Live Links Archive January 2016
A review of pharmacy practice research from Canada and the world.
Digital health refers to the use of technology to deliver health care services and to facilitate better health. In Canada, this includes the electronic health record (EHR), which is a secure record of a patient’s health care history. To provide optimal patient care pharmacists need access to patient-specific information, including medication profiles and laboratory values. In 2010, a pan-Canadian study on the provincial drug information systems (DIS), a core component of EHR that stores information about medications, found that pharmacists perceived DIS to be a valuable tool that is beneficial in areas of access, quality and productivity.
In 2014, community pharmacists across the country were invited to participate in a web-based survey by Canada Health Infoway and the Canadian Pharmacists Association aimed at understanding community pharmacists’ use and perceived benefits of digital health in practice. A total of 447 community pharmacists responded to the survey, most of whom used some form of digital health in their practice. Overall, 43% of the respondents practice in provinces with a fully implemented DIS, 65% have access to patient medication profiles through DIS and 22% have access to laboratory test results through provincial laboratory information systems (LIS). For those practicing in an environment with access to DIS, the majority of respondents estimated over 60% improvement in such areas as medication reviews and continuity of patient care. Furthermore, 92% of pharmacists with access to DIS and 87% with LIS access stated better quality of patient care as a result. Over 90% of pharmacists desired access to either resource.
Digital health is, and will continue to be, a key enabler for practice transformation and improved quality of care. As pharmacists’ scope of practice continues to change, there will be numerous opportunities for digital health to support and accelerate this transformation.
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In the US, intravenous (IV) chemotherapy is ordered and delivered to patients in a hospital setting after the adherence to many safeguards. In comparison, oral chemotherapy - which is ordered in a cancer centre, dispensed by a community pharmacy and administered at home - is subject to fewer safeguards. While research in the US shows that few of the safeguards used for IV chemotherapy have been implemented for oral chemotherapy, not much is known about the Canadian context. The purpose of this Canadian study is to determine whether similar safeguards, in the form of independent checks, are used for both IV and oral chemotherapy and to identify potential errors related to both formulations.
Human factors specialists conducted observations and interviews in cancer clinics, a cancer centre pharmacy and four community pharmacies across Nova Scotia. Analysis followed to determine if an independent check was performed, which provider completed the check and at what point of the process the check occurred.
A total of 57 systemic checks were identified for IV chemotherapy compared to only 6 systemic checks for oral chemotherapy. Community pharmacists were identified as being the only qualified professionals involved in independent systematic checking of oral chemotherapy. These checks occurred during the ordering and dispensing point of the process.
Pharmacists and other health care professionals have an opportunity to take on an expanded role in improving patient safety in relation to oral chemotherapy. A greater involvement of pharmacists in the clinic and in the community pharmacy could increase systematic checking to improve patient safety with regard to oral chemotherapy.
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The hidden role of community pharmacy technicians in ensuring patient safety with the use of e-prescribing
Medication errors are a significant problem that can lead to suboptimal patient outcomes, increased costs, prolonged hospitalization, injury and death. Electronic prescribing (e-prescribing) has been promoted to reduce these errors by allowing physicians to electronically generate and transmit prescriptions to community pharmacies.
Support personnel, such as pharmacy technicians, are key participants in the use of this health information technology. This study describes how pharmacy technicians use e-prescribing and explores the characteristics of pharmacy technicians that support pharmacists in ensuring patient safety. This qualitative study used observations, interviews and focus groups to understand the pharmacy technician’s role in e-prescribing. A total of 14 pharmacy technicians and 13 pharmacists from 5 community pharmacies participated in the study.
Direct observations, lasting approximately 9 hours in each of the 5 pharmacies, were used to understand how pharmacy technicians processed e-prescriptions and handled medication errors. The information collected from the observations was then used to guide semi-structured interviews to collect additional information on how electronic prescriptions (e-prescriptions) were processed by pharmacy technicians. Once the interviews were completed, two separate focus groups, one for pharmacy technicians and one for pharmacists, were conducted. A focus group guide was created to give the participants a chance to provide additional information not captured during the observations and interviews, to learn about the data collected from the other pharmacies and to verify the interpretation of the data collected. Observation field notes and audio recordings were transcribed and thematically analyzed.
Pharmacy technicians were primarily responsible for all steps of e-prescription processing leading up to the pharmacist review of the e-prescription and the dispensing of medication. Experience, certification status and knowledge of appropriate medication use were reported as important pharmacy technician factors needed to support a pharmacist’s role in ensuring patient safety with e-prescribing.
Pharmacy technicians play an important role in supporting pharmacists to prevent medication errors through e-prescribing and many specific characteristics of pharmacy technicians were reported to be associated with better support of pharmacists in fulfilling their patient care responsibilities and more efficient identification and resolution of medication errors.
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Models of Practice
Breastfeeding support in a community pharmacy: Improving access through the Well Babies at Walgreens program
The Well Babies at Walgreens program is a community-based corporate partnership program that offers breastfeeding support by a lactation professional in a private room at the pharmacy. The primary goal of this program is to support breastfeeding women using a model that is expandable to other pharmacy sites. A secondary goal of the program is to improve the continuity of care for breastfeeding by engaging pharmacists as vital members of the health care team.
The program currently offers drop-in services, a session with a lactation consultant and a baby weight check, and the creators of the program are currently developing a business plan and toolkit to enable program uptake in other pharmacies. Education provided to pharmacists by the program aim to improve both recommendations to breastfeeding mothers and enhancing pharmacists’ awareness of breastfeeding benefits and the need to preserve the breastfeeding relationship.
Offering breastfeeding support in pharmacies improves access to breastfeeding support for new mothers and can help establish pharmacists as integral team members in both the baby and mom’s health.
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Impact of prescription charges on people living in poverty: A qualitative study
Prescription charges, or co-payments, have been shown to reduce the consumption of prescription medication and, for those living in poverty, increase the possibility of a declined health status. While prescription charges in New Zealand are low in comparison to other countries, those living in poverty are not exempt from paying these fees. The purpose of this study was to explore the experience of those who struggle to pay prescription charges and to propose a model for how being unable to afford prescription charges might affect health.
Study participants were recruited through organizations that provide services entirely or predominantly to low-income individuals. A total of 29 individuals participated in the study and semi-structured interviews were conducted. Approximately half of the sample population was M?ori, indigenous New Zealanders. All study participants reported having to make difficult decisions when picking up their prescriptions such as purchasing only mental health medications, cutting food consumption to afford medication and only picking up children’s medications. Harmful strategies leading to sub-optimal dosing or interrupted treatment, such as reducing doses to make prescriptions last longer and delaying prescription pick up times were also reported.
Even minimal financial barriers, such as New Zealand’s low prescription charge, can have a significant impact on access to medication and reduce the effectiveness of treatment for low-income individuals. The study concluded that a patient’s inability to afford prescription medications can negatively health by preventing access to medication, reducing expenditure on other necessary items for health and potentiating stigma.
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Adding value through pharmacy validation: A safety and cost perspective
Prescribing errors (PE) can be frequent, cause significant harm to the patient and can be costly. Few studies show the impact of pharmacist interventions when it comes to prescribing errors. The purpose of this study was to characterize the severity and cost of the potential outcome of PE that pharmacists can prevent and to develop an economic analysis.
A non-randomized, prospective, observational study of all prescriptions made to adult patients admitted to a 1300-bed teaching hospital in Madrid was conducted using a computerized physician order entry tool combined with a clinical decision support system. PE were analyzed as they were intercepted through the pharmacist validation process. An independent team analyzed the severity of each potential adverse drug event (ADE) and the probability of causing an adverse drug event (PAE). The cost avoidance was estimated and an economic analysis was performed. A kappa statistic was used to verify inter-observer agreement.
A total of 484 PE were intercepted. Of those, 36.2% were classified as being of minor severity, 59.1% classified as moderate and 4.7% as serious. The most common type of PE in the moderate-serious classification were found to be excessive dose (30%), followed by insufficient dose (20%), and omission (19%). Antineoplastic agents (22.3%) and antimicrobials (17.2%) were found to be the most common classes of medications involved in moderate-serious PE. The PAE was more than 40% in 49% of PE. A cost avoidance of €291 422 ($438,348.62 Canadian) was estimated as well as a return on investment of €1.7 ($2.6 Canadian) for every €1 ($1.5 Canadian) spent on a pharmacist’s salary. The study concluded that pharmacists add important value in preventing PE and their interventions are financially beneficial for the institution.
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Education and Training
Education intervention on chronotherapy for final-year pharmacy students
Clinical knowledge of biological rhythms, sleep-wake cycles and the effect of circadian rhythm on the timing of particular medications plays a significant role in the management of particular disease states. Chronotherapy involves altering the dosing schedule of a medication such that the administration of the medication is timed with the body’s circadian rhythm. This scheduling is implemented to improve overall control of the disease and to minimize the side effects of the medication. For example, short-acting statins are more effective when administered at night, the circadian point in which cholesterol synthesis is at its peak and the enzyme HMG-CoA reductase exhibits its maximal activity. Training on chronotherapy requires pharmacy students to map different concepts and to apply them clinically. The purpose of this study was to develop, implement and evaluate an educational intervention focusing on the application of chronotherapy for final-year undergraduate pharmacy students.
At the University of Sydney Australia, an educational intervention utilizing multiple learning strategies for enhancing chronotherapy related awareness was implemented for the final year undergraduate pharmacy students. This educational intervention included a “Medications Around the Clock” lecture and a “Medications Around the Clock – Chronotherapy” workshop. Pre- and post-intervention questionnaires were administered to measure awareness about (13 items scored 0 or 1) and attitudes toward (12 items scored on a Likert scale of 1 to 5) chronotherapy. The pre-intervention mean awareness score was 6.5, which increased significantly to 10.1 after the educational intervention. Likewise, the mean attitude score increased from 47.4 pre-intervention to 54.0 post-intervention.
This study shows that carefully designed educational interventions for pharmacy students can increase awareness of, and enhance positive attitudes towards, the pharmacists’ role in optimizing drug therapy with the use of chronotherapy.
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