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Background Restricted use of third-generation cephalosporins and fluoroquinolones has been linked to a reduced incidence of hospital-acquired infections with multidrug-resistant bacteria. We implemented an intensified antibiotic stewardship (ABS) programme in the medical service of a university hospital center aiming at a reduction by at least 30% in the use of these two drug classes. Methods The ABS programme was focused on the 300-bed medical service. Prescription of third-generation cephalosporins was discouraged, whereas the use of penicillins was encouraged. Monthly drug use density was measured in WHO-ATC defined and locally recommended daily doses (DDD and RDD) per 100 patient days, to evaluate trends before (01/2008 to 10/2011) and after starting the intervention (1/2012 to 3/2013). The effect was analysed using interrupted time-series analysis with six non-intervention departments as controls. Results Following initiation of the ABS intervention, overall antibiotic use in the medical service declined (p < 0.001). There was a significant intervention-related decrease in the use of cephalosporins and fluoroquinolones (p < 0.001) outperforming the decreasing baseline trend. Trend changes observed in some of the control departments were smaller, and the difference between trend changes in the medical service and those in control departments were highly significant for overall use and cephalosporin use reductions (p < 0.001) as well as for the increasing use of penicillins (p < 0.001). Mean use density levels (in RDD per 100 patient days) dropped for cephalosporins from 16.3 to 10.3 (−37%) and for fluoroquinolones from 17.7 to 10.1 (−43%), respectively. During the same period, the use of penicillins increased (15.4 to 18.2; 18%). The changes in expenditures for antibiotics in the medical service compared to control services minus programme costs indicated initial net cost savings likely to be associated with the programme. Conclusion An intensified ABS programme targeting cephalosporin und fluoroquinolone use in the setting of a large academic hospital is feasible and effective. The intervention may serve as a model for other services and hospitals with a similar structure and baseline situation.

BackgroundDifferent studies reported that higher diabetes-specific Medication Regimen Complexity Index (MRCI) has a negative impact on glycemic control potentially by decreasing medication adherence. However, information about regimen complexity and its association with adherence and glycemic control in Ethiopian patients with diabetes is unknown.AimTo evaluate medication regimen complexity and to assess its impact on medication adherence and glycemic control among patients with type 2 diabetes Mellitus (T2DM).MethodsA hospital-based cross-sectional design was conducted at Debre Tabor General Hospital from 1 May 2018 to 30 June 2018. Medication regimen complexity was evaluated using the 65-item validated tool called Medication Complexity Index (MRCI). Adherence was measured using Morisky Medication Adherence Scale while patients were classified as having poor or good glycemic control based on the recent record of their fasting blood glucose. Multivariable logistic regression analysis was applied to determine the association between predictive variables and outcome variables.ResultsA total of 275 patients with T2DM who meet the inclusion criteria were included in the final analysis. About 22.2% of the participants were classified as having high diabetes-specific MRCI, whereas 35.6% of the participants were classified as having high patient-level MRCI. The majority (70.5%) of the respondents were adherent to their medications, and 42.9% of the total population were categorized as having good glycemic control. According to the result of the multivariate analysis, patients with low-level and moderate-level MRCI of both diabetes-specific and patient-level MRCI were more adherent to their medication compared with patients with high MRCI. High diabetes medication regimen complexity was associated with poor glycemic control in the adjusted analyses (adjusted OR = 0.276; 95% CI = 0.100 o 0.759).ConclusionThe prevalence of high MRCImedication regimen complexity index is high among patients with T2DM. Patients with low and moderate regimen complexity had improved adherence. High diabetes-specific medication regimen complexity was associated with poor glycemic control. Simplification of a complex medication regimen for patients with diabetes should be sought by physicians and pharmacists to improve medication adherence and subsequent improvement in glycemic control.

Background Anticoagulant therapy is associated with a high risk of complications. Adherence to anticoagulant therapy protocols may lower this risk but adherence is often suboptimal. The introduction of a multidisciplinary antithrombotic team may improve adherence to anticoagulant guidelines among physicians. Objective To determine the effect of hospital-based multidisciplinary antithrombotic stewardship on adherence to anticoagulant guidelines among prescribing physicians. Setting This prospective non-randomised before-and-after study was conducted in patients hospitalized between October 2015 and December 2017 and treated with anticoagulant therapy. Method A multidisciplinary antithrombotic team focusing on education, medication reviews, drafting of local anticoagulant therapy protocols, patient counseling and medication reconciliation at admission and discharge was implemented in two Dutch hospitals. Main outcome measure Primary outcome was the proportion of the admitted patients in which the prescribing physician did adhere to the anticoagulant guidelines. Results The study comprised 1886 patients, of which 941 patients were included in the usual care period and 945 patients in the intervention period. Multivariable logistic regression analysis indicated that adherence was observed significantly more often during the intervention period (adjusted odds ratio [ORadj] 1.58, 95% confidence interval [95% CI] 1.21–2.05). Detailed analysis identified that the significantly higher overall adherence in the intervention period was attributed to dosing of LMWHs (odds ratio [OR] 1.58, 95% CI 1.16–2.14). Conclusion This study shows that introduction of a multidisciplinary antithrombotic stewardship leads to a significantly higher overall adherence to anticoagulant guidelines among prescribing physicians, mainly based on the improvement of dosing of low-molecular-weight-heparins.

Background Medicine use review by pharmacists has the potential to improve anticoagulation therapy management in patients on warfarin. Objective To develop, implement and evaluate a pharmacist-led medication use review service for patients on warfarin. Setting Six community pharmacies in Malta. Method Patients (N = 100) aged 18 or older and on warfarin were recruited through pre-selected community-pharmacies. These patients were then invited to attend two sessions: a review session (t1) and a follow-up session after 2 months (t2). During the medication use review session, medication reconciliation was performed (a) to detect drug-related problems using the DOCUMENT classification system, (b) to develop an individualised care plan for each patient and (c) to recommend an action for each identified problem for physician, pharmacist or patient consideration. At t2, the degree of acceptance of the recommendations was determined by assessing the number of drug-related problems for which action was taken to address the problem. International normalisation ration (INR) control was evaluated by calculating the percentage Time in Therapeutic Range (TTR) at t1 and t2 using the Rosendaal linear interpolation method. Main outcome measures Frequency and type of drug-related problems detected; percentage of accepted recommendations; and INR control. Results A total of 481 drug-related problems were identified; 40% (n = 190) were related to warfarin treatment. Need for monitoring (30%; n = 145), lack of compliance (20%; n = 97) and need for patient education (19%; n = 90) were the top three problems identified. There was a significant correlation between frequency of the problems and number of chronic medications (Spearman Correlation 0.583, p < 0.001), number of comorbidities (Spearman Correlation 0.327, p = 0.001) and older age (Spearman Correlation 0.285, p = 0.04). A total of 475 recommendations were followed-up; 49% (n = 234) were referred for consideration by the physician. The percentage of recommendations accepted (84%; n = 397) was significantly higher than the percentage of recommendations not accepted (16%; n = 78) (p < 0.001). The time in therapeutic range improved significantly from 68.7% at t1 to 79.8% at t2 (p = 0.01). Conclusions The high percentage of accepted recommendations and the improvement in INR control indicate that a pharmacist-led medication use review service in community pharmacy contributes to improving anticoagulation therapy management in patients on warfarin.

ObjectivesPeople who are marginalised (medically underserved) experience significant health disparities and their voices are often ‘seldom heard’. Interventions to improve professional awareness and engagement with these groups are urgently needed. This study uses a co-production approach to develop an online digital educational intervention in order to improve pharmacy staffs’ intention to offer a community pharmacy medication review service to medically underserved groups.DesignBefore/after (3 months) self-completion online questionnaire.SettingCommunity pharmacies in the Nottinghamshire (England) geographical area.ParticipantsCommunity pharmacy staff.InterventionOnline digital educational intervention.Primary and secondary outcome measuresThe primary outcome measure was ‘behaviour change intention’ using a validated 12-item survey measure. The secondary outcome measure was pharmacist self-reported recruitment of underserved groups to the medication review service.ResultsAll pharmacies in the Nottinghamshire area (n=237) were approached in June 2017 and responses were received from 149 staff (from 122 pharmacies). At 3 months (after completing the baseline questionnaire), 96 participants (from 80 pharmacies) completed a follow-up questionnaire, of which two-thirds (n=62) reported completing the e-learning. A before/after comparison analysis found an improving trend in all the five constructs of behaviour change intention (intention, social influence, beliefs about capabilities, moral norms and beliefs about consequences), with a significant increase in mean score of participants’ ‘beliefs about capabilities’ (0.44; 95% CI 0.11 to 0.76, p=0.009). In the short-term, no significant change was detected in the number of patients being offered and the patient completing a medication review.ConclusionsAlthough increases in the numbers of patients being offered a medication review was not detected, the intervention has the potential to significantly improve pharmacy professionals’ 'beliefs about capabilities' in the short-term. Wider organisational and policy barriers to engagement with marginasied groups may need to be addressed. Future research should focus on the interplay between digital learning and practice to better identify and understand effective practice change pathways.

Background The Medicines use review (MUR) service, provided by community pharmacists, seeks to optimise patients’ use of medicines. There is limited evidence on the clinical effectiveness of this service. Structuring MURs to include an assessment of prescribing appropriateness, facilitated by a validated prescribing screening tool, has the capacity to enhance this service. Objective To explore community pharmacists’ views on the facilitators and barriers towards the utilisation of a screening tool as a guide to conducting structured MURs. Setting Community Pharmacy, Northern Ireland. Method Using the 14 domain Theoretical Domains Framework (TDF), semi-structured interviews were conducted with community pharmacists. Interviews were digitally recorded, transcribed verbatim and analysed using the Framework method. Main Outcome Measure Pharmacists’ views towards utilisation of a screening tool as a guide to conducting structured MURs. Results Based on the analysis of 15 interviews, 11 TDF domains (‘Knowledge’, ‘Skills’, ‘Social and professional role and identity’, ‘Beliefs about capabilities’, ‘Beliefs about consequences’, ‘Reinforcement’, ‘Goals’, ‘Memory, attention and decision process’, ‘Environmental context and resources’, ‘Social influences’, ‘Behavioural regulation’) were deemed relevant. Facilitators included: knowledge of patients, clinical knowledge, perceived professional role, patients’ clinical outcomes, influence of peers. Barriers included: prioritisation of other clinical activities, inability to access patients’ clinical information, perceived alienation from the primary healthcare team and staffing issues. Conclusions Using the TDF, key facilitators and barriers were identified in the use of a screening tool as a guide to conducting MURs. These findings may assist in further development of MURs as a means to optimise patients’ medicines use.

To the Editor—Approximately 30%–50% of antimicrobials prescribed in hospitals are either inappropriate or unnecessary.1 The Joint Commission (TJC), Centers for Disease Control (CDC), and Infectious Diseases Society of America (IDSA) in partnership with the Society of Healthcare Epidemiology (SHEA) have all issued performance elements for antimicrobial stewardship programs (ASP).2–4 One core element in these standards is use of a systematic process for evaluating the need for treatment after a set period of time, most often referred to as “antibiotic time-out.” Pharmacists are required to document SCAN using a standardized template in the electronic medical record (EMR). Strategies for antibiotic time-out are centered on prompting prescribers to assess antibiotic needs or automatically stopping antibiotics to trigger review prior to renewal.7,8 Prior studies have demonstrated that use of electronic checklists integrated into the EMR in combination with face-to-face conversations with providers are effective in prompting antibiotic review and reducing antibiotic utilization.5,6 Although there are reports of the successful use of automatic vancomycin stop orders in reducing inappropriate use, one concern frequently raised by clinicians is potential interruptions in therapy in cases where continuation is desired.8,9 SCAN differs from an automatic stop order because the medication is not discontinued rather, a discussion regarding vancomycin use is initiated between the pharmacist and provider.

Objective The objective of this study was to assess implementation of a pharmaceutical care model for the multidisciplinary care of elderly patients in nursing homes. Setting Prospective study, medication review, from January 2007 to December 2009 in ten nursing homes affiliated to the Pharmacie interjurassienne (PIJ), Switzerland. Method Medication use data were collected and reviewed by a pharmacist, focusing on drug indication, dosing, side effects, renal/hepatic elimination and interactions. Drug-related problems (DRPs) were discussed face-to-face with the responsible physician and a nurse. The pharmaceutical care issues were formulated and medication interventions proposed during this meeting. DRPs and interventions were documented using the Pharmaceutical Care Network Europe scheme version 5.00 (PCNE V5.00). The economic impact of the service was estimated through a retrospective evaluation of annual drug costs. A satisfaction evaluation was conducted among practitioners and nurses. Main outcome measures DRPs, interventions, treatment changes implemented. Results Drug therapy of 329 patients was reviewed. The number of medicines per patient ranged from 2 to 27 (mean 12.8). A total of 1,225 DRPs were detected and discussed with the physician and the nurse. Medication review led to 343 medical evaluations secondary to drug-drug interactions and 803 treatment adaptations: 373 drugs were stopped, 197 dosages changed, 95 instructions for use amended, 86 drug choices were altered, 35 drug formulations changed and 17 new drugs started. According to the Anatomical Classification System, the main classes involved in interventions were related to Alimentary tract and metabolism (n = 285), Nervous system (n = 189) and Cardiovascular system (n = 115). Since the outset of the PIJ, the annual drug costs decreased in nursing homes with medication review including a pharmacist, whereas it was stable in the other nursing homes. The satisfaction evaluation showed a very positive appreciation by practitioners and nurses. Conclusion The study showed an efficient pharmaceutical care model, well accepted by physicians and nurses. It also indicated that for elderly patients, continuous drug review contributed to improved drug therapy, reduced unnecessary polypharmacy and reduced pharmaceutical costs.

Background The prescription is one of the factors that influences rational use of medicines. The evaluation of prescribing indicators should contribute to organization of primary health care services. Objective The aim of this study was to evaluate prescribing indicators and associated factors in primary health care in the northeast health district, Belo Horizonte, Brazil. Setting Twenty primary health care units in the Northeast Health District, Belo Horizonte, Brazil. Method The study was cross sectional. Indicators proposed by World Health Organization were used to evaluate rational use of medicines. Main outcome measure Indicators evaluated were average number of medicines per prescription, proportion of medicines with antibiotic, injectable, medicines prescribed by generic name and medicines present in the essential medicines list. Results Three hundred and ninety-nine patients were interviewed. The average number of medicines per prescription was 3.5 (SD 2.2). The proportion of medicines with antibiotic, injectable, medicines prescribed by generic name and medicines present in the essential medicines list was 17.8, 9.8, 94.9, 91.4%, respectively. Patient age ≥60 years was positively associated with number of medicines per prescription ( P  =  0.00 ). Conclusion In the northeast health district of Belo Horizonte, the proportion of prescriptions of antibiotics and injections, the adoption of prescribing by generic name and the prescribing of essential medicines were satisfactory in this study considering reference values for these indicators and international scientific literature. However, the mean number of prescribed medicines requires a more in-depth evaluation.

Background Potentially inappropriate medications (PIMs) are often found in high proportion among the elderly population. The STOPP criteria have been suggested to detect more PIMs in European elderly than the Beers criteria. Objective This study aimed to determine the prevalence of PIMs and potential prescribing omissions (PPOs) in a sample of Portuguese nursing homes residents. Setting Four elderly facilities in mainland Portugal Method A descriptive cross-sectional study was used. Elderly polypharmacy patients were included in the study and their medication (registered in patient clinical records) analysed using the Beers (2012 original version and 2008 version adapted to Portugal), STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria. Data were analysed using univariate and bivariate descriptive statistics, considering a confidence interval of 95 %. Main outcome measures: Prevalence of PIMs and PPOs. Results The sample included 161 individuals, with a mean age of 84.7 years (SD = 6.35), 68.9 % being female. A total of 807 PIMs and 90 PPOs were identified through the application of the three set of criteria. The prevalence of PIMs using the most recent version of the Beers criteria was 85.1 and 42.1 % for independent and dependent of diagnosis, respectively. The Portuguese adaptation of this same tool indicated a lower prevalence of PIMs, 60.3 and 16.7 %, respectively. The prevalence of PIMs using the STOPP criteria was 75.4 %, whilst the prevalence of PPOs, using START, was 42.9 %. There were significant differences in the mean number of PIMs detected depending on the tool used. ( p  < 0.001). Conclusions The application of the studied criteria in an elderly sample enabled the identification of a notable amount of PIMs and PPOs, indicating there is room for improving the quality of care. The variation in prevalence indicates careful choice of the tool is a prerequisite for engaging in medication review. Using START/STOPP criteria enabled a more holistic approach to the quality of prescribing in the elderly, highlighting low levels of cardiovascular risk prevention and abuse of psychotropic drugs, aside with system failures largely preventable by electronic prescribing and alert generation.