| 1. |
- Hellström, Lina, 1975-, et al.
(author)
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Clinical implementation of systematic medication reconciliation and review as part of the Lund Integrated Medicines Management model – impact on all cause emergency department revisits
- 2012
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In: Journal of Clinical Pharmacy and Therapeutics. - : Hindawi Limited. - 0269-4727 .- 1365-2710. ; 37:6, s. 686-692
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Journal article (peer-reviewed)abstract
- What is known and objective: Interventions involving medication reconciliation and review by clinical pharmacists can reduce drug-related problems and improve therapeutic outcomes. The objective of this study was to examine the impact of routine admission medication reconciliation and inpatient medication review on emergency department (ED) revisits after discharge. Secondary outcomes included the combined rate of post-discharge hospital revisits or death.Methods: This prospective, controlled study included all patients hospitalised in three internal medicine wards in a university hospital, between January 1 2006 and May 31 2008. Medication reconciliation on admission and inpatient medication review, conducted by clinical pharmacists in a multiprofessional team, were implemented in these wards at different times during 2007 and 2008 (intervention periods). A discharge medication reconciliation was undertaken in all the study wards, during both control and intervention periods. Patients were included in the intervention group (n=1216) if they attended a ward with medication reconciliation and review, whether they had received the intervention or not. Control patients (n=2758) attended the wards before implementation of the intervention. Results: No impact of medication reconciliation and reviews on ED revisits (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.86-1.04) or event-free survival (HR, 0.96; 95% CI, 0.88-1.04) was demonstrated. In the intervention group, 594 patients (48.8%) visited the ED, compared to 1416 (51.3%) control patients. In total, 716 intervention (58.9%) and 1688 (61.2%) control patients experienced any event (ED visit, hospitalisation or death). Because the time to a subsequent ED visit was longer for the control as well as the intervention groups in 2007 than in 2006 (p<0.05), we re-examined this cohort of patients; the proportion of patients revisiting the ED was similar in both groups in 2007 (p=0.608).What is new and conclusion: Routine implementation of medication reconciliation and reviews on admission and during the hospital stay did not appear to have any impact on ED revisits, rehospitalisations or mortality over six months' follow-up.
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| 2. |
- Hellström, Lina, 1975-
(author)
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Clinical pharmacy services within a multiprofessional healthcare team
- 2012
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Doctoral thesis (other academic/artistic)abstract
- Background: The purpose of drug treatment is to reduce morbidity and mortality, and to improve health-related quality of life. However, there are frequent problems associated with drug treatment, especially among the elderly. The aim of this thesis was to investigate the impact of clinical pharmacy services within a multiprofessional healthcare team on quality and safety of patients’ drug therapy, and to study the frequency and nature of medication history errors on admission to hospital.Methods: A model for clinical pharmacy services within a multiprofessional healthcare team (the Lund Integrated Medicines Management model, LIMM) was introduced in three hospital wards. On admission of patients to hospital, clinical pharmacists conducted medication reconciliation (i.e. identified the most accurate list of a patient’s current medications) to identify any errors in the hospital medication list. To identify, solve and prevent any other drug-related problems, the clinical pharmacists interviewed patients and performed medication reviews and monitoring of drug therapy. Drug-related problems were discussed within the multiprofessional team and the physicians adjusted the drug therapy as appropriate.Results: On admission to hospital, drug-related problems, such as low adherence to drug therapy and concerns about treatment, were identified. Different statistical approaches to present results from ordinal data on adherence and beliefs about medicines were suggested. Approximately half of the patients were affected by errors in the medication history at admission to hospital; patients who had many prescription drugs had a higher risk for errors. Medication reconciliation and review reduced the number of inappropriate medications and reduced drug-related hospital revisits. No impact on all-cause hospital revisits was demonstrated.Conclusion: Patients admitted to hospital are at high risk for being affected by medication history errors and there is a high potential to improve their drug therapy. By reducing medication history errors and improving medication appropriateness, clinical pharmacy services within a multiprofessional healthcare team improve the quality and safety of patients’ drug therapy. The impact of routine implementation of medication reconciliation and review on healthcare visits will need further evaluation; the results from this thesis suggest that drug-related hospital revisits could be reduced.
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| 3. |
- Hellström, Lina, 1975-, et al.
(author)
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Physicians' attitudes towards ePrescribing : evaluation of a Swedish full-scale implementation
- 2009
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In: BMC Medical Informatics and Decision Making. - : Springer Science and Business Media LLC. - 1472-6947. ; 9:August, s. Article number: 37-
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Journal article (peer-reviewed)abstract
- BACKGROUND: The penetration rate of Electronic Health Record (EHR) systems in health care is increasing. However, many different EHR-systems are used with varying ePrescription designs and functionalities. The aim of the present study was to evaluate experienced ePrescribers' attitudes towards ePrescribing for suggesting improvements. METHODS: Physicians (n = 431) from seven out of the 21 Swedish health care regions, using one of the six most widely implemented EHR-systems with integrated electronic prescribing modules, were recruited from primary care centers and hospital clinics of internal medicine, orthopaedics and surgery. The physicians received a web survey that comprised eight questions on background data and 19 items covering attitudes towards ePrescribing. Forty-two percent (n = 199) of the physicians answered the questionnaire; 90% (n = 180) of the respondents met the inclusion criteria and were included in the final analysis. RESULTS: A majority of the respondents regarded their EHR-system easy to use in general (81%), and for the prescribing of drugs (88%). Most respondents believed they were able to provide the patients better service by ePrescribing (92%), and regarded ePrescriptions to be time saving (91%) and to be safer (83%), compared to handwritten prescriptions. Some of the most frequently reported weaknesses were: not clearly displayed price of drugs (43%), complicated drug choice (21%), and the perception that it was possible to handle more than one patient at a time when ePrescribing (13%). Moreover, 62% reported a lack of receipt from the pharmacy after successful transmission of an ePrescription. Although a majority (73%) of the physicians reported that they were always or often checking the ePrescription a last time before transmitting, 25% declared that they were seldom or never doing a last check. The respondents suggested a number of improvements, among others, to simplify the drug choice and the cancellation of ePrescriptions. CONCLUSION: The Swedish physicians in the group studied were generally satisfied with their specific EHR-system and with ePrescribing as such. However, identified weaknesses warrant improvements of the EHR-systems as well as of their implementation in the individual health care organisation.
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| 4. |
- Johansson Östbring, Malin, 1980-, et al.
(author)
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Effects of a pharmaceutical care intervention on clinical outcomes and patient adherence in coronary heart disease : the MIMeRiC randomized controlled trial
- 2021
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In: BMC Cardiovascular Disorders. - : BioMed Central. - 1471-2261 .- 1471-2261. ; 21:1
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Journal article (peer-reviewed)abstract
- BACKGROUND: In the treatment of coronary heart disease, secondary prevention goals are still often unmet and poor adherence to prescribed drugs has been suggested as one of the reasons. We aimed to investigate whether pharmaceutical care by a pharmacist at the cardiology clinic trained in motivational interviewing improves clinical outcomes and patient adherence.METHODS: This was a prospective, randomized, controlled, outcomes-blinded trial designed to compare pharmaceutical care follow-up with standard care. After standard follow-up at the cardiology clinic, patients in the intervention group were seen by a clinical pharmacist two to five times as required over seven months. Pharmacists were trained to use motivational interviewing in the consultations and they tailored their support to each patient's clinical needs and beliefs about medicines. The primary study end-point was the proportion of patients who reached the treatment goal for low-density lipoprotein cholesterol by 12 months after discharge. The key secondary outcome was patient adherence to lipid-lowering therapy at 15 months after discharge, and other secondary outcomes were the effects on patient adherence to other preventive drugs, systolic blood pressure, disease-specific quality of life, and healthcare use.RESULTS: 316 patients were included. The proportion of patients who reached the target for low-density lipoprotein cholesterol were 37.0% in the intervention group and 44.2% in the control group (P = .263). More intervention than control patients were adherent to cholesterol-lowering drugs (88 vs 77%; P = .033) and aspirin (97 vs 91%; P = .036) but not to beta-blocking agents or renin-angiotensin-aldosterone system inhibitors.CONCLUSIONS: Our intervention had no positive effects on risk factors for CHD, but it increased patient adherence. Further investigation of the intervention process is needed to explore the difference in results between patient adherence and medication effects. Longer follow-up of healthcare use and mortality will determine if the increased adherence per se eventually will have a meaningful effect on patient health.TRIAL REGISTRATION: ClinicalTrials.gov NCT02102503, 03/04/2014 retrospectively registered.
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| 5. |
- Johansson Östbring, Malin, 1980-, et al.
(author)
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Motivational Interviewing and Medication Review in Coronary Heart Disease (MIMeRiC) : Intervention Development and Protocol for the Process Evaluation
- 2018
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In: JMIR Research Protocols. - : JMIR Publications. - 1929-0748. ; 7:1, s. 1-12
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Journal article (peer-reviewed)abstract
- BACKGROUND: Trials of complex interventions are often criticized for being difficult to interpret because the effects of apparently similar interventions vary across studies dependent on context, targeted groups, and the delivery of the intervention. The Motivational Interviewing and Medication Review in Coronary heart disease (MIMeRiC) trial is a randomized controlled trial (RCT) of an intervention aimed at improving pharmacological secondary prevention. Guidelines for the development and evaluation of complex interventions have recently highlighted the need for better reporting of the development of interventions, including descriptions of how the intervention is assumed to work, how this theory informed the process evaluation, and how the process evaluation relates to the outcome evaluation.OBJECTIVE: This paper aims to describe how the intervention was designed and developed. The aim of the process evaluation is to better understand how and why the intervention in the MIMeRiC trial was effective or not effective.METHODS: The research questions for evaluating the process are based on the conceptual model of change processes assumed in the intervention and will be analyzed by qualitative and quantitative methods. Quantitative data are used to evaluate the medication review in terms of drug-related problems, to describe how patients' beliefs about medicines are affected by the intervention, and to evaluate the quality of motivational interviewing. Qualitative data will be used to analyze whether patients experienced the intervention as intended, how cardiologists experienced the collaboration and intervention, and how the intervention affected patients' overall experience of care after coronary heart disease.RESULTS: The development and piloting of the intervention are described in relation to the theoretical framework. Data for the process evaluation will be collected until March 2018. Some process evaluation questions will be analyzed before, and others will be analyzed after the outcomes of the MIMeRiC RCT are known.CONCLUSIONS: This paper describes the framework for the design of the intervention tested in the MIMeRiC trial, development of the intervention from the pilot stage to the complete trial intervention, and the framework and methods for the process evaluation. Providing the protocol of the process evaluation allows prespecification of the processes that will be evaluated, because we hypothesize that they will determine the outcomes of the MIMeRiC trial. This protocol also constitutes a contribution to the new field of process evaluations as made explicit in health services research and clinical trials of complex interventions.
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| 6. |
- Johansson Östbring, Malin, 1980-, et al.
(author)
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Motivational Interviewing and Medication Review in Coronary Heart Disease (MIMeRiC) : Protocol for a Randomized Controlled Trial Investigating Effects on Clinical Outcomes, Adherence, and Quality of Life
- 2018
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In: JMIR Research Protocols. - : JMIR Publications. - 1929-0748. ; 7:2, s. 1-15
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Journal article (peer-reviewed)abstract
- BACKGROUND: Preventive treatment goals for blood pressure and cholesterol levels continue to be unmet for many coronary patients. The effect of drug treatment depends on both its appropriateness and the patients' adherence to the treatment regimen. There is a need for adherence interventions that have a measurable effect on clinical outcomes.OBJECTIVE: This study aims to evaluate the effects on treatment goals of an intervention designed to improve patient adherence and treatment quality in secondary prevention of coronary heart disease. A protocol for the prespecified process evaluation of the trial is published separately.METHODS: The Motivational Interviewing and Medication Review in Coronary heart disease (MIMeRiC) trial is a prospective, randomized, outcomes-blinded trial designed to compare individualized follow-up by a clinical pharmacist using motivational interviewing (MI) and medication review with standard follow-up. Patients were randomized to 2 groups after stratification according to their beliefs about medicines. After standard follow-up at the cardiology clinic, patients in the intervention group are seen individually by a clinical pharmacist 2 to 5 times as required over 7 months, at the clinic. The pharmacist reviews each patient's medication and uses MI to manage any problems with prescribing and adherence. The primary study outcome is the proportion of patients who have reached the treatment goal for low-density lipoprotein cholesterol by 12 months after discharge. Secondary outcomes are the effects on patient adherence, systolic blood pressure, disease-specific quality of life, and health care use.RESULTS: The protocol for this study was approved by the Regional Ethics Committee, Linköping, in 2013. Enrollment started in October 2013 and ended in December 2016 when 417 patients had been included. Follow-up data collection will conclude in March 2018. Publication of the primary and secondary outcome results from the MIMeRiC trial is anticipated in 2019.CONCLUSIONS: The MIMeRiC trial will assess the effectiveness of an intervention involving medication reviews and individualized support. The results will inform the continued development of support for this large group of patients who use preventive medicines for lifelong treatment. The design of this adherence intervention is based on a theoretical framework and is the first trial of an intervention that uses beliefs about medicines to individualize the intervention protocol.TRIAL REGISTRATION: ClinicalTrials.gov NCT02102503; https://clinicaltrials.gov/ct2/show/NCT02102503 (Archived by WebCite at http://www.webcitation.org/6x7iUDohy).
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| 7. |
- Johansson Östbring, Malin, 1980-
(author)
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Pharmaceutical care in coronary heart disease
- 2021
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Doctoral thesis (other academic/artistic)abstract
- Background: In coronary heart disease (CHD), pharmaceutical care implies that health care professionals cooperate with the patient to optimize drug therapy primarily for secondary prevention. Low adherence and discontinuation of drugs are common among patients with CHD, and this is associated with increased morbidity and mortality. The achievement of guidelines-recommended treatment goals for risk factors is disappointingly low in secondary prevention.Aim: To study clinical and patient related aspects of pharmaceutical care for secondary prevention in patients with CHD.Method: A pharmacist used medication review and motivational interviewing to impact patients’ beliefs about medicines and adherence in a pilot study. This intervention was further developed and tested in a randomized controlled trial (RCT) in 316 patients with verified CHD who were planned for follow-up at the cardiology clinic in Kalmar. The primary study outcome was the proportion ofpatients who reached the treatment goal for low-density lipoprotein (LDL)cholesterol. Patients’ adherence to cholesterol-lowering drugs according to a combination of refilled prescriptions and self-report was the key secondary outcome. In the RCT, pharmacists individualized both the dose and the content of thesupport based on the patient’s need. A process evaluation was planned alongside the trial to investigate implementation and mechanisms of impact such as pharmacists’ actions and effects on patients’ medication beliefs. In a separate qualitative study, we interviewed patients with CHD who had used their medicines for at least 12 months.Results: At 15 months follow-up of the RCT, the primary outcome measure did not differ between groups. The intervention improved patient adherence to cholesterol-lowering medicines; 88% vs 77% of the patients were adherent, possibly because the intervention lowered patients’ concerns about medicines. In 84% of the intervention patients at least one actual drug-related problem (DRP) was identified, and for 90% of those DRPs actions were taken to resolve the problems. Analyses of the interviews with patients revealed that patients´ experiences with medicines varied greatly - from trivial to troublesome – and these were classified into one of seven categories: a sense of security, unproblematic, learning to live with it, taking responsibility for it, somewhat uncertain, troublesome, or distressing.Conclusion: Pharmaceutical care improved the patients’ use of medicines in CHD but did not increase treatment goal achievement for LDL-cholesterol. Overall, the findings of this thesis emphasize that when support in managing medications is offered to patients, it should encompass various aspects of medicine-taking: safety, knowledge, beliefs, practical handling, impact on day-to-day life, and the patient’s medication experience.
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