Development of a computerized intervention to improve health literacy in older Hispanics with type 2 diabetes using a pharmacist supervised comprehensive medication management.

OBJECTIVE: The primary objective was to develop a computerized culturally adapted health literacy intervention for older Hispanics with type 2 diabetes (T2D). Secondary objectives were to assess the usability and acceptability of the intervention by older Hispanics with T2D and clinical pharmacists providing comprehensive medication management (CMM). MATERIALS AND METHODS: The study occurred in three phases. During phase I, an integration approach (i.e., quantitative assessments, qualitative interviews) was used to develop the intervention and ensure cultural suitability. In phase II, the intervention was translated to Spanish and modified based on data obtained in phase I. During phase III, the intervention was tested for usability/acceptability. RESULTS: Thirty participants (25 older Hispanics with T2D, 5 clinical pharmacists) were included in the study. Five major themes emerged from qualitative interviews and were included in the intervention: 1) financial considerations, 2) polypharmacy, 3) social/family support, 4) access to medication/information, and 5) loneliness/sadness. Participants felt the computerized intervention developed was easy to use, culturally appropriate, and relevant to their needs. Pharmacists agreed the computerized intervention streamlined patient counseling, offered a tailored approach when conducting CMM, and could save them time. CONCLUSION: The ability to offer individualized patient counseling based on information gathered from the computerized intervention allows for precision counseling. Future studies are needed to determine the effectiveness of the developed computerized intervention on adherence and health outcomes.

Antimicrobial stewardship in the Western Cape: A situational analysis of existing facility-level initiatives.

BACKGROUND: Antimicrobial resistance (AMR) is a growing problem worldwide. With the current occurrence of pan-resistant bacterial infections and a paucity of novel antimicrobials in development, the world has entered a post-antibiotic era, in which previously treatable, common infections can become fatal. Antimicrobial stewardship (AMS), defined as 'co-ordinated interventions to ensure appropriate and rational use of antimicrobials', aims to decrease rates of AMR. OBJECTIVES: To co-ordinate AMS in Western Cape Province. The National Department of Health (NDoH) has identified AMS as a key strategic objective, and the Western Cape has formed a provincial AMS committee. However, not much is known regarding current AMS activities in health facilities in the province. METHODS: A self-administered, email questionnaire was sent to specific staff at all district, regional and tertiary hospitals in the 6 health districts of the Western Cape - 47 facilities in total, of which 35 (74.4%) responded. Respondents included pharmacists, managers, doctors, nurses, infection prevention and control practitioners, as well as quality assurance practitioners. The number of facilities implementing AMS were determined, as well as the composition of AMS committees and the nature and frequency of team activities. Barriers to facility-level AMS were explored. Support and outreach activities were assessed, as well as facilities' needs and expectations of the provincial AMS committee. RESULTS: Approximately half of all responding hospitals (n=19; 54.3%) had active AMS committees. Double the proportion of metropolitan (83.3%) than rural facilities (39.1%) had committees. Stewardship activities included antimicrobial prescription chart reviews and audits, AMS ward rounds, antimicrobial restriction policies and training. Most committees included a pharmacist and an infection prevention and control practitioner. More than a third of hospitals (36.1%) did not review their antimicrobial consumption data on a regular basis. Just over half of the hospitals (n=18; 51.4%) did not review AMR patterns. CONCLUSIONS: Despite the need for effective AMS, there is limited information on AMS in South Africa. Most assistance is required in rural areas and smaller hospitals with low numbers of staff and greater numbers of transient rotating junior staff. Information management support, multidisciplinary teamwork and clinical governance are required to enable regular and ongoing AMS in facilities. Rural and smaller facilities require greater support to establish effectively functioning AMS committees.

A randomized controlled trial of pharmacist-led therapeutic carbohydrate and energy restriction in type 2 diabetes.

Type 2 diabetes can be treated, and sometimes reversed, with dietary interventions; however, strategies to implement these interventions while addressing medication changes are lacking. We conducted a 12-week pragmatic, community-based parallel-group randomized controlled trial (ClinicalTrials.gov: NCT03181165) evaluating the effect of a low-carbohydrate (<50 g), energy-restricted diet (~850-1100 kcal/day; Pharm-TCR; n = 98) compared to treatment-as-usual (TAU; n = 90), delivered by community pharmacists, on glucose-lowering medication use, cardiometabolic health, and health-related quality of life. The Pharm-TCR intervention was effective in reducing the need for glucose-lowering medications through complete discontinuation of medications (35.7%; n = 35 vs. 0%; n = 0 in TAU; p < 0.0001) and reduced medication effect score compared to TAU. These reductions occurred concurrently with clinically meaningful improvements in hemoglobin A1C, anthropometrics, blood pressure, and triglycerides (all p < 0.0001). These data indicate community pharmacists are a viable and innovative option for implementing short-term nutritional interventions for people with type 2 diabetes, particularly when medication management is a safety concern.

Pharmacists' involvement in COVID-19 vaccination across Europe: a situational analysis of current practice and policy.

One year since the emergence of the COVID-19 pandemic, rapid response measures have been implemented internationally to mitigate the spread of the virus. Following rapid and successful pre-clinical and human trials, several vaccines have been authorised for use across Europe through the European Medicines Agency and national regulatory authorities. Clinical trials have shown promising results including important reductions in disease severity, hospitalisation and mortality. In order to maximise the public health benefit of available vaccines, there is a pressing need to vaccinate a large proportion of the population. Internationally, this has prompted coordination of existing services at enormous scale, and development and implementation of novel vaccination strategies to ensure maximum inoculation over the shortest possible timeframe. Pharmacists are being promoted as healthcare professionals that enhance roll-out of COVID-19 vaccination programmes. This paper aims to summarise current policy and practice in relation to pharmacists' involvement in COVID-19 vaccination in 13 countries across Europe.

Prevalence of drug-drug interactions in sarcoma patients: key role of the pharmacist integration for toxicity risk management.

BACKGROUND: The risk of drug-drug interactions (DDI) has become a major issue in cancer patients. However, data in sarcoma patients are scarce. We aimed to evaluate the frequency and the factors associated with DDI with antitumor treatments, and to evaluate the impact of a pharmacist evaluation before anticancer treatment. PATIENTS AND METHODS: We performed a retrospective review of consecutive sarcoma patients starting chemotherapy (CT) or Tyrosine kinase inhibitor (TKI). A pharmacist performed medication reconciliation and established an early toxicity risk assessment. Potential DDI with antitumor drugs were identified using Micromedex electronic software. RESULTS: One hundred and twenty-two soft-tissue and 80 bone sarcoma patients (103 males, median age 50 years,) were included before CT (86%) or TKI (14%). The median number of medications was 3; 34 patients (22% of patients with medication reconciliation) reported complementary medicine use. 37 potential DDI classified as major, were identified (12% of the 243 pre-therapeutic assessments). In multivariate analysis, TKI (p < 0.0001), proton pump inhibitor (p = 0.026) and antidepressant (p < 0.001) were identified as risk factors of DDI (p < 0.02). Only marital status (p = 0.003) was associated with complementary medicine use. A pharmacist performed 157 medication reconciliations and made 71 interventions among 59 patients (37%). In multivariate analysis, factors associated with pharmacist intervention were: complementary medicines (p = 0.004), drugs number (p = 0.005) and treatment with TKI (p = 0.0002) CONCLUSIONS: Clinical interventions on DDI are more frequently required among sarcoma patients treated with TKI than CT. Multidisciplinary risk assessment including a medication reconciliation by a pharmacist could be crucial to prevent DDI with TKI.

Impact of pharmacist consultation at clinical trial inclusion: an effective way to reduce drug-drug interactions with oral targeted therapy.

PURPOSE: Pharmacist consultation is unfrequently performed in oncology clinical trials that include patients who often have many co-treatments increasing the risk of drug-drug interactions (DDI). The aim of this study was to determine whether best possible medication history (BPMH) by hospital pharmacist at inclusion and therapeutic drug monitoring could be used for DDI risk evaluation and for current oral targeted therapy management. METHODS: A prospective clinical trial (ALCINA 2, NCT04025541) was carried out in metastatic breast cancer cohort treated by palbociclib to conduct pharmacokinetics-toxicity correlation study. BPMH was prospectively performed by the hospital pharmacist at each trial inclusion, followed by a contact to the patient's community pharmacy to complete the collected data. Pharmacokinetic analysis was performed on blood samples collected at day 15 of cycle 1 of palbociclib treatment. RESULTS: Pharmacist interventions indicated that at inclusion, current medications were incomplete for 63% of the enrolled patients (32/51). It allowed the real-time management of high-risk DDI detected in third of patients. The palbociclib Ctrough geometric median (min-max) was significantly higher in cohort with potential DDI [106 ng/mL (66.7-113)], than cohort without potential DDI [70.1 ng/mL (54.1-89.7)], p = 0.0284. CONCLUSION: This is the first prospective study evaluating the relevance of proactive BPMH by pharmacist with contact to the community pharmacy during the inclusion step of a clinical trial to ensure the efficacy and safety of the investigated drug. This investigation was thus able to highlight the statistically significant impact of these DDI on palbociclib plasma concentration variation during the clinical trial. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT04025541.

Impact of medication therapy management service on selected clinical and humanistic outcomes in the ambulatory diabetes patients of Tikur Anbessa Specialist Hospital, Addis Ababa, Ethiopia.

BACKGROUND: Diabetes mellitus (DM) patients are at increased risk of developing drug therapy problems (DTPs). The patients had a variety of comorbidities and complications, and they were given multiple medications. Medication therapy management (MTM) is a distinct service or group of services that optimize therapeutic outcomes for individual patients. The study assessed the impact of provision of MTM service on selected clinical and humanistic outcomes of diabetes patients at the diabetes mellitus clinic of Tikur Anbessa Specialized Hospital (TASH). METHODS: A pre-post interventional study design was carried out at DM clinic from July 2018 to April 2019. The intervention package included identifying and resolving drug therapy problems, counseling patients in person at the clinic or through telephone calls, and providing educational materials for six months. This was followed by four months of post-intervention assessment of clinical outcomes, DTPs, and treatment satisfaction. The interventions were provided by pharmacist in collaboration with physician and nurse. The study included all adult patients who had been diagnosed for diabetes (both type I & II) and had been taking anti-diabetes medications for at least three months. Patients with gestational diabetes, those who decided to change their follow-up clinic, and those who refused to participate in the study were excluded. Data were analyzed using Statistical Package for the Social Sciences (SPSS). Descriptive statistics, t-test, and logistic regressions were performed for data analyses. RESULTS: Of the 423 enrolled patients, 409 fulfilled the criteria and included in the final data analysis. The intervention showed a decrease in average hemoglobin A1c (HbA1c), fasting blood sugar (FBS), and systolic blood pressure (SBP) by 0.92%, 25.04 mg/dl, and 6.62 mmHg, respectively (p<0.05). The prevalence of DTPs in the pre- and post-intervention of MTM services was found to be 72.9% and 26.2%, respectively (p<0.001). The overall mean score of treatment satisfaction was 90.1(SD, 11.04). Diabetes patients of age below 40 years (92.84 (SD, 9.54)), type-I DM (93.04 (SD, 9.75)) & being on one medication regimen (93.13(SD, 9.17)) had higher satisfaction score (p<0.05). CONCLUSION: Provision of MTM service had a potential to reduce DTPs, improve the clinical parameters, and treatment satisfaction in the post-intervention compared to the pre-intervention phase.

Impact and barriers of a pharmacist-led practice with computerized reminders on intravenous to oral antibiotic conversion for community-acquired pneumonia inpatients.

WHAT IS KNOWN AND OBJECTIVE: Intravenous to oral (IV-PO) antibiotic conversion, one of the critical elements in antimicrobial stewardship (AMS), is not well implemented in China. Studies on the strategy to apply the IV-PO conversion are needed. Our objective was to evaluate the impact and its barriers of a pharmacist-led practice with computerized reminders on IV-PO antibiotic conversion for community-acquired pneumonia (CAP) inpatients. METHOD: This was a retrospective, observational pre- and post-intervention study. Interventions were introduced in 2 sequential 12-month phases: Phase 1: pharmacists implemented the conventional practice of reviewing patient charts and medication records every 24 h and verbally informed the prescribers on eligible IV-PO conversions; Phase 2: pharmacists implemented a new intervention practice to inform the prescribers with a computerized reminder in electronic medical record system on eligible IV-PO conversions. MAIN OUTCOME MEASURES: The primary outcome was the proportion of patients who converted to oral therapy on the day patients were eligible for the conversion. The secondary outcomes were length of IV antibiotic therapy days, total length of antibiotic therapy days and length of hospital stay. RESULTS: A total of 524 patients were studied (256 in phase 1 and 268 in phase 2). The proportion of patients who converted to oral therapy on the day patients were eligible for the conversion was significantly increased from 34.77% (89/256) in phase 1 to 62.69% (168/268) in phase 2 (p < 0.05). Length of IV antibiotic therapy days in phase 2 was shortened by 1.23 days, which was 5.52 days compared to 6.75 days in phase 1 (p < 0.05). Total length of antibiotic therapy days was 12.05 days in Phase 1, compared to 10.75 days in phase 2 (p > 0.05). Length of hospital stay for patients in phase 2 was significantly shorter, with a difference of 1.38 days (6.02 days vs. 7.40 days, p < 0.05). The most common barrier of not converting IV-PO was the presence of co-morbidity. CONCLUSION: The pharmacist-led IV-PO antibiotic conversion practice with computerized reminders was successful and feasible in Chinese hospitals. More IV-PO intervention studies in patients with other infections are needed in the future.

Economic Evaluations of Interventions to Optimize Medication Use in Older Adults with Polypharmacy and Multimorbidity: A Systematic Review.

PURPOSE: To conduct a systematic review of the economic impact of interventions intended at optimizing medication use in older adults with multimorbidity and polypharmacy. METHODS: We searched Ovid-Medline, Embase, CINAHL, Ageline, Cochrane, and Web of Science, for articles published between 2004 and 2020 that studied older adults with multimorbidity and polypharmacy. The intervention studied had to be aimed at optimizing medication use and present results on costs. RESULTS: Out of 3,871 studies identified by the search strategy, eleven studies were included. The interventions involved different provider types, with a majority described as a multidisciplinary team involving a pharmacist and a general practitioner, in the decision-making process. Interventions were generally associated with a reduction in medication expenditure. The benefits of the intervention in terms of clinical outcomes remain limited. Five studies were cost-benefit analyses, which had a net benefit that was either null or positive. Cost-utility and cost-effectiveness analyses resulted in incremental cost-effectiveness ratios that were generally within the willingness-to-pay thresholds of the countries in which the studies were conducted. However, the quality of the studies was generally low. Omission of key cost elements of economic evaluations, including intervention cost and payer perspective, limited interpretability. CONCLUSION: Interventions to optimize medication use may provide benefits that outweigh their implementation costs, but the evidence remains limited. There is a need to identify and address barriers to the scaling-up of such interventions, starting with the current incentive structures for pharmacists, physicians, and patients.

Impact of an integrated medication reconciliation model led by a hospital clinical pharmacist on the reduction of post-discharge unintentional discrepancies.

WHAT IS KNOWN AND OBJECTIVE: There is no optimal standardized model in the transfer of care between hospitals and primary healthcare facilities. Transfer of care is a critical point during which unintentional discrepancies, that can jeopardize pharmacotherapy outcomes, can occur. The objective was to determine the effect that an integrated medication reconciliation model has on the reduction of the number of post-discharge unintentional discrepancies. METHODS: A randomized controlled study was conducted on an elderly patient population. The intervention group of patients received a medication reconciliation model, led entirely by a hospital clinical pharmacist (medication reconciliation at admission, review and optimization of pharmacotherapy during hospitalization, patient education and counselling, medication reconciliation at discharge, medication reconciliation as part of primary health care in collaboration with a primary care physician and a community pharmacist). Unintentional discrepancies were identified by comparing the medications listed on the discharge summary with the first list of medications prescribed and issued at primary care level, immediately after discharge. The main outcome measures were incidence, type and potential severity of post-discharge unintentional discrepancies. RESULTS AND DISCUSSION: A total of 353 patients were analysed (182 in the intervention and 171 in the control group). The medication reconciliation model, led by a hospital clinical pharmacist, significantly reduced the number of patients with unintentional discrepancies by 57.1% (p < 0.001). The intervention reduced the number of patients with unintentional discrepancies associated with a potential moderate harm by 58.6% (p < 0.001) and those associated with a potential severe harm by 68.6% (p = 0.039). The most common discrepancies were incorrect dosage, drug omission and drug commission. Cardiovascular medications were most commonly involved in unintentional discrepancies. WHAT IS NEW AND CONCLUSION: The integrated medication reconciliation model, led by a hospital clinical pharmacist in collaboration with all health professionals involved in the patient's pharmacotherapy and treatment, significantly reduced unintentional discrepancies in the transfer of care.

Impact of educational intervention by community pharmacists on asthma clinical outcomes, quality of life and medication adherence: A systematic review and meta-analysis.

WHAT IS KNOWN AND OBJECTIVE: Community pharmacists can play an important role in controlling chronic diseases. This study aimed to evaluate the effects of pharmacists' educational interventions in the community pharmacy settings on asthma control and severity, quality of life (QOL) and medication adherence. METHODS: Databases PubMed, Scopus and Web of Science were searched for evidence regarding asthma severity and control, QOL, and medication adherence after pharmacists' interventions in community pharmacy settings. Twenty-one studies were eligible for qualitative and quantitative analysis. Indices and questionnaires were used in the studies, such as Asthma-related quality of life (IAQLQ), Asthma Control Test (ACT), Perceived Control of Asthma Questionnaire (PCAQ), inhaler technique (IT), Asthma Control Questionnaire (ACQ), 36-Item Short Form survey (SF-36) and peak expiratory flow rate (PEFR). The outcomes were extracted, pooled and analysed as percentages, means, standard deviations and errors, and 95% confidence intervals (CIs). RESULTS AND DISCUSSION: Community pharmacists in all studies educated and followed up the asthmatic patients, addressing the outcome measures. Pharmacists underwent training courses of at least a day. Standardized mean differences for the indices were pooled as follows: IAQLQ -0.241 (95% CI, -0.362 to -0.121), ACT 0.14 (95% CI, 0.02 to 0.27), PCAQ -0.15 (95% CI, -0.28 to 0.01), IT 0.79 (95% CI, 0.05 to 1.54), ACQ -0.50 (95% CI, -0.69 to -0.30), SF-36 0.39 (95% CI, 0.16 to 0.62), PEFR 0.13 (95% CI, 0.01 to 0.26) and asthma symptoms score -0.34 (95% CI, -0.49 to -0.18). WHAT IS NEW AND CONCLUSION: Pharmacists' educational interventions in community pharmacy settings could significantly improve asthma severity and control, QOL and medication adherence.

Can a multidisciplinary approach slow renal progression in CKD patients?

Background: Several randomized controlled trials have examined the benefits of multidisciplinary CKD care on estimated glomerular filtration rate (eGFR). But, the results are inconclusive. Purpose: This study aimed to evaluate whether or not multidisciplinary CKD care was beneficial in terms of CKD progression. Methods: This is a randomized controlled trial and conducted at community hospital, Thailand. The inclusion criteria were patients with age of 18 years or older and diagnosed with up to stage 3b CKD based on the KDIGO guidelines. Eligible patients divided into two groups: intervention and control group. The intervention group received a type of multidisciplinary treatment, while patients in the control group received the standard treatment administered at the outpatient clinic. The primary outcome was eGFR outcomes at three months after enrollment. Results: During the study period, there were 334 patients who met the study criteria. Eligible patients were divided into two groups: intervention (166 patients; 49.70%) and control (168 patients; 50.30%). There were three outcomes that differed significantly between the two groups at 3 months: mean difference of eGFR from baseline, proportion of patients with eGFR decline greater than 4 mL/min/1.73 m2, and difference in CKD stage from baseline. A significantly higher percentage of patients in the intervention group experienced CKD improvement by one stage (24.10% vs 5.95%), and a significantly lower percentage experienced decline by one stage (8.43% vs 35.12%) than in the control group. Conclusion: Slower renal progression in patients with up to stage 3b CKD was shown in patients who were treated by a multidisciplinary approach.

Impact of clinical pharmacist services on anticoagulation management of total joint arthroplasty: A retrospective observational study.

WHAT IS KNOWN AND OBJECTIVE: Even if total joint arthroplasty (TJA) patients have received conventional antithrombotic therapy, the incidence of thrombosis remains high. Clinical pharmacists have been involved in the multidisciplinary team of orthopaedics, but their roles and functions are not yet defined. The objective of this study was to assess the impact of clinical pharmacist services on the use of anticoagulant drugs, the rationality of medication and the incidence of thrombosis in patients with TJA. METHODS: This retrospective, observational cohort study was conducted for patients undergoing TJA procedures. Study variables were collected for a baseline period of 1 January 2016 to 30 June 2017 and an intervention period of 1 January 2018 to 30 June 2019, allowing for a 6-month run-in period. For demographic characteristics, the use of anticoagulant drugs and the incidence of thrombosis between the baseline and intervention periods, the data were statistically analysed. RESULTS AND DISCUSSION: During the 36-month study timeframe, a total of 591 TJA procedures were performed. A total of 577 participants were included in the study (240 in the baseline group and 377 in the intervention group). After clinical pharmacist participation, the prevention rate of anticoagulant drugs (p < 0.05), the proportion of oral anticoagulants (p = 0.000) and the course of preventive treatment (p = 0.004) increased significantly. The time of administration was shortened from after 24 h to within 24 h post-surgery (p = 0.000). Although the incidence of symptomatic DVT reduced in the intervention period, there was no statistical difference in either the hospital, 1-month follow-up, or 3-month follow-up after surgery (all p > 0.05). WHAT IS NEW AND CONCLUSION: Within the limitations of a retrospective study, clinical pharmacist intervention was associated with improvements in anticoagulation management of TJA procedures, likely conferring beneficial effects.

Evaluation of Chemotherapy Regimen Management Practice by Oncology-Specialized and Non-specialized Pharmacists Collaboration.

Chemotherapy regimen management is one of the most important oncology pharmacy practices, because chemotherapy is conducted according to the registered regimens. In this study, we evaluated the pharmaceutical practice that assumes the initial confirmation of chemotherapy regimens and the quality of practice sharing between oncology-specialized and non-specialized pharmacists in regimen management committee. Pharmacists initially confirmed the applied regimen prescribed by physicians regarding chemotherapeutic agents and prophylactic supportive care medicines. Following confirmation, the regimens were reviewed by the Hokkaido University Hospital Regimen Management Committee. A total of 233 regimens were reviewed by the committee over three years. In total, 110 pharmaceutical inquiries were conducted, 45% of inquiries were concerning chemotherapeutic agents, of which approximately half were regarding supportive care medicines. Most inquiries were regarding premedication, followed by those on administration time, solvent of infusion medicines, and dosage. Correction was performed for 84.5% of inquiries. There was no significant difference in inquiry rates between practice and trial regimens. We have entrusted the first basic regimen review according to the checklist, creation of the chemotherapy plan document, and registry of the adopted regimens in the ordering system from oncology-certified pharmacists to non-certified pharmacists. Basic regimen review was well conducted by a non-certified pharmacist, and a more advanced review was additionally performed by certified pharmacists. In conclusion, we demonstrated the utility of pharmaceutical confirmation in a chemotherapeutic regimen review, suitable review coverage, and quality practice sharing between oncology-certified and non-certified pharmacists, which is one of the recommended methods in chemotherapy regimen review.

The Impact of an Established Pharmaceutical Care Pathway on Drug Related Problems in an Intensive Care Unit.

BACKGROUND: The incidence of drug related problems (DRPs) in intensive care units (ICU) is higher compared to any other wards in the hospital, requiring a structured pathway to ensure optimum detection of DRPs. The study aimed to evaluate the impact of implementing a pharmaceutical care pathway on the detection and management of DRPs in an ICU. METHODS: The study was conducted in a general ICU and included three phases: tool preparation phase included the development of a core measures reference pathway and daily working scenario flow-charts, a control phase where the patient files and pharmacists' case assessment notes were retrospectively reviewed to detect the rate of DRPs before pathway implementation and a prospective phase similar to the control phase but with the implementation of the new pathway. The number and classification of DRPs and required core measures in the control and implementation phases were documented. RESULTS: Using the new pathway, the detection of unmet core measures increased from 7.3% in the control phase to 99% in the implementation phase (p-value <0.001). The prevalence of unidentified DRPs/1000 patients' service days decreased from 98.1 in the control phase to 27.08 in the implementation phase (p-value <0.001). However, there was no significant difference between the phases regarding mortality rate and length of ICU stay. CONCLUSIONS: The implementation of a unified pharmaceutical care pathway improved the detection of DRPs in ICU patients.