Background: The increasing elderly population is challenging todays management in healthcare. Elderly have a higher risk of adverse effect and inappropriate use of medication. The Swedish healthcare today pays 12-19 billion kronor due to adverse effects and inappropriate use of medications. By optimizing elderlies use of medicine, the social cost can decrease and contribute to a better healthcare management.  Aim: Identify communication methods that can optimize counselling and communication to the elderly in pharmacies. In the sense of preventing inappropriate use of drugs and future side effects such as adverse effects or no effect. The questions that were answered are as follows: what methods are available to optimize counselling and communication? is it possible to use the methods in pharmacies? Methods: Systematic review, data search on pubmed and web of science.  Results: Identified interventions were Alice-app, Geriatic Resources for Assessment and Care of Elders Team Care (GRACE), empathetic communication, communication education, motivational interviewing, my medical passport (MMP), in depth patient-centered care communication, smartwatch, smartphone, ingestible sensor system (ISS) and SPACE-program. Conclusions: Communication education helped to strengthen the patient-/carer relationship and management of medication counselling. Electronic notification systems helped elder with memory- and movement impairment. The implementation depends on the pharmacy resources and propensity of the patient. The most applicable methods were ALICE-app, smartwatch, smartphone, ISS, SPACE-team, empathetic communication, communication education in geriatric care, MI, MMP and partly GRACE-team concerning home visits by pharmacists and teamwork management.

Farmaceutens uppgift vid läkemedelsexpediering innefattar att kontrollera att receptet är förskrivet enligt godkända premisser. Om problem uppstår behöver farmaceuten ta ställning i om förskrivarkontakt är aktuellt för klargörande och åtgärder. Förskrivare har inte tillgång till patienters fullständiga journaler vilket kan öka risken för att olika typer av problem uppstår vid läkemedelsförskrivning. Sedan monopolet avskaffades har apoteken ökat i antal men antalet farmaceuter per apotek har snarare minskat. Underbemanning och stress kan påverka farmaceutens arbete och därmed medföra en ökad risk för felexpedieringar. Farmaceutens möjlighet till förskrivarkontakt ligger således till grund för en säker läkemedelsanvändning och ökad patientsäkerhet. Syftet med studien var att kartlägga problem som leder till förskrivarkontakt vid läkemedelsexpediering samt kartlägga problem som uppstår i samband med förskrivarkontakt. Studiens metod var att alla farmaceuter (1352) som arbetade på ett öppenvårdsapotek på Apoteket AB fick möjlighet att genomföra en onlinebaserad enkät. En länk till enkäten mejlades ut till alla apotek i Sverige tillsammans med ett följebrev med information om studien. Farmaceuterna hade möjlighet att besvara enkäten mellan 14–29 september 2023.  Resultatet visade att 200 farmaceuter deltog i enkäten. 38,5 % ansåg att fel förskrivet läkemedel genererade förskrivarkontakt varje gång det förekom följt av fel eller oklar dosering (25 %) och  läkemedel som genererar en D interaktion (24,5 %). Respondenterna upplevde att restnoterade läkemedel förekom dagligen (77,5 %) därefter läkemedel som indikerar en C interaktion (61,5 %) och missad läkemedelsförskrivning (41,5 %). Avregistrerade läkemedel (13,5 %), läkemedel som genererar en D interaktion (13 %) och restnoterade läkemedel (12,5 %) var de problem som flest respondenter ansåg tog >30 minuter att lösa med förskrivare. Dessutom var förskrivare inte anträffbara i cirka 50 % av fallen vilket 97 % ansåg. Respondenterna valde att i 58,5 % av fallen återkoppla till patienten när problemet var åtgärdat när förskrivaren inte var anträffbar. 74 % av respondenterna upplevde att tidsbrist utgjorde ett hinder för förskrivarkontakt där 16 % ansåg att det förekom dagligen. Orsaken till tidsbristen ansågs vara underbemanning och högt kundtryck enligt 55 % av respondenterna.  Slutsatsen är att fel förskrivet läkemedel, fel eller oklar dosering och läkemedel som genererar en D interaktion är de tre problemen som oftast leder till förskrivarkontakt. Tidsbrist och svårigheter i att få tag på förskrivaren är problem som uppstår i samband med förskrivarkontakt och påverkas av underbemanning och högt kundtryck. / The pharmacist’s mission at pharmaceutical dispensing includes to verify that the prescription is prescribed in the right way. The pharmacist needs to decide if contact with the prescriber is needed for clarification and actions if a problem occurs. Prescribers don´t have access to the patients complete medical records which can increase the risk of fault at drug prescribing. Since the monopoly was abolished the number of pharmacies has increased while the number of pharmacists has decreased.  Understaffing and stress will affect the pharmacist which can lead to a higher risk of fault at pharmaceutical dispensing. The pharmacist’s possibility to contact the prescriber is needed to ensure a safe drug usage and increased patient safety. Aim: The aim of this study was to assess the problems that leads to contact with the prescriber at pharmaceutical dispensing and also to assess the problems that appears when to contact the prescriber. Method: All pharmacists (1352), that were employed at a pharmacy owned by Apoteket AB, had the opportunity to complete an online survey. A link was provided to all pharmacies in Sweden together with a message containing information about the study. The pharmacists had the opportunity to answer the survey between 14-29 September 2023. The results showed that 200 pharmacists participated in the survey. In this study, 38,5 % considered that faulty prescribed drugs led to contact with the prescriber every time it occurred followed by wrong or unclear dosage (25 %) and drugs that generate a D interaction (24,5 %). The respondents experienced that the backorder drugs occurred daily (77,5 %) then drugs that indicated a C interaction (61,5 %) and missed prescriptions (41,5 %). Non licensed drugs (13,5 %), drugs that give a D interaction (13 %) and backorder drugs (12,5 %) were problems that most pharmacists considered took more than 30 minutes with the prescriber to resolve the problems. The prescriber was not even reachable in about 50 % of the cases which was answered by 97 % of the respondents. The respondents chosed, in 58,5 % of the cases, to reach out to the patient when the problem was resolved with the prescriber. 74 % of the respondents though that lack of time constituted an obstacle prohibiting contact with the prescriber, 16 % thought that this occurred daily. The cause of the lack of time was understaffing and increased number of customers, according to 55 % av the respondents. Conclusion: Prescribing wrong drugs, wrong or unclear dosage and drugs that generate a D interaction were the three most common problems that leads to contact with the prescriber. Lack of time and difficulties to get in contact with the prescriber are problems that appears in connection with the prescriber and was affected by understaffing and increased number of customers.

Background: A closed-loop medication system is planned to be implemented at Uppsala University Hospital. Thus, an advanced pharmaceutical validation system called System-Assisted Pharmaceutical VALidation (SAPVAL) is being developed, which aims to identify and manage risk prescriptions, hence reducing potential adverse drug events (ADEs). The system is based on clinical rules that generate an alert due to a "risk score”. As part of SAPVAL, this study focuses on alerts related to an increased risk of bleeding. Aim: This study aims to investigate, gain an enhanced understanding, and determine the clinical significance of alerts generated by one of the clinical rules (rule 2- risk of bleeding) that was developed within SAPVAL. Methods: A cross-sectional retrospective study where alerts 100 from randomly selected patients, with a previously identified risk of bleeding, were investigated in regard to the risk period for potential/true ADEs, undertaken mitigation measures and clinical significance. This was done by accessing the patients’ electronic health records. Results: The risk period for potential ADEs was 29 days. In total, 35 ADEs were identified, with anemia as the most common symptom. Mitigation measures were undertaken for 55 patients, of which the most common were prescription of a proton pump inhibitor and blood transfusions. The clinical evaluation showed that 66% of the 103 included alerts were deemed clinically insignificant. Conclusion: Most alerts were deemed clinically insignificant. This in turn, emphasizes the importance of a system like SAPVAL, where insignificant alerts are filtered away by pharmacists before reaching the physicians, thus reducing problems related to alert fatigue.

The word communication originates from the Latin word communicare that means to do something in common. When human beings communicate with each other, we share thoughts, emotions, values and actions. The foundation in communication is found within the interpersonal communication, which is the act of communication between two persons. All types of communications include of verbal and nonverbal acts of communication. The verbal communication consists of words either in speech or writing, the nonverbal act implies gestures, frequency of the tone and facial expressions. Within the pharmaceutical profession, good communication between the pharmacist and the customer is important and can affect the customer’s health and quality of life in both direct as well as indirect ways. In recent years, the pharmacist's role in the pharmacy has drastically changed. Nowadays the care of the customer has gained more significance than before. To improve customer health and quality of life it is important that the pharmacist acts to promote a good relationship with the customer and the foundation for this relationship should be built on good terms of communication. The purpose of this study was to study how common it is with communication errors between pharmacist and customer, and to demonstrate probable underlying causes. Secondary questions were, how is the drug advice the pharmacist provides affected by communication errors? Collection of data for the study was done with structured observation charts, where the customer and pharmacist were strictly observed. A total of 316 meetings were observed and the data collected referred to prescriptions. In more than one-third of the observed meetings, there were communication errors between the pharmacist and the customer. Communication errors that arose concerned lack of eye contact, language barriers, choice of questions, background noise from colleagues and customers and discussions from generic exchanges. To reduce future communication errors, the pharmacist's actions should be strengthened, such as eye contact, clear follow-up questions and improved feedback.

Background: Familial hypercholesterolemia (FH) is a genetic disorder estimated to affect 0,4 % of the world's population (1 in 250). Patients with FH have abnormally high LDL-cholesterol.  Aim: The aim of this study was to estimate the prevalence of FH in Stockholm County and to evaluate the health economic impact of diagnosing people with FH early in life. Methods: Two algorithms were used to estimate the number of people with high LDLcholesterol. The first method applied data on cholesterol measurements from patients in Stockholm County between 2006-2008 and a modified version of Dutch Lipid Clinic Network. The second method was based on dispensed prescriptions of ezetimibe, lomitapide, evolucumab and alirocumab during 2019. A health economic model was created to estimate the economical outcome of diagnosing and treating patients early before undergoing a cardiovascular event. Results: The prevalence of FH in Stockholm County was estimated to 0.63 %, corresponding to a total of 12 000 individuals. The accumulated costs over 20 years for FH is estimated to be more than 1,1 billion SEK for diagnosed and treated patients, and 1,7 billion SEK for undiagnosed and untreated patients. Conclusions: The prevalence of FH in Stockholm County is probably higher than previously suggested. Early diagnosis and treatment is an investment for society and necessary for the patients to prevent cardiovascular events and improve quality of life.

Background: High blood pressure (BP) or hypertension is defined as a systolic and diastolic pressure over 140/90 mmHg. High blood pressure increases the risk for premature death, and previous research has shown that many patients do not reach targets and that there are differences between primary healthcare centers in the proportion of patient reaching targets. The reasons for these variations, however, are unknown. Aim: To investigate variations in blood pressure target achievement between primary care centers in Stockholm county and how different factors such as practice size, ownership, socioeconomic and antihypertensive drug treatment can influence this diversity. Method(s): This study was designed as a cross-sectional register study with a descriptive quantitative perspective. Data was collected from three sources: National Primary Care Quality register, Care Need Index for healthcare in Stockholm region and Stockholm County Council data warehouse VAL. The study included 179 out of all 227 primary care centers in the region. The proportion of all patients with hypertension reaching targets was assessed each year during 2019-2021, and correlations studied for potential predictors. Results: there was a variation between primary care centers in target blood pressure fulfillment, ranging from 22-66% during 2021, 23-63% during 2020 and 33-66% during 2019, respectively. There was no overall difference between public and private centers in the proportion of patients reaching targets, but a larger practice variation among private centers. No correlation was found between the other studied factors and target blood pressure fulfillment during 2021. Conclusion: There was a variation between primary care centers in the proportion of patients reaching blood pressure targets. Different practices may change ranking between years and other factors than practice size, ownership and socioeconomic appears to explain the variation.

Introduction Human immunodeficiency virus (HIV) is a double stranded RNA retrovirus. According to the World Health Organization more than 30 million individuals were estimated to have HIV by the end of 2020, about 60% of which are in the African region. Pre-treatment drug resistance (PDR) can be defined as the resistant virus strains transmitted at the time of infection or acquired during previous exposure to ARV. This study asses the effect of drivers in PDR. Method: This study was conducted with data extracted from published, publicly available data bases and reports by international organizations. The main sources were United Nation data bases and published reports from World Health Organization.  Inferential statistics were used to assess the PDR to anti-retroviral drugs. A linear regression model was used to investigate the association between PDR and previous exposure to anti-retrovirals and anti-retroviral therapy, pre-exposure prophylaxis, national health expenditure, human development index, and drug stock-out for different classes of anti-retroviral drugs.   Results: The result indicated that NNRTI drug resistance was most common, and seven out of 29 countries had PDR to all four drug classes. The human development index was positively associated with INSTI and PI PDR (p<0.05), while NNRTI and NRTI were mainly positively associated with previous exposure to anti-retrovirals. Conclusion: This study assessed the impact of socio-economics determinants (human development index and national health expenditure), drug logistic determinants (stock-out), and patients’ determinants (adherence and previous exposure to any kind of anti-retrovirals) on PDR. For expensive drug classes (PI and INSTI) the resistance was positively associated with human development index. Previous exposure to anti-retrovirals was associated with increased resistance in NNRTI and NRTI.

Akut hjärtsvikt definieras som en debut eller försämring av hjärtsvikt. Hjärtsvikt är ett allvarligt tillstånd där hjärtat inte upprätthåller adekvat hjärtminutvolym för att möta kroppens metaboliska behov vilket leder till trötthet och försämrad livskvalitet. Symtom som relaterar till systemisk vätskeansamling är vanliga vid akut hjärtsvikt. Vätskeansamling och hypoperfusion ökar morbiditet och mortalitet. Patienter med akut hjärtsvikt behöver således snabba och effektiva behandlingar, men också långtidsbehandling efter utskrivning. Avsvällande/vattendrivande behandling är hörnstenen i den terapeutiska behandlingen och loopdiuretika anses som det mest effektiva och snabbverkande läkemedlet. I dagsläget är empagliflozin ett rekommenderat läkemedel för behandling av kronisk hjärtsvikt med nedsatt ejektionsfraktion, då empagliflozins diuretiska egenskap kan stärka effekten av loopdiuretika.   Syftet med detta examensarbete var att beskriva effekter hos empagliflozin vid behandling av akut hjärtsvikt som en litteraturstudie. En sökning av randomiserade kliniska prövningar gjordes i PubMed där nio artiklar valdes ut för att ingå i detta examenarbete. Resultatet av de granskade artiklarna visade att empagliflozin som tilläggsbehandling till loopdiuretika ökade urinutsöndring hos patienterna. Resultatet visade också en statistiskt signifikant minskning av NT-proBNP i studierna vars behandlingstid var 5, 7, 15 och 30 dagar jämfört med placebo. Vidare minskade empagliflozin också plasmavolymen och mängden urinsyran i plasman. Två av studierna rapporterade en statistiskt signifikant ökning i andel röda blodkroppar i behandlingsgruppen. Insättning av empagliflozin, hos kliniskt stabila sjukhusvårdade patienterna i studien EMPULSE, gav en statistiskt signifikant klinisk nytta definierat som ett hierarkiskt kompositmått av död oavsett orsak, antal hjärtsviktsepisoder, tid till första hjärtsviktsepisod och klinisk meningsfull förbättring i KCCQ-TSS med vinstratio 1,36. Vidare gav empagliflozin en positiv effekt på viktminskning, ökad diuretisk respons, ödemlindring och ökad livskvalitet under 90 dagars behandling. Hos patienter som fick empagliflozin sänktes eGFR något till en början men återställdes senare. Det fanns dock inte någon statistiskt signifikant skillnad i eGFR mellan grupperna. En av studierna visade på en signifikant minskning av biomarkörer hos patienter som fick empagliflozin vilket gav en njurfunktionsskyddande effekt mot akut njurskada.  Slutsatsen var att empagliflozin gav gynnsamma effekter såsom till exempel avsvällande/vätskedrivande effekt och klinisk fördel hos patienter med såväl akut de novo som med dekompenserad kronisk hjärtsvikt vilket betydde att läkemedlet var både säkert och effektivt. I framtiden behöver effekterna dock styrkas genom ytterligare studier med större antal deltagare och under längre behandlingstid efter sjukhusutskrivning.

There are widespread concerns about the increasing use of multiple medicines. The aims of this thesis were to identify older patients' and general practitioners' (GPs) attitudes to and experiences of multiple medicine use, as well as to describe patterns of multiple medicine use in different age groups in association with patient-related factors. An additional aim was to contribute to scientific methodological development by providing an empirical example of the application of the Lehoux, Poland, & Daudelin template for the analysis of interaction in focus groups. Data were collected via qualitative focus group discussions and from a cross-sectional community-based population survey conducted during 2001-2005. The patients revealed co-existing accounts of both immediate gratitude that medicines exist and problems with using multiple medicines such as worrying whether multiple medicine use is 'good' for the body. The patient-doctor relationship coloured their attitudes towards their treatment and care. The GPs at times felt insecure, though surrounded by treatment guidelines. Lack of communication with hospital specialists was perceived to reduce treatment quality, while influence of patient pressure was thought to contribute to the development of multiple medicine use. An interaction analysis helped in appreciating and clarifying the contexts in which results from the content analysis were created. Further discussion is needed on how to best report these results. Different cut-offs are useful in defining multiple medicine use in different age groups. Vast majorities of users of multiple medicines were found to have unique medicine combinations. Multiple medicine use was found to be associated with morbidity and poor self-rated health across all age groups.

The aim of this thesis was to explore Swedish pharmacist students’ learning during pharmacy internship. Internships are meant to introduce students to professional practice. Education programs have to reflect changes in the professional role, and take into account that learning in a professional practice setting differs from organized formal education. This thesis includes both quantitative and qualitative research approaches and applies workplace learning theories. A scheme for measuring pharmacy students’ reflective ability was developed and shown to be feasible and reliable. Factors important for reflection were found to be primarily social and contextual, especially trained tutor and small pharmacy size. Notably, learning style or critical thinking did not correlate to students’ reflective ability. Tutors and students perceived that students used a wide variety of activities supporting learning of a broad repertoire of knowledge and skills, preparing them for coming professional working life. Tutors are most important to support learning. However, the current curriculum and formal activities do not address all these outcomes and learning activities used, e.g. workplace learning. The first overall conclusion is that internship plays an essential part in the pharmacist education program. The integration of formal and informal learning activities during internship, including raising awareness of incidental learning, is important to support students in learning the professional practice of pharmacy. This integration could possibly be strengthened by introducing further tutor training, different assignments, and by using portfolios. The second conclusion is that the community of practice is essential for students’ learning during internship, especially the student-tutor interaction. Hence, the entire social context has to be considered and it is important to ensure a good learning environment at pharmacies during internship. In summary, this thesis contributes to the understanding of students’ learning during pharmacy internship and introduces educational research on the Swedish undergraduate pharmacy education programs.