Title: Ageing of the population and use of low-dose drug regimens in older patients (ii.) Author: Jana Koleníková Tutor: Assoc. Prof. Daniela Fialová, PharmD, Ph.D. University: Charles University Faculty: Faculty of Pharmacy in Hradec Králové Department: Department of Social and Clinical Pharmacy Introduction: Proportion of seniors in the population is increasing worldwide, therefore rational pharmacotherapy in older adults is more emphasized. The drug pharmacokinetics and pharmacodynamics change in older age due to physiological and pathological changes, but also due to frequent polymorbidity and polypharmacotherapy. The use of certain medicines is therefore considered risky in seniors. For this reason, explicit expert criteria of medications potentially inappropriate in the aged (so called PIMs) have been created in many countries. Considering the fact that seniors were usually not included in randomized controlled trials, information about specific dosing in older adults for many medications is not stated in Summary of Product Characteristics (SmPCs) which provide basic information on effective and safe administration of medicines. The aim of the diploma thesis was to clarify whether in case of PIMs specific information about geriatric dosing is stated in SmPCs, or at least general warnings that...

Substantial research has been done on inpatient provider order entry systems with varying degrees of clinical decision support. Such studies have examined how these technologies impact patient safety as well as the quality and cost of care. However, given that most medical care and prescriptions are administered in an ambulatory setting, the dearth of research on ACPOE systems is quite astonishing. This knowledge gap demonstrates the need for an integrative and systematic literature review that attempts to assess the research done on computerized patient safety interventions in ambulatory care. This review’s findings provided adequate evidence that ACPOE systems are effective interventions for reducing medication errors. Other evidence further indicated that, in terms of functional capabilities, commercial ACPOE and e-prescribing systems may be catching up with their homegrown counterparts. PDA-based CDSSs were depicted as useful tools for raising adherence to guidelines and inducing safer prescribing. These findings suggest that ACPOE And PDA-based CDS systems show promise for improving safety and healthcare quality in ambulatory settings. ACPOE specifically, tended to have more advanced CDS attributes but, nonetheless, showed more negative results compared to the e-prescribing systems. Close scrutiny should therefore be given to the elements of decision support that ambulatory physicians find most useful.

In recent years, several problems in the field of assistive device have been lifted. To manage the development Beslutsstöd (Decision support) has emerged as a systematic working method. Beslutsstöd is designed as a guideline and serves as a tool for physical therapists and occupational therapists in the prescription process of assistive devices. Beslutsstöd thereby aims to improve the quality and effectiveness of the prescribing process of assistive device in the organization of the municipalities. An implementation evaluation about how the implementation of Beslutsstöd in the municipalities did proceed has not been done. Neither is there any set plan for how the implementation of Beslutsstöd will proceed in the municipalities. Therefore, the evaluation's main question is: how did municipalities proceed to implement Beslutsstöd in order to develop and ensure the quality of their work regarding prescribing assistive device. Two central questions are if success factors and/or obstacles of certain significance can be detected throughout the implementation process of Beslutsstöd, if so, which? We also asked whether the respondents perceive that the local goals for implementing Beslutsstöd have been reached. The evaluation showed that the implementation processes in the three municipalities differ. Four components have distinguished as particularly significant in all municipalities in relation to success factors and obstacles. These are motivation, information, a gradually approach and the ability of the municipality to adapt Beslutsstöd towards their organization or vice versa. Two municipalities have successfully implemented Beslutsstöd and therefor reached their goals. One municipality did not succeed in fulfilling their goals and is not practicing Beslutsstöd today.

Introduction: In the past decades, the representation of seniors is increasing and the knowledge and the approaches to geriatrics and gerontology are more and more important. With the increasing age, there is also a grow in number of diseases and drugs (high incidence of polymorbidity and polypharmacotherapy). With regard to physiological, pathological and other changes related to aging, there is a higher risk of complications after drugs. For the rational use of drugs with old people, it is essential to eliminate negative influence and negative impacts of various drugs or non-drugs factors and to ensure the maximum effectiveness, safety and cost-effectiveness of given drugs regimens. Especially using anticholinergic drugs can have negative effect on older people (e.g confusion) while aging, "the cholinergic deficit" is increasing. As the anticholinergic drugs is necessary for seniors, it is required to use drugs with the lowest anticholinergic activity. This diploma thesis evaluates the prevalence of anticholinergic drugs usage. It also elaborates which anticholinergic drugs and combinations of these anticholinergic drugs are most commonly prescribed to geriatric patients in acute, ambulatory and pharmacy healthcare in the Czech Republic. Methodology: The analyzed data were collected from 2018 to...

Institution/department: Charles University, Faculty of Pharmacy in Hradec Králové, Department of Social and Clinical Pharmacy Title of diploma thesis: Rationality of benzodiazepine use in older patients Supervisor: Assoc. Prof. Daniela Fialová, PharmDr. Ph.D. Author: Adriana Magátová Introduction: Benzodiazepines are one of the most commonly prescribed potentially inappropriate drugs (PIMs) in geriatric patients in Europe and are responsible for common problems associated with risky drug prescription in older age (eg, cognitive impairment, falls, orthostatic hypotension, drug dependence, and others). Physiological and pathophysiological changes associated with the aging process, as well as frequent polymorbidity and polypharmacotherapy, are associated with more frequent occurrence of drug-related complications in older age. With the growing proportion of geriatric population, the importance of preventing drug complications in older adults increases. The aim of this study was to compare prescribing habits in the use of BZD and in the use of drug combinations with sedative potential and to determine the association of their use with drug-related risks in geriatric patients in community pharmacy practice in Spain (SP) and the Czech Republic (CZ) and in groups of patients assessed in various healthcare settings...

Background: Mannitol has been used in the past for the prevention of cisplatin-induced nephrotoxicity. Studies on its efficacy have conflicting results. An educational newsletter was designed for local oncologists on the conflicting data of mannitol use in preventing cisplatin-induced nephrotoxicity. Purpose: The purpose of this study was to determine whether a pharmacist-created newsletter intervention led to changes in the mannitol prescribing practices of local oncologists. Methods: A newsletter describing the paucity of evidence to support mannitol use to prevent cisplatin-induced nephrotoxicity was distributed via e-mail to local oncologists in October 2010. Mannitol prescribing rates were retrospectively evaluated before and after newsletter distribution. The Mann-Whitney U test was used to compare nonparametric continuous data. The chi-square test was used for nominal data. Descriptive statistics were performed for baseline demographics, and odds ratios were calculated for possible risk factors for acute kidney injury (AKI). The primary endpoint was a change in mean mannitol dose before and after the newsletter intervention. The secondary endpoint was the difference in the rate of AKI before and after the intervention. Data were collected for 67 patients with various malignancies. Results: There was a difference in the average mannitol dose before and after newsletter intervention (P = .02). The rates of AKI before and after newsletter were similar. Conclusion: A pharmacist-led newsletter intervention was associated with significantly decreased rates of mannitol usage after intervention.

Background: COVID-19 and antimicrobial resistance (AMR) are two intersecting public health crises. Antimicrobial overuse in patients with COVID-19 threatens to contribute to the growing threat of AMR. Guidelines are fundamental in encouraging antimicrobial stewardship. We sought to assess the quality of antibiotic prescribing guidelines and recommendations in the context of COVID-19, and if these guidelines incorporate principles of antimicrobial stewardship. Methods: We performed a systematic survey which included a search using the concepts “antibiotic/antimicrobial” in September to November 2022 of the eCOVID-19 living map of recommendations (RecMap) which aggregates and summarizes guidelines across a range of international sources and all languages. Guidelines providing explicit recommendations regarding antibacterial use in COVID-19 from any jurisdiction were eligible for inclusion. Guideline and recommendation quality were assessed using the AGREE II and AGREE-REX instruments, respectively. We extracted guideline characteristics including panel representation and the presence or absence of explicit statements related to antimicrobial stewardship (i.e., judicious antibiotic use, antimicrobial resistance or adverse effects as a consequence of antibiotic use). We used logistic regression to evaluate the relationship between guideline characteristics including quality and incorporation of antimicrobial stewardship principles. Results: Twenty-eight guidelines with 63 antibiotic prescribing recommendations were included. Recommendations focused on antibiotic initiation (n=52, 83%) and less commonly antibiotic selection (n=13, 21%), and duration of therapy (n=15, 24%). Guideline and recommendation quality varied widely. Twenty (71%) guidelines incorporated at least one concept relating to antimicrobial stewardship. Including infectious diseases expertise on the guideline panel (OR 9.44, 97.5%CI: 1.09 to 81.59) and AGREE-REX score (OR 3.26, 97.5%CI: 1.14 to 9.31 per 10% increase in overall score) were associated with a higher odds of guidelines addressing antimicrobial stewardship. Conclusion: There is an opportunity to improve antibiotic prescribing guidelines in terms of both quality and incorporation of antimicrobial stewardship principles. These findings can help guideline developers better address antibiotic stewardship in future recommendations beyond COVID-19. / Thesis / Master of Public Health (MPH) / COVID-19 and antimicrobial resistance (AMR) are two serious threats to public health. Inappropriate use of antibiotics in patients with COVID-19 can worsen AMR and make future infections harder to treat. Practice guidelines can help healthcare providers prescribe antibiotics wisely. Using antibiotics carefully to reduce their harms is called antibiotic stewardship. This study evaluated the quality of practice guidelines for antibiotic prescribing in patients with COVID-19. It also assessed if the guidelines included principles of antibiotic stewardship. We searched for guidelines in a database called the eCOVID-19 living map of recommendations (RecMap). We found 28 guidelines with 63 recommendations. Identified guidelines differed widely in quality. Just over two-thirds of guidelines addressed antibiotic stewardship. Guidelines developed along with infectious disease experts and guidelines with higher recommendation quality scores were more likely to address antibiotic stewardship. Our findings can help guideline developers better address antibiotic stewardship in future recommendations.

Despite national guidelines, the management of difficult asthma remains suboptimal, and there may be opportunities for pharmacists to improve asthma outcomes. This six-month prospective, randomised, open study investigated the effects of pharmaceutical care across primary and secondary care on difficult asthma. Fifty-two patients attending a hospital difficult asthma clinic were randomised (1:1) to receive usual medical care (UC), or pharmacist interventions (PI) comprising asthma review, education, and medicines optimisation from a hospital advanced clinical pharmacist, plus follow-up targeted Medicines Use Review (t-MUR) from community pharmacists. Forty-seven patients completed the study. More interventions were performed in the PI group at baseline (total 79 vs. 34, p<0.001), but only six patients received a t-MUR. At six-months, PI were non-inferior to UC for all outcomes. The primary outcome measure was Juniper’s Asthma Control Questionnaire score and reduced (improved) from a median (IQ) score of 2.86 (2.25, 3.25) and 3.00 (1.96, 3.71) in the PI and UC groups respectively to 2.57 (1.75, 3.67) and 2.29 (1.50, 3.50). At baseline, 58.8%, 46.9% and 17.6% of patients had optimal inhaler technique using Accuhalers, Turbohalers or pMDIs; education improved technique but this was not maintained at six-months. Adherence rates <80% were observed in 57.5% of patients at baseline, and was improved in the PI group at six-months (10/20 PI vs. 3/21 UC had adherence rates of 80-120%, p=0.020). This study demonstrates that the management of difficult asthma by specialist pharmacists is as effective as usual medical care. Future research should investigate whether pharmacist-led follow-up produces further improvements. / The Pharmaceutical Trust for Educational and Charitable Objects (PTECO) (now known as Pharmacy Research UK).

BACKGROUND: High-cost healthcare users (HCUs) are patients who use disproportionate healthcare resources compared to their peers. A better understanding of their co-morbidity status, medication use, and healthcare utilization is needed to improve health interventions and policies. OBJECTIVES: We aimed to: (1) synthesize what is known about HCUs and interventions for managing them, (2) characterize how HCUs differ from non-HCUs, and (3) explore the impact of medications and whether prescribing quality contributes to differences in healthcare costs and HCU status development. METHODS: We synthesized what is known about HCUs and used the GRADE framework to evaluate the evidence for interventions designed to improve their health. We conducted retrospective population-based matched cohort and case-control studies of incident older adult HCUs using health administrative data. We examined prescribing and medication costs over the non-HCU to HCU transition period and compared them to non-HCUs. We conducted logistic regression to evaluate associations between HCU status development and the use of high-cost drugs and potentially inappropriate medications. RESULTS: HCU interventions to date have shown inconsistent effects on clinical outcomes and healthcare costs and the overall quality of evidence supporting their efficacy is low. Compared to non-HCUs, HCUs have higher rates of polypharmacy, hospitalization, and mortality. Medications are the highest healthcare cost category in the pre-HCU year and these costs rise nearly 1.7-fold in the HCU year. High-cost drug use increases significantly during the HCU transition period and 3.6% achieve HCU status based on drug costs alone. Use of several potentially inappropriate medications and high-cost drugs significantly increase the odds of HCU development. CONCLUSIONS: Medications can contribute to high-cost healthcare directly through drug costs alone or indirectly through adverse effects on health. Medication optimization interventions and policies to reduce inappropriate medication use and ensure cost-effective medication use are needed to manage high-cost healthcare and prevent HCU development. / Thesis / Doctor of Philosophy (PhD) / High-cost healthcare users (HCUs) are patients who use disproportionate healthcare resources compared to their peers. More research is needed to better understand HCUs to design interventions to improve their health outcomes and costs. In this thesis, we evaluated what previous studies have discovered about HCUs and we used Ontario’s health system data to explore whether the quality of prescribing and medication use in older adults influences their risk of becoming a HCU. We found that current interventions for HCUs have had inconsistent effects on improving health outcomes and costs. We also found two medication-related factors contributing to the risk of becoming an older adult HCU: (1) use of very expensive medications, and (2) use of potentially inappropriate medications where the risk of harm may outweigh potential benefits. Interventions and health policies to optimize the appropriate and cost-effective use of medications are needed to manage high-cost healthcare and prevent HCU development.

<p><strong>Background:</strong> Despite strong evidence, strategies for improving bone health are underutilized. Knowledge translation (KT) interventions aim to improve uptake of evidence-based practices, however the feasibility and effectiveness of such strategies require further evaluation within Long-term Care (LTC). In this thesis, we examined the impacts of a province-wide osteoporosis strategy and a more intensive multifaceted KT strategy including expert-led educational meetings, audit/feed-back, and action planning for quality improvement. Both studies targeted interdisciplinary LTC teams (physicians, nurses, pharmacists, dietician, and other staff).</p> <p><strong>Methods: </strong>In the first thesis study, we examined the impact of the <em>Ontario Osteoporosis Strategy for LTC</em> by investigating changes in facility-level prescribing rates (vitamin D, calcium, osteoporosis medications) before and after its implementation (2007 versus 2012). The second study was a pilot cluster randomized trial evaluating the feasibility and effectiveness of a 12-month, multifaceted, interdisciplinary KT intervention [Vitamin D and Osteoporosis Study (ViDOS)]. Prescribing outcomes included: vitamin D ≥800 IU (primary), calcium ≥500 mg/day, and osteoporosis medications (high-risk residents only). Feasibility outcomes included recruitment, retention, data collection, intervention fidelity, and process changes. We analyzed resident level data using the generalized estimating equations (GEE) technique, adjusting for clustering.</p> <p><strong>Results:</strong></p> <p>In both studies, significant improvements were observed for vitamin D and calcium prescribing. In the first study, prescribing increased by 38% and 4%, respectively, between 2007 and 2012. In the ViDOS trial, the 12-month intervention resulted in an absolute improvement of 15% and 7%, respectively (intention to treat cohort). There was no significant effect for prescribing of osteoporosis medications in either study. In the ViDOS study, recruitment and retention rates were 22% and 63%, respectively; good intervention fidelity was achieved and intervention homes reported several process changes.</p> <p><strong>Conclusion:</strong></p> <p>This thesis study demonstrated that KT interventions targeting evidence-based osteoporosis and fracture prevention strategies were feasibly and effectively applied with interdisciplinary LTC teams.</p> / Doctor of Philosophy (PhD)