Showing papers in "International Journal of Clinical Pharmacy in 2015"
TL;DR: The aim of this paper is to highlight the importance of rigour in qualitativeResearch, present different philosophical standpoints on the issue of quality in qualitative research and to discuss briefly strategies to ensure rigour on the basis of recent research.
Abstract: The use of qualitative research methodology is well established for data generation within healthcare research generally and clinical pharmacy research specifically. In the past, qualitative research methodology has been criticized for lacking rigour, transparency, justification of data collection and analysis methods being used, and hence the integrity of findings. Demonstrating rigour in qualitative studies is essential so that the research findings have the “integrity” to make an impact on practice, policy or both. Unlike other healthcare disciplines, the issue of “quality” of qualitative research has not been discussed much in the clinical pharmacy discipline. The aim of this paper is to highlight the importance of rigour in qualitative research, present different philosophical standpoints on the issue of quality in qualitative research and to discuss briefly strategies to ensure rigour in qualitative research. Finally, a mini review of recent research is presented to illustrate the strategies reported by clinical pharmacy researchers to ensure rigour in their qualitative research studies.
181 citations
TL;DR: The need to better define clinical pharmacy services and standardize methods that assess the impact of these services on patient health outcomes is emphasized.
Abstract: Background Multiple reviews have evaluated the impact of pharmacist-delivered patient care on health-related outcomes. However, it is unclear which of the pharmacist-delivered interventions in these services are the most effective. Aim of the review To gather the evidence of the impact of clinical pharmacy services on the medication use process or on patient outcomes using an overview of systematic reviews. Methods PubMed was searched to retrieve systematic reviews published between 2000 and 2010 that assessed the impact of clinical pharmacy services on the medication use process or patient outcomes. Two independent reviewers evaluated the study eligibility and one extracted the description and results of the services. The methodological quality of each review was assessed with the R-AMSTAR tool. Results Of the 343 potentially relevant records identified, 49 systematic reviews, comprising a total of 269 randomized controlled trials, met the selection criteria. Clinical pharmacy services that focused on specific medical conditions, such as hypertension or diabetes mellitus, revealed a positive impact of pharmacists’ interventions on patient outcomes. For other medical conditions, however, the results were inconclusive (e.g., dyslipidemia or thromboprophylaxis). Interventions that targeted medication adherence and assessed the impact of clinical pharmacy services in prescription appropriateness also produced inconclusive results because of the variability of methods used to assess both medication adherence and medication appropriateness. Conclusions Systematic reviews that assessed clinical pharmacy services targeting specific conditions were more conclusive given that the intervention was well defined, and the measured outcomes were unequivocal and tangible. Conversely, the results were inconclusive for interventions with a broader target and with monitoring parameters that were unclearly established or inconsistently assessed across studies. These findings emphasize the need to better define clinical pharmacy services and standardize methods that assess the impact of these services on patient health outcomes.
103 citations
TL;DR: The majority of older inpatients using statins are willing to have one or more of their current medications, including statins, deprescribed, and these findings can be used to inform clinical practice and interventional statin deprescribing studies to optimise medication use in older adults.
Abstract: Background Deprescribing is the process of medication withdrawal with the aims of reducing the harms of potentially inappropriate medication use and improving patient outcomes. Deprescribing of statins may be indicated for some older people, because the evidence for benefit in primary prevention of cardiovascular disease is limited and there is an increased risk of side effects in old age. Objective To determine older peoples’ attitudes and beliefs regarding medication use and their willingness to have regular medications, particularly statins, deprescribed. Setting An Australian acute-care hospital. Method A cross-sectional study of patients admitted to a teaching hospital in Sydney, Australia, aged ≥65 years and taking a statin was conducted. Attitudes and beliefs regarding medication use and willingness to have medications or statins deprescribed were captured using the validated Patients’ Attitudes Towards Deprescribing questionnaire, supplemented with additional statin-specific questions. Main outcome measures. Older inpatients’ attitudes and perspectives towards stopping medications, in particular statins. Results Overall, 180 participants were recruited, with a median age of 78 years, (interquartile range 71–85). Eighty-nine percent (95 % CI 84.4–93.6) of participants reported that they would be willing to stop one or more of their regular medications if their doctor said it was possible. Ninety-five percent (95 % CI 91.8–98.2) agreed that they would be willing to have a statin deprescribed. Moreover, 94 % (95 % CI 90.5–97.5) of participants expressed concern regarding the potential side effects of taking a statin. Conclusion The majority of older inpatients using statins are willing to have one or more of their current medications, including statins, deprescribed. These findings can be used to inform clinical practice and interventional statin deprescribing studies to optimise medication use in older adults.
82 citations
TL;DR: Nearing the end of life, patients in this palliative care centre receive discomfort-relieving drugs mainly via the subcutaneous route, however, most of these drugs are unlicensed for this specific application and guidelines are based on low level of evidence.
Abstract: Background In end-of-life care, symptoms of discomfort are mainly managed by drug therapy, the guidelines for which are mainly based on expert opinions. A few papers have inventoried drug prescriptions in palliative care settings, but none has reported the frequency of use in combination with doses and route of administration. Objective To describe doses and routes of administration of the most frequently used drugs at admission and at day of death. Setting Palliative care centre in the Netherlands. Method In this retrospective cohort study, prescription data of deceased patients were extracted from the electronic medical records. Main outcome measure Doses, frequency and route of administration of prescribed drugs Results All regular medication prescriptions of 208 patients, 89 % of whom had advanced cancer, were reviewed. The three most prescribed drugs were morphine, midazolam and haloperidol, to 21, 11 and 23 % of patients at admission, respectively. At the day of death these percentages had increased to 87, 58 and 50 %, respectively. Doses of these three drugs at the day of death were statistically significantly higher than at admission. The oral route of administration was used in 89 % of patients at admission versus subcutaneous in 94 % at the day of death. Conclusions Nearing the end of life, patients in this palliative care centre receive discomfort-relieving drugs mainly via the subcutaneous route. However, most of these drugs are unlicensed for this specific application and guidelines are based on low level of evidence. Thus, there is every reason for more clinical research on drug use in palliative care.
77 citations
TL;DR: There are still major differences between community pharmacy practice in Europe, mostly due to the legal framework and remuneration issues, which impact on the range of services available from pharmacies to the community of each country.
Abstract: Background The role of the pharmacist has undergone profound changes over the recent years. In most European countries, the tendency seems to be that pharmacists are moving from being product-oriented to service-oriented. An interesting series of papers describing care related services of pharmacy in various countries has been published in 2006, but much has changed since then. This paper aims to provide an updated view on the overall health care sector in Europe, with a special focus on services in community pharmacy. Objective To list and compare health care and community pharmacy structure in Europe; and to discuss the facilitators and barriers that can be found in health care systems and may promote or hinder the implementation of new community pharmacy services. Setting European community pharmacy practice. Methods A cross-sectional study was undertaken where data were collected using an online survey sent to a purposive sample of representatives from 27 European countries. Main outcome measure variation in professional community pharmacy services across Europe. Results Data were obtained from 22 respondents in 19 countries (70.4 %). Health care is mainly provided by a form of public National Health Services in 17 of the 19 countries. Demographic criteria for founding new pharmacies were present in 17 countries. Medicines are exclusively available in pharmacies in approximately one third of the countries. Smoking cessation (93.8 %), drug waste management (81.3 %) and pharmaceutical care programmes for specific diseases (77.8 %) were reported as the most widely disseminated services in European pharmacies. Conclusions There are still major differences between community pharmacy practice in Europe. Differences are mostly due to the legal framework and remuneration issues, which impact on the range of services available from pharmacies to the community of each country.
66 citations
TL;DR: Atrial fibrillation screening in pharmacies is well accepted by pharmacists and customers, and potential for sustainable future implementation including remuneration linked to government or pharmacy incentives, combined cardiovascular screening, and automating sections of risk-assessments using touch-screen technology is identified.
Abstract: Background Atrial fibrillation guidelines advocate screening to identify undiagnosed atrial fibrillation. Community pharmacies may provide an opportunistic venue for such screening. Objective To explore the experience of implementing an atrial fibrillation screening service from the pharmacist’s perspective including: the process of study implementation; the perceived benefits; the barriers and enablers; and the challenges for future sustainability of atrial fibrillation screening within pharmacies. Setting Interviews were conducted face-to-face in the pharmacy or via telephone, according to pharmacist preference. Method The ‘SEARCH-AF study’ screened 1000 pharmacy customers aged ≥65 years using an iPhone electrocardiogram, identifying 1.5 % with undiagnosed atrial fibrillation. Nine pharmacists took part in semi-structured interviews. Interviews were transcribed in full and thematically analysed. Main outcome measure Qualitative analysis of the experience of implementing an AF screening service from the pharmacist’s perspective. Results Four broad themes relating to service provision were identified: (1) interest and engagement in atrial fibrillation screening by pharmacists, customers, and doctors with the novel, easy-to-use electrocardiogram technology serving as an incentive to undergo screening and an education tool for pharmacists to use with customers; (2) perceived benefits to the pharmacist including increased job satisfaction, improvement in customer relations and pharmacy profile by fostering enhanced customer care and the educational role of pharmacists; (3) implementation barriers including managing workflow, and enablers such as personal approaches for recruitment, and allocating time to discuss screening process and fears; and, (4) potential for sustainable future implementation including remuneration linked to government or pharmacy incentives, combined cardiovascular screening, and automating sections of risk-assessments using touch-screen technology. Conclusion Atrial fibrillation screening in pharmacies is well accepted by pharmacists and customers. Many pharmacists combined atrial fibrillation screening with other health screens reporting improved time-efficiency and greater customer satisfaction. Widespread implementation of atrial fibrillation screening requires longterm funding, which could be provided for a combined cardiovascular screening service. Further research could focus on feasibility and cost-effectiveness of combined cardiovascular screening in pharmacies.
60 citations
TL;DR: The results reinforce the need for the implementation of pharmaceutical care services to institutionalized elderly, necessary to improve medicines efficacy and safety, better clinical outcomes and cost reduction.
Abstract: Background An aging population and the increasing prevalence of chronic diseases have led to the increased use of medicines. Portugal is one of the European countries where more medicines are consumed and the associated expense is higher. Medicines are associated with enormous health benefits but also with the potential to cause illness and death. A drug related problem (DRP) is an “an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes”. In the U.S., they represent the 4th–6th leading cause of death and have an estimated cost of 130 billion dollars. Moreover, many of these DRP can be avoided. Elderly are at increased risk of DRP due to multiple factors: pluripathology and consequent polypharmacy, complex dosing regimens, pharmacokinetic/pharmacodynamic and functional/cognitive changes. Therefore, this population would be the one who would benefit most from the prevention, detection and control of DRP. The role of the pharmacist as an integral element of health care has been recognized by various international and European organizations. Providing pharmaceutical care as a patient-centered activity, focusing on their needs related to pharmacotherapy, contributes to guarantee that drug expenditure is a good investment, with benefits that outweigh potential risks. Objective To evaluate the need for pharmaceutical care implementation in institutionalized, polymedicated elderly. Methods Descriptive observational cross-sectional study carried out in six Portuguese nursing homes, selected by convenience, in November–December 2013. Each institution selected up to six patients, according to the following inclusion criteria: age ≥65 years, number of medications ≥5 and ability to respond to an interview. All participants signed an informed consent form. Pharmacists carried out a structured interview with each patient and consulted patient medical records to gather demographic data and information on health problems and medications used. To identify DRP, official drug information sources were consulted, and the STOPP and START tool was used. The ATC, the ICD-10 and the PCNE Classification V 6.2 classification systems were used for medicines, health problems and DRP classifications, respectively. For each medicine used, the cheapest equivalent available was also identified. Results The sample included 31 elderly (64.52 % female, mean age 81.65 ± 6.86). On average, subjects presented a mean of 7.94 ± 2.76 health problems with diseases of the circulatory system being the most common. The sample used a median of ten medicines per patient. Those medicines working in the cardiovascular, nervous and digestive systems were the most frequently used (29.75, 29.43 and 19.30 %, respectively). A total of 484 DRP (median: 15 DRP/patient) was found. The most common DRP were Adverse Drug Event, non-allergic (49.51 %), Drug treatment more costly than necessary (19.11 %), Effect of drug treatment not optimal (14.82 %) and Unnecessary drug treatment (6.16 %). The most cost-effective proposal, would lead to a saving of € 3,950/year in the studied sample. Conclusion These results reinforce the need for the implementation of pharmaceutical care services to institutionalized elderly, necessary to improve medicines efficacy and safety, better clinical outcomes and cost reduction.
55 citations
TL;DR: Addressing the aspect of unused drug disposition constitutes a challenge for Mexican government, due to health implications related to inadequate disposition, because no matter how efficient the programs of collection and disposal of expired drugs are, none of them can collect all unused or expired drugs.
Abstract: Background Unsafe storage of unused medications at home leads to an increased risk of toxicity, accidental childhood poisoning or risk for suicide, whereas an improper disposal of unwanted/expired medications from household raises concern about environmental pollution. Objective The aim of the study was to characterize expired medications collected according to the types of therapeutic groups, pharmaceutical dosage forms, expiration dates and were prescribed or over the counter drugs, and whether they came from Mexican health system or purchased by patients themselves. Setting The study was conducted in the metropolitan area of Monterrey during a 12-month period from March 2012 to February 2013. Method Unused/expired drugs were collected according to the collection and disposal of expired medication program instituted by the Department of Health of the State of Nuevo Leon. Pharmacists and students from The Autonomous University of Nuevo Leon recorded types of therapeutic groups, total of medicines in each group, among other classification criteria. Main outcome measure The proportion of every collected therapeutic group, type of dosage forms, and expiration date. Results The amount of medications classified was 22,140 items corresponding to a 30 % of the total collected medications in that period of time; most of them belonged to the non-steroidal anti-inflammatory drugs (16.11 %). According to the pharmaceutical dosage forms, results showed that a high percentage were solid dosage forms (73.39 %), of the total unused/expired medications, most of them were prescription drugs (91 %) which were purchased at private pharmacies. Expiration date of medications ranges from 1995 to 2016, being 2011 the outstanding year (36.66 %). Conclusion Addressing the aspect of unused drug disposition constitutes a challenge for Mexican government, due to health implications related to inadequate disposition. No matter how efficient the programs of collection and disposal of expired drugs are, none of them can collect all unused or expired drugs, that is the reason why the best approach might be to prevent this need.
50 citations
TL;DR: This commentary presents recommendations that could be incorporated into prescribing processes for all healthcare professionals and used to support the rationalization or deprescribing of medication in diminished life expectancy and uses statin therapy as an illustrative example.
Abstract: It is widely acknowledged that patients—particularly those late in life—are frequently exposed to the harms of medication. To minimize these harms, several frameworks have been developed by which prescribing can be optimized. In the context of diminishing life expectancy, these frameworks can be used to reduce medications that are no longer necessary, but appear to fall short of actual guidelines that incorporate a consideration of stopping medications. In this commentary, we present recommendations that could be incorporated into prescribing processes for all healthcare professionals and, ultimately, used to support the rationalization or deprescribing of medication in diminished life expectancy. We frame these recommendations in the same context as guidance for the initiation and discontinuation of implantable cardiac devices and argue that the two processes—with regards to decision-making—should be the same. We present our recommendations with preventive medication use in mind, and use statin therapy as an illustrative example.
46 citations
TL;DR: Clinicians and health care policy makers should direct their effort toward two main strategies to improve adherence increasing awareness and education of effective ways to remind patients about their medications.
Abstract: Background Non-adherence to long-term therapy for chronic illnesses is considered the major reason why patients fail to reach their clinical goals, resulting in suboptimal health outcomes, death, and extra costs on the health care systems. Knowledge about the disease and prescription medications, an understanding of the reason the medication is needed, and good expectations or attitudes toward treatment, all contribute to a better medication-taking behavior and are associated with higher rates of adherence. Objective This study examines the relationship between knowledge and adherence of patients receiving long-term therapy for one or more chronic illnesses in Jordan. Settings The study was conducted in the out-patient clinics of two Jordanian hospitals (The University of Jordan Hospital and Jordan Hospital). Methods This was a cross-sectional study that included 902 patients. The correlation between patients’ knowledge about their chronic medications and adherence was assessed. Effects of several sociodemographic characteristics were investigated in regard to knowledge and adherence. Main outcome measures Knowledge was assessed by a modified version of the McPherson index, and the Morisky Medication Adherence Scale was used to assess medication adherence. Results A significant correlation was found between patients’ knowledge and their adherence to medications (r = 0.357, p < 0.001). Most of the participants had low adherence. Younger age, higher education levels, high income, fewer medications and diseases were significant predictors of higher knowledge levels. Knowledgeable patients were found to be twice as likely to have moderate-to-high adherence as their unknowledgeable counterparts. Similarly, high income and higher education were associated with higher adherence scores. Conclusion Forgetfulness and aversion toward medications were the most common barriers to medication adherence. This implicates that clinicians and health care policy makers should direct their effort toward two main strategies to improve adherence increasing awareness and education of effective ways to remind patients about their medications.
44 citations
TL;DR: The findings show increasing use of NOACs by outpatients and the number of patients taking potentially harmful combinations of antithrombotic drugs was substantial, and adherence to NOacs in daily practice may be suboptimal to prevent thrombosis.
Abstract: Background Non-vitamin K oral anticoagulants (NOACs) became available in the Netherlands in 2008, providing another antithrombotic treatment besides vitamin K antagonists (VKAs) and antiplatelet agents (APAs). Objective To describe the patterns of antithrombotic drug use between 2008 and 2013 by examination of dispensing data form community pharmacies in the Netherlands; to determine the concomitant use of NOACs with VKAs and APAs and switching between the drug classes; and to compare adherence to NOACs with adherence to APAs. Setting An observational retrospective study was conducted using routinely collected dispensing data from Dutch community pharmacies. Methods For each calendar year, the numbers of NOAC, VKA, and APA users were calculated. Adherence was determined for NOACs and APAs by the percentage of days covered by medication (PDC). Information on the prescribed daily dose of VKAs was unavailable. Main outcome measures Comparison of age, sex, and co-medications of users of the three drug classes; concomitant use of different antithrombotic drug classes and switching between these in each year; and mean PDC and percentages of all users with a PDC above 80 %. Results NOAC use increased during the study period to 29,687 users in 2013. In that year there were 484,024 VKA users and 1313,032 APA users. Compared with users of VKAs, NOAC users were slightly younger and more frequently used antiarrhythmic drugs and beta blockers as co-medications. Substantial numbers of patients were dispensed potentially harmful combinations in 2013: 820 subjects were dispensed NOACs together with VKAs, and 684 subjects were dispensed NOACs, VKAs, and APAs concomitantly. Mean adherence to NOACs was 84.2 % compared with 87.3 % to APA. One in four NOAC users had a PDC lower than 80 % compared with one in five APA users. Conclusion Our findings show increasing use of NOACs by outpatients. The number of patients taking potentially harmful combinations of antithrombotic drugs was substantial. Adherence to NOACs in daily practice may be suboptimal to prevent thrombotic events.
TL;DR: A community pharmacy based medication review with follow-up service delivered by a trained pharmacist, has positive effects across clinical, economic, and humanistic outcomes.
Abstract: Background Despite many research studies demonstrating the benefit in clinical, economic, and humanistic outcomes of professional pharmacy services, there is a paucity of evidence when these services become incorporated into the usual practice of a community pharmacy. Objective The objective of the present study was to evaluate the clinical, economic, and humanistic impact of a pharmacist-conducted medication review with follow-up following 18 months implementation. Setting Community pharmacies in Spain. Method The study used an effectiveness-implementation hybrid design. During the follow-up, patients attended the pharmacy on a monthly basis and received the medication review with follow-up service. Main outcome measure Economic, clinical, and humanistic measures were used to assess the impact of the service. Results 132 patients received the service. During the 18 months of follow-up, 408 negative outcomes related to medicines (which are uncontrolled health problems) were identified, of which 393 were resolved. The average number of medicines used by patients significantly decreased from 6.1 (SD: 2.9) to 3.3 (SD: 2.2). A significant decrease was also observed in hospitalizations [OR = 0.31 (IC 95 % = 0.10–0.99)] and in emergency department visits [OR = 0.16 (IC 95 % = 0.05–0.55); p = 0.001]. A general trend to increase all quality of life domains was observed over time. The higher increase was observed in the construct health transition [mean increase: 30.7 (SD: 25.4)], followed by bodily pain [mean increase: 22.3 (SD: 25.4)], and general health [mean increase: 20.7 (SD: 23.7)]. Medication knowledge significantly increased in terms of aggregated domains of dose, frequency, drug indication [from 8.9 (SD: 17.5) to 87.9 (SD: 25.0)], and dose and frequency [from 9.3 (SD: 17.9) to 92.5 (22.1)]. Although a slight improvement was observed in terms of drug indication, this increase was not statistically significant. 68 out of 132 patients (51.5 %) were non-adherent to their treatment. This number decreased to 1 (0.8 %) after the follow-up [OR = 0.007 (IC 95 %: 0.001–0.053) p < 0.001]. Conclusion A community pharmacy based medication review with follow-up service delivered by a trained pharmacist, has positive effects across clinical, economic, and humanistic outcomes. These results are consistent with previous studies. Incorporating community pharmacists into the multidisciplinary team is a reliable solution to improve health care.
TL;DR: Prescribing potentially inappropriate medications is common among older adults receiving home health care services in Qatar, a finding that warrants further attention.
Abstract: Background Older patients receiving home health care are particularly at risk of receiving potentially inappropriate medications compared to community-dwelling population. Data on appropriateness of prescribing in these patients is limited. Objective To investigate the prevalence, patterns and determinants of potentially inappropriate medications among elderly patients receiving Home Health Care Services in Qatar. Setting Home Health Care Services department in Hamad Medical Corporation-Qatar. Methods A cross-sectional study, conducted over a 3 months period. Patients 65 years and older, taking at least one medication and receiving home care services were included. Potentially inappropriate medications were identified and classified in accordance with the American Geriatrics Society 2012 Beers Criteria. Main outcome measure Prevalence of potentially inappropriate medications using updated Beers criteria. Results A total of 191 patients (38.2 %) had at least one potentially inappropriate medication. As per Beers criteria, 35 % of medications were classified as medications to be avoided in older adults regardless of conditions and 9 % as potentially inappropriate medications when used with certain diseases or syndromes. The majority of potentially inappropriate medications (56 %) were classified as medications to be used with caution. The two leading classes of potentially inappropriate medications were antipsychotics (27.4 %) and selective serotonin reuptake inhibitors (16 %). Significant predictors of inappropriate prescribing were hypertension [adjusted OR 1.7; 95 % CI (1.0, 2.8)], dementia [adjusted OR 2.0; 95 % CI (1.2, 3.1)], depression [adjusted OR 21.6; 95 % CI (2.8, 168.4)], and taking more than ten prescribed medications [adjusted OR 1.9; 95 % CI (1.3, 2.8)]. Conclusion Prescribing potentially inappropriate medications is common among older adults receiving home health care services in Qatar, a finding that warrants further attention. Polypharmacy, hypertension, depression and dementia were significantly associated with potentially inappropriate prescribing.
TL;DR: Mild to moderate renal failure is a frequent complication during treatment with TDF although severe renal impairment is scarce and an independent association with the risk of kidney damage for age is confirmed.
Abstract: Background Since the beginning of highly active antiretroviral therapy utilization, the association of renal impairment with treatment toxicity is more prevalent. Tenofovir disoproxil fumarate (TDF) side effects include renal toxicity. Objective To assess the incidence of renal damage in human immunodeficiency virus (HIV)-positive patients treated with TDF and to identify associated potential risk factors. Setting A public university tertiary 450-beds hospital in Spain. Method Retrospective, longitudinal observational study that included adult HIV-1-infected patients treated with TDF. Patient´s treated with TDF from January 2010 to December 2012 were included. Patient follow-up started when initiating treatment with TDF up until either end of treatment or end of study (July 31, 2013). The estimated glomerular filtration rate was calculated using the four-variable modification of diet in renal disease. Renal toxicity was classified as moderate [estimated glomerular filtration rate (eGFR) < 60 ml/min] or severe (eGFR < 30 ml/min). The incidence rate for moderate and severe renal insufficiency was calculated as number of cases per 1000 patient-year. A univariate analysis and binary logistic regression was carried out in order to identify risk factors associated with renal toxicity by using the forward stepwise method (likelihood ratio) Main outcome measure: Incidence rate for moderate and severe renal insufficiency (RI) Results 451 patients were included in the study. The incidence rate of moderate RI was 29.2 cases per 1000 person-year (95 % CI 22.1–36.3), whereas the incidence of severe RI was 2.2 cases per 1000 person-year (95 % CI 0.3–4.1). Multivariate analysis confirmed an independent association with the risk of kidney damage for age (OR 1.08 95 % CI 1.05–1.12), time on treatment with TDF (OR 1.16 95 % CI 1.04–1.30), baseline creatinine (OR 49.80 95 % CI 7.90–311.92) and treatment with NNRTIs (OR 0.45 95 % CI 0.24–0.83). Conclusion Mild to moderate renal failure is a frequent complication during treatment with TDF although severe renal impairment is scarce. Risk factors include age, duration of treatment with TDF, elevated baseline creatinine levels, and treatment with protease inhibitor boosted with ritonavir combinations.
TL;DR: There was a limited knowledge of pharmacovigilance that could have affected reporting incidence and educational intervention and a practical training program need to be applied by the drug regulatory body as well as health authorities to enhance the pharmacov Vigilance and drug safety culture in Saudi Arabia.
Abstract: Background Drug safety has major implications for patients’ lives. However, this concept is still considered new to some healthcare professionals. Objective This study aims to investigate the knowledge and awareness of Saudi healthcare professionals to pharmacovigilance (PV). Setting Governmental and private hospitals at three main cities in Saudi Arabia (Riyadh, Jeddah, and Dammam). Methods A cross-sectional survey among healthcare professionals (pharmacists, physicians, and nurses) within 12 Saudi hospitals was conducted between November and December 2012. The questionnaire consisted of 18 questions assessing the knowledge, awareness, and attitude of healthcare professionals (HCPs) towards science and the concept of PV. Descriptive statistics were used to analyze the data. The data were analyzed using Statistical Analysis Software (SAS 9.3). Main outcome measure Knowledge, attitude and practice of HCPs toward pharmacovigilance. Results Three-hundred and thirty-two healthcare professionals completed the survey (response rate 72 %), 110 (34 %) physicians, 106 (33 %) pharmacists, and 104 (32 %) nurses. More than half of the participants (55 %) did not know the correct definition of PV. Two-thirds of the respondents, 207 (65.5 %), had knowledge of the aim of post-marketing surveillance, yet only 113 (36.9 %) were aware that the National Pharmacovigilance and Drug Safety Center is the official body for monitoring adverse drug reaction in Saudi Arabia. In addition, 34.7 % agreed that lack of time could be a major barrier for reporting. The majority of the respondents (78.4 %) believed that reporting was a professional obligation and hospitals should have a drug safety department. Conclusions There was a limited knowledge of pharmacovigilance that could have affected reporting incidence. Educational intervention and a practical training program need to be applied by the drug regulatory body as well as health authorities to enhance the pharmacovigilance and drug safety culture in Saudi Arabia.
TL;DR: The limited evidence available in the literature suggests that pharmacists can make positive interventions in relation to the quality of the medication use process, in collaboration with other healthcare professionals, carers and patients with ID.
Abstract: BackgroundPeople with intellectual disabilities (ID) have complex pharmaceutical care needs due to a high prevalence of multimorbidity, a notable degree of polypharmacy and a high risk of adverse drug reactions. Despite this, people with ID often experience significant health disparities compared to the general population. In most developed countries, increasing emphasis on deinstitutionalisation and community integration also means greater utilisation of primary health care services where general practitioners, pharmacists and carers may lack appropriate information about the pharmaceutical needs of this population. Aim of the review To explore what type of pharmaceutical care interventions were being undertaken for people with ID and how pharmacists’ contributed to the care of people with ID as part of multidisciplinary teams. Method Systematic searches of the following electronic databases were carried out; CINAHL, Pubmed, Medline, Embase, Cochrane library, Science Direct and International Pharmaceutical Abstracts. Results were limited to the period 1994–2014 using search terms ‘learning disabilities’, ‘intellectual disabilities’, ‘mental retardation’, ‘developmental disabilities’, ‘learning difficulties’ and ‘pharmacist intervention’, ‘pharmaceutical care’, ‘primary care', ‘pharmacy' “pharmacists” “pharmacy technicians”. Agreement on studies to be included was arrived at by consensus and by using a pre-determined set of inclusion criteria. Due to the heterogeneous nature of the study aims, methods and presentation of study outcomes found, a narrative review was considered appropriate. Results In total, after removal of duplicates, 70 abstracts were identified and screened from the initial search. After screening and consensus agreement, eight articles which met the inclusion criteria were included in the review and were analysed under the following three themes; pharmacist interventions, pharmacists collaboration in provision of care, qualitative studies relating to patient, carers, and pharmacist views on care of people with ID. Conclusions The limited evidence available in the literature suggests that pharmacists can make positive interventions in relation to the quality of the medication use process, in collaboration with other healthcare professionals, carers and patients with ID. However, further research will be required to increase the evidence base with regard to the benefits of providing pharmaceutical care to patients with intellectual disability and to inform future policy and planning.
TL;DR: Hospitalization in a geriatric division resulted in an increase in PIPs and a decrease in PPOs, and strategies to reduce PIPS need to be implemented, especially for patients with longer hospital stay and a history of falls.
Abstract: Background Screening Tool of Older Person’s Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START) have been increasingly used to evaluate potentially inappropriate prescriptions (PIPs) and potentially prescription omissions (PPOs). The impact of hospitalization on PIPs/PPOs has not been investigated in depth. Objective To compare the prevalence of PIPs/PPOs in elderly patients on hospital admission and discharge and to identify associated risk factors. Setting An acute medical geriatric division of the Tel Aviv Medical Center (Israel). Method This retrospective cross-sectional study included patients admitted from 12/2011 to 12/2012 aged ≥65 years. Data from patients’ records included demographic details, diagnoses and medications at admission and discharge. STOPP/START criteria were applied to each patient’s record. Main outcome measure Prevalence of PIPs/PPOs on hospital admission and discharge. Results Three hundred patients were included (mean ± SD age 81.9 ± 7.2 years). Admission PIPs prevalence was 39.3 % (118 patients, 172 PIPs) and it increased to 46.0 % (138 patients, 209 PIPs) at discharge (P = 0.009). Admission PPOs prevalence was 41.0 % (123 patients, 153 PPOs) and it decreased to 28.3 % (85 patients, 99 PPOs) at discharge (P < 0.001). Having at least one PIP/PPO at discharge but not at admission was associated with length of hospital stay (OR 1.02, 95 % CI 1.001–1.03). History of falls increased the risk of being a “new PIP patient” (OR 2.25, 95 % CI 1.03–4.9), whereas diabetes increased the risk of being a “new PPO patient” (OR 3.86, 95 % CI 1.2–12.5). Conclusion Hospitalization in a geriatric division resulted in an increase in PIPs and a decrease in PPOs. Strategies to reduce PIPs need to be implemented, especially for patients with longer hospital stay and a history of falls.
TL;DR: A comprehensive review of discrete choice experiments for pharmacy services can be found in this article, where the authors provide an overview of key methodological developments in the design and analysis of discrete-choice experiments.
Abstract: Background Two previous systematic reviews have summarised the application of discrete choice experiments to value preferences for pharmacy services. These reviews identified a total of twelve studies and described how discrete choice experiments have been used to value pharmacy services but did not describe or discuss the application of methods used in the design or analysis. Aims (1) To update the most recent systematic review and critically appraise current discrete choice experiments of pharmacy services in line with published reporting criteria and; (2) To provide an overview of key methodological developments in the design and analysis of discrete choice experiments. Methods The review used a comprehensive strategy to identify eligible studies (published between 1990 and 2015) by searching electronic databases for key terms related to discrete choice and best-worst scaling (BWS) experiments. All healthcare choice experiments were then hand-searched for key terms relating to pharmacy. Data were extracted using a published checklist. Results A total of 17 discrete choice experiments eliciting preferences for pharmacy services were identified for inclusion in the review. No BWS studies were identified. The studies elicited preferences from a variety of populations (pharmacists, patients, students) for a range of pharmacy services. Most studies were from a United Kingdom setting, although examples from Europe, Australia and North America were also identified. Discrete choice experiments for pharmacy services tended to include more attributes than non-pharmacy choice experiments. Few studies reported the use of qualitative research methods in the design and interpretation of the experiments (n = 9) or use of new methods of analysis to identify and quantify preference and scale heterogeneity (n = 4). No studies reported the use of Bayesian methods in their experimental design. Conclusion Incorporating more sophisticated methods in the design of pharmacy-related discrete choice experiments could help researchers produce more efficient experiments which are better suited to valuing complex pharmacy services. Pharmacy-related discrete choice experiments could also benefit from more sophisticated analytical techniques such as investigations into scale and preference heterogeneity. Employing these sophisticated methods for both design and analysis could extend the usefulness of discrete choice experiments to inform health and pharmacy policy.
TL;DR: Canadian pharmacists are willing to expand their scope of practice to include immunization, however, implementation requires professional development and certification in vaccine administration, which is not acceptable to the public.
Abstract: Background Adult immunization rates worldwide fall below desired targets. Pharmacists are highly accessible healthcare providers with the potential to increase immunization rates among adults by administering vaccines in their practice setting. Objective To determine the attitudes of community-based Canadian pharmacists with respect to expanding their scope of practice to include administration of immunizations. Method An internet-based survey was emailed to community pharmacists across Canada. The survey was piloted through focus groups for qualitative feedback, tested for content validity, and test–retest reliability prior to dissemination. Results There were 495 responses to the survey. The majority (88 %) agreed that pharmacists as immunizers would increase public access, improve rates (84 %), and be acceptable to the public (72 %). However, only 68 % agreed that pharmacists should be permitted to immunize. The majority of respondents (90 %) agreed that certification in vaccine administration should be required for pharmacists to administer vaccines. Pharmacists identified education, reimbursement, and negative interactions with other providers as barriers to pharmacists administering vaccines. Conclusion Canadian pharmacists are willing to expand their scope of practice to include immunization. However, implementation requires professional development and certification in vaccine administration.
TL;DR: Global community pharmacist knowledge of dietary supplements appears to be poor and community pharmacists have an professional responsibility to provide accurate health information about dietary supplements as they do for any other therapies they provide to patients.
Abstract: Background Internationally, the use of dietary supplements has been growing rapidly. Patient support for pharmacist sales of nutritional and dietary supplements is also strong. The increase in demand for nutritional and dietary supplements and subsequent advice about these products, however, makes it necessary that pharmacists maintain a contemporary knowledge of the area. Aim of review This systematic review was conducted to examine the current evidence regarding the level of the nutritional and dietary supplement knowledge of community pharmacists and their understanding of their therapeutic effects. Method Electronic databases including Medline, Scopus, Embase, CINAHL, Scifinder and the Cochrane Controlled Trials Register were searched. Studies assessing nutritional knowledge of pharmacists in community pharmacies were eligible for inclusion. All languages and study designs were considered. Study results were analysed and pharmacist knowledge scores were given out of 100 %. Results From 5594 studies identified, nine met the inclusion criteria. Each study tested pharmacist knowledge with predetermined questions calculating results as the number of questions answered correctly. These knowledge scores were converted to a percentage score for the purpose of this paper. The median knowledge score across all papers was 64 %. A lack of studies assessing community pharmacists’ knowledge of commonly sold vitamins and minerals was observed. Conclusions Global community pharmacist knowledge of dietary supplements appears to be poor. Community pharmacists have an professional responsibility to provide accurate health information about dietary supplements as they do for any other therapies they provide to patients. Further research including that which assesses pharmacists’ therapeutic knowledge of commonly sold vitamins and minerals is suggested.
TL;DR: It is revealed that more than one fifth of chronic medication users report primary nonadherence and more than 50 % report secondaryNonadherence, which indicates that the existence of spare medicines and financial constraints occurred were the two most frequent reasons cited fornonadherence.
Abstract: Background Portugal is currently facing a serious economic and financial crisis, which is dictating some important changes in the health care sector. Some of these measures may potentially influence patients’ access to medication and consequently adherence, which will ultimately impact on health status, especially in chronic patients. Aims This study aimed at providing a snapshot of adherence in patients with chronic conditions in Portugal between March and April 2012. Setting Community pharmacy in Portugal. Method A cross-sectional pilot study was undertaken, where patients were recruited via community pharmacies to a questionnaire study evaluating the number of prescribed and purchased drugs and, when these figures were inconsistent, the reasons for this. Main outcome measures Primary and secondary adherence measures. Failing to purchase prescription items was categorized as primary nonadherence. Secondary nonadherence was attributed to purchasing prescription items, but not taking medicines as prescribed. Results Data were collected from 375 patients. Primary nonadherence was identified in 22.8 % of patients. Regardless of the underlying condition, the most commonly reported reason for primary non-adherence was having spare medicines at home (“leftovers”), followed by financial problems. The latter appeared to be related to the class of medicines prescribed. Primary non-adherence was associated with low income (<475 €/month; p = 0.026). Secondary non-adherence, assessed by the 7-MMAS was detected in over 50 % of all patients, where unintentional nonadherence was higher than intentional nonadherence across all disease conditions. Conclusion This study revealed that more than one fifth of chronic medication users report primary nonadherence (22.8 %) and more than 50 % report secondary nonadherence. Data indicates that the existence of spare medicines and financial constraints occurred were the two most frequent reasons cited for nonadherence (47, 6–64, 8 and 19–45.5 %, depending on the major underlying condition, respectively).
TL;DR: Over-the-counter proton-pump inhibitors have a valuable role in the treatment of frequent heartburn and Pharmacists have the opportunity to guide patients through selection of the best treatment option for their symptoms.
Abstract: Background Heartburn and other symptoms of gastro-oesophageal reflux occur in ~30 % of survey respondents in multiple countries worldwide. Heartburn and acid regurgitation are common complaints in the pharmacy, where patients frequently seek relief through medication and advice. The growing number of proton-pump inhibitors available in the over-the-counter setting provides an efficacious choice to patients experiencing frequent heartburn. Pharmacists can assist patients in their treatment decisions whilst inquiring about alarm symptoms that should prompt a physician referral. Aim of the review Provide pharmacists with a review of current clinical research and expert guidelines on use of over-the-counter proton-pump inhibitors. Methods This narrative review was conducted to identify publications relevant to the following themes: overview of available treatments for frequent episodes of heartburn/acid regurgitation; treatment algorithms providing guidance on when to use over-the-counter proton-pump inhibitors; and the role of the pharmacist in the use of over-the-counter proton-pump inhibitors. Results Frequent symptoms of acid reflux, such as heartburn and acid regurgitation, can interfere substantially with daily life activities. Proton-pump inhibitors are the most efficacious treatment for frequent reflux symptoms and are recommended as an appropriate initial treatment in uncomplicated cases. Proton-pump inhibitors have varying pharmacokinetics and pharmacodynamics across the class; 20 mg esomeprazole has higher bioavailability and exposure than over-the-counter omeprazole, for example. However, differences in clinical efficacy for symptom relief have not been demonstrated. The safety and tolerability of proton-pump inhibitors have been well established in clinical trial and post-marketing settings, and use of a short regimen is associated with a very low likelihood of missing a more serious condition. Pharmacists can assist patients with accurate self-diagnosis by asking short, simple questions to characterize the nature, severity, and frequency of symptoms. Additionally, pharmacists can inquire about alarm symptoms that should prompt referral to a physician. Pharmacists should inform those patients for whom over-the-counter proton-pump inhibitors are appropriate on their proper use. Conclusion Over-the-counter proton-pump inhibitors have a valuable role in the treatment of frequent heartburn. Pharmacists have the opportunity to guide patients through selection of the best treatment option for their symptoms.
TL;DR: Clinical pharmacists perceived that a learning and practice module for successful interprofessional practice integrated into a postgraduate clinical pharmacy program enhanced their interprofessional communication skills.
Abstract: Background Interprofessional communication skills are important for pharmacists to build collaborative relationships with other health professionals, integrate into healthcare teams, maximise their effectiveness in patient care in addressing complex care needs and meet the demands of health care reforms Objective This qualitative study explores clinical pharmacists’ experiences and reflections after completing a learning and practice module which introduced them to a framework for successful interprofessional communication Setting The postgraduate clinical pharmacy program at The University of Queensland and the clinical pharmacy practice environments of forty-eight hospital and seven community based pharmacists Method A learning and practice module outlining a framework for successful interprofessional communication was designed and integrated into a postgraduate clinical pharmacy program Enrolled pharmacists applied newly learnt communication skills in pro-actively initiated, clinical discussions with a health professional in their practice environment They provided written reflections on their experiences which were analysed using thematic analysis Main outcome Pharmacists’ perceptions of the impact of applying the communication framework during their interaction with a health professional in their practice setting Results Themes which emerged from reflections described pharmacists’ confidence and capabilities to successfully conduct a clinical discussion with a health professional after initial apprehension and nervousness about the scheduled interaction The application of the communication framework enhanced their perception of their professional identity, credibility and ability to build a collaborative working relationship with other health professionals Conclusions Pharmacists perceived that a learning and practice module for successful interprofessional practice integrated into a postgraduate clinical pharmacy program enhanced their interprofessional communication skills The development of pro-active, interprofessional communication skills has the potential to increase interprofessional collaboration and pharmacists’ personal role satisfaction Pharmacists also observed it added value to their professional contribution in health care teams when addressing the demands of increasingly complex health care needs and reforms
TL;DR: Exposure to out-of-range international normalized ratio values was associated with significantly increased risk of adverse clinical outcomes among new warfarin patients with non-valvular atrial fibrillation.
Abstract: Background Although efficacious in stroke prevention in non-valvular atrial fibrillation, many warfarin patients are sub-optimally managed. Objective To evaluate the association of international normalized ratio control and clinical outcomes among new warfarin patients with non-valvular atrial fibrillation. Setting Adult non-valvular atrial fibrillation patients (≥18 years) initiating warfarin treatment were selected from the US Veterans Health Administration dataset between 10/2007 and 9/2012. Method Valid international normalized ratio values were examined from the warfarin initiation date through the earlier of the first clinical outcome, end of warfarin exposure or death. Each patient contributed multiple in-range and out-of-range time periods. Main outcome measure The relative risk ratios of clinical outcomes associated with international normalized ratio control were estimated. Results 34,346 patients were included for analysis. During the warfarin exposure period, the incidence of events per 100 person-years was highest when patients had international normalized ratio 3, patients had significantly increased risk of major bleeding (relative risk ratio: 1.5; 95 % confidence interval 1.2–2.0). Conclusion In a Veterans Health Administration non-valvular atrial fibrillation population, exposure to out-of-range international normalized ratio values was associated with significantly increased risk of adverse clinical outcomes.
TL;DR: Assessment of the frequency of potential DDI throughout the hospital stay of cancer patients undergoing systemic chemotherapy in southern Brazil found older age and number of drugs prescribed were more likely to lead to major interactions.
Abstract: Background Adverse drug–drug interactions (DDI) are a major cause of morbidity and mortality in susceptible populations Cancer patients are a population at high risk for DDI especially because they commonly receive several drugs concomitantly The knowledge about the most common interactions between drugs used in oncology inpatients is essential to reduce drug-related problems and increase the safety and efficacy of the therapy Objective To assess the frequency of potential DDI throughout the hospital stay of cancer patients undergoing systemic chemotherapy, describe their epidemiology, and identify risk factors for major DDI Setting An oncology–hematology inpatient unit of a public hospital in southern Brazil Method Drug prescriptions were prospectively reviewed throughout the hospital stay of patients admitted for systemic chemotherapy Descriptive statistics and Poisson regression were used for data analysis Main outcome measure Potential DDI and their characteristics Results The cohort consisted of 113 patients, who used a mean of 89 ± 27 drugs/day All patients had at least one potential DDI (median, 70/patient; 25th–75th percentile, 35–120), and 46 % of the patients had at least one DDI classified as major, ie that it may result in death, hospitalization, permanent injury, or therapeutic failure Only 137 % of all interactions involved antineoplastic agents, identified in 628 % of patients Most interactions were of moderate severity, 64 % were major, and 85 % had a recommendation for therapy modification Multivariate analysis revealed mean number of drugs prescribed [relative risk (RR) for each additional drug: 112; 95 % confidence interval (CI) 107–117; P < 001] and age ≥60 years (RR 148; 95 % CI 103–214; P < 001) as independent risk factors for major DDI Conclusion Potential DDI were highly frequent in this cohort Older age and number of drugs prescribed were more likely to lead to major interactions Prospective surveillance is required to detect adverse DDI, aiming primarily at reducing the risk of toxicity or treatment failure
TL;DR: Using all cumulative data, signal detection in SRS data achieved higher specificity and sensitivity than EHR data, however, when data were restricted to time prior to a regulatory action, performance characteristics changed in a manner consistent with both the type of data and nature of the ADR.
Abstract: Background Electronic reporting and processing of suspected adverse drug reactions (ADRs) is increasing and has facilitated automated screening procedures. It is crucial for healthcare professionals to understand the nature and proper use of data available in pharmacovigilance practice. Objectives To (a) compare performance of EU-ADR [electronic healthcare record (EHR) exemplar] and FAERS [spontaneous reporting system (SRS) exemplar] databases in detecting signals using “positive” and “negative” drug-event reference sets; and (b) evaluate the impact of timing bias on sensitivity thresholds by comparing all data to data restricted to the time before a warning/regulatory action. Methods Ten events with known positive and negative reference sets were selected. Signals were identified when respective statistics exceeded defined thresholds. Main outcome measure Performance metrics, including sensitivity, specificity, positive predictive value and accuracy were calculated. In addition, the effect of regulatory action on the performance of signal detection in each data source was evaluated. Results The sensitivity for detecting signals in EHR data varied depending on the nature of the adverse events and increased substantially if the analyses were restricted to the period preceding the first regulatory action. Across all events, using data from all years, a sensitivity of 45–73 % was observed for EU-ADR and 77 % for FAERS. The specificity was high and similar for EU-ADR (82–96 %) and FAERS (98 %). EU-ADR data showed range of PPV (78–91 %) and accuracy (78–72 %) and FAERS data yielded a PPV of 97 % with 88 % accuracy. Conclusion Using all cumulative data, signal detection in SRS data achieved higher specificity and sensitivity than EHR data. However, when data were restricted to time prior to a regulatory action, performance characteristics changed in a manner consistent with both the type of data and nature of the ADR. Further research focusing on prospective validation of is necessary to learn more about the performance and utility of these databases in modern pharmacovigilance practice.
TL;DR: A strong family and personal history of drug allergy were found to be significantly related to the confirmed allergic drug reactions and risk factors related to confirmed drug allergy in children.
Abstract: Background Parent or self-reported drug allergy claims frequently overestimate the real incidence of hypersensitivity reactions. A detailed and algorithmic diagnostic evaluation of drug reactions may allow a proper diagnosis. Objective The aim of this study was to determine the confirmation rates and risk factors for confirmed allergic drug reactions in children. Setting Mersin University Hospital in Turkey. Method The study consisted of children between ages of 8 months and 18 years with the history of suspected drug allergy as reported by the clinician or the patients. Parents were interviewed by a clinician to complete questionnaires that included questions about demographic data and characteristics of index drug reaction. Immediate reactions (IRs) were assessed with immediate-reading skin prick (SPT) and intradermal tests (IDT). Nonimmediate reactions (NIRs) were assessed with SPT, both early and delayed reading of IDT and patch tests. In case of negative skin tests, drug provocation tests were performed. The possible risk factors for confirmed drug allergy in univariate analysis (p < 0.1) were entered into the multivariate logistic regression analysis to determine independent predictors. Main outcome measure (1) Confirmation rates of drug allergy (2) Risk factors related to confirmed drug allergy in children. Results We evaluated a total of 180 suspected drug allergy reactions in 97 children, mainly to antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs) and anticonvulsants. Among all suspected allergic drug reactions, 97 (53.9 %) were immediate type and 83 (46.1 %) were non-immediate type. The average time interval between the reaction and allergologic work-up was 5 months. Drug allergy confirmation rates were 30.1 % for beta-lactams, 27.2 % for non-betalactams, 21.1 % for NSAIDs and 30 % for anticonvulsants. Eight of 54 confirmed NIRs showed positivity on immediate skin tests. Regulatory T cells, TGF-β and IL-10 levels were not different between groups with and without confirmed drug allergy. A strong family and personal history of drug allergy were found to be significantly related to the confirmed allergic drug reactions. Conclusion Parent or self-reported drug allergy should be evaluated with a standardized diagnostic work-up before strict prohibitions are made. In addition, family and personal histories of drug allergy were significant risk factors related to allergic drug reactions in children.
TL;DR: How a collaborative quality-improvement approach based on PDSA cycles can meet the challenge of implementing MR to improve medication management at admission is highlighted.
Abstract: Background In France, medication errors are the third leading cause of serious adverse events. Many studies have shown the positive impact of medication reconciliation (MR) on reducing medication errors at admission but this practice is still rarely implemented in French hospitals. Objective Implement and sustain a MR process at admission in two surgery units. The quality improvement approach used to meet this objective is described. Setting The gastrointestinal surgery and orthopedic surgery departments of a 407 inpatient bed French teaching hospital Methods A step by step collaborative approach based on plan–do–study–act (PDSA) cycles. Three cycles were successively performed with regular feedback during multidisciplinary meetings. Main outcome measure: mean unintended medication discrepancies (UMDs) per patients at admission. Results The three PDSA cycles and the monitoring phase allowed to implement, optimize and sustain a MR process in the two surgery units. Cycle 1, by showing a rate of 0.65 UMDs at admission (95 % CI 0.39–0.91), underlined the need for a MR process; cycle 2 showed how the close-collaboration between pharmacy and surgery units could help to reduce mean UMDs per patients at admission (0.18; 95 % CI 0.09–0.27) (p < 0.001); finally, cycle 3 allowed the optimization of the MR process by reducing the delays of the best possible medication history availability. Conclusions This work highlights how a collaborative quality-improvement approach based on PDSA cycles can meet the challenge of implementing MR to improve medication management at admission.
TL;DR: This work states that mixed-methods methodology is best suited when the research questions require: triangulating findings from different methodologies to explain a single phenomenon, and informing the design of one method based on the findings of another method, development of a scale/questionnaire and answering different research questions within a single study.
Abstract: Introduction Mixed-methods methodology, as the name suggests refers to mixing of elements of both qualitative and quantitative methodologies in a single study. In the past decade, mixed-methods methodology has gained popularity among healthcare researchers as it promises to bring together the strengths of both qualitative and quantitative approaches. Methodology A number of mixed-methods designs are available in the literature and the four most commonly used designs in healthcare research are: the convergent parallel design, the embedded design, the exploratory design, and the explanatory design. Each has its own unique advantages, challenges and procedures and selection of a particular design should be guided by the research question. Guidance on designing, conducting and reporting mixed-methods research is available in the literature, so it is advisable to adhere to this to ensure methodological rigour. When to use it is best suited when the research questions require: triangulating findings from different methodologies to explain a single phenomenon; clarifying the results of one method using another method; informing the design of one method based on the findings of another method, development of a scale/questionnaire and answering different research questions within a single study. Two case studies have been presented to illustrate possible applications of mixed-methods methodology. Limitations Possessing the necessary knowledge and skills to undertake qualitative and quantitative data collection, analysis, interpretation and integration remains the biggest challenge for researchers conducting mixed-methods studies. Sequential study designs are often time consuming, being in two (or more) phases whereas concurrent study designs may require more than one data collector to collect both qualitative and quantitative data at the same time.
TL;DR: Characteristics of on-line pharmacies which are related to whether websites are regulated or non-regulated and those characteristics which could be used by patients to increase the likelihood of accessing regulated sites are identified.
Abstract: Background Evidence suggests that consumers potentially put themselves at risk when purchasing medicines on-line. Whilst logos provided by regulators may provide some level of reassurance there may be other indicators which could be used by consumers to identify those websites which may be safely used. Objectives Identify characteristics of on-line pharmacies which are related to whether websites are regulated or non-regulated and those characteristics which could be used by patients to increase the likelihood of accessing regulated sites. Setting Online pharmacies which supply diazepam, fluoxetine and simvastatin. Methods Using piloted search terms via Google and Yahoo search engines, identified websites were screened for regulatory status, adherence to regulatory standards, administrative requirements, clinical assessment requirements and additional details deemed to be of relevance to a user. Characteristics of regulated and non-regulated (defined as those with an absence of a correctly linked regulatory logo) websites were compared to identify differences which could be used to improve patient safety. Main outcome measure Regulatory status, adherence to regulatory standards, quality of information provision, barriers to medicines access. Results 113 websites sold diazepam, fluoxetine and simvastatin; were identified within the first 100 results. Less than quarter were found to be regulated online pharmacies. 80 websites were willing to sell the medication without a prescription. The unregulated internet pharmacy websites (defined as those with an absence of a correctly linked regulatory logo) were found to adhere more closely to the clinical criteria, were less significantly likely to disclose a contact name and address, telephone number of the pharmacy or demand a prescription prior to sale (P < 0.05, Fisher’s Exact). Conclusions The three prescription-only medicines which are liable to abuse, have potentially serious interactions and require counselling to ensure patient safety are readily available via the internet. When purchasing medicines via this route UK consumers should be made aware of the importance of regulatory logos and additionally should ensure that the seller can be meaningfully contacted by the contact details provided. The provision of clinical information should not be used alone as an indication of the seller’s provenance.