Acceptability of a cross-sectoral hospital pharmacist intervention for patients in transition between hospital and general practice: a mixed methods study.

Background and objective: Drug-related problems (DRPs) are often seen when a patient is transitioning from one healthcare sector to another, for example, when a patient moves from the hospital to a General Practice (GP) setting. This transition creates an opportunity for information on medication changes and follow-up plans to be lost. A cross-sectoral hospital pharmacist intervention was developed and pilot-tested in a large GP clinic. The intervention included medication history, medication reconciliation, medication review, follow-up telephone calls, identification of possible DRPs and communication with the GP. It is unknown whether the intervention is transferable to other GP clinics. The aim of the study was to explore similarities and differences between GP clinics in descriptive data and intervention acceptability. Methods: A convergent mixed methods study design was used. The intervention was tested in four GP clinics with differing characteristics. Quantitative data on the GP clinics, patients and pharmacist activities were collected. Qualitative data on the acceptability were collected through focus group interviews with general practitioners, nurses and pharmacists. The Theoretical Framework of Acceptability was used. Results: Overall, the intervention was found acceptable and relevant by all. There were differences between the GP clinics in terms of size, daily physician work form and their use of pharmacists for ad hoc tasks. There were similarities in patient characteristics across GP clinics. Therefore, the intervention was found equally relevant for all of the clinics. Shared employment with unique access to health records in both sectors was important in the identification and resolution of DRPs. Economy was a barrier for further implementation. Conclusions: The intervention was found acceptable and relevant by all; therefore, it was considered transferable to other GP clinics. Hospital pharmacists were perceived to be relevant healthcare professionals to be utilized in GP, in hospitals and in the cross-sectoral transition of patients.

Acceptability of a pharmacist activity for patients transitioning between hospital and general practice Why was the study done? Drug-related problems are often seen in patients transitioning across healthcare sectors. A pharmacist activity was developed and pilot-tested in a large General Practice (GP) clinic. It was unknown whether the activity was transferable to other GP clinics.The pharmacist activity included talking to the patients about their usual medication and adjustment of prescriptions accordingly. The pharmacist activity also included a review of their medications, a follow-up telephone call to the patients and communication with the GP in case of drug-related problems.The aim of the study was to test the activity in different GP clinics and to explore similarities and differences in descriptive data and acceptability. What did the researchers do? The activity was tested in four GP clinics within the same geographical area for three months.Descriptive data about the GP clinics, the patients and the pharmacist's activities performed were collected.Data about acceptability of the activity was collected through focus group interviews with general practitioners, nurses and hospital pharmacists.This qualitative data was combined with descriptive data to explore similarities and differences between GP clinics. What did the researchers find? Overall, the activity was found to be acceptable and relevant by all.There were differences between the GP clinics in terms of size, daily physician work form and their use of the pharmacist for ad hoc tasks.There were similarities in patients across GP clinics e.g. in terms of the number of medications or drug-related problems. The activity was found equally relevant for every clinic.Shared employment with access to health records in both sectors was important in the identification and resolution of drug-related problems. The pharmacist had the possibility to bring issues back and forth between the hospital and the GP clinic.Economy was a barrier for further implementation. What do the findings mean? The activity was found acceptable and relevant by all; therefore, it was considered transferable to other GP clinics.Hospital pharmacists were perceived to be relevant healthcare professionals to be utilised in GP, in hospitals and in the cross-sectoral transition of patients.

Developing and piloting a cross-sectoral hospital pharmacist intervention for patients in transition between hospital and general practice.

Background: Healthcare is challenged by a rapidly growing group of patients with multi-morbidity and polypharmacy. Increasing activity and specialization puts pressure on healthcare sectors. Medication errors in cross-sectoral transition of patients are often seen. The aim of the study was to explore drug-related problems (DRPs) in the transition of patients between sectors and to develop and pilot-test a cross-sectoral hospital pharmacist intervention to overcome some of these problems. Methods: DRPs in cross-sectoral transitions were explored from four perspectives; the literature, the primary and secondary healthcare sector and the patients. An intervention was developed from the findings through co-creation between pharmacists, doctors and a nurse. The intervention was piloted and evaluated from data on the included patients and the activities performed. Results: DRPs in transitions from general practice (GP) to hospital were caused by inadequate focus on updating the Shared Medication Record (SMR). For patients being discharged, DRPs were described with multiple facets; for example, missing information on medication changes, lacking patient involvement and problems with dose-dispensed medicine or electronic prescriptions. An intervention with a pharmacist in a shared employment between Hospital Pharmacy and GP was developed and piloted. The intervention included medication reconciliation and updating SMR for patients referred to hospital; and medication review, overview of medication changes and follow-up telephone calls for patients discharged from hospital. The intervention identified and solved several DRPs; in this way, medication errors were avoided. Access to health records in both sectors was important in the identification and resolution of DRPs. Conclusion: DRPs in cross-sectoral transitions are multifaceted and the experiences depend on the point of view. The cross-sectoral hospital pharmacist intervention identified and solved several DRPs and medication errors were avoided. The intervention made sense to both healthcare sectors and patients. Shared employment and unique access to health records in both sectors showed to be of importance in the identification and resolution of DRPs. Plain language summary: Development and pilot-test of a pharmacist intervention for patients in transition between hospital and general practice Background: Healthcare is challenged by a rapidly growing group of patients with multiple chronic diseases treated with several drugs at the same time. The aim of the study was to explore drug-related problems in the transition of patients between the hospital and patients' general practitioner and to develop and pilot-test a pharmacist intervention to overcome some of these problems.Methods: Drug-related problems in patient transitions were explored from the perspectives of the hospital, the general practitioner, the patients and the literature. An intervention was developed from the findings by pharmacists, doctors and a nurse. The intervention was pilot-tested and evaluated from the descriptions of the included patients and activities performed.Results: Drug-related problems in transitions from general practice to hospital were caused by inadequate focus on updating the Shared Medication Record.For patients being discharged, drug-related problems were related to for examplemissing information on medication changessparse involvement of the patient in their own treatmentproblems with medicine dispensed on a dose dispensing machine at the local pharmacy.An intervention with a pharmacist in a shared employment between Hospital Pharmacy and general practice was developed and piloted. The intervention includedtalking to the patient about their medication and updating the Shared Medication Record for patients referred to hospitalmedication review, overview of medication changes and follow-up telephone calls for patients discharged from hospital to general practice.The intervention identified and solved several drug-related problems. Access to health records in both the general practice and at the hospital was important in the identification of drug-related problems.Conclusions: Drug-related problems in cross-sectoral transitions are multifaceted. The pharmacist intervention identified and solved several drug-related problems. The intervention made sense to the general practitioner, hospital and patients. Shared employment and unique access to health records in both the general practice and at the hospital showed to be of importance in the identification of drug-related problems.

Impaired hepatic counterregulatory response to insulin-induced hypoglycemia in hepatic denervated pigs.

OBJECTIVE: The liver reacts to hypoglycemia by increasing its glucose output. This response is assumed to depend both on glucose sensing at the liver and the brain, as well as efferent impulses from the brain to the liver. We tested the importance of this signaling pathway by studying the hepatic response to insulin-induced hypoglycemia in hepatic complete denervated pigs. MATERIALS/METHODS: Two weeks prior to the metabolic study, 36-kg pigs underwent either total hepatic denervation (DN; n = 12) or sham operation (sham; n = 12). On the metabolic study day, measurements were performed at baseline conditions and during a hypoglycemic hyperinsulinemic (5 mU/kg/min) clamp. Endogenous insulin and glucagon secretions were inhibited by somatostatin, and glucagon was replaced at baseline levels. Endogenous glucose production (EGP) and glucose utilization (Rd) were determined by [3-3H] glucose infusion. RESULTS: Baseline plasma concentrations of glucose, insulin, EGP and Rd did not differ significantly between the two groups of animals. During insulin infusion, the plasma glucose concentration was clamped at ~3 mmol/L in both groups of animals resulting in an increase in plasma concentrations of epinephrine and norepinephrine in sham pigs (both P < 0.05), while this effect was abolished in DN pigs. While insulin action (P = 0.09) and glucose utilization (P = 0.44) were similar, EGP was markedly decreased in the DN pigs (P < 0.05). CONCLUSION: The findings indicate a blunted hepatic counterregulatory response to hypoglycemia following complete hepatic denervation. This implies that intact neural impulses to and from the liver are necessary to maintain the increase in EGP that protects the organism against hypoglycemia.

Carvedilol or propranolol in portal hypertension? A randomized comparison.

OBJECTIVES: Carvedilol is a non-selective ß-blocker with intrinsic anti-α(1)-adrenergic activity, potentially more effective than propranolol in reducing hepatic venous pressure gradient (HVPG). We compared the long-term effect of carvedilol and propranolol on HVPG and assessed whether the acute response to oral propranolol predicted the long-term HVPG response on either drug. MATERIAL AND METHODS: HVPG was measured in 38 patients with cirrhosis and HVPG ≥ 12 mm Hg at baseline and then again 90 min after an oral dose of 80 mg propranolol. Patients were double-blinded randomized to either carvedilol (21 patients) or propranolol (17 patients) and after 90 days of treatment HVPG measurements were repeated. RESULTS: HVPG decreased by 19.3 ± 16.1% (p < 0.01) and by 12.5 ± 16.7% (p < 0.01) in the carvedilol and propranolol groups, respectively, with no significant difference between treatment regimens (p = 0.21). Although insignificant, an acute decrease in HVPG of ≥12% was the best cut-off value to predict long-term HVPG response to propranolol when using ROC curve analysis. CONCLUSIONS: This randomized study showed that carvedilol is at least as effective as propranolol on HVPG after long-term administration. Furthermore, a predictive value of an acute propranolol test on HVPG could not be confirmed.

Hepatic microcirculation assessed by positron emission tomography of first-pass ammonia metabolism in porcine liver.

AIMS/BACKGROUND: Intrahepatic branching of the hepatic artery (HA) to liver microcirculatory units, the acini, is more heterogeneous than that of the portal vein (PV). Furthermore, part of HA blood enters the sinusoid partially downstream between the in- and outlets. We examined the effects of these vascular variations on porcine hepatic first-pass ammonia metabolism, which is characterised by high uptake and separate periportal urea and perivenous glutamine formations. METHODS: (13)NH(3) was given via the PV, HA or caval vein, followed by 22 min dynamic liver positron emission tomography (PET) recordings in six pigs. Heterogeneity of liver (13)N-metabolism was quantified by the coefficient of variation of tissue (13)N-radioactivity measured 10 min after tracer infusion. Sinusoidal zonal clearances of (13)NH(3) into (13)N-urea and (13)N-glutamine were calculated by kinetic PET modelling. RESULTS: Liver metabolic heterogeneity was 0.65+/-0.20 (mean+/-SD, n=6) following (13)NH(3)-infusion into HA, 0.34+/-0.17 into PV and 0.10+/-0.02 into the caval vein. Clearance of (13)NH(3) to (13)N-urea was of similar magnitude following (13)NH(3) administration into HA and PV: 0.27+/-0.11 ml/min/g (mean+/-SD) and 0.29+/-0.09 ml/min/g, respectively. Clearances of (13)NH(3) to (13)N-glutamine when (13)NH(3) was given into HA and PV were also similar: 0.47+/-0.18 and 0.50+/-0.13 ml/min/g, respectively. CONCLUSIONS: The present measurements of the hepatic metabolism of (13)NH(3) showed metabolic heterogeneity compatible with variation of the HA supply of the acini. Second, results of PET modelling of the sinusoidal zonation metabolism of (13)NH(3) to (13)N-urea and to (13)N-glutamine did not indicate metabolically important partial downstream arterial entry into the sinusoids.

Determinants of [13N]ammonia kinetics in hepatic PET experiments: a minimal recirculatory model.

The aim of this study was the development of a modelling approach for the analysis of the systemic kinetics of the tracer nitrogen-13 ammonia administered for dynamic liver scanning. The radioactive half-life of this tracer is 9.8 min, which limits the time span in which data are available in a positron emission tomography experimental setting. A circulatory pharmacokinetic model was applied to the metabolism of ammonia in anaesthetised pigs, which incorporated data from serial measurements of [(13)N]ammonia and [(13)N]metabolite activity in arterial and portal venous blood together with blood flow rates through the portal vein and through the hepatic artery obtained over 20 min after intravenous injection of [(13)N]ammonia. Model analysis showed that up to 20 min after injection the time course of [(13)N]ammonia concentration in arterial blood is primarily determined by distribution kinetics (steady-state volume of distribution 1,856+/-531 ml kg(-1)). Simultaneous fitting of arterial ammonia and metabolite blood concentrations allowed for estimation of the hepatic [(13)N]ammonia clearance (10.25+/-1.84 ml min(-1) kg(-1)), which accounted for the formation of the circulating metabolites.