Intervention for a correct medication list and medication use in older adults: a non-randomised feasibility study among inpatients and residents during care transitions.

BACKGROUND: Medication discrepancies in care transitions and medication non-adherence are problematic. Few interventions consider the entire process, from the hospital to the patient's medication use at home. AIM: In preparation for randomised controlled trials (RCTs), this study aimed (1) to investigate the feasibility of recruitment and retention of patients, and data collection to reduce medication discrepancies at discharge and improve medication adherence, and (2) to explore the outcomes of the interventions. METHOD: Participants were recruited from a hospital and a residential area. Hospital patients participated in a pharmacist-led intervention to establish a correct medication list upon discharge and a follow-up interview two weeks post-discharge. All participants received a person-centred adherence intervention for three to six months. Discrepancies in the medication lists, the Beliefs about Medicines Questionnaire (BMQ-S), and the Medication Adherence Report Scale (MARS-5) were assessed. RESULTS: Of 87 asked to participate, 35 were included, and 12 completed the study. Identifying discrepancies, discussing discrepancies with physicians, and performing follow-up interviews were possible. Conducting the adherence intervention was also possible using individual health plans for medication use. Among the seven hospital patients, 24 discrepancies were found. Discharging physicians agreed that all discrepancies were errors, but only ten were corrected in the discharge information. Ten participants decreased their total BMQ-S concern scores, and seven increased their total MARS-5 scores. CONCLUSION: Based on this study, conducting the two RCTs separately may increase the inclusion rate. Data collection was feasible. Both interventions were feasible in many aspects but need to be optimised in upcoming RCTs.

Core competencies for a biomedical laboratory scientist - a Delphi study.

BACKGROUND: After completing university education, biomedical laboratory scientists work in clinical laboratories, in biomedical research laboratories, in biotech, and in pharmaceutical companies. Laboratory diagnostics have undergone rapid development over the recent years, with the pace showing no signs of abatement. This rapid development challenges the competence of the staff and will most certainly influence the education of future staff. This study aimed to examine what was considered the necessary competencies needed to pursue a career as a biomedical laboratory scientist. METHODS: A modified Delphi technique was used, with the panel of experts expressing their views in a series of three questionnaire. Consensus was defined as the point which 75 % or more of the panel participants agreed that a particular competency was necessary. RESULTS: The study highlights the perceived importance of mostly generic competencies that relate to quality, quality assurance, and accuracy, as well as different aspects of safety, respect, trustworthiness (towards patients/clients and colleagues), and communication skills. The results also stress the significance of self-awareness and professionality. CONCLUSIONS: We identified important competencies for biomedical laboratory scientists. Together with complementary information from other sources, i.e., guidelines, laws, and scientific publications, the competencies identified can be used as learning outcomes in a competency-based education to provide students with all the competencies needed to work as professional biomedical laboratory scientists.

Effects of a pharmaceutical care intervention on clinical outcomes and patient adherence in coronary heart disease: the MIMeRiC randomized controlled trial.

BACKGROUND: In the treatment of coronary heart disease, secondary prevention goals are still often unmet and poor adherence to prescribed drugs has been suggested as one of the reasons. We aimed to investigate whether pharmaceutical care by a pharmacist at the cardiology clinic trained in motivational interviewing improves clinical outcomes and patient adherence. METHODS: This was a prospective, randomized, controlled, outcomes-blinded trial designed to compare pharmaceutical care follow-up with standard care. After standard follow-up at the cardiology clinic, patients in the intervention group were seen by a clinical pharmacist two to five times as required over seven months. Pharmacists were trained to use motivational interviewing in the consultations and they tailored their support to each patient's clinical needs and beliefs about medicines. The primary study end-point was the proportion of patients who reached the treatment goal for low-density lipoprotein cholesterol by 12 months after discharge. The key secondary outcome was patient adherence to lipid-lowering therapy at 15 months after discharge, and other secondary outcomes were the effects on patient adherence to other preventive drugs, systolic blood pressure, disease-specific quality of life, and healthcare use. RESULTS: 316 patients were included. The proportion of patients who reached the target for low-density lipoprotein cholesterol were 37.0% in the intervention group and 44.2% in the control group (P = .263). More intervention than control patients were adherent to cholesterol-lowering drugs (88 vs 77%; P = .033) and aspirin (97 vs 91%; P = .036) but not to beta-blocking agents or renin-angiotensin-aldosterone system inhibitors. CONCLUSIONS: Our intervention had no positive effects on risk factors for CHD, but it increased patient adherence. Further investigation of the intervention process is needed to explore the difference in results between patient adherence and medication effects. Longer follow-up of healthcare use and mortality will determine if the increased adherence per se eventually will have a meaningful effect on patient health. TRIAL REGISTRATION: ClinicalTrials.gov NCT02102503, 03/04/2014 retrospectively registered.

Clinical pharmacists' services, role and acceptance: a national Swedish survey.

AIM: Describe, and between regions, compare the services provided, and the pharmacists' perceptions of their role and its importance. METHOD: Online survey involving active clinical pharmacists in Sweden. RESULT: The survey was completed by 118 pharmacists (66%), half of whom had at least 1 year's formal training in clinical pharmacy, and work experience in excess of 5 years. Admission medication reconciliation and medication review are provided in most regions and often on a daily basis. The most important services were: making suggestions to physicians regarding drug changes, medication review, medication reconciliation, and patient communication. On a five-point Likert-scale (where 1 = negative and 5 = positive) very few respondents scored less than 4 on the role, acceptance and skills questions. DISCUSSION: Our study confirms the strong position of clinical pharmacy and clinical pharmacists in Sweden. There were some differences regarding the services provided between regions but clinical pharmacists' patient-centred work in the clinical setting as part of the care team is well established, accepted and important. Respondents believed they could take on additional responsibilities for prescription changes without the need for further education. CONCLUSION: Patient-centred clinical pharmacy work in a clinical setting as part of the care team is well established, accepted and important.

Prospective observational study of medication reviews in internal medicine wards: evaluation of drug-related problems.

BACKGROUND: The Lund Integrated Medicines Management model offers a systematic approach for individualising and optimising patient drug treatment. Clinical, economical and humanistic outcomes have been shown as well as results from the medication reconciliation process. There is a need also to describe the medication review process. OBJECTIVE: To describe the frequency and types of drug-related problems (DRPs) identified during medication reviews and to evaluate the actions of the pharmacists and the physicians regarding the identified DRPs. METHOD: Structured medication reviews were conducted by a multi-professional team on top of standard care for 719 patients in two internal medicine wards in a Swedish University Hospital. The medication reviews were studied retrospectively to classify DRPs and actions taken. RESULTS: A total of 573 (80%) of patients had at least one actual DRP; an average of three DRPs per patient and in total 2164. Wrong drug and adverse drug reaction were the most common types of DRPs. The most frequent medication groups involved in DRPs were drugs for the cardiovascular system and the nervous system and the most frequent substances were warfarin, digoxin, furosemide and paracetamol. The 10 most common medications accounted for 27% of the actual DRPs. Of the identified DRPs, a total of 1740 (80%) were acted on. The three most common types of adjustments made were withdrawal of drug therapy, change of drug therapy and initiation of drug therapy. When the pharmacist suggested an adjustment, the physician implemented 88% (1037/1174) of the recommendations. CONCLUSION: DRPs are common among elderly patients who are admitted to hospital. Systematic identification of high-risk medications and common DRP types enables targeting of prioritised patients for medication reviews.

Medication adherence interventions and outcomes: an overview of systematic reviews.

OBJECTIVE: To present evidence for healthcare-provided medication adherence interventions on clinical, economic and humanistic outcomes among patients. METHODS: Literature search of systematic reviews in Medline, Embase and CINAHL (2007-2017), validation of quality using A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 and Preferred Reporting Items for Systematic Reviews and Meta-Analyses questionnaires and, finally, extraction, combination and tabulation of results for included studies. RESULTS: From eight systematic reviews with medium to high AMSTAR 2 score, 37 randomised controlled studies involving 28 600 participants were extracted. Patient education and counselling showed some positive effects on medication adherence. Patient education also showed some positive effects on morbidity, healthcare utilities and patient satisfaction. Counselling had some benefit on mortality and healthcare utilisation. Simplifying doses was shown to have some benefit on morbidity and patient satisfaction. Interventions delivered by pharmacists and nurses showed a better result in improving adherence and outcomes than interventions delivered by general practitioners. CONCLUSIONS: Some interventions were found to have positive effect on adherence and outcomes, but no single strategy showed improvement in all settings. For future research patients should be screened for non-adherence to reveal both if they are non-adherent and type of non-adherence, as well as bigger sample sizes and longer duration of follow-up.

Impact of medication reconciliation and review and counselling, on adverse drug events and healthcare resource use.

Background Adverse drug events from preventable medication errors can result in patient morbidity and mortality, and in cost to the healthcare system. Medication reconciliation can improve communication and reduce medication errors at transitions in care. Objective Evaluate the impact of medication reconciliation and counselling intervention delivered by a pharmacist for medical patients on clinical outcomes 30 days after discharge. Setting Sultan Qaboos University Hospital, Muscat, Oman. Methods A randomized controlled study comparing standard care with an intervention delivered by a pharmacist and comprising medication reconciliation on admission and discharge, a medication review, a bedside medication counselling, and a take-home medication list. Medication discrepancies during hospitalization were identified and reconciled. Clinical outcomes were evaluated by reviewing electronic health records and telephone interviews. Main outcome measures Rates of preventable adverse drug events as primary outcome and healthcare resource utilization as secondary outcome at 30 days post discharge. Results A total of 587 patients were recruited (56 ± 17 years, 57% female); 286 randomized to intervention; 301 in the standard care group. In intervention arm, 74 (26%) patients had at least one discrepancy on admission and 100 (35%) on discharge. Rates of preventable adverse drug events were significantly lower in intervention arm compared to standard care arm (9.1 vs. 16%, p = 0.009). No significant difference was found in healthcare resource use. Conclusion The implementation of an intervention comprising medication reconciliation and counselling by a pharmacist has significantly reduced the rate of preventable ADEs 30 days post discharge, compared to the standard care. The effect of the intervention on healthcare resource use was insignificant. Pharmacists should be included in decentralized, patient-centred roles. The findings should be interpreted in the context of the study's limitations.

Motivational Interviewing and Medication Review in Coronary Heart Disease (MIMeRiC): Protocol for a Randomized Controlled Trial Investigating Effects on Clinical Outcomes, Adherence, and Quality of Life.

BACKGROUND: Preventive treatment goals for blood pressure and cholesterol levels continue to be unmet for many coronary patients. The effect of drug treatment depends on both its appropriateness and the patients' adherence to the treatment regimen. There is a need for adherence interventions that have a measurable effect on clinical outcomes. OBJECTIVE: This study aims to evaluate the effects on treatment goals of an intervention designed to improve patient adherence and treatment quality in secondary prevention of coronary heart disease. A protocol for the prespecified process evaluation of the trial is published separately. METHODS: The Motivational Interviewing and Medication Review in Coronary heart disease (MIMeRiC) trial is a prospective, randomized, outcomes-blinded trial designed to compare individualized follow-up by a clinical pharmacist using motivational interviewing (MI) and medication review with standard follow-up. Patients were randomized to 2 groups after stratification according to their beliefs about medicines. After standard follow-up at the cardiology clinic, patients in the intervention group are seen individually by a clinical pharmacist 2 to 5 times as required over 7 months, at the clinic. The pharmacist reviews each patient's medication and uses MI to manage any problems with prescribing and adherence. The primary study outcome is the proportion of patients who have reached the treatment goal for low-density lipoprotein cholesterol by 12 months after discharge. Secondary outcomes are the effects on patient adherence, systolic blood pressure, disease-specific quality of life, and health care use. RESULTS: The protocol for this study was approved by the Regional Ethics Committee, Linköping, in 2013. Enrollment started in October 2013 and ended in December 2016 when 417 patients had been included. Follow-up data collection will conclude in March 2018. Publication of the primary and secondary outcome results from the MIMeRiC trial is anticipated in 2019. CONCLUSIONS: The MIMeRiC trial will assess the effectiveness of an intervention involving medication reviews and individualized support. The results will inform the continued development of support for this large group of patients who use preventive medicines for lifelong treatment. The design of this adherence intervention is based on a theoretical framework and is the first trial of an intervention that uses beliefs about medicines to individualize the intervention protocol. TRIAL REGISTRATION: ClinicalTrials.gov NCT02102503; https://clinicaltrials.gov/ct2/show/NCT02102503 (Archived by WebCite at http://www.webcitation.org/6x7iUDohy).

The ELENA facility.

The CERN Antiproton Decelerator (AD) provides antiproton beams with a kinetic energy of 5.3 MeV to an active user community. The experiments would profit from a lower beam energy, but this extraction energy is the lowest one possible under good conditions with the given circumference of the AD. The Extra Low Energy Antiproton ring (ELENA) is a small synchrotron with a circumference a factor of 6 smaller than the AD to further decelerate antiprotons from the AD from 5.3 MeV to 100 keV. Controlled deceleration in a synchrotron equipped with an electron cooler to reduce emittances in all three planes will allow the existing AD experiments to increase substantially their antiproton capture efficiencies and render new experiments possible. ELENA ring commissioning is taking place at present and first beams to a new experiment installed in a new experimental area are foreseen in 2017. The transfer lines from ELENA to existing experiments in the old experimental area will be installed during CERN Long Shutdown 2 (LS2) in 2019 and 2020. The status of the project and ring commissioning will be reported.This article is part of the Theo Murphy meeting issue 'Antiproton physics in the ELENA era'.

Motivational Interviewing and Medication Review in Coronary Heart Disease (MIMeRiC): Intervention Development and Protocol for the Process Evaluation.

BACKGROUND: Trials of complex interventions are often criticized for being difficult to interpret because the effects of apparently similar interventions vary across studies dependent on context, targeted groups, and the delivery of the intervention. The Motivational Interviewing and Medication Review in Coronary heart disease (MIMeRiC) trial is a randomized controlled trial (RCT) of an intervention aimed at improving pharmacological secondary prevention. Guidelines for the development and evaluation of complex interventions have recently highlighted the need for better reporting of the development of interventions, including descriptions of how the intervention is assumed to work, how this theory informed the process evaluation, and how the process evaluation relates to the outcome evaluation. OBJECTIVE: This paper aims to describe how the intervention was designed and developed. The aim of the process evaluation is to better understand how and why the intervention in the MIMeRiC trial was effective or not effective. METHODS: The research questions for evaluating the process are based on the conceptual model of change processes assumed in the intervention and will be analyzed by qualitative and quantitative methods. Quantitative data are used to evaluate the medication review in terms of drug-related problems, to describe how patients' beliefs about medicines are affected by the intervention, and to evaluate the quality of motivational interviewing. Qualitative data will be used to analyze whether patients experienced the intervention as intended, how cardiologists experienced the collaboration and intervention, and how the intervention affected patients' overall experience of care after coronary heart disease. RESULTS: The development and piloting of the intervention are described in relation to the theoretical framework. Data for the process evaluation will be collected until March 2018. Some process evaluation questions will be analyzed before, and others will be analyzed after the outcomes of the MIMeRiC RCT are known. CONCLUSIONS: This paper describes the framework for the design of the intervention tested in the MIMeRiC trial, development of the intervention from the pilot stage to the complete trial intervention, and the framework and methods for the process evaluation. Providing the protocol of the process evaluation allows prespecification of the processes that will be evaluated, because we hypothesize that they will determine the outcomes of the MIMeRiC trial. This protocol also constitutes a contribution to the new field of process evaluations as made explicit in health services research and clinical trials of complex interventions.

Medication reconciliation activities among pharmacists in Europe.

OBJECTIVE: To investigate pharmacists' involvement in medication reconciliation (MedRec) and the quality of MedRec processes throughout Europe. METHODS: A survey with six questions was sent to delegates from the 30 countries participating in the EAHP Academy Seminar Camp focusing on MedRec. The questionnaire included four questions regarding the status of MedRec on a national level including the prevalence of MedRec, available educations, requirements of the pharmacists and training of new staff. RESULTS: 52 delegates from 29 countries responded (response rate 90%). Only the participants from the UK stated that MedRec is implemented as standard practice in the country. For most countries MedRec is implemented in some hospitals for some patients (13) or as projects (12). In 11 countries a systematic approach was in place for training new staff and 13 countries have courses teaching MedRec. Only five countries had prerequisites for pharmacists performing MedRec. CONCLUSIONS: There is great heterogeneity in the implementation rate and standards of practice of MedRec processes including pharmacists in Europe.

Whose responsibility is medication reconciliation: Physicians, pharmacists or nurses? A survey in an academic tertiary care hospital.

Background: Medication errors occur frequently at transitions in care and can result in morbidity and mortality. Medication reconciliation is a recognized hospital accreditation requirement and designed to limit errors in transitions in care. Objectives: To identify beliefs, perceived roles and responsibilities of physicians, pharmacists and nurses prior to the implementation of a standardized medication reconciliation process. Methods: A survey was distributed to the three professions: pharmacists in the pharmacy and physicians and nurses in hospital in-patient units. It contained questions about the current level of medication reconciliation practices, as well as perceived roles and responsibilities of each profession when a standardized process is implemented. Value, barriers to implementing medication reconciliation and the role of information technology were also assessed. Analyses were performed using univariate statistics. Results: There was a lack of clarity of current medication reconciliation practices as well as lack of agreement between the three professions. Physicians and pharmacists considered their professions as the main providers while nurses considered physicians followed by themselves as the main providers with limited roles for pharmacists. The three professions recognize the values and benefits of medication reconciliation yet pharmacists, more than others, stated limited time to implement reconciliation is a major barrier. Obstacles such as unreliable sources of medication history, patient knowledge and lack of coordination and communication between the three professions were expressed. Conclusions: The three health care professions recognize the value of medication reconciliation and want to see it implemented in the hospital, yet there is a lack of agreement with regard to roles and responsibilities of each profession within the process. This needs to be addressed by the hospital administration to design clear procedures and defined roles for each profession within a standardized medication reconciliation process.

Developing a Competency-based Curriculum in Basic and Clinical Pharmacology--A Delphi Study among Physicians.

A new curriculum is planned for the medical school at Lund University, Sweden. Pharmacology, in a broad sense, has been identified as a subject that needs to be strengthened based on needs in the healthcare system. The aim was to identify the competencies in basic and clinical pharmacology that a newly qualified physician needs. Using a modified three-round Delphi technique, 31 physicians were invited to list necessary competencies (round 1). After content analysis, these panel members classified the list by importance on two occasions (rounds 2 and 3) using a 4-point scale (4 = necessary, 3 = desirable, 2 = useful, 1 = not necessary). Competencies with the highest ranks based on necessity were retained. Thirty physicians accepted the invitation and 25 (83%) of them completed all three rounds. Round 1 resulted in 258 suggestions, which were subsequently reduced to 95 competencies. Of these 95 competencies, 40 were considered necessary by at least 75% of the panel members. The degree of consensus increased between round 2 and round 3. Using a modified Delphi technique, we identified 40 competencies that could be transferred to learning outcomes for a new curriculum in basic and clinical pharmacology at medical school.

Evidence-based and pragmatic steps for pharmacists to improve patient adherence.

All strategies and tools to improve the potential outcomes of medications therapy are a waste of time if the clients do not take their medication as prescribed. The aim of this paper is to help pharmacists to help their clients to improve outcomes of medicines based on improving their compliance to evidence-based pharmacotherapy. To reach a good compliance (result), you have to have agreement and concordance (method) between the practitioner and the client. Barriers and strategies for this, including identifying compliance problems and reasons for it, methods for improving information and communication, the client's participation, and responsibility for their own health, are presented mainly based on Cochrane reviews. Also some general pragmatic suggestions for how pharmacists can assist their clients the best are given.

Improving the quality of pharmacotherapy in elderly primary care patients through medication reviews: a randomised controlled study.

BACKGROUND: Polypharmacy in the Swedish elderly population is currently a prioritised area of research with a focus on reducing the use of potentially inappropriate medications (PIMs). Multi-professional interventions have previously been tested for their ability to improve drug therapy in frail elderly patients. OBJECTIVE: This study aimed to assess a structured model for pharmacist-led medication reviews in primary health care in southern Sweden and to measure its effects on numbers of patients with PIMs (using the definition of the Swedish National Board of Health and Welfare) using ≥10 drugs and using ≥3 psychotropics. METHODS: This study was a randomised controlled clinical trial performed in a group of patients aged ≥75 years and living in nursing homes or the community and receiving municipal health care. Medication reviews were performed by trained clinical pharmacists based on nurse-initiated symptom assessments with team-based or distance feedback to the physician. Data were collected from the patients' electronic medication lists and medical records at baseline and 2 months after the medication review. RESULTS: A total of 369 patients were included: 182 in the intervention group and 187 in the control group. One-third of the patients in both groups had at least one PIM at baseline. Two months after the medication reviews, the number of intervention group patients with at least one PIM and the number of intervention group patients using ten or more drugs had decreased (p = 0.007 and p = 0.001, respectively), while there were no statistically significant changes in the control patients. No changes were seen in the number of patients using three or more psychotropic drugs, although the dosages of these drugs tended to decrease. Drug-related problems (DRPs) were identified in 93 % of the 182 patients in the intervention group. In total, there were 431 DRPs in the intervention group (a mean of 2.5 DRPs per patient, range 0-9, SD 1.5 at 95 % CI) and 16 % of the DRPs were related to PIMs. CONCLUSIONS: Medication reviews involving pharmacists in primary health care appear to be a feasible method to reduce the number of patients with PIMs, thus improving the quality of pharmacotherapy in elderly patients.