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Aim: This study aimed to provide insight into the congruity of acute cystitis (AC) diagnosis in women, measured both by the Acute Cystitis Symptom Score (ACSS) questionnaire and urine test(s). Background: The ACSS questionnaire was developed as a self-administering tool for assessing urinary symptoms, quality of life (QoL) and treatment outcomes in healthy, nonpregnant female patients. Methods: This prospective observational cohort study compared AC diagnosis based on the questionnaire with a GP diagnosis based on dipstick/dipslide test(s). ACSS questionnaire form A (typical and differential symptoms, QoL and relevant conditions) was filled in by the patient group, women suspected for AC visiting a GP practice with a urine sample, and the reference group, women visiting a community pharmacy for any medication. Analyses were performed assuming that the GP diagnosis based on urine test(s) was correct. Divergent result(s) of urine test(s) and ACSS questionnaire were analysed for scores of all individual questionnaire domains. Statistical analyses included descriptive statistics and the positive predictive value (PPV) and the negative predictive value (NPV) of the ACSS questionnaire and the urine test(s). Findings: In the patient group, 59 women were included, 38 of whom a GP positively diagnosed for AC. The reference group included 70 women. The PPV of the ACSS questionnaire was 77.3%, and the NPV was 73.3%. Analysis of patient data for divergent results showed that differential symptoms, QoL and relevant conditions explained false-positive and false-negative results. Revised results (most probable diagnosis) based on this analysis showed a PPV and NPV of 88.6% and 73.3% for the ACSS questionnaire and 100% and 76.2% for the urine test(s). For use in primary care, a reduction in false-positive and false-negative results can be achieved by including scores for differential symptoms, QoL and relevant conditions, alongside a total typical symptoms score of 6 or higher.

Background The Dutch general practitioners (GP) guideline for urinary tract infections (UTI) recommends patient-initiated treatment for women with recurring UTI. In countries other than the Netherlands, community pharmacists play a role in dispensing antibiotics for recurring UTI without preceding GP consultation. Objective To study GP and pharmacist opinions regarding the desirability of patient-initiated treatment, including potential pharmacist support for, and consequences of, facilitated access to antibiotics. Setting Dutch community pharmacies that cooperate with at least two GPs in their regional primary care network. Method Pharmacists in a postgraduate education program invited their residency pharmacist and 2–3 GPs to anonymously complete an online questionnaire. Questions related to diagnosis, treatment and potential role of the pharmacist. Answers were formulated as multiple-choice or ratings on a 5-point Likert scale. Data were analysed per professional group using descriptive statistics. Answers of pharmacists and GP to corresponding questions were analysed using a Chi-square test (p Main outcome measure Desirability of patient-initiated treatment and supporting role of the pharmacist. Results A total of 170 GPs and 76 pharmacists completed the questionnaires. Of the GPs, 35.1% supported patient-initiated treatment. Of the pharmacists, 69.7% were willing to dispense an antibiotic to a patient without preceding GP consultation after performing a probability check. In total, 65.7% of GPs and 44.7% of pharmacists thought that facilitated access to antibiotics would increase use of antibiotics (p Conclusion Support of GPs for facilitated access to antibiotic treatment by patient-initiated UTI treatment was limited, even with pharmacist support. The majority of pharmacists were willing to dispense an antibiotic after a probability check of an episode of recurring UTI, but both pharmacists and GPs were concerned about overuse of antibiotics.

Background The guideline on urinary tract infections (UTI) of the Dutch College of General Practitioners provides recommendations on patient‐initiated treatment and prevention of recurring UTI. Aim To study familiarity with self‐management skills for prevention of recurring UTI amongst adult women. Design and settings An online questionnaire was developed, based on the UTI guideline and interviews with women having recurring UTI. Pharmacists in a postgraduate education programme (N = 76) aimed to invite 10 adult women with a recurring UTI prescription to complete the questionnaire. Women were asked for informed consent to link medication record data to questionnaire data. Method We calculated proportions of the scores for self‐management skills and analysed differences between age groups with chi‐square test. Results Complete questionnaires were available for 719 women (mean age 55.1 ± 18.5 years). The proportions of women 18‐50 years and women 51 years or older were 36.4% and 63.6%, respectively. Education levels of women 18‐50 years were significantly higher than those of women 51 years and older. Before consulting a general practitioner (GP) for symptoms, 32.1% of all women increased fluid intake; additionally, 15.0% used analgesics and increased fluid intake. Of all women, 33.9% searched internet for information on self‐management and 18% occasionally received a prescription for patient‐initiated treatment, half of these prescriptions for use during vacation. Cranberry was used by 47%, d‐mannose by 5% and vitamin C by 29% of all women. Awareness of different preventive behavioural measures (eg, fluid intake, washing without soap and emptying bladder after sexual intercourse) varied between 20% and 90%. Conclusion Almost half of all women applied self‐management (increased fluid intake, analgesics) before consulting a GP for recurring UTI. Awareness of preventive behavioural measures for recurring UTI varied considerably. Thus, education of women about the use of analgesics and behavioural measures deserves attention.

Objective To evaluate the process of clinical medication review for elderly patients with polypharmacy performed by non-dispensing pharmacists embedded in general practice. The aim was to identify the number and type of drug therapy problems and to assess how and to what extent drug therapy problems were actually solved. Method An observational cross-sectional study, conducted in nine general practices in the Netherlands between June 2014 and June 2015. On three pre-set dates, the non-dispensing pharmacists completed an online data form about the last 10 patients who completed all stages of clinical medication review. Outcomes were the type and number of drug therapy problems, the extent to which recommendations were implemented and the percentage of drug therapy problems that were eventually solved. Interventions were divided as either preventive (aimed at following prophylactic guidelines) or corrective (aimed at active patient problems). Results In total, 1292 drug therapy problems were identified among 270 patients, with a median of 5 (interquartile range 3) drug therapy problems per patient, mainly related to overtreatment (24%) and undertreatment (21%). The non-dispensing pharmacists most frequently recommended to stop medication (32%). Overall, 83% of the proposed recommendations were implemented; 57% were preventive, and 35% were corrective interventions (8% could not be assessed). Almost two-third (64%) of the corrective interventions actually solved the drug therapy problem. Conclusion Non-dispensing pharmacists integrated in general practice identified a large number of drug therapy problems and successfully implemented a proportionally high number of recommendations that solved the majority of drug therapy problems.

Introduction There is broad consensus that community pharmacists should focus on the provision of pharmaceutical care. Studies, however, have shown that community pharmacists still spend a considerable amount of time on traditional activities such as dispensing instead of cognitive pharmaceutical services (CPS). It is not clear whether community pharmacists prefer their current time-utilization or if they are willing to spend more time on CPS. Aim The aim of this study was to identify how community pharmacists ideally would prioritize CPS compared to other daily activities. Methods A cross-sectional study design with Q-methodology was used to identify different viewpoints regarding task prioritization. Community pharmacists were asked to rank a total of 48 daily activities. Data was collected online using FlashQ©. Q-sorts were analyzed by principal component factor analysis and varimax rotation using PQmethod 2.35. Results In total, 166 community pharmacists participated in this study. Three distinguishing groups were found based on task prioritization explaining 59% of the total variance among respondents. All groups ranked the provision of CPS as important, in differing degrees. Group 1 ranked CPS as most important and was also the group that contained most participants. Group 2 and 3 ranked quality assurance as most important with CPS as second. Logistics and pharmacy management were ranked low by all groups. Discussion and conclusion Community pharmacists rank the provision of CPS as important. So factors, probably other than task prioritization, are keeping the pharmacist from focusing on CPS in daily practice. In other studies, time constraints are mostly mentioned as major barrier. Activities such as logistics and pharmacy management are given less priority and should be delegated to supporting staff members as much as possible, to enable pharmacists to focus their available time on activities they deem important.

Objective: Asthma control and quality of life (QoL) are important disease outcomes for asthma patients. Illness perceptions (cognitive and emotional representations of the illness) and medication beliefs have been found to be important determinants of medication adherence, and subsequently disease control and QoL in adults with asthma. In adolescents, this issue needs further elucidation. Therefore, the aim of this study was to explore the relationship between illness perceptions, medication beliefs, medication adherence, disease control, and QoL in adolescents with asthma. Methods: In this cross-sectional study, we used baseline data of adolescents with asthma (age 12–18 years) who participated in the ADolescent Adherence Patient Tool (ADAPT) study. Questionnaires were administrated online, and included sociodemographic variables and validated questionnaires measuring self-reported illness perceptions, medication beliefs, medication adherence, disease control, and QoL. Results: Data of 243 adolescents with asthma were available; age 15.1 ± 2.0 years and 53% females. More than half of these adolescents (62%; n = 151) reported to be non-adherent (Medication Adherence Report Scale ≤23) and 77% (n = 188) had uncontrolled asthma. There was a strong positive correlation between disease control and QoL (r = 0.74). All illness perceptions items were correlated with disease control and QoL, with the strongest correlation between ‘identity’ (symptom perception) and QoL (r=–0.66). Medication adherence was correlated to medication beliefs (r = 0.38), disease control (r = 0.23), and QoL (r = 0.14), whereas medication beliefs were only associated with adherence. Conclusions: Stimulating positive illness perceptions and medication beliefs might improve adherence, which in turn might lead to improved disease control and better QoL.

Background Urinary tract infection (UTI) is one of the most prevalent medical conditions among women seeking primary care. About 20–40% of the women have a UTI recurrence during their lifetime. Objective To provide insight in the patterns of recurring annual dispensing for antibiotics commonly used for UTI treatment in women, aged 18 years or older, during a 5-year follow-up period in the Netherlands. Methods The Dutch Foundation of Pharmaceutical statistics collects dispensing data from more than 90% of all community pharmacies. Pharmacies with complete data between years 2011 and 2017 were included. Women of age 18 years or older with a first dispensing of nitrofurantoin, fosfomycin, or trimethoprim in 2012 and a dispensing of any medication in 2017 were selected. For each year between 2013 and 2017, the proportions of women with recurring dispensing of nitrofurantoin, fosfomycin or trimethoprim were calculated and stratified for age categories. Results Within 1517 eligible community pharmacies, 463 821 women, aged 18 years or older, were dispensed one of the antibiotics in 2012, and 239 292 women still visited the same pharmacy in 2017. About 56% of them received at least one recurring dispensing during 5 years of follow-up. Each year, ~20% of the source population had at least one recurring dispensing. Approximately 2% of the source population had at least one recurring dispensing in each year of follow-up. Conclusions Over the 5-year study period, more than 50% of the source population had at least one recurring dispensing for uncomplicated UTI, most of them with at least 1 year without UTI dispensing in between., Approximately 60% of women experience complaints of urinary tract infection (UTI) in their lifetime. This study investigated the pattern of recurring dispensing of the UTI guideline antibiotics nitrofurantoin, fosfomycin, and trimethoprim over a 5-year period. In 2012, 463 821 women aged 18 years or older visited a community pharmacy in the Netherlands for a first prescription since 2010 of one of the UTI guideline antibiotics. We selected 239 292 women, aged 18 years or older (mean age 54 years), who still visited the same pharmacy for any prescription in 2017. Most of the women included (85%) had a prescription for nitrofurantoin. In each year between 2013 and 2017, ~20% of the included women had a recurring dispensing of one of the UTI guideline antibiotics. Over the entire 5-year follow-up period, 56% of the women visited the pharmacy for at least one recurring UTI guideline antibiotic dispensing. Most of these women had at least 1 year without a dispensing of a UTI guideline antibiotic in between. Approximately 2% of the source population had at least one recurring dispensing in each year of follow-up.

Background and Purpose: Statins are frequently initiated in patients aged 80 years and older after an ischemic stroke, even though evidence on prevention of recurrent cardiovascular disease is scarce. In this study, we seek evidence for statin prescription in the oldest old. Methods: We performed a retrospective cohort study in patients aged 65 years and older hospitalized for a first ischemic stroke between 1999 and 2016 without statin prescriptions in the year before hospitalization using the Clinical Practice Research Datalink. The age group 65 to 80 years was included to compare our results to current evidence on statin efficacy. The primary outcome was a composite of recurrent stroke, myocardial infarction, and cardiovascular mortality. The secondary outcome was all-cause mortality. A time-varying Cox model was used to account for statin prescription over time. We compared at least 2 years of statin prescription time with untreated and Results: Five thousand nine hundred ten patients, aged 65 years and older were included, of whom 3157 were 80 years and older. Two years of statin prescription in patients aged 80 years and older resulted in both a lower risk of the composite end point (adjusted hazard ratio, 0.80 [95% CI, 0.62–1.02]) and all-cause mortality (adjusted hazard ratio, 0.67 [95% CI, 0.57–0.80]). After correction for the mortality of 23.9% of the patients during the first 2 years, the number needed to treat was 64 for the primary outcome during a median follow-up of 3.9 years and 19 for all-cause mortality. Conclusions: Statins initiated in patients aged 80 and older, discharged home after hospitalization for an ischemic stroke are associated with a reduction in cardiovascular events.

Aim: To study whether changes in drug preferences in the Dutch guideline for the treatment of Urinary Tract Infection (UTI) for General Practitioners (GPs) in 2013, resulted in corresponding changes in antibiotic dispensing. Background: For the treatment of uncomplicated UTI, nitrofurantoin remained the first choice, while fosfomycin became the second choice and changed ranks with trimethoprim. For a subsequent febrile UTI, ciprofloxacin became the first choice and changed ranks with amoxicillin/clavulanic acid, co-trimoxazole remained the third choice. Methods: In this observational cross-sectional study, routinely collected dispensing data from the Dutch Foundation of Pharmaceutical Statistics from 2012 to 2017 were used. The number of women 18 years and older, treated with one of the guideline antibiotics for uncomplicated UTI and subsequent febrile UTI were analysed annually. Proportions were calculated. Data were stratified for age categories. Failure of uncomplicated UTI treatment was defined as the dispensing of an antibiotic for febrile UTI within 14 days after the dispensing of an antibiotic for uncomplicated UTI. Findings: Data were available from 81% of all pharmacies in 2012 to 89% in 2017. Percentages of women dispensed nitrofurantoin were relatively stable with 87.4% in 2012 and 84.4% in 2017. Percentages of women dispensed fosfomycin increased from 5.4% in 2012 to 21.8% in 2017, whereas percentages of women dispensed trimethoprim decreased from 17.8% to 8.0%. Within age categories, the percentage of women dispensed fosfomycin increased from 12.4% in women 18–30 years old to 36.7% in women above 80 years old. Percentages of women dispensed antibiotics for febrile UTI remained stable at 5% annually. Percentages of women receiving ciprofloxacin increased from 1.9% in 2012 to 3.3% in 2017, while those receiving amoxicillin/clavulanic acid decreased from 2.9% to 1.8%. New guideline recommendations resulted in corresponding changes in dispensed antibiotics for uncomplicated UTI and subsequent febrile UTI. Drug choices differed for age categories.

Background The community pharmacy profession is in transition, with emphasis on the provision of cognitive pharmaceutical services (CPS). In contrast, previous research showed that the general public prefers more convenience related services. However, this was based on currently available services and not on innovative services. Objective To identify patients’ preferences regarding innovative pharmacy services and whether they tend towards convenience related or CPS. Design Online survey using a discrete choice experiment (DCE). Participants Participants were from the AMP pharmacy patient panel. Main outcome measures: Preferences (utility scores) and the identification of specific classes (latent class analysis). Results In total 2462 panel members (27.3%) filled out the completed the online DCE questionnaire. The majority of participants were male (54.1%) with an average age of 65.3 years and used on average 4.6 medicines. Four patient classes were distinguished based on preferences for services. Highly preferred were an online mediation record, prescription drugs for minor ailments without a doctors’ prescription and clinical testing with diagnosis by the pharmacist. Discussion and conclusion The majority of participants tend towards a more CPS focused approach by the community pharmacist. Patients visiting community pharmacies can have a diverging set of preferences regarding services being provided. In daily practice, community pharmacists should provide both convenience and CPS related services to address this diverse set of preferences.

Background Community pharmacists and their teams are easy accessible healthcare providers with an important role in primary care. As a consequence of the COVID-19 epidemic, (pharmaceutical) care and specifically communication between patients and healthcare providers is compromised. Objective To describe the impact of the COVID-19 epidemic on the provision of pharmaceutical care in the Netherlands. Methods A cross-sectional study with an online questionnaire was sent to community pharmacies in the Netherlands. The questionnaire covered the following main topics: changes in pharmacy setting and logistic procedures, communication about medication and baseline characteristics. Results Pharmacies implemented hygiene measures and minimized direct patient-provider contact, e.g. by delivering medication at home to a wider range of patients (47.0%), temporarily not conducting medication reviews (55.8%) and only performing inhalation instructions via telephone (22.3%). Only a small number of pharmacies used telepharmacy, such as video calling during patient education and counseling. A total of 76.7% of the participants expressed concerns towards the pharmaceutical care for vulnerable patients. Conclusions Our results show considerable impact of the COVID-19 epidemic on both logistic procedures and services regarding patient education and counseling. Pharmacies should be stimulated to implement telepharmacy or remote service to optimally support patients during the COVID-19 epidemic.

INTRODUCTION: Older people are prone to drug-related harm. Clinical decision support systems (CDSSs) in community pharmacies may improve appropriate prescribing in this population. OBJECTIVE: This study investigated (persistent) drug therapy changes and its determinants to reduce potentially inappropriate medication (PIM) in older patients based on CDSS alerts and to investigate barriers and facilitators for implementation of drug therapy changes based on these CDSS alerts. METHODS: Five clinical decision rules based on national guidelines for inappropriate drugs in older patients were incorporated in a web-based CDSS in 31 community pharmacies between February and April 2017. The CDSS generated alerts for patients aged > 70 years who had prescriptions for one of the following drugs: alprazolam, amitriptyline, barnidipine, duloxetine, fluoxetine, trazodone, quetiapine and olanzapine. The registered alert management data and medication dispensing histories were analysed to find potential determinants of persistent drug therapy changes. Ten pharmacists were interviewed about the barriers and facilitators for implementing drug therapy changes based on CDSS alerts. An inductive thematic analysis of the transcripts was performed. RESULTS: The pharmacists recorded the management of 1810 of the 2589 generated alerts, and 158 (8.7%) alerts were associated with a persistent drug therapy change. A logistic regression analysis found that the drug triggering the alert and the type of prescription [first dispensing vs. repeat; odds ratio 2.1 (95% confidence interval 1.4-3.2)] were significantly associated with persistent drug therapy changes. No association was found between persistent changes and age, sex, number of medicines in use, or recent clinical medication review. Analysis of the interviews revealed nine barriers and facilitators associated with drug therapy change. CONCLUSION: When community pharmacists implemented CDSS alerts to reduce inappropriate drug use in older patients, they registered a persistent drug therapy change in 8.7% of the cases. Alerts triggered by a first prescription were two times more likely to be associated with a persistent drug therapy change than alerts triggered by repeat prescriptions. This study found that clinical rules can be used to detect inappropriate drug use in older patients and that drug therapy can change based on the alerts. This suggests that CDSS alerts are a useful tool for implementing guidelines on PIM in older patients in daily practice.

Objectives The aim was to recognise the professional core values in the moral dilemmas of pharmacists in community pharmacy and to customise the descriptions of these values for community pharmacy practice. Methods The narratives of 128 moral dilemmas, collected from Dutch PharmD students and early career pharmacists who experienced these dilemmas in practice, were qualitatively analysed. An expert panel deductively coded relevant portions of these narratives with the core values as formulated by the Royal Dutch Pharmacists Association. Other values that emerged were inductively coded and if possible used to further customise the respective core values. Key findings The expert panel identified all four professional core values, that is, commitment to the patient’s well-being (117, 91.4%), reliable and caring (116, 90.6%), pharmaceutical expertise (72, 56.2%) and responsibility to society (30, 23.4%) in the 128 moral dilemma narratives. Thirteen other values that emerged in the analysis could all be used for the customisation of the professional core values in descriptions that better reflect community pharmacy practice. Conclusions Professional core values were identified in moral dilemma narratives of pharmacists in community pharmacy and customised for their practice. These customised core values can enable pharmacists to better recognise moral dilemmas in practice. This can add to the advancement of the profession as a pharmaceutical care practice.

IntroductionOpioid-induced constipation is a clinically relevant side effect and a cause of potentially avoidable drug-related hospital admissions.ObjectivesTo describe the presence of laxative co-medication, the reasons for not starting laxatives and to evaluate changes in stool patterns of opioid initiators.MethodsIn this observational study community pharmacists evaluated the availability of laxative co-medication in starting opioid users and registered reasons for non-use. Two opioid initiators per pharmacy were invited to complete questionnaires (‘Bristol stool form scale’ and ‘Rome III Diagnostic Questionnaire for the Adult Functional Gastrointestinal Disorders’) on their defecation prior to and during opioid use. Descriptive statistics and Chi square tests were used to analyse reasons for non-use of laxatives and changes in defecation patterns.ResultsEighty-one pharmacists collected data from 460 opioid initiators. Of those, 344 (74.8%) used laxatives concomitantly. Main reason not to use laxatives was that either prescribers or patients did not consider them necessary. Sixty-seven (89.3%) of the 75 opioid starters with two questionnaires completed were not constipated at opioid start. Eleven of them (16%) developed constipation during opioid use (Chi square p=0.003). At follow-up within laxative users 10.6% were constipated compared to 20.7% in subjects without laxatives.ConclusionOne in four opioid starters did not dispose of laxative co-medication, mainly because they were not considered necessary by either the prescriber or the patient. The prevalence of constipation doubled during opioid use. A watchful waiting strategy for the use of laxative co-medication might include a monitoring of defecation patterns with validated questionnaires.

Purpose It is unknown if multidose drug dispensing (MDD) systems are initiated for the appropriate patients. Therefore, the objective of this study was to compare the medication management problems of patients who were about to start with a MDD system (MDD patients) and patients who continued manually dispensed medication (non-MDD users) in order to identify if the appropriate patients receive a MDD system. Methods Patient interviews (semi-structured) were conducted by 44 community pharmacists at the patient’s home. Patients over 65 years of age, home dwelling and using at least five chronic drugs, were eligible for the study. An assessment tool was developed including 22 potential medication management problems, covering four domains: functional (7), organizational (7), medication adherence (6), and medication knowledge (2). Median scores were calculated with the interquartile range. Additionally, cognitive function was assessed with the Mini-Cog and frailty using the Groningen Frailty Indicator. Results One hundred eighty-eight MDD users and 230 non-MDD users were interviewed. MDD users were older, more often female, and using more drugs. Forty-two percent of the MDD users were possibly cognitively impaired and 63% were assessed as frail compared to 20 and 27% respectively of the non-MDD users. MDD users had more potential organizational problems (3 vs. 1; p

Background With the shifting role of community pharmacists towards patient education and counselling, they are well-positioned to conduct a post-discharge home visit which could prevent or solve drug-related problems. Gaining insight into the communication during these home visits could be valuable for optimizing and consequently improving patient safety at readmission to primary care. Objective To assess patient-pharmacist communication during a post-discharge home visit. Setting The homes of patients recently discharged from a single general hospital in the Netherlands. Methods Pharmacists used a semi-structured protocol to guide the consultations and audiorecorded them. Sixty audio-recordings were included for a qualitative analysis in this study with the help of NVivo version 11 software. Main outcome measure (1) Initiator and topics under discussion. (2) Frequency of discussion of topics as per coded in themes and subthemes. Results Issues regarding the administration and use of medication, e.g. regimen and actual drug-taking issues, knowledge gaps regarding their medication and patients' health were discussed most frequently, followed by medication logistics and medication effectiveness. Patients' beliefs about their medication and adherence were less frequently discussed. The pharmacist initiated the majority of these topics. Additional non-protocolled topics were scarce and consisted mainly of patient-initiated dissatisfaction regarding the community pharmacy or health insurers. Conclusion Community pharmacists most frequently initiated practical issues, but explored patients' medication beliefs less adequately. Discussing these beliefs might be easier by increasing patient engagement in the consultation and providing training programs for pharmacists.

Supplemental Digital Content is available in the text., Background Patients’ beliefs about medicine may either reflect the necessity for treatment or concerns regarding the treatment. We explored the extent to which these beliefs have an effect on thiopurine metabolite levels and premature discontinuation in patients with inflammatory bowel disease (IBD). Patients and methods Patients enrolled in the ‘Thiopurine response Optimization by Pharmacogenetic testing in Inflammatory Bowel Disease Clinics’ (TOPIC) trial were asked to complete the Beliefs about Medicine Questionnaire (BMQ) 4 weeks after thiopurine initiation. The BMQ measures perceptions about treatment necessity and concerns. On the basis of the necessity and concern scores, patients can be categorized as accepting, ambivalent, indifferent, or skeptical. The thiopurine discontinuation rates for these belief subgroups were compared by Kaplan–Meier curves. Furthermore, clinical response and metabolite levels were compared between the belief subgroups. Results A total of 767 patients with IBD started thiopurine treatment, of whom 576 (75%) completed the BMQ. Patients could be classified as accepting (34%), indifferent (17%), ambivalent (34%), or skeptical (15%). Compared with patients in the accepting group (discontinuation rate 22%), patients with an indifferent (35%; P=0.02), ambivalent (37%; P

Item does not contain fulltext OBJECTIVE: The management of drug-drug interactions (DDIs) involves a complex risk-benefit assessment, in which patients' preferences should be taken into account. The aim of this study was to examine the aspects influencing patients' preferences with regard to DDI management options. METHODS: A qualitative study consisting of five focus groups with patients chronically using cardiovascular drugs was conducted. Key questions concerned preferences regarding DDI management options for a provided fictitious DDI. Thematic analysis of the verbatim transcripts was performed. RESULTS: Despite their limited knowledge with respect to DDIs, patients easily chose a management option for the presented DDI. When additional information was provided, preferences showed to be fluid. Ten interdependent aspects influencing preferences were derived from patients' argumentations: risk perception, fear, acceptance of uncertainty, openness to change, willingness to take risk, trust in health care professional, financial & practical burdens, health condition, experience, and knowledge & assumptions. CONCLUSION: Patients' preferences regarding DDI management options were often determined by provided information. Preferences were dependent on an interplay of diverse aspects. PRACTICE IMPLICATIONS: Tailored provision of information and individualized counseling is needed for active patient involvement in DDI decision making.

This cohort study uses nationwide data to determine opioid prescription patterns and survey data to examine risk factors associated with opioid prescription in the Netherlands., Key Points Question Are the prevalence of opioid prescriptions and the incidence of hospital admissions for opioid overdose and opioid overdose mortality changing in the Netherlands through time? Findings In this cohort study with nationwide data from the Netherlands, 814 211 individuals (4.9% of the total population) were prescribed an opioid in 2013, and 1 027 019 individuals (6.0% of the total population) were prescribed an opioid in 2017. Hospital admissions for opioid overdose increased from 9.2 per 100 000 inhabitants in 2013 to 13.1 per 100 000 inhabitants in 2017, and opioid overdose mortality increased from 0.8 per 100 000 inhabitants in 2013 to 1.2 per 100 000 inhabitants in 2017. Meaning Opioid prescription and associated adverse events are increasing in the Netherlands., Importance An increase in opioid prescription has been observed in the Netherlands. It is vital to understand this increase and to identify risk factors for opioid prescription to ensure that health interventions remain appropriately targeted. Objectives To determine the prevalence of opioid prescriptions and adverse events associated with opioids, and to identify risk factors associated with opioid prescription in the Dutch population. Design, Setting, and Participants This cohort study used national statistics from the Netherlands from January 1, 2013, to December 31, 2017, including the full Dutch population of 16 779 575 people in 2013 and 17 081 507 people in 2017. Data from the Dutch Health Monitor surveys of 2012 and 2016 were also included. Databases were anonymized prior to analysis. All analyses were performed between December 2018 and February 2019. Exposure Opioid prescription. Main Outcomes and Measures The main outcomes were the dynamics of opioid prescriptions, hospital admissions for opioid overdose, and opioid overdose mortalities. The secondary outcome was risk factors associated with opioid prescription. Results In 2013, 814 211 individuals (4.9% of the total population) received an opioid prescription. In 2017, 1 027 019 individuals (6.0% of the total population) received at least 1 opioid prescription (mean [SD] age, 59.3 [18.5] years; 613 203 [59.7%] women). The rate of hospital admissions for opioid overdose was 9.2 per 100 000 inhabitants in 2013 and 13.1 per 100 000 inhabitants in 2017 (relative risk, 1.43 [95% CI, 1.34-1.52]). Similarly, an increased risk of opioid overdose death was observed, from 0.83 per 100 000 inhabitants in 2013 to 1.2 per 100 000 inhabitants in 2017 (relative risk, 1.49 [95% CI, 1.20-1.85]). Based on data from the 2012 Dutch Health Monitor survey, risk factors associated with opioid prescription included being older than 65 years (odds ratio [OR], 4.20 [95% CI, 3.98-4.43]), having only a primary school education (OR, 3.62 [95% CI, 3.46-3.77]), being widowed (OR, 3.30 [95% CI, 3.13-3.49]), reporting always feeling symptoms of depression (OR, 3.77 [95% CI, 3.41-4.18]), and reporting poor or very poor physical health (OR, 10.40 [95% CI, 10.01-10.81]). Self-reported back pain (OR, 4.34 [95% CI, 4.23-4.46]) and rheumatoid arthritis or fibromyalgia (OR, 3.77 [95% CI, 3.65-3.90]) were also associated with opioid prescription. However, unemployment (OR, 1.05 [95% CI, 0.96-1.13]) was not associated with opioid prescription, and alcohol use disorder (OR, 0.76 [95% CI, 0.73-0.80]) was negatively associated with opioid prescription. Conclusions and Relevance This study found that opioid prescriptions have increased in the Netherlands. Although the risk of adverse events is still relatively low, there is an urgent need to review pain management to prevent a further increase in opioid prescription.

Background Community pharmacy is undergoing a transition, shifting focus from traditional roles to the provision of cognitive pharmaceutical services. However, traditional activities performed by community pharmacists reduce the amount of available time for implementing and providing such services. Therefore, hampering the community pharmacist in the transition. Objective The aim of this study was to identify characteristics of community pharmacists that spend a higher proportion of their time on cognitive pharmacy services and to identify activities that compete with time spent on such activities by community pharmacists. Setting Daily community pharmacy practice. Method Self-reporting work sampling using smartphone technology was used to register the activities of community pharmacists. Participating pharmacists recorded their current activity five times per working day for 6 weeks and also completed an online survey about baseline characteristics. Main outcome measure Time utilization. Results Ninety-one Dutch community pharmacists provided work-sampling data. The results showed that Dutch community pharmacists are predominantly spending less time on managerial activities when spending more time on cognitive services (from 25.7% to 14.5%, p = 0.016). Pharmacists who are spending more time on such services, want to spend even more time on direct patient contact compared to pharmacists who spend less time on it (p = 0.030). Conclusion This study shows that community pharmacists that spend more time on cognitive pharmacy services are devoting less time on managerial activities, logistics and other activities. Pharmacists spending more time on cognitive pharmaceutical services are mostly locum pharmacists or work at a pharmacy located in a residential area with largely older inhabitants.

Background Clinical medication reviews (CMRs) are increasingly performed in older persons with multimorbidity and polypharmacy to reduce drug-related problems (DRPs). However, there is limited evidence that a CMR can improve clinical outcomes. Little attention has been paid to patients’ preferences and needs. The aim of this study was to investigate the effect of a patient-centred CMR, focused on personal goals, on health-related quality of life (HR-QoL), and on number of health problems. Methods and findings This study was a randomised controlled trial (RCT) performed in 35 community pharmacies and cooperating general practices in the Netherlands. Community-dwelling older persons (≥70 years) with polypharmacy (≥7 long-term medications) were randomly assigned to usual care or to receive a CMR. Randomisation was performed at the patient level per pharmacy using block randomisation. The primary outcomes were HR-QoL (assessed with EuroQol [EQ]-5D-5L and EQ-Visual Analogue Scale [VAS]) and number of health problems (such as pain or dizziness), after 3 and 6 months. Health problems were measured with a self-developed written questionnaire as the total number of health problems and number of health problems with a moderate to severe impact on daily life. Between April 2016 and February 2017, we recruited 629 participants (54% females, median age 79 years) and randomly assigned them to receive the intervention (n = 315) or usual care (n = 314). Over 6 months, in the intervention group, HR-QoL measured with EQ-VAS increased by 3.4 points (95% confidence interval [CI] 0.94 to 5.8; p = 0.006), and the number of health problems with impact on daily life decreased by 12% (difference at 6 months −0.34; 95% CI −0.62 to −0.044; p = 0.024) as compared with the control group. There was no significant difference between the intervention group and control group for HR-QoL measured with EQ-5D-5L (difference at 6 months = −0.0022; 95% CI −0.024 to 0.020; p = 0.85) or total number of health problems (difference at 6 months = −0.30; 95% CI −0.64 to 0.054; p = 0.099). The main study limitations include the risk of bias due to the lack of blinding and difficulties in demonstrating which part of this complex intervention (for example, goal setting, extra attention to patients, reducing health problems, drug changes) contributed to the effects that we observed. Conclusions In this study, we observed that a CMR focused on personal goals improved older patients’ lives and wellbeing by increasing quality of life measured with EQ-VAS and decreasing the number of health problems with impact on daily life, although it did not significantly affect quality of life measured with the EQ-5D. Including the patient’s personal goals and preferences in a medication review may help to establish these effects on outcomes that are relevant to older patients’ lives. Trial registration Netherlands Trial Register; NTR5713, In a randomised controlled trial, Sanne Verdoorn and co-workers assess a patient-centred clinical medication review and health-related quality of life in people aged ≥70 years living in the Netherlands, Author summary Why was this study done? The number of older persons with long-term medication use will increase in the next decades. There is ample evidence that a medication review reduces drug-related problems but there is limited evidence whether this translates into an improvement of older persons’ wellbeing. We hypothesised that a medication review focused on patients’ health-related goals and preferences could improve their wellbeing. What did the researchers do and find? We conducted a pragmatic randomised controlled trial among 629 persons aged over 70 and using at least 7 long-term medications, comparing a clinical medication review in which participants established personal goals versus usual care. Participants were followed for 6 months, and we measured their quality of life and 12 different health problems, such as pain, dizziness, and dyspnoea, through written questionnaires at baseline and at 3 and 6 months. We found that a medication review in which the patient interview was focused on the patient’s preferences and goals improved older persons’ self-reported quality of life (EQ-VAS) and reduced health problems compared to usual care, although the quality of life measured with EQ-5D did not change. What do these findings mean? In our study, there was no effect on quality of life measured with EQ-5D, but other patient-reported outcomes, including quality of life measured with EQ-VAS, did improve, underlining the complexity of measuring improvement in the wellbeing of older persons. Focusing on the patient’s preferences during a medication review enables shared decision-making about pharmacotherapy in this older population. Future studies are needed to further assess the effects of including personal goals during medication review and to optimise and implement the use of such personal goals in care for older persons.

ObjectivesRedispensing by pharmacies of medication unused by another patient could contribute to optimal use of healthcare resources. This study aimed to assess patient willingness to use medication returned by another patient and patient characteristics associated with this willingness.DesignCross-sectional survey.SettingA total of 41 community and 5 outpatient pharmacies in the Netherlands.ParticipantsTotal of 2215 pharmacy visitors.Primary and secondary outcome measuresPatients completed a questionnaire regarding their willingness to use medication returned unused to the pharmacy by another patient, assuming quality was guaranteed. Secondary outcome measures included patient sociodemographic characteristics that were associated with patient willingness, analysed using logistic regression analysis and reported as ORs with 95% CIs.ResultsOf the 2215 patients (mean (SD) age 50.6(18.0) years; 61.4% female), 61.2% were willing to use medication returned unused to the pharmacy by another patient. Patients who were unwilling mostly found it risky. Men were more willing to use returned medication (OR 1.3 95% CI 1.1 to 1.6), as did patients with a high educational level (OR 1.8 95% CI 1.3 to 2.5), those who regularly use 1–3 medications (OR 1.3 95% CI 1.1 to 1.7), those who returned medication to the pharmacy for disposal (OR 1.5 95% CI 1.0 to 2.3) and those who ever had unused medication themselves (OR 1.3 95% CI 1.1 to 1.6)). Patients with non-Dutch cultural background were less willing to use returned medication (OR 0.395% CI 0.3 to 0.4)).ConclusionsWhen quality is guaranteed, a substantial proportion of patients are willing to use medication returned unused to the pharmacy by another patient. This suggests that implementation of redispensing may be supported by patients.

Background Atopic dermatitis affects 10–20% of the children worldwide. Unfortunately not all patients who receive treatment have optimal treatment outcomes. Objective To assess the view of parents and pharmacy staff in order to optimize pharmaceutical care for young atopic dermatitis patients. Setting Community pharmacies in the Netherlands. Method We first held an expert panel meeting to determine experts’ views on treatment of atopic dermatitis and their suggestions for areas of improvement. This input was used to develop the interview guide. We conducted telephone interviews with parents of children (aged 0–12 years) with atopic dermatitis and face-to-face interviews with pharmacy staff members. All interviews were audiotaped and transcribed verbatim. Transcripts were coded using qualitative data analysis software. Codes were used to identify themes. Main outcome measure Perspectives of parents of young atopic dermatitis patients and pharmacy staff about treatment. Results We interviewed 29 parents and 18 pharmacy staff members. Many parents mentioned fear of steroid adverse effects, with intentional nonadherence as a consequence, and difficulties with the application of topical treatment. Pharmacy employees also mentioned to encounter these issues. Some employees themselves expressed concerns towards use of steroids. Most parents were satisfied with the information they received; however, they need more practical lifestyle advices, e.g. about bathing or clothing. Both pharmacists and pharmacy technicians mentioned that technicians often lack knowledge to support patients optimally in correct medication use. Conclusion Parents’ perceptions about topical corticosteroids might negatively influence treatment outcomes. Pharmacy staff has an important role to inform parents of children with eczema on the appropriate use of topical corticosteroids and emollients. Counseling should not be influenced by their own prejudices about topical corticosteroids. Close collaboration between primary care providers should ensure that parents receive uniform messages. Electronic supplementary material The online version of this article (10.1007/s11096-019-00827-1) contains supplementary material, which is available to authorized users.

Background Automated multidose drug dispensing is used to support patients with their medication management. Though multidose drug dispensing systems are frequently used, little is known about patients' experiences with multidose drug dispensing systems. Objective To explore patients' experiences with the initiation and use of multidose drug dispensing systems. Setting A survey was carried out with patients using multidose drug dispensing systems through three community pharmacies. Method A semi-structured interview protocol was designed based on existing literature and a pilot study. Main outcome measures The main outcome measures were (1) patients' experiences with initiating multidose drug dispensing systems and (2) patients' experienced advantages and disadvantages of multidose drug dispensing systems. Results The start of multidose drug dispensing was discussed with 76% of the patients (n = 62). Ninety percent of patients expressed the opinion that the multidose drug dispensing system supported them with their medication management. Sixty patients reported 110 advantages, which can be organized into the following categories: improved medication adherence and medication safety (59%); patient's convenience (40%); and other (1%). Sixty-nine percent of patients reported no disadvantages, 24% had problems opening the bags or outer packaging and 13% had problems with the legibility of the printed text on the bag. Conclusion In concordance with the Dutch guideline, patients are generally involved in the decision to initiate an multidose drug dispensing system. Patients are very satisfied using the system and report multiple advantages. Multidose drug dispensing systems may be further improved by simplifying the manual opening of the bags and improving the legibility of the text on the bags.

BackgroundMobile health (mHealth) apps have the potential to support patients’ medication use and are therefore increasingly used. Apps with broad functionality are suggested to be more effective; however, not much is known about the actual use of different functionalities and the effective engagement. ObjectiveThe aim of this study was to explore the use and the effective engagement of adolescents (aged 12 to 18 years) with the Adolescent Adherence Patient Tool (ADAPT). MethodsThe ADAPT intervention consisted of an app for patients, which was connected to a management system for their pharmacist. The aim of the ADAPT intervention was to improve medication adherence and, therefore, the app contained multiple functionalities: questionnaires to monitor symptoms and adherence, medication reminders, short movies, pharmacist chat, and peer chat. For this study, data of the ADAPT study and a cluster randomized controlled trial were used. Adolescents with asthma had 6 months’ access to the ADAPT intervention, and all app usage was securely registered in a log file. ResultsIn total, 86 adolescents (mean age 15.0, SD 2.0 years) used the ADAPT app 17 times (range 1-113) per person. Females used the app more often than males (P=.01) and for a longer period of time (P=.03). On average, 3 different functionalities were used, and 13% of the adolescents used all functionalities of the app. The questionnaires to monitor symptoms and adherence were used by most adolescents. The total app use did not affect adherence; however, activity in the pharmacist chat positively affected medication adherence (P=.03), in particular, if patients sent messages to their pharmacist (P=.01). ConclusionsmHealth apps for adolescents with asthma should contain different functionalities to serve the diverging needs and preferences of individual patients. Suggested key functionalities to promote use and effectiveness in adolescents with asthma are questionnaires to monitor symptoms and a health care provider chat.

Background Patients with limited pharmaceutical literacy are at increased risk of drug-related problems. Recognizing these patients in daily practice is difficult. The Recognition and Addressing of Limited Pharmaceutical Literacy (RALPH) interview guide was developed as practical set of questions to recognize patients with limited pharmaceutical literacy in daily pharmacy practice. Objective To compare agreement between pharmaceutical literacy measured with the RALPH guide and a validated general health literacy questionnaire. In addition, we provide insight into patients' pharmaceutical literacy using the RALPH interview guide. Methods Structured face-to-face interviews with patients who visited a community pharmacy to fill a prescription for themselves were conducted. The interview included the RALPH guide as well as the Functional Communicative Critical Health Literacy (FCCHL) questionnaire to measure general health literacy. Functional, communicative and critical skills were measured and agreement between two methods was calculated. Results Data were collected from 508 patients. Patients with limited pharmaceutical literacy, indicated by the RALPH questions, also had a lower general health literacy level according to FCCHL scores. Agreement between the RALPH guide and FCCHL questionnaire was moderate (∼60%) for the three health literacy domains. Most patients (>90%) had correct understanding of frequency and timing of medication use, but 25% did not understand warnings or precautions correctly. Finding understandable information (39%), assessing information applicability (50%) and reliability (64%) were mentioned as difficult by patients. Conclusion Patients experienced difficulties with more complex skills, e.g. interpretation of warnings or precautions when using a medicine, finding and analyzing medication information. Whereas the FCCHL questionnaire is useful to assess general health literacy, the RALPH interview guide provides insight in the level of skills needed for good medication use and is more suitable for use in a medication specific context such as community pharmacy. Context specific assessment of skills is important to provide tailored pharmaceutical care.

Clinical medication reviews (CMR) are increasingly performed in older patients with polypharmacy. Studies have shown positive effects of CMR on process- and intermediate outcomes, like drug-related problems (DRPs). Little effect has been shown on clinical outcomes, like hospital admissions or health-related quality of life (HR-QoL). In particular, HR-QoL is related to the individual health-related goals and complaints of patients. The aim of this study is to investigate the effects of a CMR focused on personal goals on HR-QoL and health-related complaints in older patients with polypharmacy. A randomised controlled trial will be performed in 35 Dutch community pharmacies aiming to include 630 patients aged 70 years and older using seven or more chronic drugs. Patients will be randomly assigned to control or intervention group by block-randomisation per pharmacy. Patients in the intervention group receive a CMR focused on patients’ preferences, personal goals and health-related complaints. With every goal a goal attainment scale (GAS) will be proposed. Primary outcome measures are HR-QoL, measured with the EQ-5D-5L and EQ-VAS and the number of health-related complaints per patient measured with a written questionnaire, during a follow-up period of six months. Secondary outcomes are healthcare utilisation, number and type of drug changes, number and type of health-related goals, scores on GAS and number and type of DRPs and interventions. This study is expected to add evidence on the effects of a CMR on HR-QoL and health-related complaints in older patients with polypharmacy. New in this study is the use of personal goals measured with GAS and health-related complaints as patient-related outcome measures. Netherlands Trial Register; NTR5713 .

Background Studies have shown that a clinical medication review (CMR) reduces drug-related problems (DRPs), but the effects on clinical outcomes are less clear. Perhaps, CMRs in older persons could me more effective when they focus on patients’ personal goals and health-related complaints. Objective The aim of this study was to investigate whether goal attainment scaling (GAS) is a useful tool for determining goals and monitoring their attainment during CMR. Methods This study was an analysis based on data of the intervention group of the DREAMeR-study; a randomised controlled trial investigating the effects of CMR in primary care. 315 persons aged ≥70 years using ≥7 drugs were randomised to the intervention: a CMR focused on personal goals using GAS. Outcome measures were: percentage of persons with health-related goals, attainment of goals measured with GAS-scores after three and six months, type of health-related goals and implementation rates of recommendations for GAS-related DRPs and other DRPs. Results A total of 406 health-related goals were set for 283 of 315 included persons (90%). Of the 350 evaluated goals (86%), 37% was attained after three months and 43% after six months. The goals ‘reduce pain’ (n = 66, 16%), ‘improve mobility’ (n = 57, 14%) and ‘reduce number of pills’ (n = 37, 9.1%) were most prevalent. The implementation rate of recommendations for GAS-related DRPs was 81% compared to 62% for not GAS-related DRPs (p Conclusion Goal setting is important for prioritizing the most important problems during clinical medication review and Goal Attainment Scaling seems to be a useful tool for monitoring the attainment of these goals.

Introduction The management of drug–drug interactions (DDIs) is a complex process in which risk–benefit assessments should be combined with the patient’s perspective. Objective The aim of this study was to determine patients’ and pharmacists’ preferences regarding DDI management. Methods We conducted a choice-based conjoint survey about a fictitious DDI concerning the combination of a cardiovascular drug and an antibiotic for pneumonia. Patients and pharmacists had to choose 12 times between two management options. The options were described by five attributes, including risk, benefit and practical consequences. Each attribute could have two different levels, which were varied over the choice tasks. Latent class analysis was used to identify potential classes of respondents with distinct patterns of similar preferences. Results In total, 298 patients and 178 pharmacists completed the questionnaire. The latent class model for both patients and pharmacists resulted in three classes. For patients, in one class the most importance was attached to avoiding switch of medication (class probability 20%), in a second class to fewer adverse events (41%), and in a third class to blood sampling (39%). For pharmacists, again one class attached the highest importance to avoiding switch of medication (31%). The other classes gave priority to curing pneumonia (31%) and avoiding blood sampling (38%). Conclusion The results showed diverging preferences regarding DDI management among both patients and pharmacists. Different groups attached different value to risk and benefit versus practical considerations. Awareness of existing variability in preferences among and between pharmacists and patients is a step towards shared decision making in DDI management. Electronic supplementary material The online version of this article (doi:10.1007/s40264-017-0601-7) contains supplementary material, which is available to authorized users.

Background Whereas storage conditions are regulated and closely monitored in every stage of the drug supply chain before drug dispensing, it is unknown if patients store drugs at home according to storage recommendations. Objective The objective of this study was to investigate how older patients store their prescription drugs at home and to what extent they comply with drug storage recommendations. Methods We conducted a cross-sectional study between October 2015 and March 2016. Forty-four participating Dutch community pharmacies selected four home-dwelling patients (aged ≥ 65 years) using at least one prescription drug. A complete drug inventory at patients’ homes was performed. Drugs were considered to fulfill the storage recommendation when these met all drug quality (Q) and information (I) criteria: adequately stored according to drug product label storage recommendations for temperature, light, humidity (Q1); expiry date not passed (Q2); integer primary package (Q3); drug identifiability (I1); drug package insert or information leaflet availability (I2). Results One hundred and seventy patients [53.5% female, mean age 74.9 (standard deviation 7.3) years] were included and 1133 prescription drugs stored at home were registered. More than half of the patients (51.2%) complied with all storage quality and information criteria. Assessment of the individual criteria showed that 76.4% of patients were compliant with criterion Q1 while 90.6, 95.3, 97.1 and 71.2% of patients complied with criteria Q2, Q3, I1 and I2, respectively. 53.2% of drugs that should be kept refrigerated according to storage criterion Q1 were not stored between 2 and 8 °C. Conclusion This study illustrates that more than half of the older patients comply with general drug storage recommendations. Electronic supplementary material The online version of this article (10.1007/s40266-018-0524-8) contains supplementary material, which is available to authorized users.

Introduction: Little is known about the overall quality of life (QOL) in patients newly diagnosed with venous thromboembolism (VTE) and atrial fibrillation (AF). We studied QOL in patients with VTE and AF immediately after the start of anticoagulant therapy, and after three months of treatment. Furthermore we identified whether QOL was affected by age, gender and nationality. Materials and Methods: The European pharmacogenetics of anticoagulant therapy (EU-PACT) study was a multicentre, randomized controlled trial of patients aged > 18 years diagnosed with VTE or AF. QOL was assessed using EuroQol 5 dimensions (EQ-5D) questionnaires. Results: The EQ-5D questionnaires were completed by 187 patients with VTE and 660 patients with AF. The QOL in patients diagnosed with VTE or AF was significantly impaired, however, during a 3 months treatment period, patients experienced an improvement (p < 0.05). The QOL in patients diagnosed with VTE improved with increasing age, with similar effects seen in men and women. Men and women diagnosed with AF differed in QOL (respectively 0.84 and 0.74, p < 0.05), and QOL decreased with age. Comparison between countries showed significant differences in the EQ-Index score at follow-up of patients with VTE, and in both EQ-Index score and EQ-VAS of patients with AF. Conclusions: The QOL in patients with VTE and AF is strongly reduced directly after the start of anticoagulant treatment, but improves within 3 months. Moreover, QOL is influenced by demographic and disease-specific variables. These findings provide useful information for future cost-effectiveness studies.

Background Severe asthma is characterized by difficulty to achieve disease control despite high-intensity treatment. However, prevalence figures of severe asthma are lacking, whereas longstanding estimates vary between 5% and 10% of all asthmatic patients. Knowing the exact prevalence of severe refractory asthma as opposed to difficult-to-control asthma is important for clinical decision making, drug development, and reimbursement policies by health authorities. Objective We sought to estimate the prevalence of severe refractory asthma as defined by the Innovative Medicine Initiative consensus. Methods Adult patients with a prescription for high-intensity treatment (high-dose inhaled corticosteroids and long-acting β2-agonists or medium- to high-dose inhaled corticosteroids combined with oral corticosteroids and long-acting β2-agonists) were extracted from 65 Dutch pharmacy databases, representing 3% of the population (500,500 inhabitants). Questionnaires were sent to 5,002 patients, of which 2,312 were analyzed. The diagnosis of asthma and degree of asthma control were derived from questionnaires to identify patients with difficult-to-control asthma. Inhalation technique was assessed in a random sample of 60 adherent patients (prescription filling, ≥80%). Patients with difficult-to-control asthma, adherence to treatment, and a correct inhalation technique were qualified as having severe refractory asthma. Results were mirrored to the Dutch population. Results Of asthmatic adults, 3.6% (95% CI, 3.0% to 4.1%) qualified for a diagnosis of severe refractory asthma, representing 10.4 patients per 10,000 inhabitants. Conclusion The prevalence of severe refractory asthma might be lower than estimated by expert opinion. This implies that currently recognized severe asthma subphenotypes could meet the criteria of rare diseases.

In daily practice, pharmacists are regularly confronted with moral problems in which deciding what to do is not always a straightforward decision. In this contribution we show how the use of a specific method for moral deliberation can (in retrospect or prospective) aid moral judgements. We use the case of dispensing isotretinoin to demonstrate one ethical reflection method, namely the Utrecht Method.

INTRODUCTION: The nature of community pharmacy is changing, shifting from the preparation and distribution of medicines to the provision of cognitive pharmaceutical services (CPS); however, often the provision of traditional services leaves little time for innovative services. This study investigated the time community pharmacists spend on the tasks and activities of daily practice and to what extent they are able to implement CPS-related services in daily practice. METHODS: Self-reporting work sampling was used to register the activities of community pharmacists. A smartphone application, designed specifically for this purpose, alerted participants to register their current activity five times per working day for 6 weeks. Participants also completed an online survey about baseline characteristics. RESULTS: Ninety-one Dutch community pharmacists provided work-sampling data (7848 registered activities). Overall, 51.5% of their time was spent on professional activities, 35.4% on semi-professional activities, and 13.1% on non-professional activities. The proportion of time devoted to CPS decreased during the workweek, whereas the time spent on traditional task increased. DISCUSSION AND CONCLUSION: This study shows it is feasible to collect work-sampling data using smartphone technology. Community pharmacists spent almost half of their time on semi-professional and non-professional activities, activities that could be delegated to other staff members. In practice, the transition to CPS is hampered by competing traditional tasks, which prevents community pharmacists from profiling themselves as pharmaceutical experts in daily practice.

Background Pharmacists are increasingly involved in patient care. This new role in a complex healthcare system with demanding patients may lead to moral dilemmas. There has been little research into pharmacy ethics, and existing data are limited by their retrospective nature and small sample sizes. A thematic overview of the moral dilemmas experienced by community pharmacists is still missing. Objective To make a thematic overview of moral dilemmas experienced in daily pharmacy practice. Setting Dutch community pharmacy. Methods Dutch community pharmacists wrote a narrative about a moral dilemma they had experienced in clinical practice. The narratives were analysed using qualitative content analysis to identify underlying themes. Main outcome measure Themes of moral dilemmas. Results Twenty-two themes were identified in 128 narratives. These moral dilemmas arose predominantly during pharmacists' contact with patients and other health professionals. The relationship between the pharmacist, patient and other health professionals was complicated by other parties, such as legal representatives, health insurance companies, and regulators. Conclusion The moral dilemmas experienced by community pharmacists are more diverse than previously reported. The main dilemmas arose in their professional contacts, frequently when their professional autonomy was challenged by the behaviour of patients and other health professionals.

OBJECTIVE: The aim was to investigate the management of drug therapy alerts on safe use of antibiotics in elderly patients with (potential) renal impairment and the contribution of optional creatinine point of care testing (PoCT) in community pharmacy practice. METHODS: Community pharmacists used a clinical decision support system (CDSS) for seven antibiotics. Alerts were generated during prescription processing in the case of previously registered renal impairment and when no information on renal function was available for patients aged 70 and over. Pharmacists could perform PoCT when renal function could not be retrieved from other health care professionals. Actions were registered in the CDSS. A retrospective descriptive analysis of alert management, performed PoCT and medication dispensing histories was performed. RESULTS: A total of 351 pharmacists registered the management of 88,391 alerts for 64,763 patients. For 68,721 alerts (77.7%), the pharmacist retrieved a renal function above the threshold for intervention. 1.7% of the alerts (n = 1532) led to a prescription modification because of renal impairment; in 3.0% of the alerts (n = 2631), the patient had renal impairment, but the pharmacist judged that no intervention was needed. Pharmacists performed 1988 PoCTs (2.2% of the alerts), which led to 15 prescription modifications (0.8% of the PoCT). CONCLUSION: Community pharmacists performed CDSS-based interventions to prevent potentially inappropriate (dosing of) antibiotics in elderly patients with renal impairment. Pharmacists were well able to retrieve information on renal function, using PoCT in a limited number of cases. The intervention rate could be greatly increased by better registration of information on renal function. Performing PoCT seems especially worthwhile in the highest age groups.

Objectives: To identify the practical problems that older people experience with the daily use of their medicines and their management strategies to address these problems and to determine the potential clinical relevance thereof. Design: Qualitative study with semistructured face-to-face interviews. Setting: A community pharmacy and a geriatric outpatient ward. Participants: Community-dwelling people aged 70 and older (N = 59). Measurements: Participants were interviewed at home. Two researchers coded the reported problems and management strategies independently according to a coding scheme. An expert panel classified the potential clinical relevance of every identified practical problem and associated management strategy using a 3-point scale. Results: Two hundred eleven practical problems and 184 management strategies were identified. Ninety-five percent of the participants experienced one or more practical problems with the use of their medicines: problems reading and understanding the instructions for use, handling the outer packaging, handling the immediate packaging, completing preparation before use, and taking the medicine. For 10 participants, at least one of their problems, in combination with the applied management strategy, had potential clinical consequences and 11 cases (5% of the problems) had the potential to cause moderate or severe clinical deterioration. Conclusion: Older people experience a number of practical problems using their medicines, and their strategies to manage these problems are sometimes suboptimal. These problems can lead to incorrect medication use with clinically relevant consequences. The findings pose a challenge for healthcare professionals, drug developers, and regulators to diminish these problems.

Contains fulltext : 208774.pdf (Publisher’s version ) (Closed access) The objective of this study was to investigate the association between personality traits of older patients and adequate home storage of drugs. Forty-four participating Dutch community pharmacists randomly selected each up to four community-dwelling elderly patients (>/=65 years) who were using at least one prescription drug. The Big Five Inventory was used to assess the personality traits - 'openness', 'conscientiousness', 'extraversion', 'agreeableness' and 'neuroticism' - of patients. An assessment of adequate home storage of drugs was made using a summed composite score for each patient ranging from zero (adequate storage) to three (inadequate storage) was based on storage criteria representing quality, information and level of storage organization. A 51.2% of the patients stored drugs adequately in accordance with all quality ("Q") and information ("I") criteria. A high level of drug storage organization was found in 70.8% of patients. Forty-three patients (31.4%) stored their drugs adequately based on all storage criteria (composite storage score 0). No associations between personality dimensions and adequate drug storage were found. Having a lower number of drugs was associated with adequate drug home storage (ORadjusted 0.86; 95% CI: 0.77-0.96). In conclusion, this study suggests that personality is not associated with adequate home storage of drugs in older patients.

Objective The objectives of this study were to, first, describe the information exchanged between pharmacy staff and patients about prescribed medication at the community pharmacy counter, and second, to investigate to what extent this met professional medication counselling guidelines. Methods Pharmaceutical encounters were videotaped in four community pharmacies in the Netherlands. Patients were included if they collected a prescription for their own use. An observation protocol, including the MEDICODE checklist, was used to analyse the video recordings. A distinction was made between first and repeat prescriptions. Key findings One hundred fifty-three encounters were videotaped. When dispensing first prescriptions, pharmacy staff provided most information on instructions how to use the medication (83.3%), form of the medication (71.4%) and treatment duration (42.9%). Topics for repeat prescriptions (such as the effects of the medication and the incidence of observed adverse effects) were rarely discussed. Pharmacy staff rarely encouraged patients to ask questions. Conclusions Pharmacy staff members provided little medication-related information at the counter, especially for repeat prescriptions, did not encourage active patient participation, and thereby did not adhere to the guidelines of their professional organisation. Further research is needed to understand the reasons for this.

To monitor whether biologic DMARD (bDMARD) home storage temperatures comply with the manufacturers' Summary of Product Characteristics (SmPC) recommendations.This observational study included consenting adult patients from eight Dutch pharmacies who received their bDMARDs with a validated temperature logger. Patients were instructed to store their packages according to standard label instructions and to return the temperature logger(s) after use. Primary outcome was defined as the proportion of patients that stored their bDMARDs within the SmPC recommended temperature range. In addition, the proportion of patients storing bDMARDs below 0?C or above 25 ?C for longer than two consecutive hours was estimated.A total of 255 (87.0%) patients (mean age 53.2 (s.d.; 13.1) years, 51.4% female) returned their temperature logger(s) to the pharmacy. Of these, 17 patients (6.7%) stored their bDMARD within the recommended temperature range. The proportion of the patients that stored their bDMARD for more than 2 h consecutive time below 0?C or above 25?C was respectively 24.3% (median duration: 3.7 h (IQR 2.2 h; range 2.0-1,097.1 h) and 2.0% (median duration: 11.8 h (IQR 44.3 h; range 2.0-381.9 h).The majority of patients do not store their bDMARDs within the SmPC-recommended temperature range.? The Author 2015. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Efficacious lowering of low-density lipoprotein cholesterol through prolonged statin therapy has become a major strategy for primary and secondary prevention of cardiovascular disease. From the perspective of patients, however, the prophylactic efficacy may be difficult to comprehend. It refers to prospective disease prevention at the population level and an uncertain risk reduction for individual patients. At the same time, actual side effects may occur and treatment entails a lifelong regimen. (aut. ref.)

Contains fulltext : 152891.pdf (Publisher’s version ) (Open Access) Background Non-vitamin K oral anticoagulants (NOACs) became available in the Netherlands in 2008, providing another antithrombotic treatment besides vitamin K antagonists (VKAs) and antiplatelet agents (APAs). Objective To describe the patterns of antithrombotic drug use between 2008 and 2013 by examination of dispensing data form community pharmacies in the Netherlands; to determine the concomitant use of NOACs with VKAs and APAs and switching between the drug classes; and to compare adherence to NOACs with adherence to APAs. Setting An observational retrospective study was conducted using routinely collected dispensing data from Dutch community pharmacies. Methods For each calendar year, the numbers of NOAC, VKA, and APA users were calculated. Adherence was determined for NOACs and APAs by the percentage of days covered by medication (PDC). Information on the prescribed daily dose of VKAs was unavailable. Main outcome measures Comparison of age, sex, and co-medications of users of the three drug classes; concomitant use of different antithrombotic drug classes and switching between these in each year; and mean PDC and percentages of all users with a PDC above 80 %. Results NOAC use increased during the study period to 29,687 users in 2013. In that year there were 484,024 VKA users and 1313,032 APA users. Compared with users of VKAs, NOAC users were slightly younger and more frequently used antiarrhythmic drugs and beta blockers as co-medications. Substantial numbers of patients were dispensed potentially harmful combinations in 2013: 820 subjects were dispensed NOACs together with VKAs, and 684 subjects were dispensed NOACs, VKAs, and APAs concomitantly. Mean adherence to NOACs was 84.2 % compared with 87.3 % to APA. One in four NOAC users had a PDC lower than 80 % compared with one in five APA users. Conclusion Our findings show increasing use of NOACs by outpatients. The number of patients taking potentially harmful combinations of antithrombotic drugs was substantial. Adherence to NOACs in daily practice may be suboptimal to prevent thrombotic events.

BACKGROUND: Medication adherence rates often decline as children become teenagers. Effective adherence-enhancing interventions for adolescents are lacking. The objective of this study was to assess adolescent asthmatics needs and preferences regarding medication counseling and support, with focus on new media. METHODS: Three focus groups including 21 asthmatic adolescents recruited from both primary and secondary care were held to explore needs and preferences regarding asthma-self management. Questions concerned adherence behavior and needs and preferences in adherence support with focus on new media (mobile technology, social media, health games). RESULTS: Forgetting was mentioned as major reason for not using medication as prescribed. Adolescents also mentioned lack of perceived need or beneficial effects. Parents mainly play a role in reminding to take medication and collecting refills. The suggested strategies to support self-management included smartphone applications with a reminder function and easy access to online information. Participants were positive about sharing of experiences with other teenagers. CONCLUSION: Forgetfulness is a major reason for non-adherence in adolescents. Furthermore, our results suggest use of peer support may be helpful in promoting good medication use. Future interventions should be aimed at providing practical reminders and should be modifiable to individual preferences.

Objective Assess effects of pharmacists’ counseling by telephone on patients’ satisfaction with counseling, satisfaction with information and beliefs about medicines for newly prescribed medicines. Methods A cluster randomized trial in Dutch community pharmacies. Patients ≥18 years were included when starting with antidepressants, bisphosphonates, RAS-inhibitors or statins. The intervention comprised counseling by telephone to address barriers to adherent behavior. It was supported by an interview protocol. Controls received usual care. Outcomes were effects on beliefs about medication, satisfaction with information and counseling. Data was collected with a questionnaire. Results Responses of 211 patients in nine pharmacies were analyzed. More intervention arm patients were satisfied with counseling (adj. OR 2.2 (95% CI 1.3, 3.6)). Patients with counseling were significantly more satisfied with information on 4 items, had less concerns and less frequently had a ‘skeptical’ attitude towards medication (adj. OR 0.5 (0.3–0.9)). Effects on most outcomes were more pronounced in men than in women. Conclusions Telephone counseling by pharmacists improved satisfaction with counseling and satisfaction with information on some items. It had a small effect on beliefs about medicines. Practice implications Pharmacists can use counseling by telephone, but more research is needed to find out which patients benefit most.

Objective To explore pharmacy staff’s perspectives regarding medication use behaviour in adolescent patients. Methods Structured face-to-face interviews were conducted with 170 community pharmacy staff members. Key findings Medication-related problems in adolescents had been experienced by 80 respondents; non-adherence was frequently mentioned (n = 73). An important reason for medication-related problems in adolescents not being recognised was that prescriptions are often collected by the parents (with or without the teenager). Solutions suggested by the interviewees to improve adolescents’ medication use behaviour included (improving) counselling with emphasis on necessity/benefits of medication (n = 130) and more direct contact with adolescents instead of parent(s) (n = 77). Use of digital media for educational purposes or reminder services was suggested to support medication use (n = 67). Conclusions Almost half of pharmacy staff experienced problems related to medication use in adolescents. Pharmacy staff see a primary role for counselling on the benefits of therapy but foresee difficulties in obtaining direct contact with adolescents. Use of new media could be useful.

OBJECTIVE: No studies in Europe have assessed the extent of nonmedical attention-deficit/hyperactivitiy disorder (ADHD) medication use among adolescents, while also, in Europe, prescribing of these medicines has increased. Our objective was to study the prevalence and motives for nonmedical ADHD medication use among secondary school students in the Netherlands. METHODS: Adolescent students 10-19 years of age from six secondary schools were invited to complete an online survey on use of ADHD medication, tobacco, alcohol, and drugs. Nonmedical ADHD medication use was defined as self-reported use without a prescription during the previous 12 months. RESULTS: Survey data were available for 777 students (15% response rate). The overall proportion of students self-reporting nonmedical ADHD medication use was 1.2% (n = 9), which represented almost 20% of the adolescents who reported ADHD medication use (n = 49). Most adolescents reported self-medication or enhancing study performance as motives for ADHD medication use. CONCLUSIONS: The proportion of the study sample reporting nonmedical ADHD medication use in our study is lower compared with that in previous research conducted in the United States and Canada; however, on a population-based level, there might be a considerable proportion of recreational users.

Item does not contain fulltext OBJECTIVE: To describe communication between pharmacy staff and patients at the counter in outpatient pharmacies. Both content and communication style were investigated. METHODS: Pharmaceutical encounters in three outpatient pharmacies in the Netherlands were video-recorded. Videos were analyzed based on an observation protocol for the following information: content of encounter, initiator of a theme and pharmacy staff's communication style. RESULTS: In total, 119 encounters were recorded which concerned 42 first prescriptions, 16 first refill prescriptions and 61 follow-up refill prescriptions. During all encounters, discussion was mostly initiated by pharmacy staff (85%). In first prescription encounters topics most frequently discussed included instructions for use (83%) and dosage instructions (95%). In first refill encounters, patient experiences such as adverse effects (44%) and beneficial effects (38%) were regularly discussed in contrast to follow-up refills (7% and 5%). Patients' opinion on medication was hardly discussed. CONCLUSION: Pharmacy staff in outpatient pharmacies generally provide practical information, less frequently they discuss patients' experiences and seldom discuss patients' perceptions and preferences about prescribed medication. PRACTICE IMPLICATIONS: This study shows there is room for improvement, as communication is still not according to professional guidelines. To implement professional guidelines successfully, it is necessary to identify underlying reasons for not following the guidelines.

Elderly patients with multimorbidity often take several chronically used medicines. A large part of this polypharmacy is preventive in intention. Although one would expect that, at the end of life, the ratio of preventive therapy, would decrease in proportion to symptomatic treatment, this appears often not to be the case in practice. Although patients seem to be open to stopping medication, physicians seem to find it difficult to deprescribe preventive medication in particular. One of the major reasons for this is uncertainty about the potential clinical consequences of deprescribing. Since frail elderly people seldom participate in clinical drug trials, clear information is not available for this patient group on the balance between the chance of efficacy and the risk of harm of drug therapy. Discussion with the patient about his or her preferences and options with respect to drug therapy is the basis for all subsequent steps and must form part of the periodic reviews of medication.

• Elderly patients with multimorbidity often take several chronically used medicines. A large part of this polypharmacy is preventive in intention. • Although one would expect that, at the end of life, the ratio of preventive therapy, would decrease in proportion to symptomatic treatment, this appears often not to be the case in practice. • Although patients seem to be open to stopping medication, physicians seem to find it difficult to deprescribe preventive medication in particular. One of the major reasons for this is uncertainty about the potential clinical consequences of deprescribing. • Since frail elderly people seldom participate in clinical drug trials, clear information is not available for this patient group on the balance between the chance of efficacy and the risk of harm of drug therapy. • Discussion with the patient about his or her preferences and options with respect to drug therapy is the basis for all subsequent steps and must form part of the periodic reviews of medication.

Purpose The purpose of the study was to gain more insight into the attitudes of adolescents using medication for attention-deficit/hyperactivity disorder (ADHD). Methods A cross-sectional study among adolescents (aged 12–18 years) who filled at least two prescriptions for ADHD medication in the preceding year was conducted. Adolescents were invited to fill in an online questionnaire containing questions on sociodemographics, health status, illness perceptions, medication adherence, and medication beliefs. Results We invited 1,200 adolescents of whom 181 adolescents (122 males, mean age 14.2 ± 1.7 years) completed the online questionnaire. They mostly used methylphenidate (n = 167; 92%) as a pharmacological treatment for ADHD. Half of the study population (n = 93; 51%) experienced side effects, such as decreased appetite and sleep problems. Most participants (n = 150; 83%) had an indifferent attitude (perceived low necessity and low concerns) toward their ADHD medication. More than half of the study population (n = 111; 61%) reported to be nonadherent based on the Medication Adherence Report Scale. The highest score of the Brief Illness Perception Questionnaire was on "treatment control," suggesting that adolescents do think their medication is effective, despite their indifferent drug attitude. Conclusions Most adolescents using ADHD medication had an indifferent attitude toward their medication and reported low adherence rates. These findings should be taken into account when treating adolescents with ADHD; regular counseling and monitoring of the pharmacological treatment might be useful to optimize treatment.