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ABSTRACT: Background Hospitalisation often leads to increased medication regimen complexity for older patients; increased complexity is associated with medication non-adherence. There has been little research into strategies for reducing the impact of hospitalisation on medication regimen complexity. Objective To investigate the impact of pharmacist medication review, together with an educational intervention targeting clinical pharmacists and junior medical officers, on the increase in medication regimen complexity that occurs during hospitalisation. Setting Two acute general medicine wards and two subacute aged care (geriatric assessment and rehabilitation) wards at a major metropolitan public hospital in Melbourne, Australia. Methods A before-after study involving patients aged 60 years and over was undertaken over two 5-week periods. During the pre-intervention period patients received usual care. During the intervention period, clinical pharmacists were encouraged to review patients' medication regimen complexity prior to discharge, and make recommendations to hospital medical officers to simplify regimens. Prior to the intervention period, pharmacists attended an interactive case-based education session about medication regimen simplification, and completed an assessment task. A similar, but briefer, education session was delivered to junior medical officers. Main outcome measure The primary endpoint was change in medication regimen complexity index (MRCI) score (a validated measure of regimen complexity) between admission and discharge for regularly scheduled long-term medications, adjusted for age, length of hospital stay, number of medications and regimen complexity prior to admission. Results Three hundred ninety-one patients were included (mean age 80.6 years, mean 7.4 regularly scheduled long-term medications on admission). The mean increase in MRCI score between admission and discharge was significantly smaller in the 205 intervention patients than in the 186 usual care patients (2.5 vs. 4.0, p = 0.02; adjusted difference 1.6, 95 %CI 0.3, 2.9). The intervention had greatest impact in patients discharged from subacute wards (mean adjusted difference: 2.7), not using a dose administration aid after discharge (mean adjusted difference: 2.6), and not discharged to a residential care facility (mean adjusted difference: 1.9). Mean differences in MRCI scores were equivalent to ceasing one to two medications. Conclusion An educational intervention and clinical pharmacist medication review reduced the impact of hospitalisation on the complexity of older patients' medication regimens.
International journal of clinical pharmacy. 12/2012;
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ABSTRACT: Aim: To assess continuity of medication management during transition from hospital to residential care facilities (RCFs). Method: Telephone interviews with RCF staff were performed 24 hours after patient transfer to determine the proportion of patients with: missed or significantly delayed doses; RCF medication chart not written/updated in time for the first dose; suitably packed medications not available for the first dose; and RCF medication chart written/updated by a locum doctor. Retrospective audit was used to identify discharge summary discrepancies. Results: Seventy-five doses for 37/202 (18.3%) patients were missed or significantly delayed in the 24 hours after discharge. One hundred and twenty-five (61.9%) patients did not have their medication chart written/updated and 77 (38.1%) did not have suitably packed medications available for the first dose. Locum doctors wrote RCF medication charts for 66 (32.7%) patients. One hundred and ninety-seven of 392 (50.3%) changes to regularly scheduled medications were communicated. Conclusions: Strategies are needed to address gaps in the continuity of medication management.
Australasian Journal on Ageing 12/2012; 31(4):247-254. · 0.90 Impact Factor
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ABSTRACT: Medication-related problems are a serious concern in Australian primary care. Pharmacist interventions have been shown to be effective in identifying and resolving these problems. Collaborative general practitioner-pharmacist services currently available in Australia are limited and underused. Limitations include geographical isolation of pharmacists and lack of communication and access to patient information. Co-location of pharmacists within the general practice clinics is a possible solution. There have been no studies in the Australian setting exploring the role of pharmacists within general practice clinics.The aim of this study is to develop and test a multifaceted practice pharmacist role in primary care practices to improve the quality use of medicines by patients and clinic staff.
This is a multi-centre, prospective intervention study with a pre-post design and a qualitative component. A practice pharmacist will be located in each of two clinics and provide short and long patient consultations, drug information services and quality assurance activities. Patients receiving long consultation with a pharmacist will be followed up at 3 and 6 months. Based on sample size calculations, at least 50 patients will be recruited for long patient consultations across both sites. Outcome measures include the number, type and severity of medication-related problems identified and resolved; medication adherence; and patient satisfaction. Brief structured interviews will be conducted with patients participating in the study to evaluate their experiences with the service. Staff collaboration and satisfaction with the service will be assessed.
This intervention has the potential to optimise medication use in primary care clinics leading to better health outcomes. This study will provide data about the effectiveness of the proposed model for pharmacist involvement in Australian general practice clinics, that will be useful to guide further research and development in this area.
Australian New Zealand Clinical Trials Registry: ACTRN12612000742875.
BMC Health Services Research 08/2012; 12:246. · 1.66 Impact Factor
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ABSTRACT: To explore stakeholder perspectives on a government-subsidised Home Medicines Review (HMR) service and factors affecting the uptake of HMRs for older residents of retirement villages in Australia.
Thirty-two in-depth interviews and four focus groups were undertaken with a purposive sample of 32 residents of retirement villages, 10 pharmacists, nine general practitioners (GPs) and a general practice nurse. Data were transcribed verbatim and analysed using the framework approach.
Three major themes were identified: participants' perceptions of the HMR service, barriers to the uptake of HMRs and strategies for increasing the uptake of HMR. Residents had positive, negative or mixed perceptions, whereas health professionals were generally positive about the benefits of the service. Barriers to the uptake of HMRs were related to GPs, pharmacists, patients and the healthcare system. A strategy recommended by multiple stakeholders for increasing the uptake of HMRs was to use a multi-faceted intervention targeting residents and their health professionals.
Multiple barriers to the uptake of HMRs and multiple strategies for increasing the uptake of HMRs were identified. These findings could inform the design of interventions to improve uptake of HMRs by residents and health professionals, in turn leading to better medicine use and safety.
The International journal of pharmacy practice. 08/2012; 20(4):249-58.
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ABSTRACT: Aged Care Assessment Teams (ACATs) in Australia assess the care needs of frail older people. Despite being at high risk of medication-related problems (MRPs), ACAT patients do not routinely receive a comprehensive medication review.
The aims of the study were to compare three methods for facilitating a pharmacist-led comprehensive medication review for people referred to an ACAT, and compare MRPs identified via ACAT usual care with those identified via pharmacist-led medication reviews.
A prospective, randomized, comparative study involving 80 community-dwelling patients (median age 84 years) referred to an ACAT in Melbourne, Australia, was conducted. Following ACAT assessment (usual care), a clinical pharmacist reviewed all participating patients' ACAT files to identify potential MRPs not identified by the ACAT (medication review method 1). Patients were then randomized into two groups. Group A received information about the Australian government-funded, general practitioner (GP)-initiated Home Medicines Review (HMR) programme, and a letter was sent to their GP recommending an HMR (GPHMR; medication review method 2). Group B patients were referred directly to a clinical pharmacist associated with the ACAT for an ACAT-initiated pharmacist home medicines review (APHMR; medication review method 3); the pharmacist arranged a home visit, obtained a thorough medication history and conducted a comprehensive medication review. The main outcome measures were the proportion of patients who received a pharmacist home visit within 28 days; the number of MRPs identified by ACAT usual care, pharmacist review of ACAT files, and APHMR, and their clinical risk (assessed by a geriatrician-pharmacist panel); and patients', GPs' and ACAT clinicians' opinions about pharmacist medication review.
Three hundred patients were referred to the ACAT, and 80 were recruited into the study. Thirty-six of 40 APHMR patients (90.0%) received a pharmacist home visit within 28 days, compared with 7/40 GPHMR patients (17.5%).[p < 0.001]. Twenty-one MRPs were identified via ACAT usual care. Pharmacist review of ACAT files identified a further 164 potential MRPs (median 2.0 per patient; inter-quartile range [IQR] 1.0-3.0); however, in patients who received an APHMR, 35/82 potential MRPs (42.7%) turned out not to be actual problems, most commonly because of discrepancies between the patient's ACAT medication list and the medications currently being used by the patient (median 3.0 discrepancies per patient; IQR 2.0-5.5). APHMR identified a further 79 MRPs (median 2.0; IQR 1.0-3.0). One hundred and twenty-two MRPs were included in APHMR reports sent to patients' GPs. Of these, 94 (77.0%) were assessed as being associated with a moderate, high or extreme risk of an adverse event. Sixty-four APHMR recommendations (52.5%) led to changes to patients' medication regimens or medication management. Thirty-six of 39 GPs (92.3%) who provided feedback reported that pharmacist medication reviews were useful. Patients (or their carers) also reported that pharmacist home visits were useful: median rating 4.25 out of 5 (IQR 4.0-5.0). Seven of 11 ACAT clinicians (77.8%) agreed that pharmacist-led medication review should be a standard component of ACAT assessments.
ACAT assessments without pharmacist involvement detected fewer MRPs than any of the evaluated pharmacist-led medication review methods. APHMR was more effective than pharmacist review of routinely collected ACAT data, and more reliable and timely than referral to the patients' GP for a GPHMR.
Drugs & Aging 07/2012; 29(7):593-605. · 2.67 Impact Factor
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ABSTRACT: To test the impact of a hospital pharmacist-prepared interim residential care medication administration chart (IRCMAC) on medication administration errors and use of locum medical services after discharge from hospital to residential care.
Prospective pre-intervention and post-intervention study.
One major acute care hospital and one subacute aged-care hospital; 128 residential care facilities (RCF) in Victoria, Australia.
428 patients (median age 84 years, IQR 79-88) discharged to a RCF from an inpatient ward over two 12-week periods.
Seven-day IRCMAC auto-populated with patient and medication data from the hospitals' pharmacy dispensing software, completed and signed by a hospital pharmacist and sent with the patient to the RCF. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary end points were the proportion of patients with one or more missed or significantly delayed (>50% of prescribed dose interval) medication doses, and the proportion of patients whose RCF medication chart was written by a locum doctor, in the 24 h after discharge. Secondary end points included RCF staff and general practitioners' opinions about the IRCMAC.
The number of patients who experienced one or more missed or delayed doses fell from 37/202 (18.3%) to 6/226 (2.7%) (difference in percentages 15.6%, 95% CI 9.5% to 21.9%, p<0.001). The number of patients whose RCF medication chart was written by a locum doctor fell from 66/202 (32.7%) to 25/226 (11.1%) (difference in percentages 21.6%, 95% CI 13.5% to 29.7%, p<0.001). For 189/226 (83.6%) discharges, RCF staff reported that the IRCMAC improved continuity of care; 31/35 (88.6%) general practitioners said that the IRCMAC reduced the urgency for them to attend the RCF and 35/35 (100%) said that IRCMACs should be provided for all patients discharged to a RCF.
A hospital pharmacist-prepared IRCMAC significantly reduced medication errors and use of locum medical services after discharge from hospital to residential care.
BMJ open. 01/2012; 2(3).
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ABSTRACT: To investigate the prevalence of medication-related problems (MRPs) in patients attending aged care and memory disorder clinics and explore the potential role of a clinical pharmacist to obtain medication histories and identify unresolved MRPs.
The clinical pharmacist interviewed patients and reviewed their medication regimens in the outpatient clinics. Clinical significance of pharmacist-identified MRPs was rated by an independent expert panel using validated criteria.
Forty-six patients (mean age 82 years) were reviewed. They took a median of nine medications, of which three were not recorded in the medical record. One hundred and thirteen MRPs (median 2.0 per patient) were identified by the pharmacist. Independent review rated 35% of MRPs as high or extreme risk. Thirty-seven (33%) MRPs related to medications not recorded in the medical record.
Medication-related problems were present for most patients. Involvement of a clinical pharmacist resulted in a more comprehensive medication history and identified unresolved MRPs.
Australasian Journal on Ageing 09/2011; 30(3):124-9. · 0.90 Impact Factor
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ABSTRACT: The majority of retirement village residents are at risk of medication misadventure. In a recent survey of retirement village residents in Victoria, two-thirds had at least one medication-related risk factor, and hence were eligible to receive a government-subsidised Home Medicines Review (HMR). However, only 6% of eligible residents had received a HMR in the previous 12 months. Reasons for the poor uptake of HMR, and interventions for improving HMR uptake, have been identified and developed with input from stakeholders. The trial will test the effect of Pharmacist-conducted HMR to Address the Risk of Medication-related Events in Retirement Villages (PHARMER) in improving the uptake of HMRs among retirement village residents.
This is a multicentre prospective cluster randomised controlled trial. Ten retirement villages in Victoria, Australia will be recruited for this trial. Retirement villages will be selected in consultation with the Residents of Retirement Villages Victoria Inc. (RRVV), based on geographical locations (e.g. northeast or southwest), size and other factors. Residents from selected villages will be recruited with the help of RRVV Resident Liaison Officers using a range of strategies. Randomisation will be by geographical location to minimise contamination. Participating villages and residents will be allocated to either Pharmacist Intervention Group (PIG) or Usual Care Group (UCG). Each group will include five retirement villages and will have at least 77 residents in total. The intervention (PHARMER) comprises educating residents regarding HMR, and using a risk assessment checklist by residents to notify their General Practitioners of their medication risk. Uptake of HMR and medication adherence will be assessed in both PIG and UCG at three and six months using telephone interviews and questionnaires.
This study is the first to develop and test an intervention to improve the uptake of HMR among Australian residents in retirement villages, with a view to decreasing medication risk. A multi-faceted interventional approach will be used as suggested by stakeholders. The trial is expected to be complete by late 2011 and results will be available in 2012.
Australian New Zealand Clinical Trials Registry (ACTRN12611000109909).
BMC Health Services Research 01/2011; 11:292. · 1.66 Impact Factor
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ABSTRACT: BACKGROUND: Inpatient self-administration of medications programs (SAMPs) improve the medication knowledge and adherence of elderly patients after their discharge from the hospital. They may also identify patients who will have difficulties managing their medications after discharge; however, no previous study has evaluated the value of a SAMP for detecting and addressing barriers to adherence. OBJECTIVE: To evaluate the usefulness of a SAMP for detecting and addressing barriers to adherence in functionally impaired elderly hospital inpatients, and to identify predictors of patient performance in a SAMP. METHODS: A prospective cohort study was conducted on 2 subacute aged-care wards. Patients who were intending to independently manage their medications after discharge were recruited. Medications were dispensed and labeled with full directions, and the patients were educated about their medications. Each patient was required to request the medications from nursing staff when due, then select and administer them under supervision. Patient performance was documented. Barriers to adherence and interventions used to address these barriers were recorded. Analyses were performed to identify factors associated with failing the SAMP. RESULTS: Of 62 patients who were recruited, 43 (69.4%) passed the program without requiring interventions to address adherence barriers, 7 (11.3%) passed with an intervention implemented to enable them to remain independent with medication management after discharge, and 12 (19.4%) failed and required full assistance with medication management after discharge. Overall, barriers to medication adherence (eg, inability to open containers, inability to request medications without prompting) were identified for 30.6% of patients. Mini-Mental State Examination scores and patient age were independent predictors of whether a patient would fail the SAMP. CONCLUSIONS: An inpatient SAMP effectively detected barriers to medication adherence that otherwise may not have been detected and addressed prior to a patient's discharge from the hospital.
Annals of Pharmacotherapy 01/2011; · 2.13 Impact Factor
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ABSTRACT: information on medication use and risk factors among older people residing in retirement villages and their uptake of medication reviews are scant.
to identify medication use issues and risk factors for medication-related problems among retirement village residents and to evaluate the uptake of government-subsidised Home Medicines Review (HMR) services in this population.
cross-sectional, mail survey.
retirement villages in Victoria, Australia.
members of the Residents of Retirement Villages of Victoria residing in retirement villages (2,116, aged 54-100 years).
a questionnaire was developed incorporating validated scales and items to measure medication risk, medication adherence, co-morbidity, disability, information on medication use, health and the uptake of HMR services. Questionnaires were mailed to participants for self-completion and returned using reply-paid envelopes.
of the 2,116 respondents (70.7% response rate), 2,006 (94.8%; 95% confidence interval (CI) 93.9-95.7%) reported using prescribed medications. Three or more health conditions were present in 993 (46.9%; 95% CI 44.8-49.0%) respondents. Five or more regular medications were used by 988 (46.7%; 95% CI 44.6-48.8%) respondents. Twelve or more tablets/capsules per day were used by 229 (10.8%; 95% CI 9.5-12.1%) respondents. The use of narrow therapeutic index medications was reported by 264 (12.5%; 95% CI 11.1-13.9%) respondents. Changes to medication regimens in the previous 3 months were reported by 356 (16.8%; 95% CI 15.2-18.4%) respondents. One or more medication-related risk factors were seen in 1,374 (64.9%; 95% CI 62.9-66.9%) respondents. Of these at-risk residents, 76 (5.5%; 95% CI 4.5-6.5%) reported receiving an HMR in the previous 12 months, who were older (P < 0.001), were using more medicines (P < 0.001) and had greater disability (P = 0.002).
reasons for the low uptake of medication reviews in retirement village residents despite the high prevalence of medication risk require further investigation.
Age and Ageing 09/2010; 39(5):581-7. · 3.09 Impact Factor
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ABSTRACT: To design and evaluate a preregistration course utilizing asynchronous online learning as the primary distance education delivery method.
Online course components including tutorials, quizzes, and moderated small-group asynchronous case-based discussions were implemented. Online delivery was supplemented with self-directed and face-to-face learning.
Pharmacy graduates who had completed the course in 2004 and 2005 were surveyed. The majority felt they had benefited from all components of the course, and that online delivery provided benefits including increased peer support, shared learning, and immediate feedback on performance. A majority of the first cohort reported that the workload associated with asynchronous online discussions was too great. The course was altered in 2005 to reduce the online component. Participant satisfaction improved, and most felt that the balance of online to face-to-face delivery was appropriate.
A new pharmacy preregistration course was successfully implemented. Online teaching and learning was well accepted and appeared to deliver benefits over traditional distance education methods once workload issues were addressed.
American journal of pharmaceutical education 08/2009; 73(5):77. · 1.21 Impact Factor
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ABSTRACT: Older people are commonly prescribed complex multi-drug regimens while also experiencing declines in the cognitive and physical abilities required for medication management, leading to increased risk of medication errors and need for assisted living. The purpose of this study was to review published instruments designed to assess patients' capacity to self-administer medications.
Searches of Medline, EMBASE, CINAHL, PsycINFO, International Pharmaceutical Abstracts, Health and Psychosocial Instruments, Google, and reference lists of identified publications were conducted to identify English-language articles describing development and validation of instruments designed to assess patients' capacity to self-administer medications. Methodological quality of validation studies was rated independently against published criteria by two reviewers and reliability and validity data were reviewed.
Thirty-two instruments were identified, of which 14 met pre-defined inclusion criteria. Instruments fell into two categories: those that used patients' own medications as the basis for assessment and those that used a simulated medication regimen. The quality of validation studies was generally low to moderate and few instruments were subjected to reliability testing. Most instruments had some evidence of construct validity, through associations with tests of cognitive function, health literacy, activities of daily living or measures of medication management or adherence. Only one instrument had sensitivity and specificity data with respect to prediction of medication-related outcomes such as adherence to therapy. Only three instruments had validity data from more than one independent research group.
A number of performance-based instruments exist to assess patients' capacity to manage their own medications. These may be useful for identifying physical and cognitive barriers to successful medication management, but further studies are needed to determine whether they are able to accurately and reliably predict medication outcomes.
BMC Geriatrics 02/2009; 9:27. · 2.34 Impact Factor
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ABSTRACT: Background: The Society of Hospital Pharmacists of Australia's (SHPA) Standards of Practice for Clinical Pharmacy provide a risk-classification system for interventions made by pharmacists in hospital inpatients. These standards are based on Australian standards for risk management, where risk is based on an estimate of the likelihood and consequences of an adverse outcome from a medication-related problem, if no intervention was made. Aim: To adapt and validate the SHPA risk-classification system for use in geriatric ambulatory care and to explore differences in classifications of risk made by pharmacists and geriatricians. Method: The SHPA risk-classification system was modified, piloted and reviewed by experts to assess face validity. 113 medication-related problems identified by an outpatient clinical pharmacist in aged care were independently classified by a senior clinical pharmacist, a geriatrician and the outpatient clinical pharmacist. When there was disagreement, the case was discussed and consensus reached. A random sample of 30 medication-related problems, stratified by consensus risk classification was classified by a second geriatrician. Results: Face validity of the adapted risk-classification system was established. Agreement between pharmacists on medication-related problem risk was moderate and agreement between pharmacists and geriatricians was fair. Risk of adverse outcomes was rated lower by geriatricians than pharmacists. Consensus was easily reached through case discussion. Conclusion: A system for classifying risk associated with pharmacist-identified medication-related problems in geriatric ambulatory care was developed. Differences were identified between pharmacists and geriatricians in the way medication-related risks are perceived. Classification of pharmacist-identified medication-related problems/interventions may need to be based on consensus between at least one doctor and pharmacist. J Pharm Pract Res 2009; 39: 109-13.
Journal of Pharmacy Practice and Research Volume. 01/2009; 39(109).
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ABSTRACT: A range of behavioural, educational and provider-focused strategies have been tested, individually or in combination, for improving medication adherence. The results of various interventions in different patient groups, including the elderly, have been subjected to systematic reviews and meta-analyses, but because most studies have focused on improving adherence to one drug or drug group, they may have limited applicability to the general elderly population who more commonly use multiple medications for multiple co-morbidities.A systematic review of controlled studies aimed at improving adherence in community-living elderly patients prescribed at least three, or a mean/median of four or more, long-term medications was undertaken. Only studies which included a minimum of 60 patients in each group, followed patients for >or=4 weeks after intervention, and measured adherence to all medications at baseline and at the conclusion of the study were considered for inclusion in the review. Eight studies met the inclusion criteria. All eight studies used verbal and/or written medication information in combination with behavioural strategies with or without provider-focused strategies. Pharmaceutical care was the theoretical framework of the interventions used in the majority of the studies. Only four studies demonstrated a significant improvement in adherence as a result of the interventions. The relative change in adherence in the intervention groups was highly variable, ranging from -13% to +55.5% (mean +11.4%). Regular scheduled patient follow-up along with a multi-compartment dose administration aid was an effective strategy for maintaining adherence in one study, while group education combined with individualized medication cards was successful in another study. Medication review by pharmacists with a focus on regimen simplification was found to be effective in two studies.Overall, as a result of inconsistent methodology and findings across the eight studies, we were unable to draw firm conclusions in favour of any particular intervention. Innovative strategies for enhancing medication adherence in the elderly and reliable measures of adherence are needed. Until further evidence from single-intervention strategies becomes available, combinations of educational and behavioural strategies should be used to improve medication adherence in the elderly.
Drugs & Aging 01/2008; 25(4):307-24. · 2.67 Impact Factor
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ABSTRACT: Atrial fibrillation is common in older people, and is associated with an increased risk of ischaemic stroke. Antithrombotic therapy reduces stroke-risk, but is known to be under-prescribed.
To use an evidence-based indicator to audit antithrombotic prescribing for older hospital inpatients with atrial fibrillation, and to assess whether feedback of audit results to hospital staff increases antithrombotic use.
Cross-sectional notes-based audits, before and after feedback.
Six Aged Care and three General Medicine units at nine Australian public teaching hospitals between September 1998 and May 1999.
1416 hospital inpatients aged 65 years and over (median age 81).
Medication charts were reviewed to identify patients prescribed digoxin or amiodarone. Presence of atrial fibrillation was confirmed by review of the patients' medical notes. To be considered appropriate, patients with atrial fibrillation had to be receiving either warfarin or aspirin (or both), or have documented contraindications to both agents. Feedback of audit results was provided to medical, pharmacy and nursing staff at multidisciplinary meetings. Changes in antithrombotic prescribing 4-8 weeks and 6 months after feedback were assessed. Prescribing 8 weeks prior to feedback was assessed retrospectively.
Appropriateness of the decision to prescribe (or not prescribe) antithrombotic therapy increased from 81/112 (72%) immediately prior to feedback to 97/105 (92%) 4-8 weeks later (P<0.0001). Six months after feedback, appropriateness of prescribing declined slightly, to 85% (p=0.36). Over the 8 weeks prior to feedback, appropriateness of prescribing did not change (74% versus 77%, p=0.80). Increased aspirin prescribing accounted for most of the improvement in antithrombotic use after feedback, while warfarin continued to be under-used.
Antithrombotics were under-prescribed for older patients with atrial fibrillation. Audit and multidisciplinary feedback resulted in increased antithrombotic prescribing. The intervention had a greater impact on aspirin prescribing compared with warfarin.
Age and Ageing 10/2002; 31(5):391-6. · 3.09 Impact Factor
