Dissertations / Theses on the topic 'Medication-related problem'

Background: In paediatrics, the limited documentation to guide medication, the lack of suitable dosage forms, and the continuous development in childhood present a scenario where safety of medication is a particular challenge. Aim: To explore reported adverse drug reactions (ADRs) and the challenges in prescribing and administering medicines in paediatrics, in order to identify and suggest areas needing international surveillance within medication safety and improvement in the clinical setting. Methods: Four exploratory studies were conducted. Worldwide reporting of suspected ADRs (individual case safety reports, ICSR) with ages 0-17 years were examined overall. Twenty published case reports and ICSRs for adolescents, who developed a rare and incompletely documented ADR (rhabdomyolysis) during antipsychotic medicine use, were analysed in-depth. Prescribed doses of anti-inflammatory medicines were studied in a UK electronic health record database. Transcribed focus group interviews with 20 registered nurses from four paediatric wards in Sweden were analysed for factors that may promote or hinder safe medication practices. Descriptive statistics, multiple regression, and content analyses were used. Results: Although, skin reactions and anti-infective medicines were most frequently reported, and more reported in paediatric patients than in adults, medication errors and adverse reactions related to psychostimulant medicines were reported with increased frequency during 2005 to February 2010. The in-depth case analysis emphasised the need for increased vigilance following changes in patients’ medicine regimens, and indicated that ICSRs could contribute with clinically valuable information. Prescribed dose variations were associated with type of dosage form. Tablets and capsules were prescribed with a higher dose than liquid dosage forms. Six themes emerged from the interviews: preparation and administration was complex; medication errors caused considerable psychological burden; support from nurse colleagues was highly valued; unfamiliar medication was challenging; clear dose instructions were important; nurses handling medications needed to be accorded higher priority. Conclusions: Age-specific screening of ICSRs and the use of ICSRs to enhance knowledge of ADRs and medication errors need to be developed. Access to age-appropriate dosage forms is important when prescribing medicines to children. To improve medication safety practices in paediatric care, interdisciplinary collaborations across hospitals on national or even global levels are needed.

Background: Medications are used to treat, cure, or relieve symptoms of diseases, but there is a risk with the use of medications. Drug-related-problems are known to increase morbidity and mortality. Incorrect medical list and discrepancies in these lists can lead to drug-related problems as side effects, hospitalization, non-compliance, drug interactions and overtreated or undertreated patients. Discrepancies can be for example: more prescriptions than necessary, outdated prescriptions, i.e., medicines that will not be used, prescriptions with incorrect dosing and missing prescriptions i.e., medicines used by patients that cannot be seen in the medication list. Purpose:  The aim of this study was to investigate discrepancies in the Swedish prescription list "My saved prescriptions at the pharmacy". The secondary aim was to investigate how common it is to use this prescription list or the dosage label on the medicine packaging to know which medicines to use and which dosage. Methods: The data collection was performed by four pharmacy students at seven pharmacies in Sweden over a period of three weeks during Jan-Feb. 2021 where the prescription list was investigated together with patients to identify any discrepancies. The study included patients who was over 18 years old, spoke Swedish, had three or more prescribed drugs, and agreed to participate.  Results A total of 215 patients were interviewed, where 61% had one or more discrepancies in their medication list. A total of 1717 prescriptions were analyzed, of which 10% were double prescriptions (n = 167), 8% outdated prescriptions (n = 141) and 3% prescriptions with the wrong dosage (n = 42). When analyzing the primary sources of information used by patients to know which medicine to use, the printout of the list "my saved prescriptions at the pharmacy” dominated (n = 72).  Most used information source to know drug dosage was the dosage label on the medicine packaging (n = 112). Conclusions: It is important to have an updated and correct information in the medication list, to prevent drug-related-problems caused by discrepancies. It becomes even more important when we see that the medication list "My saved prescriptions at the pharmacy" and dosage label (containing the same information in the medication list), are the most used primary sources by patients to know which drug to use and in what dosage. Finally, results show a relationship between the number of prescribed drugs and the number of discrepancies that occur, and therefore we see more discrepancies in elderly patients who are usually ill and are being treated for several diseases.  There are opportunities for further research to study e.g., which drug-related-problems are caused by discrepancies in the medication list as well as the degree of danger in these problems.
Användning av läkemedel som avses behandla, lindra eller bota sjukdomar kan i vissa fall utgöra en risk för patientens hälsa. Läkemedelsrelaterade problem p.g.a. felmedicinering står för en stor andel av morbiditeten och mortaliteten bland patienter. En bidragande orsak är ofullständig information i patientens läkemedelslista.   Syftet med studien var att undersöka antalet avvikelser som förekommer i receptlistan ”Mina sparade recept på apoteket”. Studiens sekundära syfte var att undersöka vilka informationskällor som användes av patienter för att veta vilka läkemedel som ska adminstreras och i vilken dos dosering.  Studiens metod var att intervjua patienter som kom till apoteket för att hämta ut läkemedel till sig själva och uppfyllde inklusionskriterierna för att delta i studien. Studien utfördes av fyra farmaceutstudenter på sju olika apotek i fyra olika städer i Sverige som tillsammans med patienter gick igenom receptlistan för att identifiera avvikelser.  Resultatet blev totalt 1717 recept som studerades varav 21% hade avvikelser. Av recepten var 10% dubbla recept (n = 167), 8% inaktuella recept (n = 141) och 3% recept med fel dosering (n = 42). Vid analys av primära informationskällor som används dominerade utskrift av listan ”Mina sparade recept på apoteket” (n = 72) resp. doseringsetiketten på läkemedelsförpackningen (n = 112).  Resultaten visade även ett samband mellan ökade antal läkemedel och antalet avvikelser.  Avvikelser i läkemedelslistan Mina sparade recept är vanligt förekommande därmed är listan inte alltid aktuell. Det är vanligt att denna lista och doseringsetikett på läkemedels-förpackningar används som primära källor av patienter under deras behandlingstid vilket kan innebära en risk för läkemedelsrelaterade problem. En gemensam nationell läkemedelslista är en möjlig lösning till att förebygga läkemedelsrelaterade problem orskade av infromationsbrist i läkemedelslistor. Det är dock nödvändigt med läkemedelsgenomgångar för att bibehålla uppdateringen av listan.

Background: The purpose of drug treatment is to reduce morbidity and mortality, and to improve health-related quality of life. However, there are frequent problems associated with drug treatment, especially among the elderly. The aim of this thesis was to investigate the impact of clinical pharmacy services within a multiprofessional healthcare team on quality and safety of patients’ drug therapy, and to study the frequency and nature of medication history errors on admission to hospital. Methods: A model for clinical pharmacy services within a multiprofessional healthcare team (the Lund Integrated Medicines Management model, LIMM) was introduced in three hospital wards. On admission of patients to hospital, clinical pharmacists conducted medication reconciliation (i.e. identified the most accurate list of a patient’s current medications) to identify any errors in the hospital medication list. To identify, solve and prevent any other drug-related problems, the clinical pharmacists interviewed patients and performed medication reviews and monitoring of drug therapy. Drug-related problems were discussed within the multiprofessional team and the physicians adjusted the drug therapy as appropriate. Results: On admission to hospital, drug-related problems, such as low adherence to drug therapy and concerns about treatment, were identified. Different statistical approaches to present results from ordinal data on adherence and beliefs about medicines were suggested. Approximately half of the patients were affected by errors in the medication history at admission to hospital; patients who had many prescription drugs had a higher risk for errors. Medication reconciliation and review reduced the number of inappropriate medications and reduced drug-related hospital revisits. No impact on all-cause hospital revisits was demonstrated. Conclusion: Patients admitted to hospital are at high risk for being affected by medication history errors and there is a high potential to improve their drug therapy. By reducing medication history errors and improving medication appropriateness, clinical pharmacy services within a multiprofessional healthcare team improve the quality and safety of patients’ drug therapy. The impact of routine implementation of medication reconciliation and review on healthcare visits will need further evaluation; the results from this thesis suggest that drug-related hospital revisits could be reduced.
Läkemedelsgenomgångar och läkemedelsavstämning - LIMM-modellen

Medication reconciliation is a systematic and comprehensive review of medication regimens during care transitions aiming to prevent adverse drug events. Poorly executed transitions negatively impact patient welfare and cause financial burden. Medication-related problems (MRPs) experienced during transitions to an assisted living facility (ALF) were evaluated. Data was collected from pharmacy records for transitions to an ALF over three months, including demographics, medications, potentially inappropriate medications, and MRPs. MRPs were categorized and summarized using descriptive statistics. Forty-five patients (71% female) experienced 59 transitions. Average age was 85.6 years. Median length of stay away from the ALF was three days. There were averages of 18.3 pre-transition medications, 12.5 medications in the discharge orders and/or upon ALF admission, and 15.9 final medications. 979 MRPs were identified, mostly no indication documented, followed by underuse, overuse, and non-adherence. Many of the identified MRPs are potentially preventable. Interventions are needed to reduce MRPs during ALF transitions.

Class of 2015 Abstract
Objectives: To compare provider acceptance rates of medication therapy management (MTM) interventions initiated by a MTM center for potential drug-related problems in 2012. Interventions included cost-savings to patients, adherence to clinical guidelines, medication adherence, and safety initiatives. Methods: This retrospective cross-sectional project measured the provider acceptance rates of MTM interventions for Medicare Part D beneficiaries. Intervention count and acceptance rates were analyzed from the center’s MTM software and database that utilizes prescription claims analysis post-intervention to determine intervention success. A chi-square test was used to assess the statistical significance between the interventions. An alpha level of 0.5 was determined a-priori. This was a quality improvement project, and Institutional Review Board approved this project as exempt status. Results: The total percent of recommendations accepted was 35% (159,795 out of 455,898). The rate of acceptance was highest for safety interventions (51%), followed by cost (35%), adherence (12%), and guidelines (8%). The acceptance rates for the four intervention types were statistically different from each other (p-value <0.0001). Within each intervention type, the most frequently accepted interventions were: removal of medications from the Beer’s Criteria (8% of safety related changes); changes from a brand name, non-oral medication like eye drops and nasal sprays, to a generic within the same class (15% of cost-saving related changes); improved adherence to hypertension and diabetic medications (29% of adherence related changes); and adding an antihypertensive agent to diabetic patients (62% of clinical guideline related changes). Conclusions: Safety initiatives had the highest acceptance percentage of all four intervention types. Approving more safety interventions with medication use may reduce the risk of morbidity and mortality. Pharmacists providing MTM services may want to increase focus on drug safety as providers are accepting more safety interventions. More research is needed to determine why providers approve the other recommendations at lower rates.

Pharmaceutical care and medicines management are terms which are often used interchangeably to describe the patient-centred services provided by pharmacists. The programme of research presented within this thesis evaluated a range of topics within this area of endeavour. The extent of pharmaceutical care provision within the community pharmacy setting was examined in a cross-sectional survey in N. Ireland and across 15 European countries. The findings indicated that community pharmacists' provision of comprehensive pharmaceutical care can be deemed as limited in Northern Ireland (mean score 41.4% of the total achievable score) and across Europe (scores ranged from 56.6% in England to 29.4% in Moldova). To inform the development of a definitive RCT for novel post-discharge medicines management clinic (MMC), a feasibility study was carried out, and identified a number of methodological challenges, in particular, challenges around patient recruitment, attrition rates and clinic scheduling. A series of risk assessment models was developed to help with the targeting of patients to be recruited for the RCT referred to above. These models were designed to forecast the likelihood of patient early readmission to hospital (within 30 and 8 to 30 days) and high-cost readmissions. Important risk factors for readmission identified included the Charlson age-adjusted co-morbidity score, respiratory- and genitourinary-related primary diagnoses and number of medications prescribed on discharge, and new patient targeting criteria for the RCT to explore the impact of the MMC was developed. A systematic content analysis revealed that the print media coverage of medicine-related adverse effects requires significant improvement in order to properly inform the public on this matter. Specifically, the reporting of adverse effects, in terms of medicines implicated and organ systems affected, did not correspond with those commonly cited in scientific journal articles. Findings from the present research help contextualise and provide evidence based advice on a number of issues which need to be addressed in pharmaceutical care / medicines management practice and research.

Pharmacists as members of health care teams, have a central role to play with respect to medication. The pharmaceutical care and cognitive services which pharmacists are able to provide can help prevent, ameliorate or correct medication-related problems. There are however many barriers to the provision of these services and one of the barriers commonly cited by pharmacists is the lack of remuneration for their expert services. The aim of this study is to ascertain if patients in South Africa are willing to pay for pharmacist-provided services which may reduce medication related problems, and thereby determine the perceived value of the pharmacist-provided services, by patients. The study will also seek to determine factors that influence willingness to pay (WTP), including financial status, gender, race, age and level of education. In addition the perceived value of the pharmacist‘s role in patient care, by third party payers (SA Medical Aid providers) and their WTP for pharmacist-provided services (such as DSM) on behalf of patients through their monthly premiums will also be investigated. The study was conducted as a two-phase process: the first phase focused on the opinions of patients and the second phase on the medical aid companies. In phase-1 a convenience sample of 500 patients was recruited by fifty community pharmacies distributed throughout the nine South African provinces. Data collection, consisting of telephonic administration of the questionnaires, was conducted and the survey responses were captured on a Microsoft Excel® spreadsheet. All the captured information was analyzed using descriptive statistics, box and whisker plots, analysis of variance (ANOVA) and regression analysis. In phase-2, medical aid schemes that are registered with the Council of Medical Schemes (CMSs) of South Africa were included in this research. A fifteen point questionnaire was completed electronically via e-mail by willing medical aid participants. Data was analyzed using descriptive statistics only. Only 233 or 88.6 percent, of the 263 participating respondents, were willing to pay at least one rand towards pharmacist-provided services. On average respondents were willing to pay R126.76 as out-of-pocket expenses. Respondents‘ WTP increased as the risk associated with medication-related problems was reduced due to pharmaceutical care intervention. Of the 263 respondents who took part in this research, fifty percent were willing to pay at least R100 for a risk reduction of 30 percent, R120 for a 60 percent reduction and approximately R150 for a greater than 90 percent risk reduction. It was also found that the respondents‘ willingness to pay was influenced by their age, earnings, racial grouping, employment status, medical aid status and their level of satisfaction with pharmacist-provided care services. Of the thirty-one open medical aid schemes only eight (25.8 percent) participated in the study. Findings indicate that all the participating medical aid respondents were unwilling to pay for pharmacist-provided care services, although they perceived pharmacists as very influential healthcare providers and as having a significant role to play in reducing medication-related problems. In conclusion it was found that majority of participants were willing to pay for pharmacist-provided services directed towards reducing risks associated with medication-related problems. Until pharmacists are able to prove pharmaceutical care‘s utility and cost-effectiveness to third-party payers, pharmacists must look to the patient for reimbursement.

The work presented in this dissertation focuses on two important medication-related problems in older adults, that is, untreated indication and drug-drug interactions, specifically with respect to a high-risk medication such as warfarin. Warfarin is a challenge to use in clinical practice due to its narrow therapeutic index, variability in dose-response and its interactions with numerous foods and drugs. This dissertation presents the research from two projects. In the first project the prevalence and predictors of warfarin use in nursing home (NH) residents with atrial fibrillation (AF), and use of secondary stroke prevention strategies was determined, in order to understand the patterns of anticoagulant use in frail NH residents and to identify patient characteristics associated with warfarin use. In the second project the effect of oral antibiotics on anticoagulation outcomes, when prescribed concomitantly with warfarin, was determined, in order to provide evidence on the clinical significance of warfarin-antibiotic interactions in older adults. In the first project a cross-sectional analysis of the prescription and resident files from the 2004 National Nursing Home Survey was done to determine the prevalence of AF and rates of use of warfarin and other anti-platelet agents, such as aspirin and clopidogrel. A multiple logistic regression model was used to determine factors associated with warfarin use. In this sample of older NH residents, 13% of residents had a diagnosis of AF, with indications for warfarin use and no contraindications to warfarin. From these patients, 30% received anticoagulant therapy with warfarin and 23% of the remaining patients received either aspirin or clopidogrel, suggesting that more than 50% of residents with AF did not receive any form of anticoagulant therapy. Non-white race, history of bleeding, and use of anti-platelet medications were associated with reduced odds of receiving warfarin. The second project was a retrospective medical record review of older patients from an outpatient anticoagulation clinic at a Veterans Affairs medical center. Results of the repeated measures ANOVA suggested a significant increase in post-antibiotic INR values with fluoroquinolones, azithromycin and amoxicillin. In addition, the percentage of patients with warfarin dose adjustments was significantly greater with fluoroquinolones and azithromycin as compared to cephalexin. No bleeding events were reported for any of these patients. In conclusion, the results of the projects suggest that there is underuse of warfarin in NH settings. Furthermore, antibiotics may be safely prescribed with warfarin in older adults as long as the INR is monitored closely.

BACKGROUND AND OBJECTIVES: Interprofessional education (IPE) is recommended by many as a means by which to prepare clinicians for collaborative practice and a mechanism by which to improve the overall quality of health care. The objective of this study was to determine the impact of an interprofessional medicine-pharmacy student home visit experience on students’ self-assessments of skills and abilities related to team-based care and identification of medication-related problems. METHODS: Third-year medical and fourth-year pharmacy students completed an interprofessional home visit centered on identification of medication-related problems. Students were surveyed before and after the IPE assignment to assess changes in self-assessed skills and abilities. Survey items consisted of Likert-type statements on a 5-point scale (1=strongly disagree, 5=strongly agree) and free-text responses. Students also completed reflection papers regarding their experiences. RESULTS: Twenty-two medical and 20 pharmacy students conducted medication-focused interviews of 22 patients at home as interprofessional teams. Medical and pharmacy student self-assessments of skills and abilities related to team-based care and identification of medication-related problems improved after completion of the assignment. Both groups of students perceived an improvement in confidence regarding communication skills, both with patients and with other health professions students. Changes were reported on 12 survey items. Student feedback on the IPE experience was positive. CONCLUSIONS: Students’ self-perception of skills and abilities related to interprofessional team-based care and identification of medication-related problems are improved after IPE medication-focused home visit assignment. Student feedback supports the value of interprofessional patient care clinical experiences.

The social and economic impact of medication-related problems (MRPs) of cardiovascular drugs has been under-reported in the community setting. Cardiovascular patients on multiple drug therapy do not know whether side-effects they experience are medication-related or due to their condition. The aim of this study was therefore to develop a system to detect medication side-effects of cardiovascular drugs and their impact on patients' social and economic well-being. The problem was overcome by developing a Socioeconomic Impact Profile (SEIP) questionnaire in which patients were asked if they experienced medication side-effects and what impact these MRPs have on their ability to work, socialise or use healthcare services. The Socioeconomic Impact Profile (SEIP) consisted of 19 items in three domains. Each item was scored from 1 to 5 (1=all of the time, 2=most of the time, 3=some of the time, 4=a little of the time, 5=never). Higher scores indicated better socioeconomic well-being. Psychometric evaluation of the SEIP was carried out in 348 patients with cardiovascular disease (mean age=58.8, median=58.5, age range=37-84, male 175, female=173) recruited from five pharmacies across South West England and South Wales. The SEIP was generally acceptable to most patients with a mean completion time of 5.7 minutes. A high level of agreement among expert panel members on all items of the SEIP was achieved during content validation (Kappa coefficient "k"= 0.85). Factor analysis was used to identify redundant items and also provide initial evidence of construct validity. Evidence supporting internal consistency reliability was excellent (Cronbach's a =0.77-0.95). To further examine the reliability of the SEIP, test-retest reliability was carried out in 92 patients with cardiovascular disease 50 (42.3%) males mean age=57.7 median=57.0 range=39-78 from five community pharmacies in South Wales and the reliability coefficient was high (rs= 0.91-0.93). Evidence supporting the validity of the SEIP was also shown in 96 patients 49 (51.0%) males mean age=63.1 median=63.0 age rangesss39-84 with a cardiovascular condition from the community pharmacy setting. Convergent validity was demonstrated as SEIP patient scores showed moderate to good correlation with the patient MIDAS (Myocardial Infarction Dimensional Assessment Scale) scores. Divergent validity was established as the Short Form-12 health survey (SF-12) overall score demonstrated weak to moderate correlation with the SEIP scores. This study has established the practicality, reliability and validity of the SEIP as a promising socioeconomic related tool, especially in cardiovascular patients with medication-related problems in the community setting. Future work needs to focus on promoting use of the SEIP as part of the new community pharmacy initiatives in the UK for evaluation of treatment outcomes in patients with medication-related side-effects.

Background: Drugs are one of the cornerstones in the management of many diseases. In general, drugs are used for diagnosis, prevention, mitigation of symptoms, and, sometimes, to cure disease. However, drug treatment in elderly people, especially those with dementia and cognitive impairments, may involve significant risk of adverse drug events.  The aim of this thesis was to identify the extent of potentially inappropriate drug treatment among people with dementia and cognitive impairment and to assess the occurrence and character of drug-related problems that lead to acute hospital admissions. Another aim was to assess the potential impact of a comprehensive medication review conducted by clinical pharmacists as part of a health care team on quality of patients’ drug therapy and drug-related hospital readmission rates. Method: Long-term use of antipsychotic/psychotropic drugs and associated factors were investigated among 344 and 278 people respectively with dementia living in specialized care units. Trends in the prescribing of potentially inappropriate drugs between 2007 and 2013, comprising 2772 and 1902 people, living in nursing homes in the county of Västerbotten, were assessed using six national quality indicators. Data on drug use, function in the activities of daily living, cognitive function and behavioral and psychological symptoms were collected using the Multi-Dimensional Dementia Assessment Scale. Further, an investigation of a separate corresponding population from 2012 was done, where potentially inappropriate drug use was measured before and after a total of 895 medication reviews. Finally, a randomized, controlled trial was carried out among people 65 years or older with dementia or cognitive impairment in internal medicine and orthopedic wards at two hospitals in northern Sweden. The proportion of hospital admissions that were drug-related were estimated, and also whether comprehensive medication reviews conducted by clinical pharmacists as part of a health care team could affect the risk of drug-related hospital readmissions. Results: Antipsychotic and other psychotropic drugs were frequently prescribed to people with dementia living in specialized care units for prolonged periods. Associations were found between behavioral and psychological symptoms and different psychotropic drugs. The extent of potentially inappropriate drug use declined between 2007 and 2013. In the separate corresponding population from 2012, the frequency of potentially inappropriate drug use was significantly reduced among people who underwent medication reviews. Hospitalizations due to drug-related problems among old people with dementia or cognitive impairment were prevalent. We found that inclusion of a clinical pharmacist in the health care team significantly reduced the risk of drug-related 30-day and 180-day readmissions. However, in a subset of patients with concomitant heart failure no effect was seen. Conclusion: Among patients with dementia or cognitive impairment long-term treatment with antipsychotic and other psychotropic drugs is common. The results indicate that these drugs are prescribed to treat behavioral and psychological symptoms among cognitively impaired individuals, despite limited evidence of their efficacy and the high risk of adverse effects. Drug-related problems, such as adverse drug reactions, constituted a major cause of hospital admissions. By reducing potentially inappropriate drug use and optimizing overall drug therapy, inclusion of clinical pharmacists in a health care team might improve the quality of patient care and reduce the risk of hospital readmissions among people with dementia.

The overall aim of this thesis was to evaluate clinical pharmacist interventions with the focus on methods aiming to improve the quality of drug therapy and increase patient safety. Adverse drug events caused by medication errors, suboptimal dosages and inappropriate prescribing are common causes of drug-related morbidity and mortality. Clinical pharmacists integrated in multi-professional health-care teams are increasingly addressing these issues. A randomised controlled trial (RCT) was conducted to investigate the effectiveness of clinical pharmacists’ interventions in reducing morbidity and use of hospital care for patients 80 years or older. The results showed that the intervention group had fewer visits to hospital and that the intervention was cost-effective. In a subsequent study based on the population in the RCT, the appropriateness of prescribing was assessed using three validated tools. The results indicated improved appropriateness of prescribing for the intervention group as a result of the intervention. The tools and the number of drugs at discharge were then tested for validity in terms of causal links between the scores at discharge and hospitalisation. No clear correlations between high scores for the tools or a high number of drugs and increased risk of hospitalisation could be detected. During the inclusion period of the RCT a survey based study was conducted where the perceived value of ward-based clinical pharmacists, from the perspective of hospital-based physicians and nurses as well as from general practitioners (GPs) was evaluated. The respondents were positive to the new collaboration to a high degree and stated increased patient safety and improvements in patients’ drug therapy as the main advantages. In the last study the frequency and severity of prescription and transcription errors, when patients enrolled in the multidose-dispensed medications (MDD) system are discharged from hospital, was investigated. The results showed that errors frequently occur when MDD patients are hospitalised.

Aim: To identify type(s) and possible cause(s) of medicine-related problems (MRPs) from the SA and ME patients' perspectives. Setting and Method: The study was a cross-sectional study. Patients were from SA and ME origins, aged over 18 and prescribed three or more regular medicines. Patients were identified through previous medicine use reports (MUR), patient medication records (PMR) or when presenting with a prescription. The data were collected in 80 face-to-face semi-structured interviews in seven pharmacies in London using MRPs tool, 8-item MMAS and EuroQol questionnaire (EQ-5D-3L). Interviews were audiotaped, transcribed verbatim and analysed thematically using Gordon’s coding frame and Nvivo 10 software. The SPSS 21.0 software was used for analysis of descriptive data obtained quantitatively. Results: Participants (61% male) had mean (SD) age 58 (13.4) years and on a mean (SD) of 8 (4) medicines. Final analysis showed the following types of MRPs: adverse drug reactions and drug interactions; intentional non-compliance; cognitive, physical and sensory problems and issues with concurrent use of herbal and alternative therapies. Problems with drug prescribing; lack of information; monitoring and review; repeat prescriptions; GP surgery and pharmacy service were also identified. Interviews revealed that several factors contribute to the development of MRPs; some appeared to be specific to SA and ME cultures and others were similar to the general population. Many of these factors could be expected to influence patient’s safety, adherence, and informed decision-making. Conclusion: This study demonstrated that SA and ME patients have their own problems and needs with both medicine use and service access. By uncovering particular problems experienced by these groups the study can inform healthcare professionals to support SA and ME patients in the use of their medicines.

Medication is an essential part of health care and enables the prevention andtreatment of many conditions. However, medication errors and drug-relatedproblems (DRP) are frequent and cause suffering for patients and substantial costsfor society. eMedication, defined as information technology (IT) in themedication management process, has the potential to increase quality, efficiencyand safety but can also cause new problems and risks.In this thesis, we have studied the employment of IT in different steps of themedication management process with a focus on the user's perspective. Sweden isone of the leading countries when it comes to ePrescribing, i.e. prescriptionstransferred and stored electronically. We found that ePrescribing is well acceptedand appreciated by pharmacists (Study I) and patients (Study II), but that therewas a need for improvement in several aspects. When the pharmacy market inSweden was re-regulated, four new dispensing systems were developed andimplemented. Soon after the implementation, we found weaknesses related toreliability, functionality, and usability, which could affect patient safety (StudyIII). In the last decade, several county councils in Sweden have implementedshared medication lists within the respective region. We found that physiciansperceived that a regionally shared medication list generally was more complete butoften not accurate (Study IV). Electronic expert support (EES) is a decisionsupport system which analyses patients´ electronically-stored prescriptions in orderto detect potential DRP, i.e. drug-drug interactions, therapy duplication, highdose, and inappropriate drugs for geriatric or pediatric patients. We found thatEES detected potential DRP in most patients with multi-dose drug dispensing inSweden (Study V), and that the majority of alerts were regarded as clinicallyrelevant (Study VI).For an improved eMedication, we need a holistic approach that combinestechnology, users, and organization in implementation and evaluation. The thesissuggests a need for improved sharing of information and support for decisionmaking, coordination, and education, as well as clarification of responsibilitiesamong involved actors in order to employ appropriate IT. We suggestcollaborative strategic work and that the relevant authorities establish guidelinesand requirements for IT in the medication management process.
Läkemedel förbättrar och förlänger livet för många och utgör en väsentlig del av dagens hälso- och sjukvård men om läkemedel tas i fel dos eller kombineras felaktigt med varandra kan behandlingen leda till en försämrad livskvalitet, sjukhusinläggningar och dödsfall. En del av dessa problem skulle kunna förebyggas med rätt information till rätt person vid rätt tidpunkt och i rätt form. Informationsteknik i läkemedelsprocessen har potentialen att öka kvalitet, effektivitet och säkerhet genom att göra information tillgänglig och användbar men kan också innebära problem och risker. Det är dock en stor utmaning att i läkemedelsprocessen föra in effektiva och användbara IT-system som stödjer och inte stör personalen inom sjukvård och på apotek, skyddar den känsliga informationen för obehöriga och dessutom fungerar tillsammans med andra system. Dagens IT-stöd i läkemedelsprocessen är otillräckliga. Till exempel saknar läkare, farmaceuter och patienter ofta tillgång på fullständig och korrekt information om en patients aktuella läkemedel; det händer att fel läkemedel blir utskrivet eller expedierat på apotek; och bristande eller långsamma system skapar frustration hos användarna. Dessutom är det flera delar av läkemedelsprocessen som fortfarande är pappersbaserade. Därför är det viktigt att utvärdera IT-system i läkemedelsprocessen. Vi har studerat IT i olika delar av läkemedelsprocessen, före eller efter införandet, framför allt utifrån användarnas perspektiv. Sverige har lång erfarenhet och tillhör de ledande länderna i världen när det gäller eRecept, det vill säga recept som skickas och lagras elektroniskt. I två studier fann vi att eRecept är väl accepterat och uppskattat av farmaceuter (Studie I) och patienter (Studie II), men att det finns behov av förbättringar. När apoteksmarknaden omreglerades 2009 infördes fyra nya receptexpeditionssystem på apoteken. Vi fann att det efter införandet uppstod problem med användbarhet, tillförlitlighet och funktionalitet som kan ha inneburit en risk för patientsäkerheten (Studie III). I Sverige har man inom flera sjukvårdsregioner infört gemensamma elektroniska läkemedelslistor. I en av studierna kunde vi visa att detta har inneburit en ökad tillgänglighet av information, men att en gemensam lista inte alltid blir mer korrekt och kan innebära en ökad risk att känslig information nås av obehöriga (Studie IV). I två av studierna undersöktes beslutsstödssystemet elektroniskt expertstöd (EES):s potential som stöd för läkare att upptäcka läkemedelsrelaterade problem till exempel om en patient har två olika läkemedel som inte passar ihop, eller ett läkemedel som kanske är olämpligt för en äldre person. Studierna visade att EES gav signaler för potentiella problem hos de flesta patienter med dosdispenserade läkemedel i Sverige (Studie V), och läkarna ansåg att majoriteten av signalerna är kliniskt relevanta och att några av signalerna kan leda till förändringar i läkemedelsbehandlingen (Studie VI). Sammantaget visar avhandlingen att IT-stöd har blivit en naturlig och nödvändig del i läkemedelsprocessen i Sverige men att flera problem är olösta. Vi fann svagheter med användbarhet, tillförlitlighet och funktionalitet i de använda IT-systemen. Patienterna är inte tillräckligt informerade och delaktiga i sin läkemedelsbehandling. Läkare och farmaceuter saknar fullständig och korrekt information om patienters läkemedel, och de har i dagsläget inte tillräckliga beslutsstöd för att förebygga läkemedelsrelaterade problem. Eftersom läkemedelsprocessen är komplex med många aspekter som påverkar utfall behöver vi ett helhetstänkande när vi planerar, utvecklar, implementerar och utvärderar IT-lösningar där vi väger in både tekniska, sociala och organisatoriska aspekter. Avhandlingens resultat visar på ett behov av ökad koordination och utbildning samt förtydligande av ansvaret för inblandade aktörer. Vi föreslår gemensamt strategiskt arbete och att inblandade myndigheter tar fram vägledning och krav för IT i läkemedelsprocessen.

This study used the Andersen Model for Health Services Utilization to examine a pharmacist-provided telephone MTM program among Medicare Part D beneficiaries. Predisposing (age, gender, race) and need factors (number of medications, number of chronic diseases, medication regimen complexity) were assessed. The health behavior, MTM utilization, distinguished the intervention and control groups. The health outcomes were change in number of medication-related problems, change in medication adherence [using the medication possession ratio (MPR)], and change in total drug costs. Medication knowledge, medication adherence (using the Morisky Scale), and patient satisfaction were also measured in the intervention group. The intervention and control groups were not significantly different in age (71.2 ± 7.5 vs. 73.9 ± 8.0 years), number of medications (13.0 ± 3.2 vs. 13.2 ± 3.4), number of chronic diseases (6.5 ± 2.3 vs. 7.0 ± 2.1), and medication regimen complexity [21.5 (range 8 – 43) vs. 22.8 (range 9 – 42.5)], respectively. For the subset of problems that was evaluated in the intervention and control groups, 4.8 (± 2.7) and 9.2 (± 2.9) problems were identified at baseline and 2.7 (± 2.3) and 8.6 (± 2.9) problems remained at the 3-month follow-up, respectively. Cost-related and preventative care needs and drug-drug interactions were the three most common problems identified. Multivariate regression analysis revealed that the intervention group had significantly more problems resolved (p < 0.0001) when compared to the control group, while controlling for predisposing and need factors. Significantly fewer problems were resolved (p = 0.01) as number of diseases increased and significantly more problems were resolved (p = 0.01) as medication regimen complexity increased. There were no significant predictors of change in MPR or total drug costs from baseline to the 3-month follow-up. Medication knowledge and medication adherence measured by the Morisky scale did not change significantly from baseline to the 2-week follow-up. However, patients were very satisfied with the service. A pharmacist-provided telephone MTM program was an effective method for identifying and resolving medication and health-related problems. A longer follow-up period may be necessary to detect the impact of pharmacist provision of MTM on adherence, total drug costs, and knowledge.
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