Prospective medication risk management in primary care : Enhancing coordination of care and community pharmacists' participation

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http://urn.fi/URN:ISBN:978-951-51-6464-3
Title: Prospective medication risk management in primary care : Enhancing coordination of care and community pharmacists' participation
Author: Toivo, Terhi
Contributor: University of Helsinki, Faculty of Pharmacy, Farmakologian ja lääkehoidon osasto, kliinisen farmasian ryhmä
Doctoral Programme in Drug Research
Publisher: Helsingin yliopisto
Date: 2020-09-18
Language: en
Belongs to series: URN:ISSN:2342-317X
URI: http://urn.fi/URN:ISBN:978-951-51-6464-3
http://hdl.handle.net/10138/318724
Thesis level: Doctoral dissertation (article-based)
Abstract: Over the last decade, a great deal of research has described the medication safety risks in hospitals and institutional care both in Finland as well as globally. Less attention has been paid to the safety of medicine use in outpatient care, even though majority of the use occurs at home. The aim of this study was to enhance prospective medication risk management in outpatient care, by enhancing coordination of care with community pharmacists’ participation and use of risk management screening tools available. Specific objectives of studies I–III were: I) to demonstrate how community pharmacies can utilize their prospective surveillance system for screening clinically significant drug-drug interactions (DDIs) in outpatients and assess the rate of DDIs in a large national prescription sample. II) To integrate risk assessment tools, procedures and databases available in Finland to form a coordinated medication management model (CoMM) for older home clients involving home care nurses and practical nurses (PNs), physicians and community pharmacists. III) To assess the impact of the CoMM on medication risks identified in drug regimens of older home care clients over a one-year period. Medication risks assessed related to potentially inappropriate medications (PIMs), excessive use of psychotropics, anticholinergic and serotonergic load, as well as clinically significant DDIs. In study I, all DDI alerts issued by the online surveillance system were collected during a one-month period in 16 out of 17 University Pharmacy outlets in Finland, covering approximately 10% of the national outpatient prescription volume. The surveillance system was based on the FASS database, which categorizes DDIs into four classes (A–D) according to their clinical significance. Potential DDIs were analyzed for 276,891 dispensed prescriptions and they were associated with 11.2% of the prescriptions. Clinically significant DDIs categorized as FASS classes D (most severe, should be avoided) and C (clinically significant but controllable) were associated with 0.5% and 7.2% of the prescriptions, respectively. Studies II–III were conducted in primary care in the city of Lohja, Southern Finland. Health care units involved were the home care, public primary healthcare center and a private community pharmacy. System-based risk management theory and the action research method were applied to construct the collaborative procedure utilizing each profession’s existing resources in medication risk management of older (>65 years, n=191) home care clients. Study II produced a 5-stage medication management model (CoMM) suitable for screening medications of a high number of home care clients and identifying clients with potential clinically significant drug-related problems (DRPs). The core of the model was the triage meetings that proved to be a feasible method for customizing comprehensiveness of collaborative medication reviews, according to their clinical needs while minimizing physicians’ time demands. In study III, an RCT study design was used to assess the impact of the CoMM on medication risks identified in drug regimens of older home care clients over a one-year period. Participants’ (n=129) mean age was 82.8 years, 69.8% were female and mean number of prescription medicines in use was 13.1. The intervention did not show an impact on the medication risks between the original intervention group and the control group in the intention to treat analysis, but the per protocol analysis indicated a tendency for effectiveness, particularly in optimizing central nervous system medication use (benzodiazepines). Half (50.0%) of the participants with a potential need for medication changes, agreed on in the triage meeting, had none of the changes actually implemented. Study I demonstrated that community pharmacists can actively contribute to DDI risk management and systematically use their surveillance systems for identifying patients with clinically significant DDIs. In study II, the developed care coordination model (CoMM) was feasible for screening and reviewing medications of a high number of older home care clients in order to identify clients with severe DRPs and provide interventions to solve them, utilizing existing primary care resources. In study III, the CoMM intervention indicated a tendency for effectiveness when implemented as planned, particularly in optimizing CNS medication use during a 12-month follow-up. Our study revealed that organizations and health care units involved in home care clients’ medication therapy are currently working independently in silos, where no specific team membertakes holistic responsibility for medications. This study demonstrated the challenges to overcome when trying to change clinical practice and improve coordination between units involved in medication management of home care clients. Even though the outcomes of the intervention were not optimal, the value of the study is in discussing the real-world experiences and challenges of implementing new practices in home care. This study indicated that practitioners in Finnish health care are not well acquainted with systems thinking, a fact which needs to be addressed in the future. Further studies are needed on care culture and other contributing factors to high prevalence of PIM use and other risks for clinically significant DRPs identified in this study. Particularly, further investigation is needed on system-based factors contributing to situations where identified preventable clinically significant medication risks are left unsolved, as well as the relationship between inappropriate medication use and medication errors. A need for the organizational and national development of medication safety in primary care was identified in this thesis, which is line with the national and international publications, policy documents and recommendations. Furthermore, community pharmacists’ contribution to medication safety, particularly in older adults, should be better utilized in the future, as this thesis shows promising demonstrations. KEYWORDS: Medication risk management, medication-related risk, drug-drug interaction, primary care, home care, older adult, community pharmacy  Avohoidossa toteutetaan valtaosa lääkehoidosta. Väitöstutkimuksessa tutkittiin avohoidon lääkitysturvallisuutta ennakoivan riskienhallinnan näkökulmasta. Tutkimus koostuu kolmesta osatyöstä, jotka ajoittuvat suomalaisen järjestelmälähtöisen lääkitysturvallisuustyön eri vaiheisiin. Osatyössä I tutkittiin apteekissa tunnistettujen lääkeyhteisvaikutusten yleisyyttä. Osatyössä II kehitettiin koordinoitu, moniammatillinen toimintamalli iäkkäiden kotihoidon asiakkaiden lääkitysriskien tunnistamiseen ja selvittämiseen. Osatyössä III tutkittiin toimintamallin vaikuttavuutta. Osatyön I aineisto kerättiin 2004, jolloin ensimmäinen sähköinen tietokanta lääkeyhteisvaikutusten tunnistamiseen oli juuri otettu käyttöön Suomessa. Yliopiston Apteekki (YA) kehitti tietokannan käyttöönottoon toimintamallin paikallisten lääkäreiden kanssa. Lääkeyhteisvaikutusten yleisyys tutkittiin kuukauden aikana YA:n toimipisteistä toimitetuista resepteistä (n=280 000). Lääkeyhteisvaikutusten riski liittyi 11,2 % resepteistä, vakavimpien riski löytyi 0,5 % resepteistä. Yleisimmin nämä koskivat tulehduskipulääkkeiden yhteiskäyttöä varfariinin tai metotreksaatin kanssa. Osatyöt II-III toteutettiin Lohjan kotihoidossa. Työssä II kehitettiin toimintatutkimusta käyttäen koordinoitu toimintamalli iäkkäiden (>65 vuotta) kotihoidon asiakkaiden lääkitysriskien tunnistamiseen ja ratkaisemiseen hyödyntäen olemassa olevia kotihoidon, apteekin ja lääkäreiden resursseja. Toimintamallissa kotihoidon hoitajat seuloivat lääkehoidon riskejä riskimittarilla. Tunnistettujen riskien ja ajantasaisten lääkityslistojen perusteella arvioitiin tarkempien lääkehoidon arviointien tarve hyödyntämällä ns. triage-menettelyä. Tarkempaa arviointia tarvitsi 55 % tutkittavista. Apteekin (Lohjan 1. apteekki) farmasistit toteuttivat tarvittavat lääkehoidon arvioinnit ja tutkittavien omalääkärit päättivät mahdollisista lääkemuutoksista. Toimintamalliin kuului myös lääkitysmuutosten seuranta. Osatyössä III tutkittiin toimintamallin vaikuttavuutta vertaamalla lääkitysriskimuutoksia interventio- ja kontrolliryhmissä vuoden seuranta-ajalla. Tutkittavien (n=129) keski-ikä oli 83 vuotta, 70 % oli naisia ja käytössä oli keskimäärin 13 reseptilääkettä. Toimintamallin vaikuttavuutta ei pystytty osoittamaan ryhmien välisessä vertailussa, koska 50 %:ssa tunnistettuihin lääkehoidon ongelmiin ei puututtu. Tutkimus osoitti, että nykyisessä terveydenhuoltojärjestelmässä koordinaatiota on vaikea rakentaa. Tämä johtuu useista järjestelmälähtöisistä syistä, joita tulisi tutkia tarkemmin olemassa olevien resurssien, kuten apteekkien, tehokkaammaksi hyödyntämiseksi lääkehoitojen riskienhallinnassa.
Subject: farmasia
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