How much time do emergency department physicians spend on medication-related tasks? A time- and-motion study.

BACKGROUND: Medication-related problems are an important cause of emergency department (ED) visits, and medication errors are reported in up to 60% of ED patients. Procedures such as medication reconciliation and medication review can identify and prevent medication-related problems and medication errors. However, this work is often time-consuming. In EDs without pharmacists, medication reconciliation is the physician's responsibility, in addition to the primary assignments of examining and diagnosing the patient. The aim of this study was to identify how much time ED physicians spend on medication-related tasks when no pharmacists are present in the EDs. METHODS: An observational time-and-motion study of physicians in three EDs in Northern Norway was conducted using Work Observation Method by Activity Timing (WOMBAT) to collect and time-stamp data. Observations were conducted in predefined two-hour observation sessions with a 1:1 relationship between observer and participant, during Monday to Friday between 8 am and 8 pm, from November 2020 to October 2021. RESULTS: In total, 386 h of observations were collected during 225 observation sessions. A total of 8.7% of the physicians' work time was spent on medication-related tasks, of which most time was spent on oral communication about medications with other physicians (3.0%) and medication-related documentation (3.2%). Physicians spent 2.2 min per hour on medication reconciliation tasks, which includes retrieving medication-related information directly from the patient, reading/retrieving written medication-related information, and medication-related documentation. Physicians spent 85.6% of the observed time on non-medication-related clinical or administrative tasks, and the remaining time was spent standby or moving between tasks. CONCLUSION: In three Norwegian EDs, physicians spent 8.7% of their work time on medication-related tasks, and 85.6% on other clinical or administrative tasks. Physicians spent 2.2 min per hour on tasks related to medication reconciliation. We worry that patient safety related tasks in the EDs receive little attention. Allocating dedicated resources like pharmacists to contribute with medication-related tasks could benefit both physicians and patients.

A Trial-Based Cost-Utility Analysis of a Medication Optimization Intervention Versus Standard Care in Older Adults.

BACKGROUND: Older adults are at greater risk of medication-related harm than younger adults. The Integrated Medication Management model is an interdisciplinary method aiming to optimize medication therapy and improve patient outcomes. OBJECTIVE: We aimed to investigate the cost effectiveness of a medication optimization intervention compared to standard care in acutely hospitalized older adults. METHODS: A cost-utility analysis including 285 adults aged ≥ 70 years was carried out alongside the IMMENSE study. Quality-adjusted life years (QALYs) were derived using the EuroQol 5-Dimension 3-Level Health State Questionnaire (EQ-5D-3L). Patient-level data for healthcare use and costs were obtained from administrative registers, taking a healthcare perspective. The incremental cost-effectiveness ratio was estimated for a 12-month follow-up and compared to a societal willingness-to-pay range of €/QALY 27,067-81,200 (NOK 275,000-825,000). Because of a capacity issue in a primary care resulting in extended hospital stays, a subgroup analysis was carried out for non-long and long stayers with hospitalizations < 14 days or ≥ 14 days. RESULTS: Mean QALYs were 0.023 [95% confidence interval [CI] 0.022-0.025] higher and mean healthcare costs were €4429 [95% CI - 1101 to 11,926] higher for the intervention group in a full population analysis. This produced an incremental cost-effectiveness ratio of €192,565/QALY. For the subgroup analysis, mean QALYs were 0.067 [95% CI 0.066-0.070, n = 222] and - 0.101 [95% CI - 0.035 to 0.048, n = 63] for the intervention group in the non-long stayers and long stayers, respectively. Corresponding mean costs were €- 824 [95% CI - 3869 to 2066] and €1992 [95% CI - 17,964 to 18,811], respectively. The intervention dominated standard care for the non-long stayers with a probability of cost effectiveness of 93.1-99.2% for the whole willingness-to-pay range and 67.8% at a zero willingness to pay. Hospitalizations were the main cost driver, and readmissions contributed the most to the cost difference between the groups. CONCLUSIONS: According to societal willingness-to-pay thresholds, the medication optimization intervention was not cost effective compared to standard care for the full population. The intervention dominated standard care for the non-long stayers, with a high probability of cost effectiveness. CLINICAL TRIAL REGISTRATION: The IMMENSE trial was registered in ClinicalTrials.gov on 28 June, 2016 before enrolment started (NCT02816086).

Emergency department physicians' experiences and perceptions with medication-related work tasks and the potential role of clinical pharmacists.

PURPOSE: Medication-related problems are frequent among emergency department patients. Clinical pharmacists play an important role in identifying, solving, and preventing these problems, but are not present in emergency departments worldwide. We aimed to explore how Norwegian physicians experience medication-related work tasks in emergency departments without pharmacists present, and how they perceive future introduction of a clinical pharmacist in the interprofessional team. METHODS: We interviewed 27 physicians in three emergency departments in Norway. Interviews were audio-recorded, transcribed, and analysed using qualitative content analysis. RESULTS: Our informants' experience with medication-related work tasks mainly concerned medication reconciliation, and few other tasks were systematically performed to ensure medication safety. The informants were welcoming of clinical pharmacists and expressed a need and wish for assistance with compiling patient's medication lists. Simultaneously they expressed concerns regarding e.g., responsibility sharing, priorities in the emergency department and logistics. These concerns need to be addressed before implementing the clinical pharmacist in the interprofessional team in the emergency department. CONCLUSIONS: Physicians in Norwegian emergency departments welcome assistance from clinical pharmacists, but the identified professional, structural, and legislative barriers for this collaboration need to be addressed before implementation.

Patient perceptions and experiences with medication-related activities in the emergency department: a qualitative study.

BACKGROUND: Emergency department (ED) pharmacists reduce medication errors and improve quality of medication use. Patient perceptions and experiences with ED pharmacists have not been studied. The aim of this study was to explore patients' perceptions of and experiences with medication-related activities in the ED, with and without an ED pharmacist present. METHODS: We conducted 24 semistructured individual interviews with patients admitted to one ED in Norway, 12 before and 12 during an intervention, where pharmacists performed medication-related tasks close to patients and in collaboration with ED staff. Interviews were transcribed and analysed applying thematic analysis. RESULTS: From our five developed themes, we identified that: (1) Our informants had low awareness and few expectations of the ED pharmacist, both with and without the pharmacist present. However, they were positive to the ED pharmacist. (2) Our informants expressed a variation of trust in the healthcare system, healthcare professionals and electronic systems, though the majority expressed a high level of trust. They believed that their medication list was automatically updated and assumed to get the correct medication. (3) Some informants felt responsible to have an overview of their medication use, while others expressed low interest in taking responsibility regarding their medication. (4) Some informants did not want involvement from healthcare professionals in medication administration, while others expressed no problems with giving up control. (5) Medication information was important for all informants to feel confident in medication use, but the need for information differed. CONCLUSION: Despite being positive to pharmacists, it did not seem important to our informants who performed the medication-related tasks, as long as they received the help they needed. The degree of trust, responsibility, control and information varied among ED patients. These dimensions can be applied by healthcare professionals to tailor medication-related activities to patients' individual needs.

Is anticholinergic and sedative drug burden associated with postdischarge institutionalization in community-dwelling older patients acutely admitted to hospital? A Norwegian registry-based study.

PURPOSE: Investigate the association between anticholinergic (AC) and sedative (SED) drug burden before hospitalization and postdischarge institutionalization (PDI) in community-dwelling older patients acutely admitted to hospital. METHODS: A cross-sectional study using data from the Norwegian Patient Registry and the Norwegian Prescription Database. We studied acutely hospitalized community-dwelling patients ≥70 years during 2013 (N = 86 509). Patients acutely admitted to geriatric wards underwent subgroup analyses (n = 1715). We calculated drug burden by the Drug Burden Index (DBI), use of AC/SED drugs, and the number of AC/SED drugs. Piecewise linearity of DBI versus PDI and a knot point (DBI = 2.45) was identified. Statistical analyses included an adjusted multivariable logistic regression model. RESULTS: In the total population, 45.4% were exposed to at least one AC/SED drug, compared to 52.5% in the geriatric subgroup. AC/SED drugs were significantly associated with PDI. The DBI with odds ratios (ORs) of 1.11 (95% CI 1.07-1.15) for DBI < 2.45 and 1.08 (95% CI 1.04-1.13) for DBI ≥ 2.45. The number of AC/SED drugs with OR of 1.07 (95% CI 1.05-1.09). The AC component of DBI with OR 1.23 and the number of AC drugs with OR 1.13. In the subgroup, ORs were closer to 1 for AC drugs. CONCLUSIONS: The use of AC/SED drugs was highly prevalent in older patients before acute hospital admissions, and significantly associated with PDI. The number, or just using AC/SED drugs, gave similar associations with PDI compared to applying the DBI. Using AC drugs showed higher sensitivity, indicating that to reduce the risk of PDI, a clinical approach could be to reduce the number of AC drugs.

Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) - a randomized controlled trial.

BACKGROUND: Suboptimal medication use contributes to a substantial proportion of hospitalizations and emergency department visits in older adults. We designed a clinical pharmacist intervention to optimize medication therapy in older hospitalized patients. Based on the integrated medicine management (IMM) model, the 5-step IMMENSE intervention comprise medication reconciliation, medication review, reconciled medication list upon discharge, patient counselling, and post discharge communication with primary care. The objective of this study was to evaluate the effects of the intervention on healthcare use and mortality. METHODS: A non-blinded parallel group randomized controlled trial was conducted in two internal medicine wards at the University Hospital of North Norway. Acutely admitted patients ≥ 70 years were randomized 1:1 to intervention or standard care (control). The primary outcome was the rate of emergency medical visits (readmissions and emergency department visits) 12 months after discharge. RESULTS: Of the 1510 patients assessed for eligibility, 662 patients were asked to participate, and 516 were enrolled. After withdrawal of consent and deaths in hospital, the modified intention-to-treat population comprised 480 patients with a mean age of 83.1 years (SD: 6.3); 244 intervention patients and 236 control patients. The number of emergency medical visits in the intervention and control group was 497 and 499, respectively, and no statistically significant difference was observed in rate of the primary outcome between the groups [adjusted incidence rate ratio of 1.02 (95% CI: 0.82-1.27)]. No statistically significant differences between groups were observed for any of the secondary outcomes, neither in subgroups, nor for the per-protocol population. CONCLUSIONS: We did not observe any statistical significant effects of the IMMENSE intervention on the rate of emergency medical visits or any other secondary outcomes after 12 months in hospitalized older adults included in this study. TRIAL REGISTRATION: The trial was registered in clinicaltrials.gov on 28/06/2016, before enrolment started (NCT02816086).

Medication adherence among persons with coronary heart disease and associations with blood pressure and low-density-lipoprotein-cholesterol.

PURPOSE: To describe medication adherence to lipid-lowering drugs (LLDs), antihypertensive drugs, and acetylsalicylic acid (ASA) among persons with coronary heart disease (CHD) and explore its association with low-density-lipoprotein (LDL)-cholesterol, and systolic and diastolic blood pressure. METHODS: Based on record linkage between the seventh wave of the Tromsø Study and the Norwegian Prescription Database, medication adherence was calculated as the proportion of days covered (PDC) for persistent prevalent users in the period of 365 days before the attendance date. Multivariable linear regression models were used to assess the association between systolic and diastolic blood pressure and medication nonadherence to antihypertensive drugs, age, sex, lifestyle, body mass index (BMI), current and previous diabetes, and between LDL-cholesterol and medication nonadherence to LLDs, age, sex, lifestyle, BMI, and current and previous diabetes. RESULTS: Mean PDC was 0.94 for LLDs and antihypertensive drugs and 0.97 for ASA. Among persons with PDC ≥ 0.80 for LLDs, 12.0% had an LDL-cholesterol < 1.8 mmol/L. Blood pressure < 140/90 mmHg (< 140/80 mmHg if diabetes patient) was reached by 55.1% of those with a PDC ≥ 0.80 for antihypertensive drugs. Adherence to LLDs was associated with lower LDL-cholesterol, while neither systolic nor diastolic blood pressure was associated with adherence to antihypertensive drugs. CONCLUSION: Adherence to antihypertensive drugs, LLDs, and ASA among persons with CHD were high despite low achievement of treatment goals for blood pressure and LDL-cholesterol. There was a statistically significant association between adherence to LLDs and LDL-cholesterol, but not between adherence to antihypertensive drugs and blood pressure.

Intervention fidelity and process outcomes of the IMMENSE study, a pharmacist-led interdisciplinary intervention to improve medication safety in older hospitalized patients.

WHAT IS KNOWN AND OBJECTIVE: The majority of hospitalized older patients experience medication-related problems (MRPs), and there is a call for interventions to solve MRPs and improve clinical outcomes like medical visits. The IMMENSE study is a randomized controlled trial investigating the impact of a pharmacist-led interdisciplinary intervention on emergency medical visits. Its multistep intervention is based on the integrated medicines management methodology and includes a follow-up step with primary care. This study aims to describe how the intervention in the IMMENSE study was delivered and its process outcomes. METHODS: The study includes the 221 intervention patients in the per-protocol group of the IMMENSE study. Both intervention delivery, reasons for not performing interventions and process outcomes were registered daily by the study pharmacists in a Microsoft Access® database. Process outcomes were medication discrepancies, MRPs and how the team solved these. RESULTS AND DISCUSSION: A total of 121 (54.8%) patients received all intervention steps if appropriate. All patients received medication reconciliation (MedRec) and medication Review (MedRev) (step 1 and 2), while between 10% and 20% of patients were missed for medication list in discharge summary (step 3), patient counselling (step 4), or communication with general practitioner and nurse (step 5). A total of 437 discrepancies were identified in 159 (71.9%) patients during MedRec, and 1042 MRPs were identified in 209 (94.6%) patients during MedRev. Of these, 292 (66.8%) and 700 (67.2%), respectively, were communicated to and solved by the interdisciplinary team during the hospital stay. WHAT IS NEW AND CONCLUSION: The fidelity of the single steps of the intervention was high even though only about half of the patients received all intervention steps. The impact of the intervention may be influenced by not implementing all steps in all patients, but the many discrepancies and MRPs identified and solved for the patients could explain a potential effect of the IMMENSE study.

Self-reported medication use among coronary heart disease patients showed high validity compared with dispensing data.

OBJECTIVE: To validate self-reported use of medications for secondary prevention of coronary heart disease (CHD) in a population-based health study by comparing self-report with pharmacy dispensing data, and explore different methods for defining medication use in prescription databases. STUDY DESIGN AND SETTING: Self-reported medication use among participants with CHD (n = 1483) from the seventh wave of the Tromsø Study was linked with the Norwegian Prescription Database (NorPD). Cohen's kappa, sensitivity, specificity, and positive and negative predictive values were calculated, using NorPD as the reference standard. Medication use in NorPD was defined in three ways; fixed-time window of 180 days, and legend-time method assuming a daily dose of one dosage unit or one defined daily dose (DDD). RESULTS: Kappa-values for antihypertensive drugs, lipid-lowering drugs and acetylsalicylic acid all showed substantial agreement (kappa ≥0.61). Validity varied depending on the method used for defining medication use in NorPD. Applying a fixed-time window gave higher agreement, positive predictive values and specificity compared with the legend-time methods. CONCLUSION: Self-reported use of medication for secondary prevention of CHD shows high validity when compared with pharmacy dispensing data. For CHD medications, fixed-time window appears to be the most appropriate method for defining medication use in prescription databases.

Adherence to prescription guidelines and achievement of treatment goals among persons with coronary heart disease in Tromsø 7.

BACKGROUND: Adherence to clinical practice guidelines for coronary heart disease (CHD) reduces morbidity, mortality and treatment costs. We aimed to describe and compare adherence to prescription guidelines for persons with CHD, and explore its association with treatment goal achievement. METHOD: We included all participants reporting myocardial infarction, angina, percutaneous coronary intervention and/or coronary artery bypass surgery in the seventh wave of the Tromsø Study (2015-2016, n = 1483). Medication use and treatment goal measures (blood pressure, low-density lipoprotein (LDL)-cholesterol and HbA1c) were compared to clinical practice guidelines on secondary CHD prevention. Propensity score matched logistic regression was used to assess the association between the use of antihypertensive drugs and achievement of treatment goal for blood pressure, and the use of lipid-lowering drugs (LLDs) and achievement of treatment goal for LDL-cholesterol. RESULTS: The prevalence of pharmacological CHD treatment was 76% for LLDs, 72% for antihypertensive drugs and 66% for acetylsalicylic acid. The blood pressure goal (< 140/90 mmHg, < 140/80 mmHg if diabetic) was achieved by 58% and the LDL-cholesterol goal (< 1.8 mmol/l or < 70 mg/dL) by 9%. There was a strong association between using LLDs and achieving the treatment goal for LDL-cholesterol (OR 14.0, 95% CI 3.6-54.7), but not between using antihypertensive drugs and blood pressure goal achievement (OR 1.4, 95% CI 0.7-2.7). CONCLUSION: Treatment goal achievement of LDL-cholesterol and blood pressure was low, despite the relatively high use of LLDs and antihypertensive drugs. Further research is needed to find the proper actions to increase achievement of the treatment goals.

Empirical prescribing of penicillin G/V reduces risk of readmission of hospitalized patients with community-acquired pneumonia in Norway: a retrospective observational study.

BACKGROUND: Norwegian guideline recommendations on first-line empirical antibiotic prescribing in hospitalised patients with community-acquired pneumonia (CAP) are penicillin G/V in monotherapy, or penicillin G in combination with gentamicin (or cefotaxime) in severely ill patients. The aim of this study was to explore how different empirical antibiotic treatments impact on length of hospital stay (LOS) and 30-day hospital readmission. A secondary aim was to describe median intravenous- and total treatment duration. METHODS: We included CAP patients (≥18 years age) hospitalised in North Norway during 2010 and 2012 in a retrospective study. Patients with negative chest x-ray, malignancies or immunosuppression or frequent readmissions were excluded. We collected data on patient characteristics, empirical antibiotic prescribing, treatment duration and clinical outcomes from electronic patient records and the hospital administrative system. We used directed acyclic graphs for statistical model selection, and analysed data with mulitvariable logistic and linear regression. RESULTS: We included 651 patients. Median age was 77 years [IQR; 64-84] and 46.5% were female. Median LOS was 4 days [IQR; 3-6], 30-day readmission rate was 14.4% and 30-day mortality rate was 6.9%. Penicillin G/V were empirically prescribed in monotherapy in 51.5% of patients, penicillin G and gentamicin in combination in 22.9% and other antibiotics in 25.6% of patients. Prescribing other antibiotics than penicillin G/V monotherapy was associated with increased risk of readmission [OR 1.9, 95% CI; 1.08-3.42]. Empirical antibiotic prescribing was not associated with LOS. Median intravenous- and total treatment duration was 3.0 [IQR; 2-5] and 11.0 [IQR; 9.8-13] days. CONCLUSIONS: Our findings show that empirical prescribing with penicillin G/V in monotherapy in hospitalised non-severe CAP-patients, without complicating factors such as malignancy, immunosuppression and frequent readmission, is associated with lower risk of 30-day readmission compared to other antibiotic treatments. Median total treatment duration exceeds treatment recommendations.

Quality of medication information in discharge summaries from hospitals: an audit of electronic patient records.

Background Low quality of medication information in discharge summaries from hospitals may jeopardize optimal therapy and put the patient at risk for medication errors and adverse drug events. Objective To audit the quality of medication information in discharge summaries and explore factors associated with the quality. Setting Helgelandssykehuset Mo i Rana, a rural hospital in central Norway. Method For each month in 2013, we randomly selected 60 discharge summaries from the Department of Medicine and Surgery (totally 720) and evaluated the medication information using eight Norwegian quality criteria. Main outcome measure Mean score per discharge summary ranging from 0 (lowest quality) to 16 (highest quality). Results Mean score per discharge summary was 7.4 (SD 2.8; range 0-14), significantly higher when evaluating medications used regularly compared to mediations used as needed (7.80 vs. 6.52; p < 0.001). Lowest score was achieved for quality criteria concerning generic names, indications for medication use, reasons why changes had been made and information about the source for information. Factors associated with increased quality scores are increasing numbers of medications and male patients. Increasing age seemed to be associated with a reduced score, while type of department was not associated with the quality. Conclusion In discharge summaries from 2013, we identified a low quality of medication information in accordance with the Norwegian quality criteria. Actions for improvement are necessary and follow-up studies to monitor quality are needed.

Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting.

BACKGROUND: Medication errors are frequent and may cause harm to patients and increase healthcare expenses. AIM: To explore whether a new labelling influences time and errors when preparing medications in accordance with medication charts in an experimental setting. METHOD: We carried out an uncontrolled before and after study with 3 months inbetween experiments. Phase I used original labelling and phase II used new generic labelling. We set up an experimental medicine room, simulating a real-life setting. Twenty-five nurses and ten pharmacy technicians participated in the study. We asked them to prepare medications in accordance with medication charts, place packages on a desk and document the package prepared. We timed the operation. Participants were asked to prepare medications in accordance with as many charts as possible within 30 min. RESULTS: Nurses prepared significantly more medication charts with the generic labelling compared with the original 3.3 versus 2.6 (p=0.009). Mean time per medication chart was significantly lower with the generic labelling 6.9 min/chart versus 8.5 min/chart (p<0.001). Pharmacy technicians were significantly faster than the nurses in both phase I (6.8 min/chart vs 9.5 min/chart; p<0.001) and phase II (6.1 min/chart vs 7.2 min/chart; p=0.013). The number of errors was low and not significantly different between the two labellings, with errors affecting 9.1% of charts in phase I versus 6.5% in phase II (p=0.5). CONCLUSIONS: A new labelling of medication packages with prominent placement of the active substance(s) and strength(s) in the front of the medication package may reduce time for nurses when preparing medications, without increasing medication errors.

An audit and feedback intervention study increased adherence to antibiotic prescribing guidelines at a Norwegian hospital.

BACKGROUND: Appropriate antibiotic prescribing is associated with favourable levels of antimicrobial resistance (AMR) and clinical outcomes. Most intervention studies on antibiotic prescribing originate from settings with high level of AMR. In a Norwegian hospital setting with low level of AMR, the literature on interventions for promoting guideline-recommended antibiotic prescribing in hospital is scarce and requested. Preliminary studies have shown improvement potentials regarding antibiotic prescribing according to guidelines. We aimed to promote appropriate antibiotic prescribing in patients with community-acquired pneumonia (CAP) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD) at a respiratory medicine department in a Norwegian University hospital. Our specific objectives were to increase prescribing of appropriate empirical antibiotics, reduce high-dose benzylpenicillin and reduce total treatment duration. METHODS: We performed an audit and feedback intervention study, combined with distribution of a recently published pocket version of the national clinical practice guideline. We included patients discharged with CAP or AECOPD and prescribed antibiotics during hospital stay, and excluded those presenting with aspiration, nosocomial infection and co-infections. The pre- and post-intervention period was 9 and 6 months, respectively. Feedback was provided orally to the department physicians at an internal-educational meeting. To explore the effect of the intervention on appropriate empirical antibiotics and mean total treatment duration we applied before-after analysis (Student's t-test) and interrupted time series (ITS). We used Pearson's χ2 to compare dose changes. RESULTS: In the pre-and post-intervention period we included 253 and 155 patients, respectively. Following the intervention, overall mean prescribing of appropriate empirical antibiotics increased from 61.7 to 83.8 % (P < 0.001), overall mean total treatment duration decreased from 11.2 to 10.4 days (P = 0.015), and prescribing of high-dose benzylpenicillin decreased from 48.8 to 38.6 % (P = 0.125). With ITS we found that six months post-intervention, the effect on appropriate empirical antibiotic prescribing had increased and sustained, while the effect on treatment duration was at pre-intervention level. CONCLUSION: The combination of audit and feedback plus distribution of a pocket version of guideline recommendations led to a substantial increase in prescribing of appropriate empirical antibiotics, which is important due to favourable effect on AMR and clinical outcomes.

A pharmacist-led follow-up program for patients with established coronary heart disease in North Norway - a randomized controlled trial / / Programa farmacéutico de seguimiento para pacientes con enfermedad coronaria establecida en el norte de Noruega - Ensayo controlado aleatorizado

Objectives: The aim of the study was twofold; 1) to develop a clinical pharmacist-led 12 month lasting followup program for patients with established coronary heart disease (CHD) discharged from the University Hospital of North Norway, and 2) to explore the impact of the program with regards to adherence to a medication assessment tool for secondary prevention of CHD and change in biomedical risk factors. Methods: A total of 102 patients aged 18-82 years were enrolled in a non-blinded randomized controlled trial with an intervention group and a control group. The intervention comprised medication reconciliation, medication review and patient education during three meetings; at discharge, after three months and after twelve months. The control group received standard care from their general practitioner. Primary outcomes were adherence to clinical guideline recommendations concerning prescription, therapy goal achievement and lifestyle education defined in the medication assessment tool for secondary prevention of CHD (MAT-CHDSP). Secondary outcomes included changes in the biomedical risk factors cholesterol, blood pressure and blood glucose. Results: Ninety-four patients completed the trial, 48 intervention group patients and 46 controls. Appropriate prescribing was high, but therapy goal achievement was low in both groups. Overall adherence to MAT-CHDSP criteria increased in both groups and was significantly higher in the intervention group at study end, 78.4% vs. 62.0%, p<0.001. The difference was statistically significant for the documented lifestyle advices in intervention group patients. No significant improvements in biomedical risk factors were observed in favor of the intervention group. Conclusions: The study showed an increased guideline adherence in both study groups. This indicates that attention to clinical practice guideline recommendations in itself increases adherence - which may be a clinical pharmacist task. A larger adequately powered study is needed to show a significant difference in biomedical risk factor improvements in favor of the intervention. Amendments to the follow-up program are suggested before implementation in standard patient care can be recommended (AU)

Objetivos: El objetivo del presente estudio fue doble: 1) desarrollar un programa de seguimiento farmacéutico de 12 meses de duración para pacientes con enfermedad coronaria establecida (CHD) dados de alta del Hospital Universitario de Noruega del Norte, y 2) explorar el impacto del programa en relación a un instrumento de evaluación para la prevención secundaria de CHD y cambios en los factores de riesgo biomédicos. Métodos: Se incluyeron en un estudio controlado aleatorizado no cegado un total de 102 pacientes de 18- 82 años. La intervención consistió en reconciliación de la medicación, revisión de la medicación, y educación del paciente en tres encuentros: al alta, después de 3 meses y después de 12 meses. El grupo control recibió los cuidados habituales de su médico general. Los outcomes primarios fueron la adherencia a las guías de práctica clínica relativa a la prescripción, la consecución de los objetivos terapéuticos y los hábitos de vida definidos en el instrumento de evaluación de la prevención secundaria de CHD (el MAT-CHDSP). Los outcomes secundarios incluían cambios en los factores biomédicos de riesgo, como colesterol, presión arterial y glucemia. Resultados: 94 pacientes completaron el ensayo, 48 en el grupo intervención y 46 controles. La prescripción adecuada fue elevada, pero la consecución de los objetivos terapéuticos fue baja en ambos grupos a lo largo del estudio. La adherencia total a los criterios del MAT-CHDSP aumentó en ambos grupos, y fue significativamente mayor en el grupo intervención al final del estudio, comparado con el control (78.4% vs. 60.2%, respectivamente, p<0.001). La diferencia fue estadísticamente significativa para los estilos de vida aconsejados en los pacientes del grupo intervención. No se observaron cambios significativos en los factores biomédicos de riesgo a favor del grupo intervención. Conclusiones: El estudio mostró un aumento de adherencia a las guías en ambos grupos. Esto indica que la atención a las recomendaciones de las guías de práctica clínica por sí mismo aumenta la adherencia - lo que podría ser una tarea del farmacéutico. Se necesita un estudio mayor y con más poder para mostrar una diferencia significativa en la mejoría a favor de la intervención de los factores biomédicos de riesgo. Pueden recomendarse modificaciones a los programas de seguimiento que mejoren la implantación en los cuidados normales de los pacientes (AU)

Should nurses or clinical pharmacists perform medication reconciliation? A randomized controlled trial.

PURPOSE: To study differences in outcomes of medication reconciliation (MR) when performed by clinical pharmacists compared to nurses. METHODS: 201 patients (21-92 years) admitted to the Department of Cardiology at the University Hospital of North Norway, autumn 2012, were randomized into a pharmacist group (PG) and a nurse group (NG). The nurses and the pharmacists were trained for performing the MR process by an independent clinical pharmacist. Medication discrepancies (MDs) were discussed with the physicians. Time spent during the MR was recorded. An independent expert group rated clinical relevance of the MDs retrospectively. RESULTS: At least one MD was identified in 78 % and 84 % of patients in PG and NG, respectively (P = 0.269) with a mean number of MDs per patient 3.1 (SD 2.1) and 2.8 (SD 2.2), respectively (P = 0.528). Mean time spent/patient on the MR process was 22.9 min (SD 11.6) in the PG and 32.2 min (SD 20.3) in the NG (P < 0,001). Physicians agreed significantly more often to act upon the MDs presented by pharmacists compared to nurses (P = 0.001). The expert group finally assessed 48 % and 49 % of the MDs to be of the clinical relevance in the PG and the NG, respectively. CONCLUSIONS: By applying a structured method for MR, a small however not statistically significant difference in identified MDs between nurses and clinical pharmacists was revealed. The pharmacists spent significantly less time than the nurses, and physicians agreed significantly more often with the pharmacist that action should be taken on the MDs. This is important in the discussion of who to perform MR.

MAT-CAP: a novel medication assessment tool to explore adherence to clinical practice guidelines in community-acquired pneumonia.

BACKGROUND/PURPOSE: Community-acquired pneumonia (CAP) is a disease with high morbidity and mortality. Adherence to clinical practice guidelines (CPGs) in treatment of CAP is associated with favourable outcome. We aimed to develop and validate a medication assessment tool (MAT) to explore adherence to CPG recommendations in patients with CAP admitted to a Norwegian hospital. The tool is named MAT-CAP. METHOD: Sixteen quality indicators (QIs) based on local and international CPGs were developed. Content validity was explored in an expert panel using a two-round modified Delphi technique. QIs demonstrating content valdity were reformulated into review criteria forming the MAT-CAP. Feasibility and adherence to MAT-CAP were explored in a retrospective study using data from electronic patient records of CAP patients admitted to the University Hospital of North Norway Tromso during 2008. Reliability was explored using Cohen's kappa (ĸ) statistics for inter- and intra-observer agreements. RESULTS: Content validity was demonstrated for 15 QIs covering areas as initial empirical treatment, microbiological diagnostics, pathogen specific treatment, dose adjustment according to renal function, switch from intravenous to oral treatment and treatment duration. Overall reliability was excellent with ĸ-values of 0.88 and 0.95 for inter-observer and intra-observer agreements, respectively. Overall applicability was 37.2%, and mean application times were 3.1 and 3.8 min for the two observers. Overall adherence to 812 criteria applied was 59% (range 0-100). CONCLUSIONS: We have demonstrated content validity, feasibility and reliability of a 15-criterion MAT-CAP. Adherence results from applying MAT-CAP criteria pinpointed areas with good clinical performance and areas with improvement potentials.

A pharmacist-led follow-up program for patients with coronary heart disease in North Norway--a qualitative study exploring patient experiences.

BACKGROUND: Coronary heart disease (CHD) is one of the leading causes of death worldwide. Scientific literature shows that prevention of CHD is inadequate. The clinical pharmacist's role in patient-centred care has been shown favourable in a large amount of studies, also in relation to reduction of risk factors related to CHD. We developed and piloted a pharmacist-led follow-up program for patients with established CHD after hospital discharge from a hospital in North Norway. The aim of the present study was to explore how participants in the follow-up program experienced the program with regard to four main topics; medication knowledge, feeling of safety and comfort with medications, the functionality of the program and the clinical pharmacist's role in the interdisciplinary team. METHODS: We performed semi-structured thematic interviews with four patients included in the program. After verbatim transcribing, we analysed the interviews using "qualitative content analyses" by Graneheim and Lundman. Trial registration http://www.clinicaltrials.gov: NCT01131715. RESULTS: All participants appreciated the follow-up program because their medication knowledge had increased, participation had made them feel safe, they were reassured about the appropriateness of their medications, and they had become more involved in their own medication. The participants reported that the program was well structured and the clinical pharmacist was said to be an important caretaker in the health-care system. The importance of collaboration between pharmacists and physicians, both in hospital and primary care, was emphasized. CONCLUSION: Our results indicate that the follow-up program was highly appreciated among the four participants included in this study. The results must be interpreted in the context of the health care system in Norway today. Here, few pharmacists are working in hospitals or in close relation to the general practitioners. In addition, physicians are short of time in order to supply appropriate medication information, both in hospital and primary care. Involving pharmacists in follow-up of patients with CHD seems to be highly appreciated among patients and may be a step towards improving patient care. The study is limited by the low number of participants.

Application of the MAT-CHDSP to assess guideline adherence and therapy goal achievement in secondary prevention of coronary heart disease after percutaneous coronary intervention.

PURPOSE: Numerous studies have documented suboptimal adherence to guideline recommendations in secondary prevention of coronary heart disease (CHD(SP)). Clinical practice guidelines (CPGs) are continuously developed to define appropriate patient care, aiming to reduce risk of morbidity and death. The Medication Assessment Tool for CHD(SP) (MAT-CHD(SP)) was developed to assess adherence to CPGs concerning medication therapy and follow-up of patients with CHD(SP). The aim of this study was to explore whether the MAT-CHD(SP) could be applied retrospectively to assess guideline adherence and therapy goal achievement in secondary prevention of CHD. METHODS: We collected data from electronic medical records of all patients who underwent percutaneous coronary intervention with stent implantation from January to March 2008 (n = 300) and applied the MAT-CHD(SP). We measured time for data collection and MAT application and tested reproducibility by calculating Cohen's kappa (κ) value for inter and intraobserver agreement. RESULTS: A total of 247 MAT applications were analyzed, showing overall applicability of 66 % of the 4,446 MAT-CHD(SP) criteria and a high reproducibility of MAT-CHD(SP) application (κ values 0.93 and 0.95 for intra- and interobserver agreement, respectively). Mean time for data collection and MAT-CHD(SP) application was 11 min. Adherence to criteria concerning prescription was high (>75 %), but achievement of therapy goals for cholesterol and blood pressure was low (<50 %). Documentation of lifestyle advice achieved intermediate (50-75 %) or low adherence, as did therapy amendments in patients in whom therapy goals were unachieved at hospital admission. CONCLUSIONS: The MAT-CHD(SP) offers a means to identify both adherence and nonadherence to CPGs concerning CHD(SP) is applicable in retrospective assessment of CHD(SP), and identifies potentials for improved patient care.