Yes / Introduction As a consequence of the low cost and perceived safety, proton pump inhibitors (PPIs) are widely prescribed but they can cause longterm adverse effects and are often overprescribed. For most patients PPIs should not be continued long-term as patients can become dependent on PPIs and they are rarely stepped down/off treatment. We aimed to measure whether a dyspepsia review service could help patients on PPIs to step down/off treatment whilst still keeping them symptom free. Methods Pharmacists were provided with training on dyspepsia management. Four general practices were selected. Patients taking a PPI for more than two months were included. A list of exclusion criteria (e.g. active ulcers, newly initiated) was applied. Between six and eight dyspepsia review clinics were run at each site. Patients were booked into a 15-minute consultation. A concordance style consultation was held with clinicians providing information on dyspepsia management and exploring the patients’ ideas, concerns and expectations about stepping down or stepping off treatment. A follow-up audit was performed at four months to determine if patients had remained stepped down/off. An economic evaluation of clinic costs and drugs savings was performed. Results A total of 508 patients were invited to a review; 136 did not attend and 58 were excluded due to not meeting the inclusion criteria, leaving 314 patients reviewed for step-down/step-off. Successful step down/step off was achieved in 257 people (82% of those reviewed). The total cost savings of PPIs was £7,100. The additional cost of alginates was £1,207 giving a net saving on medicines of £5,893 per annum. Set-up costs were £1,194 and staff costs £3,524 to £5,156 giving total running costs, which vary dependent on the Agenda for Change (AfC) grade of pharmacist involved, of £4,720 - £6,351. Conclusion A dyspepsia review clinic is cost-neutral to run but, given that many patients are on polypharmacy, PPI step down might best be considered as part of a holistic medication review clinic. / Reckitt Benckiser, National Institute for Health Research, Health Education England

Background: In older age polypharmacy is common due to a higher rate of chronic diseases. Taking multiple medications can result in drug related problems resulting in higher health care costs. OptiMEDs is an information and communications technology (ICT) guided medication review program that was created to improve the quality of the prescription of medicines in elderly. A pilot study of OptiMEDs was performed in 3 nursing homes in Belgium during 2019-2020.  Aim: To update the explicit criteria behind OptiMEDs and to make the tool more specific.  Method: Through a literature search of explicit criteria of potentially inappropriate prescribing (PIM-lists), newer versions published between 1st of January 2018 – 31st of October 2022 were sought. Redundancy of alerts was reduced by removing all the double alerts of PIMs. To minimize the number of alerts issued by the tool, several approaches to exemptions from and exclusion to PIMs were tested. To evaluate the improvement, results from the previous and new rule base were compared using the same dataset from the OptiMEDs feasibility trial.  Results:OnlyonePIM-list(Beer’scriteria)hadanewversion,resultingin45PIMsbeingadded to the database and 33 PIMs were removed. Removal of the duplicates resulted in a database with 594 PIMs. With the OptiMEDs data set; The amount of patients having a PIM decreased with 25.1 % when removing EU(7)-list as a source. The amount of patient having at least one candidate for deprescribing decreased with 10.4 % when only keeping the deprescribing.org and RTCs as a source.  Conclusion: The update probably made OptiMEDs more user-friendly as the number of PIMs decreased and the number of medications candidated for deprescribing decreased. However, an important further update is still needed, which is to include the clinical-based PIMs.

Medication-related problems (MRPs) are a common issue that lead to suboptimal healthcare outcomes and increased healthcare cost. Overall, older adults have a high risk of experiencing MRPs due to large medication consumption and recession of biological functions. One approach to reduce such a risk is for elderly patients to use comprehensive medication reviews (CMRs), the fundamental service of Medication Therapy Management (MTM). The Centers of Medicare and Medicaid (CMS) has been promoting CMRs among Medicare Part D beneficiaries since 2009, such as offering of an annual free CMR to eligible MTM beneficiaries and making “CMR completion rate” a quality rating (Star) measurement for Part D plans. However, statistics from the report of CMS 2017 Star rating measures showed that the CMR completion rate among MTM eligible was still low. Even though Medicare Part D beneficiaries ultimately make the decision, there are insufficient U.S. studies examining patient perceived factors affecting their use of CMRs. Thus, there is critical need to better understand decision making for using CMRs from a consumer perspective. This dissertation project aimed to explore Medicare Part D beneficiaries’ perceptions on using a CMR, using a conceptual framework adapted from consumer decision making, which consisted of internal need, external influence, perceived risks of using CMRs, and alternative comparison. The dissertation project also aimed to describe how CMR recipients and non-recipients were different and to identify main factors associated with Medicare Part D beneficiaries’ decision making for using CMRs. To achieve these objectives, this study used an exploratory sequential mixed-method approach in a cross-sectional setting. Semi-structured personal interviews were conducted as the qualitative phase followed by self-administered mailed survey as the quantitative phase. Both interview questions and survey items were developed based on the conceptual framework, though findings from qualitative phase informed the survey item generation as well. Survey items and administration were further refined using a panel of expert review and pilot study. A convenient sample consisted of older adults recruited from one pharmacy in Iowa and a senior registry maintained by University of Iowa was used for the qualitative phase (n = 13). The quantitative study sample were randomly selected from each sampling frame: 1) elderly residents of the States of Florida (n = 320), Washington (n = 320), Wisconsin (n = 320), and Pennsylvania (n = 320) covered in a commercial mailing list; and 2) older adults included in the same senior registry used for the qualitative phase (n = 460). The study inclusion criteria were: 1) must be at least 65 years old in 2016, 2) must be taking at least one prescription currently, and 3) must be a Medicare Part D beneficiary. A thematic analysis was conducted for qualitative data, using MaxQDA version 12. Descriptive analysis and multiple logistic regression modeling were used to analyze data of the quantitative phase, using SAS version 9.4. A total of 13 study participants were included in the qualitative analysis, of which 5 were CMR recipients. The thematic analysis yielded five themes, which supported the use of the conceptual framework (i.e. internal need, external influences, perceived risks of using CMRs, and alternative comparison) to understand Medicare Part D beneficiaries’ decision making for using CMRs. Plus, consumers who received a CMR expressed a positive attitude towards them. Safety worriers or knowledge seekers appeared more likely to use CMRs while physician believers or privacy worriers are more likely to not use CMRs. Meanwhile, awareness of CMRs remains low after being available for 7 years, possibly due to an infrequent marketing activity. An overall usable response rate of 26.8% and an overall completion rate of 89.4% were obtained in the mailed survey phase. Of the study sample, 381 respondents who were Medicare Part D beneficiaries, were using at least one prescription, and returned a complete survey were included for analysis. There were 27.56% respondents (n = 105) reported that they had a CMR in 2016 or before, which was consistent with the low CMR completion rate nationwide. Meanwhile, about two thirds of respondents never heard of CMRs, supporting findings from the qualitative phase. CMR recipients and non-recipients had several characteristics differences in the domain of internal need, external influences, and perceived risks of using CMRs. Compared to CMR non-recipients, CMR recipients took slightly more prescription medications (p = 0.0299), were self-reported less healthy (p = 0.0009), had better provider communication in previous pharmacy encounters (p < 0.0001), had higher overall satisfaction in previous pharmacy encounters (p = 0.0053), perceived more seriousness of MRPs (p = 0.0016), perceived more susceptibility of MRPs (p < 0.0001), expected more positive outcome from suing CMRs (p < 0.0001), were more likely influence by a physician’s opinion (p = 0.0184) or a pharmacist’s opinion (p < 0.0001) when considering the use of CMRs, were more likely received a physician recommendation (p < 0.0001) or a pharmacist recommendation (p < 0.0001), had less concern of psychological risk (p = 0.0170), functional risk (p < 0.0001), and social risk (p = 0.0016). The regression modeling further determined that a pharmacist or a physician recommendation, pharmacist’s communication in previous pharmacy encounters, perceived susceptibility of MRPs, and positive outcome expectancy were positively associated with Medicare Part D beneficiaries’ decision making for using CMRs at a significant level of .05, when holding other variables fixed. Meanwhile, perceived functional risk, access to general counseling in previous experiences, and family/friends influence were negatively associated with Medicare Part D beneficiaries’ decision making for suing CMRs at a significant level of .05, when holding other variables fixed. This study is the first to adapt consumer behavior frameworks to explore factors affecting Medicare Part D beneficiaries’ decision making for using CMRs. Unfortunately, it was found that CMR awareness among older population was still low after years’ of promotion efforts among Medicare Part D beneficiaries. Findings of this dissertation suggested that policy makers should not entirely focus on promoting CMRs through Part D plan sponsors, but seek for collaborations from healthcare professionals, particularly community pharmacists and physicians. Meanwhile, addressing key components and benefits of CMRs in an understandable way to general older population could help them establish a link between benefit expectation and their demand. Furthermore, using short surveys or phone interviews to obtain self-perceived internal need among older population could be used by Part D plans or other stakeholders to target potential CMR users more effectively.

Class of 2013 Abstract / Specific Aims: To compare the Comprehensive Medication Review (CMR) rate for Workflow Model #1 (used in 2010) to the CMR rate for Workflow Model #2 (used in 2011) at the Medication Management Center (MMC). Methods: A retrospective database analysis was completed in which Comprehensive Medication Review (CMR) completion rates for 2010 and 2011 were assessed. Comparison included only Center for Medicare and Medicaid Services (CMS) contracts that the Medication Management Center (MMC) provided Medication Therapy Management (MTM) services for both in 2010 and 2011. Data was used to determine the effect a process change had on CMR participation rate at the MMC and best practices for improving the rate of Medication Therapy Management Program (MTMP) beneficiaries participating in a CMR. Main Results: In 2010, patient participation and response to a CMR offer letter was low (0.2%). The changes in process yielded an increase in the CMR completion rate (6.93%); this in turn yielded higher performance measurements for prescription drug plans. Conclusion: Workflow modifications, including a pro-active secondary CMR offer, led to a marked increase in member participation and CMR rates. Patients are more apt to consent to a CMR if they are called for a specific medication related problem. It is recommended to continue to convert TMR calls to CMRs whenever possible, monitor CMR rates at least quarterly, and make cold calls where needed to increase CMR percentages.

Introduction: In recent year, the role of the pharmacist has evolved from product-focused to patient-focused activities. Following this evolution, new professional pharmacy services were simultaneously developed by researchers and started to be legally implemented and remunerated for community pharmacists around the world. Implementation, essential to ensure a good programme delivery and therefore its effectiveness, was seen as a passive process for which diffusion and dissemination were sufficient to translate research into practice. However, the transition from theory to practice is often difficult as different factors hinder or facilitate the implementation of such services. In consequence of that, implementation research started to be developed in the community pharmacy field to understand and fil the gap between theory and practice.Objectives of the thesis: Three projects were conducted in Belgium and Switzerland; (1) to understand the implementation of an existing programme in Belgium; the isotretinoin pregnancy prevention programme (PPP) (Chapter IV, point 4.1), and (2) to study the implementation of two new developed pharmaceutical services, which include an interview between the pharmacist and the patient and require interprofessional collaboration; the medication adherence program in Switzerland and the medication review in Belgium (Chapter IV, point 4.2). Methods: To understand the implementation of the isotretinoin PPP, two studies were conducted. The first study was a survey sent to health care professionals (pharmacists, general practitioners and dermatologists) and patients. The outcomes of the survey were the PPP awareness and compliance to safety recommendations related to the teratogenic risk of isotretinoin. The second study was cross-sectional and analysed the reimbursed prescription data of the Belgian population taking isotretinoin between January 2012 and August 2015. The outcomes were medication adherence to isotretinoin and to contraception, and the concomitant use of contraception and isotretinoin. Medication adherence was measured using the medication possession ratio (MPR), dividing the total days of medication supplied within the refill interval by the number of days in the refill interval. The concomitant use of isotretinoin and contraception was realised in combining prescription database of both isotretinoin and contraception of women between 12 and 21 years old, who received at least one prescription of isotretinoin during the study period.To study the implementation of the medication adherence program in Switzerland and the medication review service in Belgium, two prospective and observational studies were conducted with a mixed method approach (quantitative and qualitative outcomes). The defined outcomes, based on the RE-AIM model, were; reach of the target patients, adoption of the service by health care professionals providing the service, implementation (facilitators, barriers and fidelity or the extent to which the intervention is delivered as intended), and maintenance (the extent to which the intervention become institutionalized or part of the routine activity). Outcomes were collected through web platforms for quantitative data, and interviews and focus groups for qualitative data.Results and discussion: The study of the isotretinoin PPP implementation showed that two safety recommendations related to the teratogenic risk were particularly poorly applied by interviewed health care professionals. These two recommendations were the use of a second contraceptive method (like condoms) and the monthly pregnancy test. They considered these two recommendations as unnecessary for women taking an effective contraceptive method. Through the prescription refill data analysis, we observed that 46.1% of patients were adherent to isotretinoin (MPR ≥ 0.8) and 74.0% of women taking isotretinoin to their prescribed contraception (oral contraceptive, rings and patches). Lastly, 83.4% of women between 12 and 21 years taking isotretinoin did not receive an effective contraceptive method one month before, during and one month after isotretinoin treatment. However, the proportion of women receiving at least one prescription of contraception during (74.1%) and after (72.1%) isotretinoin treatment was higher than one month before isotretinoin treatment (35.7%). Regarding these results, less adopted recommendations should be reviewed by an expert committee and interventions focused on the improvement of the use of contraception during isotretinoin treatment could be developed.The two studies related to two new developed pharmaceutical services showed that their implementation was feasible in community pharmacy practice. Most of pharmacists participating in both projects had positive attitude regarding the implementation of these services in their daily practice. They considered it as professionally satisfying and important for patients and perceived the benefits of the programs. However, similar barriers were observed; difficulties to include patients and lack of interprofessional collaboration, and lack of time (related to lack of staff, administrative burden and lack of team adoption). According to participating health care professionals, the development of new strategies to overcome these barriers is necessary to anticipate the future implementation and the maintenance of these services at the national level. Following these results, the proposed strategies are for example the development of broad based media campaigns (for health care professionals and patients), or the development of specific trainings focusing on interprofessional collaboration, service-process, practice change management and leadership. Conclusion: The legal evolution of the pharmacists’ role is a positive progress but insufficient to ensure a full implementation in practice. Implementation strategies should be considered at different implementation stages (exploration, preparation, testing, operation and maintenance) and levels (individual, pharmacy, local setting, and system). The use of implementation science would allow a quicker and more effective implementation of these new professional pharmacy services. The anticipation of change and the selection of appropriate strategies would allow a higher fidelity level to the different components of the service by health care professionals and therefore a higher effectiveness, e.g. clinical and economic outcomes. Health care professionals, professional associations, academics and policy makers should be aware of implementation science and integrate it in the development of the new pharmacists’ role. As shown in our results, it should also be considered for existing programmes such as the isotretinoin PPP. / Doctorat en Sciences biomédicales et pharmaceutiques (Pharmacie) / info:eu-repo/semantics/nonPublished

No / The objective of this article was to evaluate the effectiveness of pharmacist-led medication review in chronic pain management. Six electronic databases (Medline, Embase, PsycInfo, CINHAL, CENTRAL, International Pharmaceutical Abstracts) reference lists of retrieved articles and relevant websites were searched for randomized controlled trials published in the English language involving adults with chronic pain. Studies were included if one of the intervention arms had received pharmacist-led medication review independently or as part of a multidisciplinary intervention. Risk of bias was assessed for all the included studies. The search strategy yielded 583 unique articles including 5 randomized controlled trials. Compared with control, meta-analysis showed that participants in the intervention group had: a 0.8-point reduction in pain intensity on a 0 to 10 numerical rating scale at 3 months [95% confidence interval (CI), -1.28 to -0.36] and a 0.7-point reduction (95% CI, -1.19 to -0.20) at 6 months; a 4.84 point (95% CI, -7.38 to -2.29) and -3.82 point (95% CI, -6.49 to -1.14) improvement in physical functioning on a 0- to 68-point function subscale of Western Ontario and McMaster Universities Osteoarthritis Index at 3 and 6 months, respectively; and a significant improvement in patient satisfaction equivalent to a "small to moderate effect." Pharmacist-led medication review reduces pain intensity and improves physical functioning and patient satisfaction. However, the clinical significance of these findings remain uncertain due to small effect size and nature of reported data within clinical trials that limits recommendation of wider clinical role of pharmacist in chronic pain management.

No description available.

Background: The cumulative effect of taking anticholinergic medicines (anticholinergic burden) is associated with adverse outcomes for older people. Prevalence of anticholinergic prescribing is increasing, and there is a need for tools to proactively identify at-risk patients for medication reviews. Aim: To explore the need for, and feasibility of, an integrated case-finding tool that predicts risks using electronic health records (EHRs), facilitating the review of anticholinergic medicines for frail older people. Methods: Mixed methods, adopting a pragmatic approach. A systematic review, prediction modelling of cohort study data, and qualitative interviews were undertaken. Results: The systematic review found anticholinergic exposure was associated with adverse outcomes for the frail; poorer physical function, falls, and mortality, indicating a need for a risk reducing intervention. In the prediction modelling study, predicting risks using composite measures of anticholinergic burden and frailty indicated limited feasibility. Neither enhanced the performance of best subset models using cohort study data. Their predictive utility needs to be investigated using EHR data, to determine their feasibility within primary care. The qualitative study found healthcare professionals needed a proactive tool, supporting risk prediction as a feasible approach. Factors influencing future implementation were; upskilling requirements, deprescribing confidence, patient reluctance, motivation, holistic care, interoperability, trust in risk prediction, remuneration, among other barriers and facilitators. Conclusions: Through identifying a need, and potential feasibility, foundations towards the future developments of a case-finding tool have been provided, informing an early tool prototype (AC-FRAIL). Recommendations for further work suggest a roadmap ahead, to maximise the potential for integrated solutions to proactively reduce anticholinergic risks. / NIHR Yorkshire and Humber Patient Safety Translational Research Centre (NIHR YHPSTRC)

La iatrogénie médicamenteuse à l’hôpital est un problème majeur de santé publique dont les causes sont multiples. Les bilans de médications et le rôle des cohortes de patients pourraient permettre de diminuer ce phénomène. L’objectif de cette thèse d’apporter des éléments utiles à la décision publique sur l’évolution des pratiques pharmaceutiques et l’effet iatrogène des médicaments et d’autre part de fournir des outils directement utiles au pharmacien afin de cibler les patients les plus à risques d’évènements iatrogènes médicamenteux. Ce travail se décline en trois séquences : (i) définition et contexte, (ii) évaluation de l’impact clinique et économique du pharmacien clinicien dans une démarche pro-active de soins pharmaceutiques dans les unités de soins, (iii) facteurs de risque d’événements indésirables médicamenteux à court terme et à long terme. Au vu de ces résultats et des données de la littérature, il apparaît que les bilans de médication est un moyen d’optimisation de la qualité et de l’efficience des soins. / Medication errors in hospital is a major public health problem with multiple reasons. Medication reviews and the role of cohorts of patients could help reduce this phenomenon. The objective of this thesis is to provide useful elements for public decision on the evolution of pharmaceutical practices and the adverse drugs reactions and secondly to provide tools directly useful to the pharmacist to target patients most at risk of adverse drugs events. This work is divided into three parts: (i) definition and context, (ii) evaluation of the clinical and economic impact of the clinical pharmacist in a pro-active approach of pharmaceutical care in the care units, (iii) risk factors adverse drug events in the short and long term. In view of these results and data from the literature, it appears that medication reports are a means of optimizing the quality and efficiency of care.

Yes / Background: Anticholinergic medicines are associated with adverse outcomes for older people. However, little is known about their use in frailty. The objectives were to (1) investigate the prevalence of anticholinergic prescribing for older patients, and (2) examine anticholinergic burden according to frailty status. Methods: Cross-sectional analysis of Welsh primary care data from the Secure Anonymised Information Linkage (SAIL) databank including patients aged ≥65 at their first GP consultation between 1st January and 31st December 2018. Frailty was identified using the electronic Frailty Index (eFI) and anticholinergic burden using the Anticholinergic Cognitive Burden (ACB) scale. Descriptive analysis and logistic regression were conducted to 1) describe the type and frequency of anticholinergics prescribed; 2) to estimate the association between frailty and cumulative ACB score (ACB-Sum). Results: In this study of 529,095 patients, 47.4% of patients receiving any prescription medications were prescribed at least one anticholinergic medicine. Adjusted regression analysis showed that patients with increasing frailty had higher odds of having an ACB-Sum of >3 compared to patients who were fit (mild frailty, adj OR 1.062 (95%CI 1.061–1.064), moderate frailty, adj OR 1.134 (95%CI 1.131–1.136), severe frailty, adj OR 1.208 (95%CI 1.203–1.213)). Conclusions: Anticholinergic prescribing was high in this older population. Older people with advancing frailty are exposed to the highest anticholinergic burden despite being the most vulnerable to the associated adverse effects. Older people with advancing frailty should be considered for medicines review to prevent overaccumulation of anticholinergic medications given the risks of functional and cognitive decline that frailty presents. / NIHR / Research Development Fund Publication Prize Award winner, May 2023.