Informing policy makers in developing countries:Practices and limitations of geriatric home medication review in Malaysia-A qualitative inquiry

Objective:To explore existing practices and challenges in the delivery of geriatric home medication review(HMR).The study was part of a larger study aimed to offer solution to expand the range of geriatric HMR.Methods:This study employed qualitative exploratory design through semi-structured individual in-depth interviews with the public pharmacists involved in the delivery of geriatric HMR at public hospitals.The purpose of the interviews was to explore challenges faced by them in the delivery of geriatric HMR.Results:Based on the emerging themes from the qualitative data,the study reveals that geriatric HMR in Malaysia is integrated as part of multidisciplinary home care visits,encompassing a diverse patient population with various healthcare needs.However,it faces challenges such as the lack of outcome monitoring,formal training,and workforce constraints.Despite these hurdles,there is a pressing need for the expansion of this service to better serve the community,and collaboration with community pharmacists holds potential to broaden its scope.Ultimately,the findings suggest that pharmacist-led HMR is both warranted and feasible within the Malaysian healthcare context.In order to optimize medicine-use among older people living in the community,approaches for expanding geriatric HMR services in Malaysia must be developed.Conclusions:This study holds profound implications as it attempts to illuminate policy makers in developing countries,enabling them to formulate effective HMR plans.By considering the challenges highlighted within this research,policy makers can design a comprehensive HMR service that caters adeptly to the healthcare needs of the mass population.

Clinical Medication Review and Falls in Older People—What Is the Evidence Base?

Background: This paper reports findings from a literature review undertaken to assess the current evidence base for clinical medication review and falls in older people. This forms part of a larger, organisational supported project design work-stream, where the objectives are to define the operational details for clinical medication review as part of multi-factorial assessment for elderly fallers in the community. Patients will be identified and targeted through an integrated care pathway mapping and elderly patient care screening service. Objective: A review of national and best practice guidance to help our understanding of how clinical medication review could be optimised. Methods: A PubMed database search was undertaken with search terms including “elderly” and “falls” and “medicines” followed by study of relevant publications in English and including cited referenced publications within selected papers. Results: Our findings were that both medication over-use and under-use in the elderly occur frequently and can be harmful. Many drugs commonly used by older persons have not been systematically studied as risk factors for falls. The screening tool of older people’s prescriptions (STOPP) and screening tool to alert to right treatment (START), validated for assessment of potentially inappropriate prescribing in the elderly, offer the possibility of provision of a structured clinical medication review to patients, with a need for more research on the impact of the STOPP START interventions on both the rates of falls and risk of falls in the elderly.

Quality Improvement Project of Pharmacist-Assisted Medication Reconciliation and Regimen Review Following Veteran Discharge to Hospice

The Joint Commission NPSG （National Patient Safety Goals） requires that medication reconciliation be performed upon any transition of care （NPSG 03.06.01）. The hospice clinical pharmacist, in delivering pharmaceutical care, performs medication regimen reviews to identify medication-related problems. This project aims to improve the medication reconciliation process upon transition from inpatient units to non-VA （Veterans Affairs） hospice care by identifying and resolving medication discrepancies and medication-related problems. Patients discharged from inpatient to non-VA hospice care from October 2013-March 2014 were included. Medication reconciliation was performed by the pharmacist via telephone with the patient/caretaker and the hospice agency within two weeks of discharge. The patient＇s primary care provider was contacted via telephone when changes were recommended, and upon agreement, medication lists were updated electronically. A total of 18 patients were included. The results found that following medication reconciliation and regimen review, the mean number per patient of VA medications discontinued and non-VA medication documented was 5.7 and 10.8 respectively. The mean number per patient of medication discrepancies and medication-related problems was 14.4 and 8.6 respectively. This quality improvement project demonstrates the vulnerability of patients to medication discrepancies and medication-related problems and highlights the role of pharmacists in resolving these issues during this transition of care.

Identifying High-Risk Medication Prescriptions to Prevent Potentially Severe Adverse Drug Events in Primary-Care Patients with Chronic Multimorbidities:The Polychrome Study

Background:The association between multimorbidities and polypharmacy among elderly individuals is well documented,and polypharmacy has been shown to increase the risk of adverse drug events(ADEs).However,little information is available about the risks associated with the lifelong use of medications to treat chronic multimorbidities.Objective:To determine the prevalence and nature of high-risk prescriptions among primary-care patients with chronic multimorbidities.Methods:We studied a weighted stratified random sample of 105 prescriptions for different patients with chronic multimorbidities taken from the Polychrome database established using information from the French primary-care record database(Observatoire de la Médecine Générale).A medication review was conducted to identify contra-indications and potential drug-drug interactions for each prescription.Results:Contra-indications were identified for 60(57.1%)prescriptions,potential drug-drug interactions for 70(66.7%),absolute contra-indications for 9(8.6%),and inadvisable drug combinations for 11(10.5%).In all,19(18.1%)different patients were at risk for major ADEs.Cardiovascular and nervous-system drugs contributed 66.2% of contra-indications and 69.3% of potential drug-drug interactions.Conclusions:This exploratory study confirms the high prevalence and potential seriousness of prescriptions at risk for ADEs in a population of primary-care patients with chronic multimorbidities.The high prevalence of interactions involving the cardiovascular and nervous systems indicates that efforts to improve prescription practices should target these two categories of conditions and drugs in patients with chronic multimorbidities.

Medical Joumal Reviews医学期刊回顾2007年12月(第12期)

Richard F.Lockey教授,医学博士,WAO网站主编;Gary Hellermann,博士,为从业的变态反应科医生回顾了主要医学期刊的一些重要文章。

Medical Joumal Reviews医学期刊回顾2007年10月(第10期)

Richard F.Lockey教授,医学博士,WAO网站主编;Gary Hellermann,博士,为从业的变态反应科医生回顾了主要医学期刊的一些重要文章。

Medical Journal Reviews医学期刊回顾2007年11月(第11期)

Richard F.Lockey教授,医学博士,WAO网站主编;Gary Hellermann,博士,为从业的变态反应科医生回顾了主要医学期刊的一些重要文章。

3所综合医院住院抗菌药物使用合理性

目的分析上海市A区3所区属公立综合医院3个代表性病种的住院抗菌药物的使用合理性。方法通过病案评阅,分析3个代表性病种的抗菌药物使用的合理性。结果住院急性单纯性/化脓性阑尾炎(行腹腔镜阑尾切除术)、社区获得性肺炎和输尿管结石(行输尿管镜碎石取石术)的抗菌药物使用不规范且医院间存在较大的差异,有预防性抗菌用药不合理或抗菌药物用药超量的问题。结论应通过强化管理改变医疗机构及其临床医师抗菌药物的不合理使用习惯。

Deprescribing antihypertensive treatment in nursing home patients and the effect on blood pressure

Background It is debatable whether treating multimorbid nursing home patients with antihypertensive drugs produces beneficial effects. Most cardiovascular guidelines promote treatment; few have advice on how to deprescribe when treatment may no longer be necessary. We investigated the effect of medication review on antihypertensive drug use and the association between cognition, blood pressure, and prescribing. Methods From August 2014 to December 2015, 765 patients from 72 units （clusters） in 32 Norwegian nursing homes were included in a 4-month, multicentre, cluster-randomized, controlled trial, with 9-month follow-up. Patients ≥ 65 years old with antihypertensive treatment （n = 295, 39%） were randomized to systematic medication review where the physician received support from peers （collegial mentoring） or were given care as usual （control condition）. Outcome measures were the number of antihypertensive drugs, systolic blood pressure, and pulse. We used hospitalizations and deaths as criteria to assess harm. Results At baseline, each patient used 9.2 ± 3.5 regular drugs, and 1.6 ± 0.7 antihypertensives. Mean blood pressure was 128/71 mmHg and 9% had a systolic pressure ≥ 160 mmHg. Between baseline and month four, antihypertensives were deprescribed to a significantly higher extent in the intervention group （n = 43, 32%） compared to control （n = 11, 10%）; Incidence Rate Ratio = 0.8, 95% CI = 0.7？0.9. In the intervention group, there was an immediate increase in systolic blood pressure when antihypertensives were reduced, from baseline 128 ± 19.5 mmHg to 143 ± 25.5 mmHg at month four. However, at month nine, the blood pressure had reverted to baseline values （mean 134 mmHg）. Deprescription did not affect pulse and systolic pressure. The number of hospitalizations was higher in control patients at month four （P = 0.031） and nine （P = 0.041）. Conclusion A systematic medication review supported by collegial mentoring significantly decreased the use of antihypertensive drugs in nursing home patients without an effect on the systolic blood pressure over time.

Improving Cost Savings and Patient Outcomes with Hepatitis C Triple Therapy Treatment in the Medicaid Population

One of the major infections that plague our world today, hepatitis C, has been causing liver disease in humans since early history. Over time, human ingenuity has allowed us to develop more effective treatments, but at traditionally massive monetary costs. In order to combat such costs, PerformRx came up with three ways to drive costs downward but also increase different outcomes for the Pennsylvania Medicaid population it serves. By restricting access to drugs via prior authorizations, tracking members within a DTM （drug therapy management） program, and giving members touchscreen tablet devices, there was an observed cost savings and a better ability to service members. Even though there was little impact on overall member outcomes, these initial interventions were the right steps to be innovative and create a beneficial scenario for both members and clients.

Oxaliplatin Induced Neurotoxicity among Patients with Colorectal Cancer: Documentation in Medical Records—A Pilot Study

Patients with colorectal cancer (CRC) can have chemotherapy with oxaliplatin postoperatively. Oxaliplatin can cause acute and chronic neurotoxicity. It is important to be aware of neurotoxic side effects so they can be documented and action taken at an early stage. The study aimed to identify and explore neurotoxic side effects documented in the medical records of patients with colorectal cancer treated with oxaliplatin-based adjuvant chemotherapy. Data in this study were medical records;presenting documentation about patients treated at the University Hospital in the south of Sweden between 2009 and 2010. A summative content analysis approach was used to explore the neurotoxic side effects. Identification and quantification of the content of medical records were carried out by using a study-specific protocol. “Cold sensitivity” and “tingling in the hands” were the most frequently documented neurotoxicity-related terms in the medical records. This identification was followed by interpretation. Three categories were identified in the interpretive part of the study: acute, chronic, and degree of neurotoxicity. The results show the importance of awareness of neurotoxic side effects so that they can be documented and action taken at an early stage. The documentation could be more reliable if patient-reported structured measurements were used, combined with free descriptions in the medical records. Being able to follow the progression of the symptoms during and after treatment would improve patient’s safety and also quality of life. The protocol that we developed and used in this review of medical records may be helpful to structure the documentation in the electronic system for documentation of neurotoxicity side effects.