute myocardial infarction (AMI). This study aimed to determine whether intervention by clinical pharmacists can mitigate blood glucose and glucose fluctuations in these fragile patients. This retrospective study enrolled patients with diabetes and AMI, from 1 January 2019 to 30 June 2020 in our institution. Blood glucose and glucose fluctuations were calculated before and after the pharmacist's intervention and between patients who underwent intervention and those who did not. Propensity score matching (PSM) was used to reduce the impact of patient characteristics on the results. A total of 170 patients were included in our primary analysis, including 29 patients who received the pharmacist intervention and 141 patients who did not. After the pharmacist's intervention, blood glucose (fasting blood glucose-FBG, from 11.9 to 9.8; postprandial blood glucose-PBG, from 15.3 to 13.2; mean blood glucose-BG, 14.5 to 12.3 mmol/L; p < .001), and glucose fluctuations (standard deviation of blood glucose-SDBG, from 3.8 to 3.0, mmol/L, p = .005) were significantly improved. Before PSM, no clear effects were found in intervention versus nonintervention patients, in terms of blood glucose and glucose fluctuation indicators, except for FBG (9.3 vs. 8.0. mmol/L, p = .005). Further analysis indicated a high incidence of FBG <7.8 mmol/L in nonintervention versus intervention patients (51.5% vs. 27.6%, p = .003). After PSM, a significant reduction in blood glucose fluctuation (SDBG, 3.0 vs. 4.1, p = .031; PBGE, 2.1 vs. 4.1, p = .017; LAGE, 4.7 vs. 7.2, mmol/L, p = .004), and PBG (11.1 vs. 13.0, mmol/L, p = .048) was observed in the intervention group than in the nonintervention group. The clinical pharmacist intervention contributed to improved outcomes, specifically, in reducing blood glucose fluctuations and potential hypoglycemia risk.

Pharmacogenomics guided versus standard antidepressant treatment in a community pharmacy setting: A randomized controlled trial.

The literature on pharmacogenomics as a tool to support antidepressant precision is burgeoning. Recently, a more active role has been argued for pharmacists in pharmacogenomic testing, with both pharmacists and family physicians perceiving pharmacist-led testing as a valuable method by which to scale this innovation for depression treatment. In this prospective, single-blind randomized controlled design, we evaluated the impact of pharmacogenomics guided versus standard antidepressant treatment of depression and anxiety, implemented in three large community pharmacies. Participants were 213 outpatients diagnosed with major depressive disorder and/or generalized anxiety disorder, randomized to receive pharmacogenomics guided (n = 105) or standard antidepressant treatment (n = 108); participants were blinded to the study. Patient reported outcomes of depression, anxiety, disability, and treatment satisfaction were assessed at months 0, 1, 3, and 6. Hypotheses were investigated using mixed effect models on the full data. All clinical outcomes improved significantly. The primary outcome (depression) and two secondary outcomes (generalized anxiety and disability) exhibited significant time by group interactions indicating that they improved for participants who received pharmacogenomics guided treatment more so than they did for participants who received standard treatment. Treatment satisfaction improved similarly for both groups. Results contribute to a growing body of work evaluating the impact of pharmacogenomics testing to inform antidepressant medication treatment for depression and anxiety, and provides important initial evidence for the role of pharmacists in care delivery. Pharmacogenomic testing may be a valuable tool to allow pharmacists to more effectively collaborate in facilitating clinical treatment decisions. ClinicalTrials.gov registration: (NCT03591224).

A qualitative study on the development of pharmacist-managed clinics in Taiwan.

WHAT IS KNOWN AND OBJECTIVE: Pharmacist-managed clinics (PMCs) are established to solve drug-related problems and enhance the quality of care of ambulatory patients. Although the benefits of such services have been demonstrated, little is known about PMC operations, especially outside the United States. The aim of this study was to explore how PMCs were established and to discuss implementation issues of PMCs in Taiwan. METHODS: A purposive sample of pharmacists, pharmacy administrators and physicians involved with PMCs was recruited from hospitals of varying scales across Taiwan. Semi-structured, individual interviews were conducted to understand the perceptions of the clinical service of PMCs. Interviews were transcribed verbatim and analysed by thematic analysis to find underlying themes. RESULTS: A total of 12 pharmacists, 5 pharmacy administrators and 3 physicians from 8 institutions were interviewed. Pharmacists spent 4 to 20 h per week at PMCs, and the practice experiences of PMC ranged from 1 to 6 years. PMCs have been provided in these institutions for 4 to 11 years with an average volume of 28 h and 25 patient visits weekly. Study participants described influential factors in establishing PMCs, including clinical expertise, attitude towards patient care and trust building with collaborating physicians. Operational concerns in implementing PMCs included role clarifications, manpower shortage, inadequate advanced training or certification, regulatory issues and a lack of service promotion. WHAT IS NEW AND CONCLUSION: This research broadens the understanding of operating PMC services and reveals key requirements and concerns regarding the care model, which can be useful for other countries. Resolving perceived barriers and collecting other stakeholders' perspectives may reinforce the integration of PMCs into patient care in the future.