Best practice in dementia health care: Key clinical practice pointers from a national conference and innovative opportunities for pharmacy practice.

OBJECTIVE: Sub-optimal care of people living with dementia has serious consequences for older populations. The 2021 Australian Royal Commission noted that a large proportion of older adults in aged care live with dementia, yet there are limitations in the knowledge and understanding of staff who care for them. In the pursuit of educating pharmacists, physicians, allied health care professionals, researchers, academics, people living with dementia and their carers, and the public, who are facing the challenges of dementia management, the 'Best Practice in Dementia Health Care' conference was held on November 10, 2022 at Western Health (Sunshine Hospital, Melbourne, Australia). METHODS: Sixteen experts presented on the current practice and challenges associated with delivering best practice dementia health care to older Australians, often highlighting how medication-related challenges impacted on their area of practice. RESULTS: Presenters highlighted the importance of individualised medication management plans, considerations of culture and Indigenous communities, the role of technology, and the impact of exercise and the physical environment on care of people living with dementia. Key clinical practice messages from each expert presenter fit into four main topics: 'navigating complexities of medication management'; 'enhancing wellbeing'; 'supportive settings and environments'; and 'programs and services improving care'. CONCLUSIONS: Pharmacists are crucial members of allied health care teams. They have the necessary medication and comorbidity expertise to review medication regimens, liaise with all health care providers, and provide holistic, pharmacological and non-pharmacological patient education. Towards providing best practice dementia health care, pharmacists can contribute in several ways, such as providing health practitioner education to increase understanding about medications and how they can impact on allied health practice, to ensure that medications are prescribed appropriately and safely. Further, pharmacists can make available resources to ensure people living with dementia receive culturally safe and appropriate care, while advocating for greater understanding of the history and experiences of people living with dementia to ensure care aligns with their day-to-day routines. Finally, pharmacists can provide peer-support to other health care professionals and care staff to ensure optimal management of behavioural and psychological symptoms of dementia. The information and insights shared at the conference can serve as a valuable resource for pharmacists and other health care professionals and researchers working to improve the lives of those living with dementia.

A collaborative pharmacist-led intervention to prevent hospital readmissions among elderly patients discharged from the emergency department: a retrospective cohort study.

Unplanned hospital readmission is a safety and quality healthcare measure, conferring significant costs to the healthcare system. Elderly individuals, particularly, are at high risk of readmissions, often due to issues related to medication management. Pharmacists play a pivotal role in addressing medication-related concerns, which can potentially reduce readmissions. This retrospective single-centre cohort study, conducted from November 2022 to February 2023 in an emergency department, aimed to determine if integrating emergency medicine pharmacists into Emergency Department care models reduces unplanned hospital readmissions within 28 days and to identify the interventions they employ. The inclusion criteria included patients aged ≥ 65, taking ≥ 3 medications, and presenting with falls, cognition changes, or reduced mobility and were planned for discharge to home from the emergency department. Collaborating with the Emergency Department Aged Care Service Emergency Team, a pharmacist provided comprehensive medication management consultations, discharge liaison services, and other pharmacy related interventions to eligible participants whenever the pharmacist was available. Patients who met the eligibility criteria but did not receive pharmacist interventions due to the pharmacist's unavailability served as the control group. This method was chosen to ensure that the control group consisted of comparable patients who only differed in terms of receiving the pharmacist intervention. The study included 210 participants, with 120 receiving pharmacist interventions and 90 acting as controls. The results revealed a significant reduction in unplanned hospital readmissions among participants who received pharmacist interventions (10.0%, n = 12) compared to controls (22.2%, n = 20), with a notable difference of 12.2% (95% confidence interval 2.4-23.4%, p = 0.01). A total of 107 interventions were documented, emphasising medication selection recommendations (28.0%) and identification of adverse drug reactions/drug-drug interactions (21.5%) as primary areas of focus. These findings suggest that integrating skilled pharmacists into Emergency Department Aged Care Service Emergency Team (ASET) lowered the rate of unplanned hospital readmission within 28 days resulting in improved hospital performance metric outcomes. This highlights the potential role of pharmacists in addressing medication-related issues and enhancing the quality and safety of healthcare delivery, particularly for elderly patients transitioning from the ED to home care settings.

Validation of an algorithm to prioritize patients for comprehensive medication management in primary care settings.

BACKGROUND: Comprehensive medication management (CMM) programs optimize the effectiveness and safety of patients' medication regimens, but CMM may be underutilized. Whether healthcare claims data can identify patients appropriate for CMM is not well-studied. AIM: Determine the face validity of a claims-based algorithm to prioritize patients who likely need CMM. METHOD: We used claims data to construct patient-level markers of "regimen complexity" and "high-risk for adverse effects," which were combined to define four categories of claims-based CMM-need (very likely, likely, unlikely, very unlikely) among 180 patient records. Three clinicians independently reviewed each record to assess CMM need. We assessed concordance between the claims-based and clinician-review CMM need by calculating percent agreement as well as kappa statistic. RESULTS: Most records identified as 'very likely' (90%) by claims-based markers were identified by clinician-reviewers as needing CMM. Few records within the 'very unlikely' group (5%) were identified by clinician-reviewers as needing CMM. Interrater agreement between CMM-based algorithm and clinician review was moderate in strength (kappa = 0.6, p < 0.001). CONCLUSION: Claims-based pharmacy measures may offer a valid approach to prioritize patients into CMM-need groups. Further testing of this algorithm is needed prior to implementation in clinic settings.

Age-Friendly Health Systems 4Ms: Implementing Medication Management in Hamad Medical Corporation, Qatar.

PURPOSE: To implement the Age-Friendly Health Systems (AFHS) 4Ms framework, focusing on Medication and its impact on Mobility, Mentation, and What Matters, within Hamad Medical Corporation in Qatar. METHOD: A quality improvement approach was used to implement, extend, and sustain the AFHS 4Ms framework at Hamad Medical Corporation. The Medication "M" was described as the use case to illustrate the impact of high-risk medications on Mobility, Mentation, and What Matters, using an evidence-based, interdisciplinary approach. RESULTS: Implementation of the AFHS 4Ms framework revealed success in aligning multidisciplinary teams to prioritize patient-centered care and caregiver engagement. Through this collaboration, a process map, modified medication screening tool, documentation templates, and educational efforts were developed. CONCLUSION: Applying the AFHS 4Ms framework into health care settings is crucial to improve the care of older adults. Medication management is a cornerstone, involving interdisciplinary team input during screening and act phases to ensure proper medication prescribing and use in older adults. [Journal of Gerontological Nursing, 50(6), 6-9.].

Pharmacist-led medication management services: a qualitative exploration of transition-of-care cardiovascular disease patient experiences.

OBJECTIVE: Hospitalisation due to medication-related problems is a major health concern, particularly for those with pre-existing, or those at high risk of developing cardiovascular disease (CVD). Postdischarge medication reviews (PDMRs) may form a core component of reducing hospital readmissions due to medication-related problems. This study aimed to explore postdischarge CVD patients' perspectives of, and experiences with, pharmacist-led medication management services. A secondary aim explored attitudes towards the availability of PDMRs. DESIGN: An interpretative qualitative study involving 16 semistructured interviews. Data were analysed using an inductive thematic approach. SETTING: Patients with CVD discharged to a community setting from the John Hunter Hospital, an 820-bed tertiary referral hospital based in New South Wales, Australia. PARTICIPANTS: Patients with pre-existing or newly diagnosed CVD who were recently discharged from the hospital. RESULTS: A total of 16 interviews were conducted to reach thematic saturation. Nine participants (56%) were male. The mean age of participants was 57.5 (±13.2) years. Three emergent themes were identified: (1) poor medication understanding impacts transition from the hospital to home; (2) factors influencing medication concordance following discharge and (3) perceived benefits of routine PDMRs. CONCLUSIONS: There is a clear need to further improve the quality use of medicines and health literacy of transition-of-care patients with CVD. Our findings indicate that the engagement of transition-of-care patients with CVD with pharmacist-led medication management services is minimal. Pharmacists are suitable to provide essential and tailored medication review services to patients with CVD as part of a multidisciplinary healthcare team. The implementation of routine, pharmacist-led PDMRs may be a feasible means of providing patients with access to health education following their transition from hospital back to community, improving their health literacy and reducing rehospitalisations due to medication-related issues.

Simplifying medication regimens for residents of aged care facilities: Pharmacist and physician use of a structured five-step medication simplification tool.

BACKGROUND: Pharmacist-led medication regimen simplification using a structured approach can reduce unnecessary medication regimen complexity in residential aged care facilities (RACFs), but no studies have investigated simplification by different health professionals, nor the extent to which simplification is recommended during comprehensive medication reviews. OBJECTIVES: To compare medication regimen simplification opportunities identified by pharmacists, general medical practitioners (GPs), and geriatricians and to determine if pharmacists identified simplification opportunities during routinely conducted comprehensive medication reviews in RACFs for these same residents. METHODS: Three pharmacists, three GPs and three geriatricians independently applied the Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE) to medication data for 83 residents taking medications at least twice daily. Interrater agreement was calculated using Fleiss's kappa. Pharmacist medication review reports for the same 83 residents were then examined to identify if the pharmacists conducting these reviews had recommended any of the simplification strategies. RESULTS: Overall, 77 residents (92.8 %) taking medications at least twice daily could have their medication regimen simplified by at least one health professional. Pharmacists independently simplified 53.0-77.1 % of medication regimens (Κ = 0.60, 95%CI 0.46-0.75, indicating substantial agreement), while GPs simplified 74.7-89.2 % (Κ = 0.44, 95%CI 0.24-0.64, moderate agreement) and geriatricians simplified 41.0-66.3 % (Κ = 0.30, 95%CI 0.16-0.44, fair agreement). No simplification recommendations were included in the reports previously prepared by pharmacists as part of the comprehensive medication reviews undertaken for these residents. CONCLUSION: Pharmacists, GPs, and geriatricians can all identify medication regimen simplification opportunities, although these opportunities differ within and between professional groups. Although opportunities to simplify medication regimens during comprehensive medication reviews exist, simplification is not currently routinely recommended by pharmacists performing these reviews in Australian RACFs.

A survey on the implementation of clinical medication reviews in community pharmacies within a multidisciplinary setting.

BACKGROUND: Polypharmacy is common in chronic medication users, which increases the risk of drug related problems. A suitable intervention is the clinical medication review (CMR) that was introduced in the Netherlands in 2012, but the effectiveness might be hindered by limited implementation in community pharmacies. Therefore our aim was to describe the current implementation of CMRs in Dutch community pharmacies and to identify barriers to the implementation. METHODS: An online questionnaire was developed based on the Consolidated Framework for Implementation Research (CFIR) and consisted of 58 questions with open ended, multiple choice or Likert-scale answering options. It was sent out to all Dutch community pharmacies (n = 1,953) in January 2021. Descriptive statistics were used. RESULTS: A total of 289 (14.8%) community pharmacies filled out the questionnaire. Most of the pharmacists agreed that a CMR has a positive effect on the quality of pharmacotherapy (91.3%) and on medication adherence (64.3%). Pharmacists structured CMRs according to available selection criteria or guidelines (92%). Pharmacists (90%) believed that jointly conducting a CMR with a general practitioner (GP) improved their mutual relationship, whereas 21% believed it improved the relationship with a medical specialist. Lack of time was reported by 43% of pharmacists and 80% (fully) agreed conducting CMRs with a medical specialist was complicated. Most pharmacists indicated that pharmacy technicians can assist in performing CMRs, but they rarely do in practice. CONCLUSIONS: Lack of time and suboptimal collaboration with medical specialists are the most important barriers to the implementation of CMRs.

Revisión de grupos farmacológicos en el tratamiento de cáncer de próstata / Review of pharmacological groups in the treatment of prostate cancer

EPIDEMIOLOGÍA: El cáncer de próstata es uno de los cánceres más comunes en los hombres en todo el mundo, con un estimado de 1.600.000 casos y 366.000 muertes al año. En los Estados Unidos, al 11 por ciento de los hombres se les diagnostica cáncer de próstata a lo largo de su vida, y la incidencia generalmente aumenta con la edad; Se estima que hay 268.490 casos y 34.500 muertes al año. La tasa de supervivencia general a cinco años es superior al 98 por ciento. Según los datos de GLOBOCAN1 al 2022 para El Salvador, el cáncer de próstata es el diagnóstico más frecuente dentro de la población masculina, siendo la 2da causa de diagnóstico de cáncer a nivel nacional, con 1392 casos nuevos para este año, representando el 33.1%; tiene una prevalencia a 5 años de 13.4 por 100, habitantes. Aproximadamente el 83 % de los cánceres de próstata se detectan cuando la enfermedad se encuentra únicamente en la próstata y los órganos cercanos (70 % local y 13 % regional). Para las personas diagnosticadas con cáncer de próstata que se ha diseminado a otras partes del cuerpo, la tasa de supervivencia relativa a 5 años es del 32 %2 . DIAGNÓSTICO: Enfermedad no metastásica3 : el diagnóstico de cáncer de próstata requiere un examen histológico del tejido obtenido mediante una biopsia de próstata. El cáncer de próstata no se puede diagnosticar basándose en el resultado del antígeno prostático específico (PSA), un examen físico, pruebas de laboratorio complementarias, estudios de imágenes o síntomas. Una biopsia puede mostrar cáncer de próstata, hallazgos precancerosos o benignos. Si la biopsia indica cáncer de próstata, se utilizan patrones arquitectónicos de las células en la muestra de biopsia para generar una puntuación de Gleason primaria y secundaria que luego se utiliza para definir el grupo de grado, un sistema de clasificación de cinco niveles para el cáncer de próstata (grupos GRADE de 1 a 5), que se correlaciona con el pronóstico y se utiliza para determinar enfoques de tratamiento para la enfermedad localizada según la estratificación del riesgo. METODOLOGÍA: Se ha realizado una búsqueda en las principales bases de datos bibliográficas, páginas web de agencias reguladoras, Guías de Práctica Clínica Internacionales, base de datos www.uptodate.com y Bibliografía Especializada de Referencia Médica. También se realizó una búsqueda manual en otras bases de datos bibliográficas (Cochrane, NIH, TRIP DATABASE), en buscadores genéricos de internet, agencias de evaluación de tecnologías sanitarias y financiadores de salud. Se priorizó la inclusión de revisiones sistemáticas, meta-análisis, estudios clínicos aleatorizados y controlados, guías de práctica clínica, evaluaciones de tecnología sanitaria, evaluaciones económicas y políticas de cobertura de otros sistemas de salud. Se brinda un resumen de la revisión rápida del material obtenido. CONCLUSIONES: El cáncer de próstata es uno de los cánceres más comunes en los hombres en todo el mundo; Según los datos de GLOBOCAN* al 2022 para El Salvador, es el diagnóstico más frecuente dentro de la población masculina, siendo la 2da causa de diagnóstico de cáncer a nivel nacional, con 1392 casos nuevos para este año, representando el 33.1%; tiene una prevalencia a 5 años de 13.4 por 100, habitantes. Cuando este se ha propagado a los ganglios linfáticos o a otras partes del cuerpo, hablamos de enfermedad metastásica; cuando necesita andrógenos (hormonas masculinas) para crecer y que, por consiguiente, deja de crecer cuando no hay andrógenos, se conoce como sensible a castración (CPHSm); cuando ya no hay respuesta completa al tratamiento de deprivación hormonal, se conoce como resistente a la castración (CPHRm); además, su nivel de riesgo y volumen se determinan mediante parámetros clínicos, estudios de imagen, hallazgos encontrados en biopsias y niveles de antígeno prostático específico (PSA); todos estos componentes influyen de manera directa en la toma de decisiones de la terapia a implementar en cada paciente al inicio del tratamiento, así como determinan la continuidad de este. En los listados institucionales de medicamentos se encuentran múltiples terapias para tratar esta afección, y se ha solicitado por parte de la especialidad de oncología la incorporación de diversos medicamentos para esta; sin embargo, al momento no hay un protocolo determinado de tratamiento el cual determine el uso de los fármacos ya existentes en el cáncer de próstata y sus diferentes estadios, tampoco que describa las diversas indicaciones que estos tienen, por lo tanto no hay un análisis específico y concreto de los medicamentos disponibles previo a la solicitud de incorporación de medicamentos nuevos. Con respecto a los costos de los medicamentos, Cabazitaxel y Apalutamida son los fármacos que representan mayores costos respectivamente; al hacer la proyección con el número de pacientes propuestos por especialidad se observa que todas las incorporaciones de estos medicamentos representarían un aumento muy importante en el costo de su uso teniendo en cuenta que no son monterapias, por lo que aumentaría aún más al realizar la sumatoria del total de fármacos usados en cada indicación; sin embargo, se expresó en revisión con jefatura de especialidad, que se considere las indicaciones precisas de cada fármaco para la estimación del número de pacientes en quienes se usarían los medicamentos ya que así el número estimado disminuiria, y se tomara como base las solicitudes actuales de medicamentos NILO; al realizar una nueva proyección con estos datos se observa una reducción significativa de estos, y además se puede sumar el beneficio a mediano plazo al mejorar la sintomatología, calidad de vida y por ende ingresos hospitalarios y los costos que estos conllevan. Los fármacos Apalutamida, Enzalutamida y Darolutamida se consideran convenientes; existen registros activos (1 para Apalutamida y Darolutamida, 3 para Enzalutamida) a nivel nacional; además al ser fármacos de administración vía oral, no necesitan el uso concomitante de esteroides y tampoco ingresos hospitalarios o accesos IM o EV para su administración; en el caso de cabazitaxel, de los fármacos evaluados, es el menos conveniente debido a la necesidad de cumplirse en el ámbito hospitalario, por personal capacitado, además de aumentar la necesitad de fármacos para contrarrestar efectos adversos y posibles transfusiones de hemoderivados; A pesar de lo anterior se consideró en conjunto con la Jefatura de Departamento de Oncología que al ampliar las indicaciones de Apalutamida, Abiraterona y el considerar la incorporación de Enzalutamida se puede dar la cobertura necesaria para todas las indicaciones de Cáncer de Próstata en los derechohabientes.

Implementation of a Pilot PharmD Medication Optimization Telehealth Clinic Within a Veterans Affairs System.

Background Patients older than 65 years of age with an anticipated life-expectancy of 12 months or less may have complex medication regimens and an increased risk of adverse drug reactions, and drug-drug interactions. Within the Department of Veterans Affairs, a commonly used medication optimization model is known as the VIONE methodology. Objective This project aimed to pilot implementation of board-certified clinical pharmacist practitioners utilizing the VIONE model within a patient-aligned care team targeting patients 65 years of age and older. Methods The population was identified through the VIONE dashboards. Veteran inclusion criteria included five or more medications, a VIONE risk score of 5 or greater, and CAN scores of greater than 90. The project team reached out via telephone to the patients for a medication regimen review and a 14-day follow-up call. Primary outcomes were quantity of medications discontinued per patient, classes of medications that were discontinued, number and encounter time spent, and cost avoidance over 1 year. Secondary outcomes were VIONE classification of medications, VIONE discontinuation reason, number of recommendations given and accepted by primary provider, and safety analysis. Results There were 53 patients who were successfully contacted via telephone. The top four most discontinued medication classes included 1) vitamins/supplements, 2) ophthalmology medications, 3) gastrointestinal medications, and 4) non-controlled analgesic medications. During the project period the potential cost avoidance over 1 year was $17,716. CONCLUSION: This project demonstrated that usage of VIONE methodology ensures medication optimization with minimal harm and provides significant cost savings in the ambulatory care setting.

Exploring the implementation of a novel community pharmacist-led support service for people living with severe and persistent mental illness.

BACKGROUND: Community pharmacists are well-placed to promote and provide mental health medication management services. However, literature evaluating the impact of pharmacy services in supporting people living with severe and persistent mental illness (SPMI) is currently limited. An individualised, goal-oriented pharmacist-led support service that focused on improving the physical and mental health of consumers living with SPMI, namely the PharMIbridge intervention, was provided to consumer participants as part of the PharMIbridge Randomised Controlled Trial (RCT). OBJECTIVE(S): To explore the experiences of the participants who delivered and supported the implementation of the PharMIbridge intervention and propose ideas and supports needed for broader implementation and sustainability of pharmacist-led support services for people living with SPMI. METHODS: Interviews and focus group discussions were undertaken with PharMIbridge pharmacists and mentors, respectively. Audio-recordings were de-identified and transcribed verbatim. Data analysis was conducted using an iterative, inductive approach. The key themes identified were furthered divided into subthemes. Subthemes were then mapped to the EPIS (Exploration, Preparation, Implementation and Sustainment) framework. RESULTS: Data were collected from one focus group involving six RCT mentors and 16 semi-structured interviews with community pharmacists. Five overarching themes emerged: "Training needs", "Pharmacist integration within the healthcare system", "Environmental factors", "Attitudes and behaviour" and "Pharmacy operations". Twelve subthemes were mapped to EPIS phases "Preparation", "Implementation" and "Sustainment" and EPIS constructs "Outer" context, "Inner" context and "Bridging" factors. CONCLUSION: Adequate remuneration and supports to encourage healthcare professional collaboration are necessary to establish and sustain functioning, integrated pharmacy mental health services. A shift in pharmacy business and workflow models is necessary to support community pharmacies to implement mental health services. In addition, there is a need to promote psychological support services to ensure that pharmacists are well supported while delivering pharmacy mental health services.

Impact of automated dispensing solutions in long-term care facilities and closed-door pharmacies: A mixed methods study of medication management.

BACKGROUND: Financial, operational, and clinical workflow impacts of deploying an automated dispensing cabinet (ADC) in long-term care (LTC) facilities based on actual observations have not been documented in peer-reviewed literature. OBJECTIVES: To evaluate the impact of a closed-door pharmacy (CDP) implementing an ADC with unique secure, removable, and transportable locked pockets in an unstudied setting (LTC facilities) for management of first and emergency dose medications. PRACTICE DESCRIPTION: This study was conducted in 1 CDP and 2 LTC facilities. PRACTICE INNOVATION: Enhancing emergency medication management and inventory tracking in an unstudied setting through implementation of an ADC system featuring unique electronically encoded medication storage pockets that can be prepared in the CDP, locked and securely transported to the LTC, and when inserted into ADC it informs staff of its presence, position, and contents. EVALUATION METHODS: Mixed methods, pre- and poststudy to assess the impact of replacing manual emergency medication kits with an ADC. Outcomes were evaluated using rapid ethnography with workflow modeling; inventory and delivery reports; a nursing perception survey; and transactional data from the ADC during postimplementation phase. RESULTS: Pharmacy technician preparation time and pharmacist checking time decreased by 59% and 80%, respectively, and standing inventory was reduced by more than $10,000 combined for the CDP and 2 LTCs by replacing emergency medication kits with the ADC. In the LTCs, this change led to a 71% reduction in emergency medication retrieval time, an increase in emergency medication utilization, and a 96% reduction in the cost of unscheduled deliveries. Over 70% of the nurses surveyed favored replacement of the emergency medication kits with the ADC system. CONCLUSION: Replacing manual emergency medication kit with the described ADC system improved workflow efficiency in the CDP and LTC. It also significantly reduced unscheduled (STAT) deliveries and standing inventory and increased the availability of medications commonly used.

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.

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.

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.

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.