Pharmacy, Volume 7, Issue 4 (December 2019) – 33 articles

Background: Development of professional behaviors must occur in tandem with clinical skills to ensure graduates provide quality care. Portfolios have been widely utilized as a medium to document and reflect on experiences related to professional skills. Methods: Students were required to complete a series of co-curricular activities and document them via paper or electronic portfolios, which were shared with their advisors for feedback and review. To gather perception data, student surveys were administered twice: once for the electronic cohort and once for the paper cohort after their first-year experience with the platform, and focus groups were conducted a year later. Faculty advisors were also asked to complete surveys. Results: Both students and advisors felt that electronic portfolios resulted in a greater understanding of the educational outcomes and was the preferred method for recording co-curricular requirements. Several technical challenges arose with the use of the electronic portfolio and many students and advisors felt they needed more education regarding mapping of activities. Conclusions: The electronic portfolio was found to be more sustainable as compared with paper portfolios, as it helped students adhere to the criteria and self-assessment process. Further research is needed to evaluate long-term benefit of documenting and assessing co-curricular experiences within an electronic platform. Full article

Compliance with recommended infusion rates was evaluated before, during, and after the implementation of extended-infusion (EI) piperacillin-tazobactam at an academic medical center. Software-controlled infusion-pump alert data were studied for piperacillin-tazobactam administrations before and after implementation of a four-hour EI protocol. Compliance was analyzed 16 weeks before (pre-EI), two weeks after (peri-EI), and an additional 16 weeks after (post-EI) protocol implementation. We defined potential harm as a programmed infusion rate exceeding the recommended rate, possible harm as a programmed infusion aborted by the user, and compliance as reversion to recommended rates. Potential and possible harm were standardized to 1000 patient days. Overall, 3110 alerts were identified during the period. Potential harm per 1000 patient days for pre-, peri-, and post-EI were 0, 6.12, and 1.05 (p < 0.001). Possible harm per 1000 patient days for the pre-, peri-, and post-EI were 0.33, 21.9, and 5.02 (p < 0.001). Compliance after an initial potential harm alert occurred more often post-EI (0.4 per 1000 patient days vs. 0 per 1000 patient days for pre- and peri-EI; p < 0.001), while alerts remaining in non-compliance were more prevalent if they initially occurred during the peri- and post-EI vs. pre-EI (6.1 and 0.6 per 1000 patient days vs. 0 per 1000 patient days; p < 0.001) period. Piperacillin-tazobactam infusions were administered faster than recommended during implementation (i.e., peri-EI) despite standardized orders. Full article

Pharmacy technicians are essential for inner workings of pharmacy teams and their depth of involvement in roles continues to evolve. An innovative role for pharmacy technicians, administration of vaccines, has emerged. With Idaho, Rhode Island, and Utah recently implementing changes that allow pharmacy technicians to safely perform this role, the need arose for a detailed examination of the law climate in all 50 states and the District of Columbia. A nine-question survey was sent out to all 51 state boards of pharmacy inquiring to legislative and regulatory environment of pharmacy technician vaccine administration. Additionally, a protocol driven, peer-reviewed process of state-specific regulations and statutes revealed categorized trends pertaining to this topic. Each state was classified per protocol into four different categories. The categorization resulted in identification of nine states in which pharmacy technician administered vaccination may be considered “Not Expressly Prohibited”. A majority of states were categorized as prohibited (either directly or indirectly). Board of pharmacy respondents (43%) reported varying viewpoints on technician administered vaccines. While three states (Idaho, Rhode Island, Utah) have already made changes to allow for pharmacy technician administered vaccinations, opportunities exist for other states to consider changes to statutes or rules. Full article

Background: Quality pharmaceutical services are an integral part of primary healthcare and a key determinant of patient outcomes. The study focuses on pharmaceutical service delivery among private healthcare facilities serving informal settlements within Nairobi County, Kenya and aims at understanding the drug procurement practices, task-shifting and ethical issues associated with drug brand preference, competition and disposal of expired drugs. Methods: Forty-five private facilities comprising of hospitals, nursing homes, health centres, medical centres, clinics and pharmacies were recruited through purposive sampling. Structured electronic questionnaires were administered to 45 respondents working within the study facilities over an 8-week period. Results: About 50% of personnel carrying out drug procurement belonged to non-pharmaceutical cadres namely; doctors, clinical officers, nurses and pharmacy assistants. Drug brand preferences among healthcare facilities and patients were mainly pegged on perceived quality and price. Unethical business competition practices were recorded, including poor professional demeanour and waiver of consultation fees veiled to undercut colleagues. Government subsidized drugs were sold at 100% profit in fifty percent of the facilities stocking them. In 44% of the facilities, the disposal of expired drugs was not in conformity to existing government regulatory guidelines. Conclusions: There is extensive task-shifting and delegation of pharmaceutical services to non-pharmaceutical cadres and poor observance of ethical guidelines in private facilities. Strict enforcement of regulations is required for optimal practices. Full article

Vaccines represent fundamental public health interventions aimed to counteract or, at least, partially mitigate the severe epidemiological and economic burden generated by communicable disorders, in terms of (i) outcome-related, (ii) behavior-related productivity gains, and (iii) community externalities in developed settings as well as in developing countries. Despite their importance, several parents choose not to immunize their children due to the rising phenomenon of anti-vaccination movements that divulge vaccine-related “fake news” and “post-modern, post-factual truths”. Vaccine hesitancy represents a threat that can seriously jeopardize the implementation and success of vaccination campaigns. Within this framework, from a public health perspective, community pharmacies can play a vital role in that pharmacists can: (i) act as immunizers (vaccine distributors, educators, facilitators and administrators), (ii) improve vaccine-related health literacy and vaccination coverage rates as well as (iii) remove barriers and obstacles to the access to healthcare settings offering immunization services and (iv) counteract vaccine hesitancy. Full article

Achieving and maintaining weight loss for large segments of the population remains elusive, despite evidence demonstrating the value of many weight management programs. This study aimed to gather patients’ perceptions on weight management education needs, and ideas for the structure of a weight management program to be delivered in community pharmacies. This was an exploratory mixed methods study combining qualitative focus group interviews with a cross-sectional survey. Three focus group interviews were conducted, along with a brief survey based on focus groups findings and sent to all eligible participants. The survey allowed for individual responses on the program components and narrowing down of focus group findings. Nearly half of the respondents (45.9%) wanted further education on limiting carbohydrate and sugar intake. Participants were most interested in identifying different exercises appropriate for those with physical limitations (48.6%). Most participants preferred 1 h meetings (70.3%) that contain a mix of one-on-one and group meeting formats (67.6%). The results of the study suggest a three-month weight management program, with a combination of group and individual in-person meetings occurring twice per month, would be of most interest to patients. Full article

Transitions of care create complex management challenges for providers and leave patients vulnerable to medication errors and hospital readmissions. This article examines the evolution of an interdisciplinary team of pharmacists and nurse care managers and their impact on safe and effective transitions from the acute care settings back into primary care. This article explores successes and challenges of this primary-care-based clinic in managing patients safely through often-complex situations, and explores future directions for improving care processes and outcomes. Full article

Adherence and persistence to specialty medications are necessary to achieve successful outcomes of costly therapies. The increasing use of specialty medications has exposed several unique barriers to certain specialty treatments’ continuation. Integrated specialty pharmacy teams facilitate transitions in sites of care, between different provider types, among prescribed specialty medications, and during financial coverage changes. We review obstacles encountered within these types of transitions and the role of the specialty pharmacist in overcoming these obstacles. Case examples for each type of specialty transition provide insight into the unique complexities faced by patients, and shed light on pharmacists’ vital role in patient care. This insightful and real-world experience is needed to facilitate best practices in specialty care, particularly in the growing number of health-system specialty pharmacies. Full article

Documentation of community pharmacists’ clinical activities, such as the identification and management of drug-related problems (DRPs), is recommended. However, documentation is not systematic in Swiss community pharmacies, and relevant information about DRPs, such as consequences or involved partners, is frequently missing. This study aims to evaluate the interrater and test-retest reliability, appropriateness and acceptability of the Clinical Pharmacy Activities Documented (ClinPhADoc) tool. Ten community pharmacists participated in the study. Interrater reliability coefficients were computed using 24 standardized cases. One month later, test-retest reliability was assessed using 10 standardized cases. To assess the appropriateness, pharmacists were asked to document clinical activities in their own practice using ClinPhADoc. Acceptability was assessed by an online satisfaction survey. Kappa coefficients showing a moderate level of agreement (>0.40) were observed for interrater and test-retest reliability. Pharmacists were able to document 131 clinical activities. The good level of acceptability and brief documentation time (fewer than seven minutes) indicate that ClinPhADoc is well-suited to the community pharmacy setting. To optimize the tool, pharmacists proposed developing an electronic version. These results support the reliability and acceptance of the ClinPhADoc tool. Full article

Our objectives were to describe the use of pharmacological treatments in older adults with diabetes and to identify the factors associated with the use of a combination of hypoglycemic, antihypertensive and lipid-lowering agents. Using the Quebec Integrated Chronic Disease Surveillance System, we conducted a population-based cohort study among individuals aged 66–75 years with diabetes in 2014–2015. We described the number of medications and the classes of medications used and calculated the proportion of individuals using at least one medication from each of these classes: hypoglycemics, antihypertensives and lipid-lowering agents. We identified the factors associated with the use of this combination of treatments by performing robust Poisson regressions. The 146,710 individuals used an average of 12 (SD 7) different medications, mostly cardiovascular (91.3% of users), hormones, including hypoglycemic agents (84.5%), and central nervous system medications (79.8%). The majority of individuals (59%) were exposed to the combination of treatments and the factor most strongly associated was the presence of cardiovascular comorbidities (RR: 1.29; 99% CI: 1.28–1.31). Older individuals with diabetes are exposed to a large number of medications. While the use of the combination of treatments is significant and could translate into cardiovascular benefits at the population level, the potential risk associated with polypharmacy needs to be documented. Full article

Immunization screening forms are completed for each patient that is to be vaccinated in the pharmacy. Screening forms contain demographic and health questions, which are used to determine if a patient is contraindicated to receive a vaccine. The objective is to determine if patient responses to questions on these forms can be used to identify potential vaccine indications. De-identified data was retrospectively collected from 11 community pharmacies in California and Michigan that included basic demographics, answers to immunization screening questions, and vaccine(s) administered during that visit. The Advisory Committee on Immunization Practices (ACIP) recommendations were used to forecast vaccine needs using the limited demographic and health history available from the screening forms. Descriptive statistics are presented, characterizing patient demographics and health condition-based recommendations, and the percentage of patients in a pharmacy population that may have potential indications for additional vaccines. Data were collected from 8669 pharmacy vaccine screening forms. Using the patient’s date of birth on the screening form, 10% (n = 759) and 34.6% (n = 2615) of patients receiving vaccines at the pharmacy may be indicated for the zoster, or both the zoster and pneumococcal vaccines, respectively. Screening form questions that inquire about medical history are also able to identify 13.9% (n = 977) of patients with a potential need for pneumococcal vaccines. Our data indicate that pharmacists can identify potential immunization opportunities proactively by using their immunization screening form, not only to identify contraindications, but also indications. Full article

Objective: To assist with identifying patients who may be managed by pharmacists without additional travel medicine training, versus those who may benefit from referral, we developed and validated a clinical practice framework. This framework was then piloted in eight pharmacies in Ontario, Canada, from March to August 2019. Methods: A panel of experts, comprised of physicians and pharmacists from Ontario, Canada, holding a Certificate in Travel Health^TM from the International Society of Travel Medicine was recruited. This panel participated electronically in the development of the framework in three stages: (1) Sharing their current approach when performing information gathering and assessing risk in a traveling patient; (2) judging of items collated from all panellists on the basis of how essential they are to a risk assessment; and (3) validation of items deemed essential by the panel using the Item and Average Content Validity Index. The framework was then released to community pharmacies, where pharmacists that self-identified as beginners to travel medicine completed pre- and post-test phase surveys to determine the utility of the framework. Key Findings: A total of 64 items for consideration were deemed essential enough to proceed to content validation, organized into 5 ‘W’ domains: Who, What, Where, When, and Why. Each item was ranked by the experts according to its relevancy, resulting in an Average-Content Validity Index of 0.91. The resulting framework was titled “The 5W Approach to Travel Risk Identification.” This clinical practice framework is the first published assessment tool for travel medicine tailored for pharmacy’s scope of practice that has been content validated. Pharmacists reported that the framework is simple to use and provides structure for interactions with travelling patients. However, it may not be as beneficial for those with a higher level of travel medicine expertise than the average pharmacist. Conclusion: The 5W Approach tool allows pharmacists inexperienced in travel medicine to collect information when required to use their professional judgement when assessing traveling patients as either high-risk (requiring a referral to a travel medicine specialist) or low-risk. With the aim of supporting pharmacists to be more confident in caring for traveling patients and increasing their involvement in travel medicine, future research will test this framework for feasibility in Canadian community pharmacy practice. Full article

This pilot study sought to evaluate the impact of pharmacist involvement in the preexisting telehealth transitional care management (TCM) program at Atrium Health on the quality and safety of the medication discharge process for high medication risk patients. Eligible participants were those 18 years of age or older with moderate-to-high risk for hospital readmission who were contacted by a TCM Nurse, identified as high medication risk patients, and referred to the TCM Pharmacist from September 2018 through February 2019. The TCM Pharmacist contacted patients by phone, completed a comprehensive medication review, identified medication list discrepancies (MLDs) and medication-related problems (MRPs), and made interventions or recommendations to primary care providers. Primary endpoints included the number and types of MLDs identified, number and types of MRPs identified, and the rate of unplanned 30-day hospital readmissions. Seventy-six patients were enrolled, and 78 MLDs and 108 MRPs were identified. Of the identified MRPs, 74.1% were resolved. A relative risk reduction of 36.8% was achieved for 30-day hospital readmissions for those with high medication risk contacted by the TCM Pharmacist compared to those only contacted by the TCM Nurse. Overall, TCM Pharmacists identified and resolved 80 medication-related problems, improved access to medication therapy, provided comprehensive medication counseling, and bridged gaps in care following hospital discharge. Full article

Many medications are prescribed and administered PRN (pro re nata, as needed). However, there are few integrative reviews to inform PRN psychotropic medication use in long-term care facilities and nursing or care homes. Accordingly, this integrative systematic review aimed to improve our understanding of PRN medicines management with a focus on psychotropic medications (antipsychotics, sedatives, anxiolytics, and hypnotics) in long-term care settings. Keywords relating to PRN in English, Norwegian, and Spanish were used, and articles published between 2009 and 2019 were retrieved. Based on the inclusion criteria, eight articles were used for data analysis and synthesis. This review offers a description of PRN prescription and administration of psychotropic medications in long-term care. Variations were observed in the management of PRN psychotropic medications based on residents’ underlying health conditions and needs, duration of use, and changes between medications and doses. Neither the reasons for PRN prescription and administration nor the steps taken to identify and manage any associated adverse reactions or adverse drug events were reported. Further initiatives are needed to improve PRN medicines management to explore factors that affect PRN prescription and administration and to develop appropriate PRN guidelines to prevent harm and improve the safety of people living in long-term care facilities. Full article

The Centers for Medicare and Medicaid Services (CMS) have mandated that acute care and critical access hospitals implement an Antimicrobial Stewardship (AMS) Program. This manuscript describes the process that was implemented to ensure CMS compliance for AMS, across a 14-member health system (eight community hospitals, five critical access hospitals, and an academic medical center) in the Omaha metro area, and surrounding cities. The addition of the AMS program to the 14-member health system increased personnel, with a 0.5 full-time equivalent (FTE) infectious diseases (ID) physician, and 2.5 FTE infectious diseases trained clinical pharmacists to support daily AMS activities. Clinical decision support software had previously been implemented across the health system, which was also key to the success of the program. Overall, in its first year, the AMS program demonstrated a $1.2 million normalized reduction (21% total reduction in antimicrobial purchases) in antimicrobial expenses. The ability to review charts daily for antimicrobial optimization with ID pharmacist and physician support, identify facility specific needs and opportunities, and to collect available data endpoints to determine program effectiveness helped to ensure the success of the program. Full article

Several methods exist for measuring medication adherence. The Time4Med^TM device (Adherence Innovations, Hong Kong) is a small, electronic card to affix on medication packaging that records date and time of intakes when a button is pushed. We aimed to validate the device with an emphasis on polypharmacy. Twenty volunteers used Time4Med^TM devices with a virtual thrice daily intake over 14 days. Diary-recorded date and time were compared to electronically-stored events. Functionality, reliability and recovery for different stress conditions were calculated. User‘s acceptability was assessed with the System Usability Scale (SUS). Eleven elderly outpatients (mean age 80.2 ± 8.1 years) taking >3 medications daily used the device over 4 weeks. Volunteers logged 847 events. Functionality (100%), sensitivity (94.9%), specificity (99.4%) and recovery (100%) were high. Dropping the smart card and storing it in a refrigerator caused either the recording of false events or no recording at all. The mean SUS score was 82.6 (SD 14.8), demonstrating excellent acceptability. Satisfaction was very high for volunteers and patients, except for pushing the button. Time4Med^TM devices are highly accurate in recording, retaining and delivering electronic data of multiple medication intake. They are well accepted by elderly patients. They can be recommended in clinical studies and for practitioners who desire to elucidate adherence patterns of ambulatory patients. Full article

Continuing Education (CE) or Continuing Professional Development (CPD) are used by pharmacists globally to maintain up-to-date knowledge and skills throughout their careers. The primary aim of this study was to identify the formats or models used by pharmacists for CE and CPD globally. The secondary aim was to identify preferences of pharmacists, in relation to the variety of formats or models used to fulfil mandatory requirements, in order to support future planning of lifelong learning events. A systematic review was performed using PubMed, Science Direct, and Web of Science covering a time period from 1995 until March 2018. Searches were conducted in English, with studies on undergraduate studies being excluded. Eighteen papers from an initial search of 4561 were included from 2004 to 2014. All studies focused on pharmacists. Three studies identified face-to-face learning as a preference, with six studies identifying a positive impact of interactive learning. All four identified studies focusing on online provision were linked to CE. One study highlighted the benefits of blended learning. Two studies identified concluded that no one size fits all. A clear structure of event was highlighted in three studies. Three studies highlighted the relevance of topics to practice, and two studies showed the need for opportunities to apply knowledge. Due to the variety of formats and no consistent model, no perfect model or activity has been identified. However, CPD showed increased practice outcomes versus CE. Although an increasing amount of technology is being utilized, face-to-face learning is still preferred. Interactive, multiple-format learning should be used where possible, to reflect preferences of different learners. There is a need for a structured approach to the planning and learning event itself to support CE and CPD. Full article

Persons experiencing homelessness have a high prevalence of severe mental health problems, alcohol dependence, substance misuse and infectious hepatitis C, and face up to twelve times higher mortality rates compared to the general population. They also face barriers to accessing healthcare. However, clinical pharmacy services are currently not available to homeless populations in England. The aim of this study was to conduct public involvement sessions with persons experiencing homelessness with a view to inform the design of patient-centred clinical pharmacy healthcare services. Qualitative methodology was used, using a focus group with homeless persons from emergency shelters and one to one engagement with those sleeping rough, using a topic guide. A total of nine homeless persons took part—seven males and two females. The participants of the sessions said that patient-centred clinical pharmacy services delivered for homeless persons would address many of their unmet needs around access to medicines, their understanding of prescribed medicines and holistic management of their health. The service would be able to make a positive impact on their health outcomes by screening for health conditions, facilitating better integration across services, referral and liaison with other services, and minimising misuse of prescribed medicines. The findings of this study will be used to inform the development, implementation and evaluation of a patient-centred clinical pharmacy service tailored to meet the specific needs of the homeless population. Full article

Background: Pharmacy technicians are legally allowed to administer immunizations in specific U.S. states, provided they meet certain criteria, including the completion of an accredited immunization training course. Immunizing pharmacy technicians were incorporated into an Indian Health Services federal facility, Whiteriver Service Unit (WRSU), in 2018. The objective of this research was to gather information about implementing immunizing pharmacy technicians in a federal facility serving a large rural and medically underserved population. Methods: WRSU launched a Pharmacy Technician Immunization Program in June 2018 after seven federally employed pharmacy technicians participated in the Washington State University accredited technician immunization training. The types of vaccinations administered, and the ages of patients immunized by pharmacy technicians, were tracked from July 1, 2018 to June 30, 2019. Results: Seven immunization-trained pharmacy technicians administered 4394 injections for a total of 4852 vaccinations in one year. Vaccinations were administered to patients ranging in age from 2 months old to 85 years old and included protection against diphtheria, tetanus, polio, hepatitis A and B, H. influenza, human papillomavirus, seasonal influenza, meningococcal, measles, mumps, rubella, varicella, pneumonia, and rotavirus. Conclusion: In one year, seven pharmacy technicians administered more than 4800 vaccinations to underserved patients. Pharmacy technicians trained and certified to administer immunizations increase access to vaccination care and have the potential to drastically increase the number of immunizations given and reduce the number of deaths from vaccine-preventable diseases. Full article

The Arabic-speaking immigrant group, which makes up the fourth largest language group in Australia, has a high prevalence of cardiovascular disease. The objective of this study was to explore the health care challenges and needs of Arabic-speaking immigrants with cardiovascular disease (CVD), using a comparative approach with English-speaking patients with CVD as the comparable group. Methods: Participants were recruited from community settings in Melbourne, Australia. Face-to-face semi-structured individual interviews were conducted at the recruitment sites. All interviews were audio-taped, transcribed, and coded thematically. Results: 29 participants with CVD were recruited; 15 Arabic-speaking and 14 English-speaking. Arabic-speaking immigrants, and to a lesser extent English-speaking patients with CVD may have specific health care challenges and needs. Arabic-speaking immigrants’ health care needs include: effective health care provider (HCP)-patient communication, accessible care, participation in decision-making, and empowerment. English-speaking participants viewed these needs as important for CVD management. However, only a few English-speaking participants cited these needs as unmet health care needs. Conclusion: This study suggests that Arabic-speaking immigrants with CVD may have unique needs including the need for privacy, effective HCP-patient communication that takes into account patients’ limited English proficiency, and pharmacist-physician collaboration. Therefore, there may be a need to identify a health care model that can address these patients’ health care challenges and needs. This, in turn, may improve their disease management and health outcomes. Full article

This research aims to identify the most prevalent and impactful sales promotion tools used by pharmaceutical companies on consumers’ purchasing decisions at community pharmacies. A cross-sectional study design was carried out using the non-repeated random sampling technique. Standardized questionnaires were administered by means of face-to-face interviews or via emails. The relative importance of prevalence (RIP) and the mean evaluation of effectiveness (MEE) were determined for all studied marketing tools for the different groups of respondents (pharmaceutical sales representatives (PSRs), community pharmacists, consumers, and the entire sample). Inter-individual differences in RIP and MEE were assessed by computing the coefficient of variation, whereas inter-group differences were determined by one-way analysis of variance (ANOVA) with the Scheffé test as a post-hoc test. Research findings showed that, according to all respondents, the consumer promotion technique had the strongest impact on consumers’ purchasing decisions while merchandising was the most common sales promotion technique at community pharmacies. PSRs and pharmacists identified trade promotion as the most effective and prevalent technique. Furthermore, research findings showed that, according to all respondents, the following sales promotion tools had the strongest impact on consumers’ purchasing decisions: arrangement and design of showcases among the studied tools for merchandising; buy 1 and get 2 among the studied tools for consumer promotion; and gifts among the trade promotion studied tools. The same tools were identified as the most prevalent by all respondents. Free samples of promoted products appeared to be the most prevalent tool, but at the same time was the least effective. In conclusion, the results of the present research enable an understanding of which sales promotion tools are commonly used at community pharmacies and which ones have the strongest impact on consumers’ purchasing decisions. Full article

Lack of standardization related to compounded drug preparations, especially in the transition of care situations, threatens patient safety by facilitating medication error. This paper outlines progress to-date from the United States Pharmacopeia (USP) Expert Panel on the Exchange of Compounded Drug Preparation Information in Health IT Systems. The work plan developed for the group is focused on proposing a set of encoding rules that would govern how compounded nonsterile drug preparations (CNSPs) are digitized and exchanged, including patient electronic health records (EHR), pharmacy systems, e-prescribing (eRx), and other Health IT (HIT) systems to ensure a seamless compounding process tailored to the needs of an individual patient. Included in this work are identifying authorized compounding monographs, surveying provider and end-user groups for information about data specificity during e-prescribing, and generating guidelines for the development of a compatible data model for clinical formulation identifiers (CF-IDs). This paper will also discuss how evolving nomenclature standards for CNSPs within HIT systems are part of a quality assurance system for comprehensive medication management (CMM) in children, thereby minimizing medication errors across the continuum of care. Finally, a network approach for the design of medication management systems for children and their families/caregivers is proposed. Full article

Background: The provision of responsible medication therapy to old nursing home residents with comorbidities is a difficult task and requires extensive knowledge about optimal pharmacotherapy for different conditions. We describe a stepwise pharmacist-led medication review service in combination with an interdisciplinary team collaboration in order to identify, resolve, and prevent medication related problems (MRPs). Methods: The service included residents from four rural Norwegian nursing homes during August 2016–January 2017. All residents were eligible if they (or next of kin) supplied oral consent. The interdisciplinary medication review service comprised four steps: (1) patient and medication history taking; (2) systematic medication review; (3) interdisciplinary case conference; and (4) follow-up of pharmaceutical care plan. The pharmacist collected information about previous and present medication use, and clinical and laboratory values necessary for the medication review. The nurses collected information about possible symptoms related to adverse drug reactions. The pharmacist conducted the medication reviews, identified medication-related problems (MRPs) which were discussed at case conferences with the responsible physician and the responsible nurses. The main outcome measures were number and types of MRPs, percentage agreement between pharmacists and physicians and factors associated with MRPs. Results: The service was delivered for 151 (94%) nursing home residents. The pharmacist identified 675 MRPs in 146 (97%) medication lists (mean 4.0, SD 2.6, range 0–13). The MRPs most frequently identified concerned ‘unnecessary drug’ (22%), ‘too high dosage’ (17%) and ‘drug interactions’ (16%). The physicians agreed upon 64% of the pharmacist recommendations, and action was taken immediately for 32% of these. We identified no association between the number of MRPs and sex (p = 0.485), but between the number of MRPs, and the number of medications and the individual nursing homes. Conclusion: The pharmacist-led medication review service in the nursing homes was highly successfully piloted with many solved and prevented MRPs in interdisciplinary collaboration between the pharmacist, physicians, and nurses. Implementation of this service as a standard in all four nursing homes seems necessary and feasible. If such a service is implemented, effects related to patient outcomes, interdisciplinary collaboration, and health economy should be studied. Full article

The purposes of this study were: (1) to determine pharmacists’ perceptions of the impact of certification on competence in specific job skills, its impact in combination with job experience, and its impact in combination with other types of vocational education/training; (2) to identify elements that could potentially enhance the value, or impact of national certification; and (3) to determine how pharmacists view certification in light of various personnel management and organizational behavior phenomena. A self-administered survey was constructed and delivered in spring of 2019 to a random sample of four U.S. states chosen for their geographic diversity and relatively high proportions of both certified and non-certified pharmacy technicians. Following multiple reminders, a response rate of 19.3% was obtained. The 326 responding pharmacists saw certification being less impactful alone than when combined with other types of education/training and previous job experiences. They saw the need for more skills-related and “soft skills” content on the certification examination and agreed that certification is a factor in hiring decisions and that it should be required for designation for advanced practice status. Taken together, respondents saw the need for pharmacy leaders to integrate certification with other aspects of preparation to make for a more competent and professional workforce support team. Full article

The global workforce needs to be competent, flexible, adaptable, sustainable, and patient-focused. A competency approach towards education, development, and professional practice strengthens services and increases better health outcomes. This paper will provide a global perspective on competency approaches from different health care professions. It will focus on two case reports, describing the use of competency methodologies at an undergraduate and postgraduate level, as well as supporting the internship and/or pre-registration training. Challenges and opportunities will be highlighted by addressing some of the key questions posed for this special edition. Full article

Antimicrobial stewardship (ASP) is becoming an increasingly high priority worldwide, yet the emergency department (ED) is an area where stewardship is often neglected. Implementing care bundles, guidelines, and protocols appears to be a rational strategy for ED stewardship given the inherently dynamic and hectic environment of care. Multiple questions still exist such as whether to target certain disease states, optimal implementation of ASP interventions in the ED, and the benefit of unique ED-specific guidelines and protocols. A narrative review was performed on interventions, guidelines, and bundles implemented in the ED setting, in an effort to improve ASP or management of infectious diseases. This review is meant to serve as a framework for the reader to implement these practices at their own institution. We examined various studies related to ASP interventions or care bundles in the ED which included: CNS infections (one study), skin and soft-tissue infections (one study), respiratory infections (four studies), urinary tract infections and sexually transmitted infections (eight studies), sepsis (two studies), culture follow-up programs (four studies), and stewardship in general or multiple infection types (five studies). The interventions in this review were diverse, yet the majority showed a benefit in clinical outcomes or a decrease in antimicrobial use. Care bundles, guidelines, and antimicrobial stewardship interventions can streamline care and improve the management of common infectious diseases seen in the ED. Full article

Background: Patients’ perception of diabetes mellitus is one of the psychosocial factors influencing diabetic behavior. This patients’ perception of the disease is a mental image formed from the experience of patients with type 2 diabetes mellitus and reportedly reflects the aspect of recuperation. We investigated the relationship between changes in the patients’ perception of the disease and medication adherence, as influenced by the active involvement of community pharmacists. Methods: A prospective cohort study that used patient registry based in community pharmacies was conducted in patients with type 2 diabetes using oral antidiabetic agents at a pharmacy in Ishikawa Prefecture in Japan. Patients responded to the questionnaire at the time of enrollment and at the end of the one-year intervention period. The pharmacist confirmed the patient's medication status and treatment problems via telephone calls at least once every two weeks for one year. Main outcome measures: Type 2 diabetes patients’ perception of the disease related to medication adherence. Results: The study enrolled 113 patients. Among the seven diabetes image factors, “Living an orderly life” and “Feeling of fear” were significantly associated with medication adherence. “Feeling of neglect of health” was significantly associated at the subscale level. Conclusion: All the three factors related to medication adherence indicated self-care ability. To enhance the self-care ability of the patient, pharmacists should assist in self-care interventions for the patients. Full article

The use of anticholinergic medications by residents in aged care homes is associated with increased risk of adverse effects. These include cognitive impairment, sleep disturbances, and falls, and necessitate increased healthcare visits and the associated burden on healthcare systems. The objective of this study was to investigate associations between anticholinergic burden and health outcomes such as independence in activities for daily living, frailty, quality of life, and sleep quality. The study was conducted among residents in Malaysian aged care homes, aged 60 years and above. Anticholinergic burden was calculated using the Anticholinergic Cognitive Burden (ACB) scale. Health outcome measures included independence, assessed using the Katz Activities for Daily Living scale (Katz ADL); quality of life, assessed using the Older People’s Quality of Life Questionnaire (OPQOL); frailty, assessed using the Groningen Frailty Index (GFI); and sleep quality, measured using the Pittsburg Sleep Quality Index (PSQI). Just over one-third (36%) of the study population was exposed to at least one medication with anticholinergic effect. An increased anticholinergic cognitive burden was associated with frailty (p = 0.031), sleep latency (p = 0.007), and sleep disturbances (p = 0.015). Further studies are required to assess the effect of prolonged exposure to anticholinergic medications on health outcomes. Full article

Introduction: The scope of pharmacy practice has evolved over the last few decades to focus on the optimization of medication therapy. Despite this positive impact, the lack of reimbursement remains a significant barrier to the implementation of innovative pharmacist practice models. Summary: We describe the successful development, implementation and outcomes of three types of pharmacist collaborative care models: (1) a pharmacist with physician oversight, (2) pharmacist–interprofessional teams and (3) physician–pharmacist teams. The outcome measurement of these pharmacist care models varied from the design phase to patient volume measurement and to comprehensive quality dashboards. All of these practice models have been successfully funded by affiliated health systems or grants. Conclusions: The expansion of pharmacist services delivered by clinical faculty has several benefits to affiliated health systems: (1) significant improvements in patient care quality, (2) access to experts in specialty areas, and (3) the dissemination of outcomes with national and international recognition, increasing the visibility of the health system. Full article