Pharmacotherapy Principles And Practice 3rd Pdf 39

The vast amount of digital information produced in healthcare is increasingly transformed into real-world evidence (RWE) on the safety and effectiveness of medical products in clinical practice, and playing a critical role in decision-making for regulators, payers and physicians1,2,3,4. Advances in the understanding of valid study design and analysis of longitudinal healthcare data for causal inference5,6,7,8 have made it possible for database studies to both reproduce9,10,11,12 and predict13,14,15,16 results from randomized clinical trials (RCT), as well as provide evidence that changed clinical practice in situations where trials were not feasible17,18,19.

The analysis of massive amounts of individual-level longitudinal healthcare data is becoming more and more common. It can produce evidence on the effectiveness of medical interventions in clinical practice, which in turn informs decision in the healthcare systems that produced the data. Reproducibility of findings derived from such analyses is essential to have confidence in decision making. In 150 RWE studies we showed that the resulting effect sizes were strongly correlated between the original publications and study reproductions in the same data sources and developed insights on where there was room for improvement. While our reproduced estimates were relatively close to the original estimates from the majority of studies, there was a subset of findings that the study team was unable to closely recreate, even though we applied the reported methods to the same healthcare data sources as the original authors.

pharmacotherapy principles and practice 3rd pdf 39

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Medication errors occur frequently at points of transition in care. The key problems causing these medication errors are: incomplete and inappropriate medication reconciliation at hospital discharge (partly arising from inadequate medication reconciliation at admission), insufficient patient information (especially within a multicultural patient population) and insufficient communication to the next health care provider. Whether interventions aimed at the combination of these aspects indeed result in less discontinuity and associated harm is uncertain. Therefore the main objective of this study is to determine the effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in patients discharged from the internal medicine department.

The last problem regards insufficient communication to the next health care provider. Discharge letters and discharge prescriptions generally do not contain the entire pharmacotherapy [7, 8]. This incompleteness could lead to confusion about whether the medication which is not listed is discontinued or just not mentioned. Both the general practitioner and community pharmacy are not informed on reasons for changes in the pharmacotherapy leading to confusion whether these changes should be maintained or were temporal [9, 10].

Therefore, the COACH (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) program is designed to improve continuity of care by combining interventions, including non-native patients and using pharmaceutical consultants (i.e. pharmacy technicians who have followed additional training) to perform the intervention. The intervention consists of medication reconciliation at discharge (in addition to medication reconciliation at admission to prevent medication errors from carrying over to the discharge medication), patient counselling at discharge and communication of medication information to the next healthcare providers.

The study is performed at the internal medicine ward. All patients admitted with at least one prescribed drug intended for chronic use are invited to participate. Exclusion criteria are: no informed consent, no medication intended for chronic use prescribed at discharge, death, transfer to another ward or hospital, discharge within 24 hours or out of office hours, discharge to a nursing home (as patients do not administer their own medication) and patients who cannot be counselled (as stated by the resident due to physical/mental constraints, being critically ill or due to language restrictions without relatives or healthcare personnel to translate, i.e. languages other than Dutch, Turkish, English and Arabic/Berber). Only the patient's first hospital admission is included in the study period (readmissions are the main outcome measure). The St. Lucas Andreas Hospital institutional review board has stated that this study is exempt from review by the institutional review board as the Dutch legislation does not request this for studies that do not affect the patient's integrity. In this study the burden was considered minimal for the patient and therefore the medical ethics committee waived the review. The burden is minimal as the patient will receive counselling about his discharge medication in the intervention group. This should be usual practice as the hospital has a legal obligation to inform patients. The patients is also asked to fill in questionnaires and cost diaries. This is expected to take 60 minutes of the patient's time. To respect the wish of a patient to participate in a study we decided to ask the patients for an informed consent to obtain information from their general practitioner on readmission rates and for filling in the questionnaires/cost diaries. Patient data are sampled and stored in accordance with privacy regulations.

To support the patient counselling a medication list is written down by the resident using the information in the hospital's CPOE. At present, residents and nurses are involved in patient instructions on pharmacotherapy. For both professionals this aspect is only a relatively small part of a large amount of tasks, making the time to be spent on medication related patient instructions rather limited or the patient counselling is not performed at all. Also, the knowledge necessary for providing adequate instructions is often insufficient in residents (inexperienced) and nurses (training provides little knowledge on drugs).

The communication to the general practitioner takes place through the discharge letter in which the medication is typed by the resident. The medication list in the discharge letter is generally incomplete and provides little or no information on changes in the pharmacotherapy and the reasons for these changes.

The COACH intervention program is carried out by a team of pharmaceutical consultants with clinical pharmacists as supervisors. Pharmaceutical consultants are pharmacy technicians who have followed an additional three year bachelor program which is focused on pharmaceutical patient care. They are specifically trained in pharmacotherapy and communication with patients. In contrast to nurses and residents, they can dedicate more time to the patient, as this job is their main task. Because of their lower level of education, when compared to pharmacists who have had a 6 year university training, salary expenditures for pharmaceutical consultants are lower, which is why they are used besides a supervising pharmacist.

At discharge medication reconciliation is performed again using a protocol which contains the steps for medication reconciliation (see figure 2 and table 1, step 3-5) [24]. First in the verification step the presence of discrepancies with the pre-admission medication is examined again by using the medication history of the community pharmacy. Second, in the clarification step the appropriateness of the pharmacotherapy is checked and the pharmacotherapy is evaluated. Also the international normalized ratio, glomerular filtration rate, glucose, sodium and potassium blood levels are checked to adjust medication if necessary. In the third step the newly initiated medication is evaluated to ensure all changes are intentional and changes in the pharmacotherapy are documented. Finally, the results of all steps are discussed with the resident and the prescriptions are adjusted if necessary.

Medication summary for the patient (front side). The administration scheme is filled in with the help of the patient. In bold text the reasons for changes in the pharmacotherapy, drug related problems and follow-up actions can be specified.

After the medication reconciliation has been performed and discussed with the resident, the pharmaceutical consultant counsels the patient and/or his family. The patient counselling is also carried out by following the steps for medication reconciliation (see figure 2 and table 1, step 7-9). First, details of all medications are confirmed in the verification step by using the medication summary. The pharmaceutical consultant asks the patient how medication is used (to see whether the use is correct), whether medication is not in use anymore or whether additional medication is used. Second, the clarification step is performed through checking whether improvements can be made on safety and quality of pharmacotherapy and explaining or answering questions. Third, in the reconciliation step new medication is discussed to evaluate whether the patient understands why this medication is prescribed. 2ff7e9595c