Health care professionals’ perspectives on automated multi-dose drug dispensing / Perspectivas de los profesionales de la salud sobre la dispensación de medicamentos en multi-dosis automatizadas

Background: During the 1980s, manual repackaging of multi-dose medications from pharmacies in Sweden was successively substituted with automated multi-dose drug dispensing (MDD). There are few studies evaluating the consequences of automated MDD with regard to patient safety, and those that investigate this issue are not very extensive. Objectives: To investigate Swedish health care professionals’ perceived experience of automated MDD and its effects on patient adherence and patient safety. Methods: Three questionnaire forms, one for physicians, nurses, and assistant nurses/nursing assistants, were developed based on reviews of the literature and pilot testing of the questions in the intended target groups. The target groups were health professionals prescribing or administrating MDD to patients. A sample (every sixth municipality) was drawn from the sampling frame of Swedish municipalities, resulting in 40 municipalities, about 14% of all municipalities in Sweden. Email addresses of general practitioners were obtained from county councils, while the municipalities assisted in getting contact details for nurses, assistant nurses and nursing assistants. A total of 915 questionnaires were distributed electronically to physicians, 515 to nurses, and 4,118 to assistant nurses/nursing assistants. The data were collected in September and October 2012. Results: The response rate among physicians, nurses and assistant nurses/nursing assistants was 31%, 43% and 23%, respectively. The professionals reported that automated MDD reduces duplication of medication, contributes to correct dosages, helps patients take their medication at the right time, and reduces confusion among patients. Fifteen per cent of the physicians and about onethird of the nurses and assistant nurses/nursing assistants reported that generic substitution makes it more difficult for the patient to identify the various medicines available in the sachets. The physicians did, however, note that prescribing medicine to patients with automated MDD is complicated and can be a risk for patient safety. Both physicians and nurses requested more information on and training in automated MDD. They also asked for more medication reviews. Conclusions: The professionals generally had a positive attitude to automated MDD with regard to improved medication adherence, but said they believed that the electronic prescribing system posed a safety risk for patients (AU)

Antecedentes: Durante los años 1980s, el re-embalaje manual de medicamentos en las farmacias suecas fue gradualmente substituido por la dispensación multi-dosis automatizada (MDD). Hay pocos estudios que evalúen las consecuencias del MDD automatizado en relación a la seguridad del paciente, y los que lo han hecho no eran muy extensivos. Objetivos: Investigar las percepciones de los profesionales de salud suecos del MDD automatizado y sus efectos en la adherencia y seguridad del paciente. Métodos: Basándose en la literatura, se desarrollaron tres cuestionarios, para médicos, enfermeras y auxiliares de enfermería, y se pilotaron en cada uno de los tres grupos. Los grupos diana eran profesionales que prescribían o administraban MDD a pacientes. Se extrajo una muestra /una de cada seis) municipios del marco mostral de municipios de Suecia, obteniéndose 40 municipios, cerca del 40% de todos los que hay en Suecia. Se obtuvieron las direcciones de correo electrónico de los consejos de condado, mientras que los ayuntamientos ayudaron a conseguir los contactos de enfermeras y auxiliares de enfermería. Se distribuyeron electrónicamente un total de 915 cuestionarios a médicos, 515 a enfermeras y 4118 a auxiliares de enfermería. Los datos fueron recogidos entre septiembre y octubre de 2012. Resultados: La tasa de respuesta entre médicos, enfermeras y auxiliares de enfermería fue del 31%, 43% y 23%, respectivamente. Los profesionales reportaron que los MDD reducen la duplicidad e medicamentos, contribuye a la correcta dosificación, ayuda a los pacientes a tomar la medicación a la hora correcta, y reduce la confusión entre los pacientes. Un 15% de médicos y cerca de un tercio de enfermeras y auxiliares reportaron que la sustitución genérica hace más difícil al paciente identificar los varios medicamentos en los sobres. Sin embargo, los médicos apuntaron que prescribir medicamentos en MDD automatizado es complicado y puede ser de riesgo para la seguridad de los pacientes. Tanto médicos como enfermeras pidieron más información y entrenamiento sobre MDD automatizados. También pidieron más revisiones de la medicación. Conclusiones: Los profesionales en general tienen una actitud positiva hacia los MDD automatizados en cuento a la mejora de la adherencia a medicación, pero dicen que creen que la l sistema de prescripción electrónica ha creado un riesgo para los pacientes (AU)

Implementation of a shared medication list: physicians' views on availability, accuracy and confidentiality.

BACKGROUND: Physicians, patients and others involved need to have accurate information on patients' current drug prescriptions available, and have that information protected from unauthorized access. During the past decade, many counties in Sweden have implemented regionally shared medication lists within health care. OBJECTIVE: The aim of this study was to describe physicians' views on changes in accuracy, availability and confidentiality in the transition from local medication lists to a regionally shared medication list. SETTING: Health care units in four different counties of Sweden after the transition from local medication lists to a regionally shared medication list. The shared medication list was an integrated part of the electronic health record system in the respective counties, but the system and implementation process varied. METHODS: Physicians (n = 7) with experience of transition from local medication lists to a regionally shared medication list were interviewed in a semi-structured manner. MAIN OUTCOME MEASURE: Physicians' views on changes in information risks, focusing on accuracy, availability and confidentiality. Results The transition from local medication lists to a shared medication list increased the availability of information: from being time consuming or not possible to access from other care givers to most information being available in one place. A regionally shared medication list was perceived as having the potential to provide a greater accuracy of information, but not always: the shared medication list was perceived as more complete but with more non-current drugs. On the other hand, a shared medication list implied an increased risk of violating patient privacy, placing greater demands on IT security in order to protect the confidentiality of information. CONCLUSION: Physicians perceived a regionally shared medication list to increase the availability of information about current prescriptions and potentially the accuracy but may decrease the confidentiality of information. To implement a shared medication list, we recommend providing clear description of responsibilities and routines for normal activities as well as back-up routines, consider IT-security and data protection early, involve patients to improve the accuracy of the list as well as to monitor and evaluate the implementation.

Health care professionals' perspectives on automated multi-dose drug dispensing.

BACKGROUND: During the 1980s, manual repackaging of multi-dose medications from pharmacies in Sweden was successively substituted with automated multi-dose drug dispensing (MDD). There are few studies evaluating the consequences of automated MDD with regard to patient safety, and those that investigate this issue are not very extensive. OBJECTIVES: To investigate Swedish health care professionals' perceived experience of automated MDD and its effects on patient adherence and patient safety. METHODS: Three questionnaire forms, one for physicians, nurses, and assistant nurses/nursing assistants, were developed based on reviews of the literature and pilot testing of the questions in the intended target groups. The target groups were health professionals prescribing or administrating MDD to patients. A sample (every sixth municipality) was drawn from the sampling frame of Swedish municipalities, resulting in 40 municipalities, about 14% of all municipalities in Sweden. Email addresses of general practitioners were obtained from county councils, while the municipalities assisted in getting contact details for nurses, assistant nurses and nursing assistants. A total of 915 questionnaires were distributed electronically to physicians, 515 to nurses, and 4,118 to assistant nurses/nursing assistants. The data were collected in September and October 2012. RESULTS: The response rate among physicians, nurses and assistant nurses/nursing assistants was 31%, 43% and 23%, respectively. The professionals reported that automated MDD reduces duplication of medication, contributes to correct dosages, helps patients take their medication at the right time, and reduces confusion among patients. Fifteen per cent of the physicians and about one-third of the nurses and assistant nurses/nursing assistants reported that generic substitution makes it more difficult for the patient to identify the various medicines available in the sachets. The physicians did, however, note that prescribing medicine to patients with automated MDD is complicated and can be a risk for patient safety. Both physicians and nurses requested more information on and training in automated MDD. They also asked for more medication reviews. CONCLUSIONS: The professionals generally had a positive attitude to automated MDD with regard to improved medication adherence, but said they believed that the electronic prescribing system posed a safety risk for patients.

Use of a generic protocol in documentation of prescription errors in Estonia, Norway and Sweden / Uso de un protocolo genérico en la documentación de los errores de prescripción en Estonia, Noruega y Suecia

Pharmacists have an important role in detecting, preventing, and solving prescription problems, which if left unresolved, may pose a risk of harming the patient. Objective: The objectives of this study were to evaluate the feasibility of a generic study instrument for documentation of prescription problems requiring contact with prescriber before dispensing. The study was organized: 1) by countries: Estonia, Norway and Sweden; 2) by type of prescriptions: handwritten prescriptions, printouts of prescriptions in the electronic medical record and electronically transmitted prescriptions to pharmacies; and 3) by recording method - self-completion by pharmacists and independent observers. Methods: Observational study with independent observers at community pharmacies in Estonia (n=4) and Sweden (n=7) and self-completed protocols in Norway (n=9). Results: Pharmacists’ in Estonia contacted the prescriber for 1.47% of the prescriptions, about 3 times as often as in Norway (0.45%) and Sweden (0.38%). Handwritten prescriptions dominated among the problem prescriptions in Estonia (73.2%), printouts of prescriptions in the electronic medical record (89.1%) in Norway and electronically transmitted prescriptions to pharmacies (55.9%) in Sweden. More administrative errors were identified on handwritten prescriptions and printouts of prescriptions in the electronic medical record in Estonia and in Norway compared with electronically transmitted prescriptions to pharmacies in Sweden (p<0.05 for prescription types and p<0.01 for countries). However, clinically important errors and delivery problems appeared equally often on the different types of prescriptions. In all three countries, only few cases of drug interactions and adverse drug reactions were identified. Conclusion: Despite the different patterns of prescription problems in three countries, the instrument was feasible and can be regarded appropriate to document and classify prescription problems necessitating contact with prescriber before dispensing, irrespective of the type of prescription or recording method (AU)

Los farmacéuticos juegan un papel importante en la detección, prevención y resolución de problemas de prescripción, que si no se resuelven pueden poner en riesgo de daño al paciente. Objetivo: Los objetivos de este estudio fueron evaluar la factibilidad de un instrumento de genérico de estudio para documentar los problemas de prescripción que requieren contactar al prescriptor antes de dispensar. El estudio se organizó: 1) por países: Estonia, Noruega y Suecia; 2) por tipo de recetas: recetas manuscritas, recetas impresas desde el historial electrónico del médico, y prescripción electrónica; y 3) por método de registro: auto-cumplimentación por los farmacéuticos o por observadores independientes. Métodos: Estudio observacional con observadores independientes en las farmacias comunitarias en Estonia (n=4) y Suecia (n=7) y protocolos autocumplimentados en Noruega (n=9). Resultados: Los farmacéuticos en Estonia contactaron a los prescriptores en el 1.47% de las recetas, unas 3 veces más frecuentemente que en Noruega (0.45%) y Suecia (0.38%).Las recetas manuscritas dominaron entre los problemas de prescripción en Estonia (73.2%), las impresiones de recetas desde el historial electrónico (89.1%) en Noruega, y las prescripciones electrónicamente transmitidas a las farmacias (55.9%) en Suecia. Se identificaron más errores administrativos en las recetas manuscritas y en las impresas desde el historial electrónico en Estonia y Noruega, comparadas con las electrónicamente transmitidas a la farmacia de Suecia (p<0.05 para los tipos de recetas y p<0.01 para los países). Sin embargo, los errores clínicamente importantes y los problemas de entrega aparecieron igualmente entre los diferentes tipos de recetas. En los tres países, se identificaron unos pocos casos de interacciones medicamentosas y de reacciones adversas. Conclusión: A pesar de los tres patrones diferentes de prescripción en los tres países, el instrumento fue factible y puede considerarse apropiado para documentar y clasificar los problemas de prescripción que necesitan contactar con el prescriptor antes de ser dispensados, independientemente del tipo de receta o del método de registro (AU)

Use of a generic protocol in documentation of prescription errors in Estonia, Norway and Sweden.

UNLABELLED: Pharmacists have an important role in detecting, preventing, and solving prescription problems, which if left unresolved, may pose a risk of harming the patient. OBJECTIVE: The objectives of this study were to evaluate the feasibility of a generic study instrument for documentation of prescription problems requiring contact with prescriber before dispensing. The study was organized: 1) by countries: Estonia, Norway and Sweden; 2) by type of prescriptions: handwritten prescriptions, printouts of prescriptions in the electronic medical record and electronically transmitted prescriptions to pharmacies; and 3) by recording method - self-completion by pharmacists and independent observers. METHODS: Observational study with independent observers at community pharmacies in Estonia (n=4) and Sweden (n=7) and self-completed protocols in Norway (n=9). RESULTS: Pharmacists''in Estonia contacted the prescriber for 1.47% of the prescriptions, about 3 times as often as in Norway (0.45%) and Sweden (0.38%). Handwritten prescriptions dominated among the problem prescriptions in Estonia (73.2%), printouts of prescriptions in the electronic medical record (89.1%) in Norway and electronically transmitted prescriptions to pharmacies (55.9%) in Sweden. More administrative errors were identified on handwritten prescriptions and printouts of prescriptions in the electronic medical record in Estonia and in Norway compared with electronically transmitted prescriptions to pharmacies in Sweden (p<0.05 for prescription types and p<0.01 for countries). However, clinically important errors and delivery problems appeared equally often on the different types of prescriptions. In all three countries, only few cases of drug interactions and adverse drug reactions were identified. CONCLUSIONS: Despite the different patterns of prescription problems in three countries, the instrument was feasible and can be regarded appropriate to document and classify prescription problems necessitating contact with prescriber before dispensing, irrespective of the type of prescription or recording method.

Discrepancies between the electronic medical record, the prescriptions in the Swedish national prescription repository and the current medication reported by patients.

PURPOSE: To study discrepancies between (i) the prescribed current treatment stated by patients with congestive heart failure (CHF) compared with patients with other chronic diseases, (ii) the data in the medication list (ML) in the electronic medical record and (iii) the data in the prescription list (PL) on the prescriptions stored in the national prescription repository in Sweden, to determine current, noncurrent, duplicate and missing prescriptions. METHODS: At one healthcare centre, a random sample of patients 18 years and older with a diagnosis of CHF, diabetes mellitus (DM) or osteoarthritis (OA) provided written informed consent to participate. Participants were interviewed by telephone on the prescribed current treatment. RESULTS: Of 161 invited patients (61 CHF, 50 DM and 50 OA), 66 patients were included. More than 80% of the patients had at least one discrepancy, a noncurrent, a duplicate or a missing prescription, in the ML and PL. The overall congruence for unique prescriptions on current treatment between the ML and the PL was only 55%. Patients with CHF had overall more discrepancies and patients with DM fewer discrepancies in the ML. CONCLUSIONS: Prescriptions for noncurrent treatment, duplicates and missing prescriptions are common in both the ML in the electronic medical record and the list on prescriptions stored in the Swedish National Prescription Repository. Patients with CHF had more discrepancies in the ML. The risk for medication errors in primary care due to incorrect information on prescribed treatment may be substantial.

Problem prescriptions in Sweden necessitating contact with the prescriber before dispensing.

BACKGROUND: Pharmacists have an important role in detecting, preventing, and solving prescription problems, which if left unresolved, may pose a risk of harming the patient. OBJECTIVES: The aim was to examine prescription problems detected at pharmacies in Sweden, where pharmacists consider it necessary to contact the prescribers for clarification, completion or correction of the prescriptions before dispensing, and to compare the intervention rates at public pharmacies at hospitals (PPHs) with those at city center pharmacies (CCPs). METHODS: All attempts to contact the prescriber about a prescription problem were recorded by trained observers (pharmacy students). Analyses were made of overall distribution of problem prescriptions, including data from all 14 participating pharmacies, and a comparison between CCPs and PPHs with data from the 5 areas, each consisting of 1 CCP and 1 PPH (10 pharmacies). Chi-square-analyses were used to compare proportions, Spearman's rank-correlation coefficient was used to test correlation between recorded rates and dispensed volume, and Wilcoxon two-sample test was used to test differences between the CCPs and PPHs. P<.05 is regarded as statistically significant. RESULTS: The pharmacists contacted the prescribers for 1% of all new prescriptions before dispensing. Errors that may compromise patient safety and medication outcome constituted almost 60% of the problems. However, there was an inverse correlation between the intervention rates and the pharmacy's dispensing volume. Significantly lower rates of problem prescriptions were recorded for women than for men. The highest rates were seen for prescriptions to patients younger than 15 years, and the rates decreased with increasing patient age. Pharmacists at PPHs contacted the prescribers about prescription problems twice as often as those at large CCPs. Pharmacists spent an average of 5 minutes on the telephone to solve the problem (median time), but 25% of the prescriptions took 10 minutes or more. CONCLUSIONS: Computerized physician order entry (CPOE) and electronically transmitted prescriptions (ETP) can not only reduce the total rate of prescription problems, but also introduce new clinically important errors that may compromise patient safety and medication outcome. The prescription problem rates in the present study differed across prescriber groups and patient age and gender, and the inverse correlation to pharmacy size indicates that all problems are not revealed and corrected and may thus reach the patient. CPOE and ETP have been used extensively in Sweden for the past decade, but the present study indicates that there is still a potential and need for improvement for the vision of "no prescribing errors/problems will reach the patient" to come true.

Community pharmacists' prescription intervention practices--exploring variations in practice in Norwegian pharmacies.

BACKGROUND: Evidence suggests that prescription intervention frequencies have been found to vary as much as 10-fold among Norwegian pharmacies and among pharmacists within the same pharmacy. OBJECTIVE: To explore community pharmacists' perceptions of how their prescription intervention practices were influenced by their working environment, their technological resources, the physical and social structures of the pharmacies, their relations with colleagues, and to the individual pharmacist's professional skills. METHODS: Two focus groups consisting of 14 community pharmacists in total, from urban and rural areas in Norway, discussed their working procedures and professional judgments related to prescription interventions. Organizational theories were used as theoretical and analytical frameworks in the study. A framework based on Leavitt's organizational model was to structure our interview guide. The study units were the statements of the individual pharmacists. Recurrent themes were identified and condensed. RESULTS: Two processes describing variations in the dispensing workflow including prescription interventions were derived--an active dispensing process extracting information about the patient's medication from several sources and a fast dispensing process focusing mainly on the information available on the prescription. Both workflow processes were used in the same pharmacies and by the same pharmacist but on different occasions. A pharmacy layout allowing interactions between pharmacist and patients and a convenient organization of technology, layout, pharmacist-patient and pharmacist-coworker transactions at the workplace was essential for detecting and solving prescription problems. Pharmacists limited their contact with general practitioners when they considered the problem a formality and/or when they knew the answers themselves. The combined use of dispensing software and the Internet was a driving force toward more independent and cognitively advanced prescription interventions. CONCLUSION: Implementation of a general organizational model made it easier to analyze and interpret the pharmacists' intervention practices. Working environment, technology, management and professional skills may all contribute to variations in pharmacists' prescription intervention practices in and between community pharmacies.

Electronically transmitted prescriptions not picked up at pharmacies in Sweden.

BACKGROUND: Electronically transmitted prescriptions (ETPs) became common after 1995 in Sweden; however, it is accompanied by a substantial increase in the number of prescriptions not picked up at pharmacies. OBJECTIVE: To investigate the "no pick-up" rates of ETPs at pharmacies across type of drug and patient age and gender and the reasons patients' report for no pick-up. METHODS: A cross-sectional study examining no pick-up of ETPs transmitted during 3 months in 2002, and a mail survey of patients to determine the reasons for failure to pick-up in the county of Sörmland, Sweden, with a population of 261,000, and 21 pharmacies. Chi-square tests were used for calculations of frequency differences among groups. RESULTS: The overall no pick-up rate of ETPs was 2.5%; men had consistently higher rates than women. The highest rates were seen for adolescents and young adults. Rates were higher than average for antibiotics. About 60% of the answers indicated that prescriptions not picked up were duplicate prescriptions or not needed. "Unintentional nonadherence" was reported by one-fifth of patients. CONCLUSIONS: No pick-up rate in general was low (2.5%), but there were differences across patient age and gender, the rates being higher among adolescents and young adults. Duplicate prescriptions may explain a significant share of the abandoned prescriptions.

Decreasing incidence of peptic ulcer complications after the introduction of the proton pump inhibitors, a study of the Swedish population from 1974-2002.

BACKGROUND: Despite a decreasing incidence of peptic ulcer disease, most previous studies report a stabile incidence of ulcer complications. We wanted to investigate the incidence of peptic ulcer complications in Sweden before and after the introduction of the proton pump inhibitors (PPI) in 1988 and compare these data to the sales of non-steroid anti-inflammatory drugs (NSAID) and acetylsalicylic acid (ASA). METHODS: All cases of gastric and duodenal ulcer complications diagnosed in Sweden from 1974 to 2002 were identified using the National hospital discharge register. Information on sales of ASA/NSAID was obtained from the National prescription survey. RESULTS: When comparing the time-periods before and after 1988 we found a significantly lower incidence of peptic ulcer complications during the later period for both sexes (p < 0.001). Incidence rates varied from 1.5 to 7.8/100000 inhabitants/year regarding perforated peptic ulcers and from 5.2 to 40.2 regarding peptic ulcer bleeding. The number of sold daily dosages of prescribed NSAID/ASA tripled from 1975 to 2002. The number of prescribed sales to women was higher than to males. Sales of low-dose ASA also increased. The total volume of NSAID and ASA, i.e. over the counter sale and sold on prescription, increased by 28% during the same period. CONCLUSION: When comparing the periods before and after the introduction of the proton pump inhibitors we found a significant decrease in the incidence of peptic ulcer complications in the Swedish population after 1988 when PPI were introduced on the market. The cause of this decrease is most likely multifactorial, including smoking habits, NSAID consumption, prevalence of Helicobacter pylori and the introduction of PPI. Sales of prescribed NSAID/ASA increased, especially in middle-aged and elderly women. This fact seems to have had little effect on the incidence of peptic ulcer complications.

Assessment of ePrescription quality: an observational study at three mail-order pharmacies.

BACKGROUND: The introduction of electronic transfer of prescriptions (ETP) or ePrescriptions in ambulatory health care has been suggested to have a positive impact on the prescribing and dispensing processes. Thereby, implying that ePrescribing can improve safety, quality, efficiency, and cost-effectiveness. In December 2007, 68% of all new prescriptions were transferred electronically in Sweden. The aim of the present study was to assess the quality of ePrescriptions by comparing the proportions of ePrescriptions and non-electronic prescriptions necessitating a clarification contact (correction, completion or change) with the prescriber at the time of dispensing. METHODS: A direct observational study was performed at three Swedish mail-order pharmacies which were known to dispense a large proportion of ePrescriptions (38-75%). Data were gathered on all ePrescriptions dispensed at these pharmacies over a three week period in February 2006. All clarification contacts with prescribers were included in the study and were classified and assessed in comparison with all drug prescriptions dispensed at the same pharmacies over the specified period. RESULTS: Of the 31225 prescriptions dispensed during the study period, clarification contacts were made for 2.0% (147/7532) of new ePrescriptions and 1.2% (79/6833) of new non-electronic prescriptions. This represented a relative risk (RR) of 1.7 (95% CI 1.3-2.2) for new ePrescriptions compared to new non-electronic prescriptions. The increased RR was mainly due to 'Dosage and directions for use', which had an RR of 7.6 (95% CI 2.8-20.4) when compared to other clarification contacts. In all, 89.5% of the suggested pharmacist interventions were accepted by the prescriber, 77.7% (192/247) as suggested and an additional 11.7% (29/247) after a modification during contact with the prescriber. CONCLUSION: The increased proportion of prescriptions necessitating a clarification contact for new ePrescriptions compared to new non-electronic prescriptions indicates the need for an increased focus on quality aspects in ePrescribing deployment. ETP technology should be developed towards a two-way communication between the prescriber and the pharmacist with automated checks of missing, inaccurate, or ambiguous information. This would enhance safety and quality for the patient and also improve efficiency and cost-effectiveness within the health care system.

Impact of postal and telephone reminders on pick-up rates of unclaimed e-prescriptions.

OBJECTIVE: To investigate the impact of a reminder (i.e., a mailed letter or short telephone call) from the pharmacy to patients, compared with no reminder in a control group, on the pick-up rates of unclaimed e-prescriptions. METHOD: Patients, with e-prescriptions transmitted to four large community pharmacies in two counties in northern Sweden and remaining unclaimed after 4 weekdays, were randomised to one of two intervention groups (a mailed reminder or a short telephonic reminder) or a control group. MAIN OUTCOME MEASURES: Rates of patients' pick-up of their e-prescriptions at follow-up after about 1, 2 and 3 weeks. RESULTS: Altogether, 320 patients with e-prescriptions, transmitted from March 21 through April 6 and not picked-up or dispensed, were identified and randomised to the study. There were no statistically significant differences in overall pick-up rates between the groups or with respect to gender. However, pick-up rates increased with increasing age. Higher pick-up rates were observed for two subgroups (but only in the mailed reminder group compared with controls)--for cardiovascular drugs to men and for respiratory drugs to adolescents and young adults. CONCLUSION: A reminder (i.e., a mailed letter or short telephone call) from the pharmacy to the patient had no statistically significant effect on overall pick-up rates of unclaimed e-prescriptions compared with no reminders.

Can selective serotonin inhibitor drugs in elderly patients in nursing homes be reduced?

OBJECTIVE: To investigate whether treatment with selective serotonin reuptake inhibitors (SSRIs) could be withdrawn for elderly residents who had been on treatment for at least one year and to evaluate a method for systematic drug review. DESIGN: Open, prospective, interventional study. SETTING: Four counties in Sweden. SUBJECTS: Elderly residents at 19 nursing homes, with ongoing treatment with SSRIs for more than one year. MAIN OUTCOME MEASURES: Clinical evaluation, registration of drugs used and rating with Montgomery-Asberg Depression Rating Scale (MADRS). A semi-structured telephone interview with 15 participating physicians and 19 nurses. RESULTS: About one-third of all 822 residents in the nursing homes had ongoing antidepressant treatment, predominantly with SSRIs; 75% of them had been treated with SSRIs for at least one year and 119 (60%) of these were considered eligible for the study. The intervention was judged successful in 52% of these residents of whom 88% had a MADRS rating of less than 20 points. The GPs and the nurses experienced the method as practicable. CONCLUSIONS: Withdrawal of SSRI treatment was successful in the majority of cases. The MADRS may be a valuable addition to clinical evaluation when deciding whether to end or continue SSRI treatment.

Refill non-adherence to repeat prescriptions leads to treatment gaps or to high extra costs.

OBJECTIVE: To determine the nature and extent of undersupply and the economic consequences of oversupply of medication among non-adherent patients. METHODS: This study used copies of repeat prescriptions (= multiple dispensations), collected during 1 week in 2002 at 16 Swedish community pharmacies. For patients with a refill adherence below 80%, treatment gaps were defined as the number of days they had no drug available. The cost of drug oversupply (i.e., refill adherence > 120%) was calculated from the prices of the drug packages dispensed. RESULTS: The number of collected repeat prescriptions was 3,636. The median of treatment gaps among patients with a refill adherence below 80% was 53 days per 90-100 days treatment period and the corresponding median for oversupply was 40 days. The cost of oversupply for exempt patients (i.e., patients who have paid 1,800 SEK (Euro 196; US$ 243) per year for medicines) was 32,000 SEK (Euro 3,500; US$ 4,300) higher than for non-exempt patients. An extrapolation to all Sweden indicates that exemption from charges leads to an additional oversupply of about 142 million SEK (Euro 15 million; US$ 19 million) per year above that of non-exempt patients. CONCLUSION: Both undersupply and oversupply of prescribed medicines are common in Sweden. Patients with a refill adherence below 80% seem to have less than half of the prescribed treatment available. Oversupply or drug stockpiling occurs more frequently among exempt than among non-exempt patients, and this oversupply leads to high unnecessary costs.

Reasons why medicines are returned to Swedish pharmacies unused.

OBJECTIVE: To identify the reasons and their relative importance why medicines are returned to Swedish pharmacies unused. SETTING: A random sample of the pharmacies in Sweden. METHOD: Interviews using a semi-structured interview form with pharmacy customers returning unused medicines to the pharmacy. MAIN OUTCOME MEASURE: Reasons given by patients/relatives/carers for returning unused medicines to the pharmacy. RESULTS: The four main reasons for returning unused medicines to the pharmacy were: (1) the medicines were too old, (2) the user had died, (3) there was no need for the medicine anymore, and (4) therapy changes. These reasons made up 75% of all reported reasons. CONCLUSION: Hoarding or over-supply of prescribed medicines may explain a large part of the volume of medicines that remain unused. Actions aiming to reduce waste of prescribed medicines ought to focus on those patients who contribute to a substantial part of all unused medicines.