| 1. |
- Alassaad, Anna, 1977-
(författare)
-
Improving the Quality and Safety of Drug Use in Hospitalized Elderly : Assessing the Effects of Clinical Pharmacist Interventions and Identifying Patients at Risk of Drug-related Morbidity and Mortality
- 2014
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Older people admitted to hospital are at high risk of rehospitalization and medication errors. We have demonstrated, in a randomized controlled trial, that a clinical pharmacist intervention reduces the incidence of revisits to hospital for patients aged 80 years or older admitted to an acute internal medicine ward. The aims of this thesis were to further study the effects of the intervention and to investigate possibilities of targeting the intervention by identifying predictors of treatment response or adverse health outcomes.The effect of the pharmacist intervention on the appropriateness of prescribing was assessed, by using three validated tools. This study showed that the quality of prescribing was improved for the patients in the intervention group but not for those in the control group. However, no association between the appropriateness of prescribing at discharge and revisits to hospital was observed.Subgroup analyses explored whether the clinical pharmacist intervention was equally effective in preventing emergency department visits in patients with few or many prescribed drugs and in those with different levels of inappropriate prescribing on admission. The intervention appeared to be most effective in patients taking fewer drugs, but the treatment effect was not altered by appropriateness of prescribing.The most relevant risk factors for rehospitalization and mortality were identified for the same study population, and a score for risk-estimation was constructed and internally validated (the 80+ score). Seven variables were selected. Impaired renal function, pulmonary disease, malignant disease, living in a nursing home, being prescribed an opioid and being prescribed a drug for peptic ulcer or gastroesophageal reflux disease were associated with an increased risk, while being prescribed an antidepressant drug (tricyclic antidepressants not included) was linked with a lower risk. These variables made up the components of the 80+ score. Pending external validation, this score has potential to aid identification of high-risk patients.The last study investigated the occurrence of prescription errors when patients with multi-dose dispensed (MDD) drugs were discharged from hospital. Twenty-five percent of the MDD orders contained at least one medication prescription error. Almost half of the errors were of moderate or major severity, with potential to cause increased health-care utilization.
|
|
| 2. |
- Gillespie, Ulrika, et al.
(författare)
-
A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older : a randomized controlled trial
- 2009
-
Ingår i: Archives of Internal Medicine. - : American Medical Association (AMA). - 0003-9926 .- 1538-3679. ; 169:9, s. 894-900
-
Tidskriftsartikel (refereegranskat)abstract
- BACKGROUNDPatients 80 years or older are underrepresented in scientific studies. The objective of this study was to investigate the effectiveness of interventions performed by ward-based pharmacists in reducing morbidity and use of hospital care among older patients.METHODSA randomized controlled study of patients 80 years or older was conducted at the University Hospital of Uppsala, Uppsala, Sweden. Four hundred patients were recruited consecutively between October 1, 2005, and June 30, 2006, and were randomized to control (n = 201) and intervention (n = 199) groups. The interventions were performed by ward-based pharmacists. The control group received standard care without direct involvement of pharmacists at the ward level. The primary outcome measure was the frequency of hospital visits (emergency department and readmissions [total and drug-related]) during the 12-month follow-up period.RESULTSThree hundred sixty-eight patients (182 in the intervention group and 186 in the control group) were analyzed. For the intervention group, there was a 16% reduction in all visits to the hospital (quotient, 1.88 vs 2.24; estimate, 0.84; 95% confidence interval [CI], 0.72-0.99) and a 47% reduction in visits to the emergency department (quotient, 0.35 vs 0.66; estimate, 0.53; 95% CI, 0.37-0.75). Drug-related readmissions were reduced by 80% (quotient, 0.06 vs 0.32; estimate, 0.20; 95% CI, 0.10-0.41). After inclusion of the intervention costs, the total cost per patient in the intervention group was $230 lower than that in the control group.CONCLUSIONIf implemented on a population basis, the addition of pharmacists to health care teams would lead to major reductions in morbidity and health care costs.
|
|
| 3. |
- Gillespie, Ulrika, 1971-
(författare)
-
Effects of Clinical Pharmacists' Interventions : on Drug-Related Hospitalisation and Appropriateness of Prescribing in Elderly Patients
- 2012
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- 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.
|
|
| 4. |
- Gillespie, Ulrika, et al.
(författare)
-
Effects of pharmacists’ interventions on appropriateness of prescribing for elderly and exploration of a possible correlation between scores for appropriateness and clinical outcomes : analyses from a randomized controlled trial
-
Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- Background:Inappropriate prescribing can cause substantial morbidity and represents a clinical and economic burden for patients and society. Appropriateness of prescribing can be assessed by various measures and screening tools, however, for a tool to be valid there should be casual links to important clinical health outcomes. The aim of this study was to investigate the effect of a pharmacist intervention on appropriateness of prescribing, and to explore the relationship between these results and clinical health outcomes defined as re-visits to hospital.Methods:The study population from a previous randomized controlled study, in which the effects of a comprehensive pharmacist intervention on re-hospitalisation was investigated, was used. The criteria from the validated instruments STOPP, START and MAI were applied retrospectively to the study patients (368 patients; intervention group n=182, control group n=186). The quality assessments were done on admission and at discharge to detect differences over time between the control- and the intervention group. Hospital care consumption one year after admission was recorded and the correlation between scores for appropriateness, as well as number of drugs at discharge, and hospital visits was analysed.Results:The number of Potentially Inappropriate Medicines (PIMs) per patient as identified by STOPP was reduced for the intervention group but not for the control group (1.42 and 0.93 vs. 1.46 and 1.66 respectively, p<0.01) The number of Potential Prescription Omissions (PPOs) per patient as identified by START was reduced for the intervention group but not for the control group (0.36 and 0.09 vs. 0.42 and 0.45 respectively, p<0.001). The summated score for MAI was reduced for the intervention group but not for the control group (8.5 to 5.0 and 8.7 to 10.0 respectively, p< 0.001). There was no correlation between the scores of the tools and total visits to hospital. Number of drugs (unadjusted) correlated with visits to hospital and the rate ratio was 4%. For readmissions to hospital, MAI (unadjusted) and the number of drugs showed a positive correlation. There was a correlation between MAI and STOPP and drug-related readmissions (RR 8-9% and 30-34% respectively).Conclusion:The addition of a comprehensive pharmacist service to standard care significantly improved the appropriateness of prescribing for patients in the intervention group that participated in the randomized controlled trial, as evaluated by all three instruments used; STOPP, START and MAI. However, the results on correlation between the tools and re-visits to hospital were inconclusive.
|
|
| 5. |
- Gillespie, Ulrika, et al.
(författare)
-
Perceived value of ward-based pharmacists from the perspective of physicians and nurses
- 2012
-
Ingår i: International Journal of Clinical Pharmacy. - : Springer. - 2210-7703 .- 2210-7711. ; 34:1, s. 127-135
-
Tidskriftsartikel (refereegranskat)abstract
- BackgroundClinical pharmacy in a hospital setting is relatively new in Sweden. Its recent introduction at the University Hospital in Uppsala has provided an opportunity for evaluation by other relevant professionals of the integration of clinical pharmacists into the health-care team.ObjectivesThe objectives of this descriptive study were to evaluate the perceived value of wardbased clinical pharmacists from the perspective of hospital based physicians and nurses and to identify potential advantages and disadvantages related to the new inter professional collaboration. Another objective was to evaluate the experiences of general practitioners on receiving medication reports from wardbased clinical pharmacists.SettingTwo acute internal medicine wards at the University Hospital in Uppsala, where a previously reported randomized controlled trial investigating the effects of ward based clinical pharmacists on re-visits to hospital was undertaken.MethodsData were collected by questionnaires containing closed- and openended questions. The questionnaires were distributed during the nine-month study period of the randomized controlled trial by an independent researcher to 29 hospital-based physicians and 44 nurses on the study wards and to 21 general practitioners who had received two or more medication reports. Answers were analysed descriptively for the closedended questions and by content analysis for the open-ended questions.Main outcome measure The main outcome measure was the physicians’ and nurses’ level of satisfaction with the new collaboration with clinical pharmacists, from a hospital and primary care perspective.ResultsSeventy-six percent of the hospital-based physicians and 81% of the nurses completed the questionnaire. Ninety-five percent of the physicians and 93% of the nurses were very satisfied with the collaboration. Out of the 17 general practitioners (81%) that completed the questionnaire 71% wanted to continue to receive medication reports in a similar way in the future. Increased patient safety and improvements in patients’ drug therapy were the main advantages stated by all three groups of respondents. Eighteen percent of the hospital-based physicians and 21% of the nurses thought that the collaboration had been time-consuming to certain or to a high extent.Conclusions The majority of the respondents, both GPs and hospital based physicians and nurses, were satisfied with the new collaboration with the ward based pharmacists and perceived that the quality of the patients’ drug therapy and drug-related patient safety had increased.
|
|
| 6. |
- Linde, Torbjörn, et al.
(författare)
-
Blood viscosity and peripheral vascular resistance in patients with untreated essential hypertension
- 1993
-
Ingår i: Journal of Hypertension. - 0263-6352 .- 1473-5598. ; 11:7, s. 731-736
-
Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVES: The viscosity of blood is increased in patients with essential hypertension. The aim of the present study was to investigate the importance of the different variables of blood rheology to total peripheral resistance, and to elucidate whether inappropriate regulation of the formation of erythropoietin could be important. DESIGN: Nineteen consecutive patients with untreated essential hypertension were examined and compared with a group of matched healthy volunteers. METHODS: The haemorheologic variables were assessed by rotational viscometry and the haemodynamic variables by bioimpedance cardiography. The serum concentrations of erythropoietin were determined by radioimmunoassay. RESULTS: The whole blood viscosity and peripheral resistance index were elevated in the hypertensive group. The two variables were positively correlated with each other (r = 0.68, P = 0.0015). The plasma viscosity and erythrocyte aggregation tendency were increased and the erythrocyte deformability, measured as fluidity, was decreased in the hypertensive patients. In the male subpopulation (n = 12) the aggregation tendency was positively, and the deformability negatively, correlated with body mass index. The serum concentrations of erythropoietin were equal in the two groups. CONCLUSIONS: The increased total peripheral resistance in patients with essential hypertension may in part be explained by an increased blood viscosity, but the possibility of an opposite cause-effect relationship must also be taken into consideration. The haemorheological abnormalities observed in the present patients cannot be explained by high serum levels of erythropoietin.
|
|
| 7. |
- Linde, Torbjörn, et al.
(författare)
-
Decreased blood viscosity and serum levels of erythropoietin after anti-hypertensive treatment with amlodipine or metoprolol : results of a cross-over study
- 1996
-
Ingår i: Journal of Human Hypertension. - 0950-9240 .- 1476-5527. ; 10:3, s. 199-205
-
Tidskriftsartikel (refereegranskat)abstract
- The increased viscosity of blood of hypertensive patients can be assumed to be a risk factor for the development of cardiovascular diseases. The aim of the present study was to elucidate whether anti-hypertensive treatment has any impact on blood theology. Twenty patients with previously untreated hypertension who consecutively attended our outpatient hypertension clinic were included in this prospective, open, cross-over study. The patients were randomly selected to treatment with amlodipine or metoprolol. The antihypertensive therapy was switched after 4 months. Haemorheological and haemodynamic variables were measured with rotational viscometry and impedance cardiography, respectively. Fifteen and 16 patients could be evaluated after amlodipine or metoprolol treatment respectively. The mean blood pressure (BP) decreased from 159 +/- 22/105 +/- 7 to 139 +/- 21/91 +/- 6 mm Hg on amlodipine and from 162 +/- 22/104 +/- 5 to 145 +/- 24/90 +/- 8 mm Hg on metoprolol therapy. After amlodipine treatment, the total peripheral resistance index decreased whereas metoprolol treatment was accompanied by a decrease in the cardiac index. Decreases in whole blood viscosity, haematocrit and serum erythropoietin were found after amlodipine as well as metoprolol treatment. After amlodipine the plasma viscosity decreased and the erythrocyte deformability increased in the majority of patients. Plasma fibrinogen decreased after metoprolol treatment. Despite the differences in haemodynamic mechanisms underlying the decrease in BP, amlodipine and metoprolol exert beneficial effects on blood viscosity. Haemodilution and a decrease in serum erythropoietin may be factors underlying this decrease in blood viscosity.
|
|
| 8. |
- Ljungberg, Christina, 1978-, et al.
(författare)
-
Primary care and hospital doctors’ experiences of prescribing information transfer using a shared electronic patient medical record system
-
Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- Rationale, aim and objective Uppsala county council has implemented a shared electronic patient medical record (e-PMR) system between primary and secondary care. Uppsala is one of the first counties in Sweden to implement such a system, and has the largest number of affiliated health care users with a shared e-PMR. The aim of this study was to investigate primary care and hospital doctors’ experiences of using the shared e-PMR, regarding information about individual patients’ drug therapies between the health care levels.Method Semi-structured focus groups were conducted. Four groups were held with hospital and four with primary care doctors. Data were analysed from an interpretivist perspective, aiming at capturing the physicians’ perspective. They were coded, categorised and similar categories grouped into themes. The constant comparative method was used; all new data were compared to earlier data and earlier analyses, and categories were formed and reformed throughout the analysis. After analysis of the data from the separate groups, a mixed focus group was held with doctors from both primary care and hospital, in which the earlier findings were discussed, to explore variations in the data. The analysis was informed by the Data-Information-Knowledge-Wisdom hierarchy, where a differentiation is made between raw facts (data) and their conversion into, for example, a useful form for a particular context (knowledge).Results The shared e-PMR was perceived as having many advantages, especially as all information was available electronically, which was convenient and time saving. The large amount of information, however, made it difficult to handle. The sought-after knowledge could be hard to retrieve in an information overload. Information about a patient’s drug therapy was not always collected in the medication list; additional information could be found in the e-PMR-notes, given by the patient or in the list of the patient’s automated medication dispensing service. Doctors did not summarize information as often, instead cross-referencing information that could be found elsewhere in the e-PMR.Conclusions The information in the e-PMR needs to be structured in a comprehensible way to facilitate reading and knowledge production. It is not just about providing information, the knowledge needs to be communicated in a good way to the next care-giver.
|
|
| 9. |
- Ljungberg, Christina, 1978-, et al.
(författare)
-
Responsibility for a patient’s drug therapy : perspectives of primary care and hospital doctors
-
Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- Background: Health care provision is complex, with many actors, bringing difficulties in ensuring the responsibility for different health care providers is clear. Perceived lack of responsibility for a patient between primary and hospital care can lead to non-compliance with drug guidelines. The aim of this study was to investigate hospital and primary care doctors’ views of responsibility for patients’ drug therapy.Methods: Four audio-recorded focus groups were held with hospital doctors and four with primary care doctors. Fourteen hospital and 27 primary care doctors participated. The data were transcribed and analysed from an interpretivist perspective, to capture the physicians’ perspectives. Data were coded and categorised and similar categories grouped into themes. A mixed focus group was then held with 14 doctors from both primary care and hospital, who had participated in earlier focus groups. This allowed doctors from both settings to discuss the findings from the separate groups and to explore variations in the data.Results: Taking responsibility for the patient’s drug therapy was seen as being discharged when the doctors reviewed the patient’s drugs and updated the list of medications in the medical record. Nobody said they had the overall responsibility for the individual patient’s drug therapy. Secondary care doctors often only took responsibility for drugs within their own clinical area. Primary care doctors found it difficult to take overall responsibility, especially for highly specialized treatments, even though they described themselves as having a more comprehensive perspective of the patient’s drugs than the hospital doctors. Barriers to taking responsibility for both sectors included time constrains, lack of information regarding prescribing decisions by other doctors, highly specialized or expensive drugs and lack of economic incentives. Doctors from different health care levels did not routinely meet, informally or formally, and, at the time of the study, had no clear channels for communication between them. Conclusions: Taking responsibility to review the patient’s list of medications was perceived as important, but was described as difficult in daily practice.
|
|
| 10. |
|
|
