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Background: The home medicines review (HMR) is an important tool for promoting a model of patient-centred care. This article seeks pa-tients' perspectives on understanding, and perceived benefits and difficulties of HMRs., Methods: A qualitative study based on semi-structured interviews of adult participants who completed an HMR was undertaken in Black-town, a growing, multicultural suburb in Western Sydney. The medical centre is a large general practice offering comprehensive, integrated care. Fifteen participants consented to be interviewed. There was even representation of men and women, and the majority had completed high school., Results: Three major areas were explored: understanding and expectation of an HMR, perceived patient benefits and difficulties., Discussion: The HMR has the potential to be a useful tool in patients' management of their medications. There are clear benefits when per-formed well. However, we have identified areas of limitations in effectiveness, which present opportunities for strengthening the HMR process. Training of doctors and pharmacists may be needed to ensure better patient outcomes.

Background: Value-based insurance design attempts to align drug copayment tier with value rather than cost. Previous implementations of value-based insurance design have lowered copayments for drugs indicated for select "high value" conditions and have found modest improvements in medication adherence. However, these implementations have generally not resulted in cost savings to the health plan, suggesting a need for increased copayments for "low value" drugs. Further, previous implementations have assigned equal copayment reductions to all drugs within a therapeutic area without assessing the value of individual drugs. Aligning the individual drug's copayment to its specific value may yield greater clinical and economic benefits. In 2010, Premera Blue Cross, a large not-for-profit health plan in the Pacific Northwest, implemented a value-based drug formulary (VBF) that explicitly uses cost-effectiveness analyses after safety and efficacy reviews to estimate the value of each individual drug. Concurrently, Premera increased copayments for existing tiers., Objective: To describe and evaluate the design, implementation, and first-year outcomes of the VBF., Methods: We compared observed pharmacy cost per member per month in the year following the VBF implementation with 2 comparator groups: (1) observed pharmacy costs in the year prior to implementation, and (2) expected costs if no changes were made to the pharmacy benefits. Expected costs were generated by applying autoregressive integrated moving averages to pharmacy costs over the previous 36 months. We used an interrupted time series analysis to assess drug use and adherence among individuals with diabetes, hypertension, or dyslipidemia compared with a group of members in plans that did not implement a VBF. , Results: Pharmacy costs decreased by 3% compared with the 12 months prior and 11% compared with expected costs. There was no significant decline in medication use or adherence to treatments for patients with diabetes, hypertension, or dyslipidemia., Conclusions: The VBF and copayment changes enabled pharmacy plan cost savings without negatively affecting utilization in key disease states.

An epidemic of morbidity and mortality has swept across the United States related to the use of prescription opioids for chronic noncancer pain. More than 100,000 people have died from unintentional overdose, making this one of the worst manmade epidemics in history. Much of health care delivery in the United States is regulated at the state level; therefore, both the cause and much of the cure for the opioid epidemic will come from state action. We detail the strong collaborations across executive health care agencies, and between those public agencies and practicing leaders in the pain field that have led to a substantial reversal of the epidemic in Washington State.

We present a pilot validation study performed on 10 European Union (EU) Member States, of a point prevalence survey (PPS) of healthcare-associated infections (HAIs) and antimicrobial use in Europe in 2011 involving 29 EU/European Economic Area (EEA) countries and Croatia. A total of 20 acute hospitals and 1,950 patient records were included in the pilot study, which consisted of validation and inter-rater reliability (IRR) testing using an in-hospital observation approach. In the validation, a sensitivity of 83% (95% confidence interval (CI): 79–87%) and a specificity of 98% (95% CI: 98–99%) were found for HAIs. The level of agreement between the primary PPS and validation results were very good for HAIs overall (Cohen’s κappa (κ):0.81) and across all the types of HAIs (range: 0.83 for bloodstream infections to 1.00 for lower respiratory tract infections). Antimicrobial use had a sensitivity of 94% (95% CI: 93–95%) and specificity of 97% (95% CI: 96–98%) with a very good level of agreement (κ:0.91). Agreement on other demographic items ranged from moderate to very good (κ: 0.57–0.95): age (κ:0.95), sex (κ: 0.93), specialty of physician (κ: 0.87) and McCabe score (κ: 0.57). IRR showed a very good level of agreement (κ: 0.92) for both the presence of HAIs and antimicrobial use. This pilot study suggested valid and reliable reporting of HAIs and antimicrobial use in the PPS dataset. The lower level of sensitivity with respect to reporting of HAIs reinforces the importance of training data collectors and including validation studies as part of a PPS in order for the burden of HAIs to be better estimated.

Background: Duplicate prescribing is known to occur across health systems and is one of the most frequent drug related problems. Therapeutic duplication (TD) increases the risk of adverse drug reactions without additional therapeutic benefits., Objectives: This study aimed to develop TD criteria concerning four drug categories which are acid-related disorder drugs, antimicrobials, antihypertensives, and lipid modifying drugs and to estimate the prevalence of therapeutic duplicate prescribing at the ambulatory care settings in Korea., Methods: TD criteria were developed using the WHO anatomical therapeutic chemical classification and modified with an expert consensus panel using the Delphi method. The prevalence of TD including ingredient duplication (ID) of four drug categories was examined using National Health Insurance claim database including 15 million patients during one month in 2009 (December). TD was defined as prescribing medications within the same category in the developed TD criteria list., Results: The numbers of patients who received acid-related disorder drugs, antimicrobials, antihypertensives, and lipid-modifying drugs in the study period were 10,049,292, 7,584,131, 4,349,945, and 1,425,292 respectively. In the field of acid-related disorder drugs prescribed, there were 0.3 % IDs and 2.5 % TDs within a prescription issued by one prescriber. There were 8.4 % IDs and 14.5 % TDs between prescriptions issued at different ambulatory visits. In the field of antimicrobial medicines, there were 0.1 % IDs and 2.6 % TDs within a prescription, while there were 5.0 % IDs and 7.6 % TDs between different prescriptions. Amongst the antihypertensives prescribed, there were 0.4 % IDs and 1.9 % TDs within a prescription, while there were 9.9 % IDs and 11.5 % TDs between prescriptions. Lastly, looking at lipid-modifying drugs prescribed, there were 0.3 % IDs and 0.5 % TDs within one prescription, while there were 8.9 % IDs and 9.4 % TDs between prescriptions., Conclusion: The prevalence of duplicate prescribing was substantial in the ambulatory care setting which is to be improved using the TD criteria developed from this study in the national drug utilization review system in Korea.

What Is Known and Objective: Endocrine therapy is an effective treatment for post-menopausal women with 'oestrogen receptor-positive' invasive breast cancers. There are two main types of endocrine therapies: selective oestrogen receptor modulators (tamoxifen) and aromatase inhibitors (anastrozole, letrozole and exemestane). The aim of this study was to compare the patterns of use of endocrine therapies for breast cancer in women between nine developed countries., Methods: A longitudinal, cross-national drug utilization study was conducted. The endocrine therapies included were tamoxifen and the aromatase inhibitors: anastrozole, letrozole and exemestane. Annual drug utilization data were collected from Australia, Denmark, England, Finland, France, Iceland, the Netherlands, Norway and Sweden over the period 2001-2012. Utilization was measured in DDD/1000 inhabitants/day and was also adjusted for breast cancer incidence and female population statistics., Results and Discussion: Total use of endocrine therapies either increased or remained steady in all countries. Total endocrine therapy usage was consistently highest in England and France. Norway showed the lowest usage of endocrine therapies overall, using only 1.80 DDD/1000 inhabitants/day in 2012. Downward trends in tamoxifen use and upward trends in aromatase inhibitors were seen across all countries over the study period. By 2012, aromatase inhibitors represented over half of total endocrine therapy use in all countries, and as high as 74% and 80% in France and Denmark, respectively., What Is New and Conclusion: Our analysis found a shift in use of endocrine therapy from tamoxifen to aromatase inhibitors. This trend is consistent with major clinical guidelines endorsing preferential use of aromatase inhibitors in post-menopausal women. Stabilization or small increase in tamoxifen use in the recent years may reflect the recognition of tamoxifen as still an appropriate first-line treatment. The similarity in utilization patterns may be due to the relatively comparable healthcare systems in the countries, namely universal health insurance and pharmaceutical coverage. Differences in utilization observed could be due to differences in breast cancer incidence, prescribing behaviours, interpretation of new trial evidence, and timing of drug marketing approval and reimbursement between countries., (© 2014 John Wiley & Sons Ltd.)

Medicines have made an appreciable contribution to improving health. However, even high-income countries are struggling to fund new premium-priced medicines. This will grow necessitating the development of new models to optimize their use. The objective is to review case histories among health authorities to improve the utilization and expenditure on new medicines. Subsequently, use these to develop exemplar models and outline their implications. A number of issues and challenges were identified from the case histories. These included the low number of new medicines seen as innovative alongside increasing requested prices for their reimbursement, especially for oncology, orphan diseases, diabetes and HCV. Proposed models center on the three pillars of pre-, peri- and post-launch including critical drug evaluation, as well as multi-criteria models for valuing medicines for orphan diseases alongside potentially capping pharmaceutical expenditure. In conclusion, the proposed models involving all key stakeholder groups are critical for the sustainability of healthcare systems or enhancing universal access. The models should help stimulate debate as well as restore trust between key stakeholder groups.

Background: The incidence of chronic illnesses is increasing globally. Non-adherence to medications and other medication-related problems are common among patients receiving long-term medications. Medication use review (MUR) is a service provision with an accredited pharmacist undertaking structured, adherence-centered reviews with patients receiving multiple medications. MUR services are not yet available in community pharmacies in Qatar., Objective: The current study aims to evaluate community pharmacists' knowledge, attitudes, and perception towards establishing MUR as an extended role in patient care., Setting: Private community pharmacies in Qatar including chains and independent pharmacies. Methodology A cross-sectional survey using a self-administered questionnaire was conducted among licensed community pharmacists from December 2012 to January 2013. Data analysis was conducted using descriptive and inferential statistics., Main Outcome Measures: Knowledge, attitudes, and practices related to MUR concept and services., Results: A total of 123 participants responded to the survey (response rate 56%). The mean total knowledge score was 71.4 ± 14.7%. An overwhelming proportion of the participants (97%) were able to identify the scope of MUR in relation to chronic illnesses and at enhancing the quality of pharmaceutical care. Furthermore, 80% of the respondents were able to identify patients of priority for inclusion in an MUR program. However, only 43% of the participants knew that acute medical conditions were not the principal focus of an MUR service, while at least 97% acknowledged that the provision of MUR services is a great opportunity for an extended role of community pharmacists and that MUR makes excellent use of the pharmacist's professional skills in the community. The participants generally reported concerns about time, dedicated consultation area, and support staff as significant barriers towards MUR implementation., Conclusion: This study suggests that community pharmacists in Qatar had sufficient knowledge about the concept of MUR and its scope, but there were still important deficiencies that warrant further education. The findings have important implications on policy and practice pertaining to the implementation of MUR as an extended role of pharmacists and as part of Qatar's National Health Strategy to move primary health care forward.

Despite rigorous expert review, medications often fall into routine use with unrecognized and unwanted complications. Use of some medications remains controversial because information to support efficacy is conflicting, scant, or nonexistent. Medication use evaluation (MUE) is a performance improvement tool that can be used when there is uncertainty regarding whether a medication will be beneficial. It is particularly useful when limited evidence is available on how best to choose between two or more medications. MUEs can analyze the process of medication prescribing, preparation, dispensing, administration, and monitoring. MUEs can be part of a structured or mandated multidisciplinary quality management program that focuses on evaluating medication effectiveness and improving patient safety. Successful MUE programs have a structure in place to support completion of rapid-cycle data collection, analysis, and intervention that supports practice change., (© 2014 Pharmacotherapy Publications, Inc.)

Background: Home Medicines Reviews could improve the quality use of medicines and medicines adherence among Aboriginal people. Despite high level of chronic disease very few Home Medicines Review are currently being conducted for Aboriginal and Torres Strait Islander people., Objective: The aim of this research was to explore the barriers and facilitators from the pharmacists' perspective for the provision of Home Medicines Review to Aboriginal people attending Aboriginal Health Services., Setting: A cross sectional survey was used to gather demographic, qualitative and quantitative data from 945 Australian pharmacists accredited to undertake Home Medicines Review., Method: The survey consisted of 39 items which included both closed, open ended and Likert scale questions. Data was extracted from the online survey tool and analysed. Descriptive statistics were used to explore the quantitative data while qualitative data was thematically analysed and coded for emergent themes., Main Outcome Measure: Number of Home Medicines Review conducted for Aboriginal and Torres Strait Islander patients., Results: A total of 187 accredited pharmacists responded to the survey. They reported that barriers to Home Medicines Review to Aboriginal patients may include lack of understanding of cultural issues by pharmacists; lack of awareness of Home Medicines Review program by Aboriginal Health Service staff; difficulties in implementation of Home Medicine Review processes; burdensome program rules; the lack of patient-pharmacist relationship, and the lack of pharmacist-Aboriginal Health Service relationship., Conclusion: Changes to the medication review processes and rules are needed to improve the accessibility of the Home Medicine Review program for Aboriginal and Torres Strait Islander people. Improved relationships between pharmacists and Aboriginal health service staff, would increase the likelihood of more Home Medicines Reviews being conducted with Aboriginal and Torres Strait Islander patients.

Background: Inappropriate drug use has been identified as one of the most important problems affecting the quality of care in older people. Inappropriate drug use may increase the risk of the occurrence of 'geriatric giants' such as immobility, instability, incontinence and cognitive impairment. There are indications that clinical medication reviews (CMR) can reduce inappropriate drug use. However, CMRs have not yet been implemented at a large scale in primary care. An innovative medication review program in primary care will be developed which tackles the most important obstacles for a large scale implementation of CMRs. The aim of this study is to assess whether this CMR program is (cost-) effective compared with usual general practice care for older patients with geriatric symptoms with regard to quality of life and geriatric symptoms., Methods: A cluster randomised controlled trial will be performed in 20 Dutch general practices including 500 patients. Patients of 65 years and older are eligible if they newly present with pre-specified geriatric symptoms in general practice and chronic use of at least one prescribed drug. GP practices will be stratified by practice size and randomly allocated to control (n = 10) or intervention group (n = 10). The intervention consists of CMRs which will be facilitated and prepared by an expert team consisting of a GP and a pharmacist. Primary outcome measures are patient's quality of life and the presence of self-reported geriatric symptoms during a follow-up period of 6 months. Secondary outcomes are costs of healthcare utilisation, feasibility, number of drug related problems, medication adherence and satisfaction with medication., Discussion: This study is expected to add evidence on the (cost-) effectiveness of an optimally facilitated, prepared and structured CMR in comparison with usual care in older patients who present a geriatric symptom to their GP. The strength of this study is that it will be conducted in daily clinical practice. This improves the possibilities to implement the CMRs in the primary care setting on a large scale., Trial Registration: Netherlands Trial register: NTR4264.

Introduction: Nursing home residents often have a high number of comorbidities resulting in polypharmacy. Inappropriate prescribing is therefore likely to occur, which in turn is expected to worsen cognitive impairment, to increase the fall risk and to decrease residents' quality of life. The objective of the 'Discontinuing Inappropriate Medication in Nursing Home Residents' (DIM-NHR) study is to examine the efficacy and cost-effectiveness of the Multidisciplinary Multistep Medication Review (3MR) that is aimed at optimising prescribing and discontinuing inappropriate medication., Methods: A cluster randomised controlled trial will be conducted. Elderly care physicians and their wards (clusters) will be randomised. Data will be collected at baseline and 4 months after the 3MR has taken place. Six hundred nursing home residents will be recruited of whom more than half are expected to suffer from dementia. The 3MR will be based on consensus criteria and the relevant literature and will be performed by the patient's elderly care physician in collaboration with a pharmacist., Analysis: Primary outcomes-the difference in proportion of residents who successfully discontinued inappropriate medication between the intervention and control group at follow-up. Secondary outcomes-undertreatment, exposure to anticholinergic and sedative medicines, neuropsychiatric symptoms, cognitive function, falls, hospital admission, quality of life and cost-effectiveness., Ethics and Dissemination: Participant burden will be kept at a minimum. The elderly care physician will remain free to adjust medication when symptoms relapse or adverse events occur, rendering serious adverse events highly unlikely. Study findings will be published in peer-reviewed journals and a 3MR toolkit will be developed., Trial Registration Number: This study has been registered at http://www.ClinicalTrials.gov (trial registration number: NCT01876095)., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Aims: Medication reviews by a third party have been introduced as a method to improve drug treatment in older people. We assessed whether this intervention reduces mortality and hospitalization for nursing home residents., Methods: Systematic literature searches were performed (from January 1990 to June 2012) in Medline, EMBASE, Cochrane Library, ProQuest Nursing & Allied Health Sources and Health Technology Assessment databases. We included randomized and nonrandomized controlled trials (RCTs and non-RCTs) of medication reviews compared with standard care or other types of medication reviews in nursing home residents. The outcome variables were mortality and hospitalization. Study quality was assessed systematically. We performed meta-analyses using random-effects models., Results: Seven RCTs and five non-RCTs fulfilled the inclusion criteria. The mean age of included patients varied between 78 and 86 years. They were treated with a mean of 4-12 drugs. The study quality was assessed as high (n = 1), moderate (n = 4) or low (n = 7). Eight studies compared medication reviews with standard care. In six of them, pharmacists were involved in the intervention. Meta-analyses of RCTs revealed a risk ratio (RR) for mortality of 1.03 [medication reviews vs. standard care; five trials; 95% confidence interval (CI) 0.85-1.23]. The corresponding RR for hospitalization was 1.07 (two trials; 95% CI 0.61-1.87)., Conclusions: Our findings indicate that medication reviews for nursing home residents do not reduce mortality or hospitalization. More research in the setting of controlled trials remains to be done in order to clarify how drug treatment can be optimized for these patients., (© 2014 The Authors. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of The British Pharmacological Society.)

Background: Area-level variation in treatment and outcomes may be a potential source of confounding bias in observational comparative effectiveness studies. This paper demonstrates how to use exploratory spatial data analysis (ESDA) and spatial statistical methods to investigate and control for these potential biases. The case presented compares the effectiveness of two antipsychotic treatment strategies: oral second-generation antipsychotics (SGAs) vs. long-acting paliperiodone palmitate (PP)., Methods: A new-start cohort study was conducted analyzing patient-level administrative claims data (8/1/2008-4/30/2011) from Missouri Medicaid. ESDA techniques were used to examine spatial patterns of antipsychotic prescriptions and outcomes (hospitalization and emergency department (ED) visits). Likelihood of mental health-related outcomes were compared between patients starting PP (N = 295) and oral SGAs (N = 8,626) using multilevel logistic regression models adjusting for patient composition (demographic and clinical factors) and geographic region., Results: ESDA indicated significant spatial variation in antipsychotic prescription patterns and moderate variation in hospitalization and ED visits thereby indicating possible confounding by geography. In the multilevel models for this antipsychotic case example, patient composition represented a stronger source of confounding than geographic context., Conclusion: Because geographic variation in health care delivery is ubiquitous, it could be a comparative effectiveness research (CER) best practice to test for possible geographic confounding in observational data. Though the magnitude of the area-level geography effects were small in this case, they were still statistically significant and should therefore be examined as part of this observational CER study. More research is needed to better estimate the range of confounding due to geography across different types of observational comparative effectiveness studies and healthcare utilization outcomes.

A key regulatory requirement pertaining to drug development is characterization of the role of kidney function in drug disposition and response, along with provision of corresponding renal dose adjustment recommendations. Traditionally, this information has been derived from Phase I pharmacokinetic studies in which regulatory guidance exists for pharmaceutical manufacturers on the design, conduct, analysis, and interpretation of data. Categorization and stratification of subjects into kidney function groups and dosing recommendations have historically been based on creatinine clearance estimates using the Cockcroft-Gault equation. As new estimating equations have emerged, the choice of equation for assessment of kidney function has become an area of debate. This review highlights these equations and provides recent examples of the use of quantitative models, incorporating efficacy and safety to make rational dose recommendations in subjects with impaired kidney function.

Measurement of antimicrobial use before and after an intervention and the associated outcomes are key activities of antimicrobial stewardship programs. In the United States, the recommended metric for aggregate antibiotic use is days of therapy/1000 patient-days. Clinical outcomes, including response to therapy and bacterial resistance, are critical measures but are more difficult to document than economic outcomes. Interhospital benchmarking of risk adjusted antimicrobial use is possible, although several obstacles remain before it can have an impact on patient care. Many challenges for stewardship programs remain, but the methods and science to support their efforts are rapidly evolving., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Throughout the literature, drug-related problems (DRPs), such as medication reconciliation issues and potentially inappropriate prescribing, have been reported to be associated with adverse outcomes in older individuals. Both structured pharmacist review of medication (SPRM) interventions and computerized decision support systems (CDSSs) have been shown to reduce DRPs., Objective: The objectives of this study were to (i) evaluate the impact of a specially developed SPRM/CDSS intervention on the appropriateness of prescribing in older Irish hospital inpatients, and (ii) examine the acceptance rates of these recommendations., Methods: We prospectively reviewed 361 patients, aged ≥65 years who were admitted to an Irish university teaching hospital over a 12-month period. At the point of admission, the patients received a SPRM/CDSS intervention, which screened for DRPs. Any DRPs that were identified were then communicated in writing to the attending medical team. The patient's medical records were reviewed again at 7-10 days, or at the point of discharge (whichever came first)., Results: Of the 361 patients reviewed, 181 (50.1 %) were female; the median age was 77 years [interquartile range (IQR) 71-83 years). A total of 3,163 (median 9, IQR 6-12) and 4,192 (median 12, IQR 8-15) medications were prescribed at admission and discharge, respectively. The SPRM generated 1,000 recommendations in 296 patients. Of the 1,000 recommendations, 548 (54.8 %) were implemented by the medical teams accordingly. The SPRM/CDSS intervention resulted in an improvement in the appropriateness of prescribing as defined by the medication appropriateness index (MAI), with a statistically significant difference in the median summated MAI at admission (15, IQR: 7-21) and follow-up (12, IQR: 6-18); p < 0.001. However, the SPRM did not result in an improvement in appropriateness of underprescribing as defined by a modified set assessment of care of vulnerable elders (ACOVE) criteria., Conclusion: This study indicated that DRPs are prevalent in older Irish hospitalized inpatients and that a specially developed SPRM intervention supported by a CDSS can improve both the appropriateness and accuracy of medication regimens of older hospitalized inpatients.

With dwindling number of new antibiotics and inappropriate use of antibiotics, the emergence and spread of antibiotics resistance occurs commonly in healthcare institutions worldwide. In China, antibiotics are commonly over prescribed and misused. This study is to assess the effect of the nationwide special campaign on antibiotic stewardship program (ASP) at specialized hospitals in China by investigating prescription information from 2011 to 2012. Data on the hospital consumption and prescription of systemic antibiotics were obtained from four specialized hospitals, including maternity, children's, stomatological and cancer hospitals. Systematic random sampling was used to select outpatient prescriptions and inpatient cases. A total of 105 specialized hospitals in 2011 and 121 specialized hospitals in 2012 were analysed. The defined daily doses (DDDs) per 100 inpatient days, the percentage of antibiotic use in outpatient prescriptions, and the percentage of antibiotic use in inpatient cases were used as measurements of antibiotic use. The overall antibiotic use density in the selected hospitals decreased between 2011 and 2012 from 39.37 to 26.54 DDD/100 inpatient days (P<0.001). The percentage of antibiotic use in outpatient prescriptions (range: 24.12%-18.71%, P=0.109) and inpatient cases (64.85%-60.10%, P=0.006) also decreased within the two years. Significant changes were observed among regions and different hospitals within the two years. And antibiotic consumption was correlated with the type and size of specialized hospital in 2012, but not with the regions. This analysis of antibiotic consumption of specialized hospitals allows relevant comparisons for benchmarking and shows that national ASP has improved antibiotic rational use in China. The data will assist policymakers in formulating effective strategies to decrease antibiotic overuse and identify areas that require further work.

Background: The assessment of the benefit-risk of medicines needs careful consideration concerning their patterns of utilization. Systems for the monitoring of medicines consumption have been established in many European countries, and several international groups have identified and described them. No other compilation of European working groups has been published. As part of the PROTECT project, as a first step in searching for European data sources on the consumption of five selected groups of medicines, we aimed to identify and describe the main characteristics of the existing collaborative European working groups., Findings: Google and bibliographic searches (PubMed) of articles containing information on databases and other sources of drug consumption data were conducted. For each working group the main characteristics were recorded.Nineteen selected groups were identified, focusing on: a) general drug utilisation (DU) research (EuroDURG, CNC, ISPE'S SIG-DUR, EURO-MED-STAT, PIPERSKA Group, NorPEN, ENCePP, DURQUIM), b) specific DU research: b.1) antimicrobial drugs (ARPAC, ESAC, ARPEC, ESGAP, HAPPY AUDIT), b.2) cardiovascular disease (ARITMO, EUROASPIRE), b.3) paediatrics (TEDDY), and b.4) mental health/central nervous system effects (ESEMeD, DRUID, TUPP/EUPoMMe). Information on their aims, methods and activities is presented., Conclusions: We assembled and updated information on European working groups in DU research and in the utilisation of five selected groups of drugs for the PROTECT project. This information should be useful for academic researchers, regulatory and health authorities, and pharmaceutical companies conducting and interpreting post-authorisation and safety studies. European health authorities should encourage national research and collaborations in this important field for public health.

Background and Objective: Antimicrobial stewardship programs (ASPs) are a mechanism to ensure the appropriate use of antimicrobials. The extent to which ASPs are formally implemented in freestanding children's hospitals is unknown. The objective of this study was to determine the prevalence and characteristics of ASPs in freestanding children's hospitals., Methods: We conducted an electronic survey of 42 freestanding children's hospitals that are members of the Children's Hospital Association to determine the presence and characteristics of their ASPs. For hospitals without an ASP, we determined whether stewardship strategies were in place and whether there were barriers to implementing a formal ASP., Results: We received responses from 38 (91%) of 42. Among responding institutions, 16 (38%) had a formal ASP, and 15 (36%) were in the process of implementing a program. Most ASPs (13 [81%] of 16) were started after 2007. The median number of full-time equivalents dedicated to ASPs was 0.63 (range, 0.1-1.8). The most common antimicrobials monitored by ASPs were linezolid, vancomycin, and carbapenems. Many hospitals without a formal ASP were performing stewardship activities, including elements of prospective audit and feedback (9 [41%] of 22), formulary restriction (9 [41%] of 22), and use of clinical guidelines (17 [77%] of 22). Antimicrobial outcomes were more likely to be monitored by hospitals with ASPs (100% vs 68%; P = .01), although only 1 program provided support for a data analyst., Conclusions: Most freestanding children's hospitals have implemented or are developing an ASP. These programs differ in structure and function, and more data are needed to identify program characteristics that have the greatest impact.

Purpose: To examine the age and gender-specific trends of Schedule II opioid use among California residents, with special reference to multiple provider users (doctor shoppers)., Methods: Utilizing data from the California Prescription Drug Monitoring Program, we examined age and gender-specific trends of Schedule II opioid use during calendar years 1999-2007. Specifically, we analyzed the following: (1) the prevalence of Schedule II opioid users among California's population and (2) the proportion of these opioid users who were doctor shoppers (defined as an individual who used more than five different prescribers for all Schedule II opioids he or she obtained in a calendar year)., Results: Among all age and gender groups, the prevalence of Schedule II opioid users in California increased by 150%-280% and the prevalence of doctor shoppers among users increased by 111%-213% over 9 years. The prevalence of opioid users was lowest among 18-44 year old men (1.25%) and highest among 65-year and older women (5.31%) by 2007. The prevalence of doctor shoppers was approximately 1.4% among those up to age 64 years and 0.5% among those 65 years and older. The gender difference in doctor shoppers among all age groups was negligible. On average, the cumulative morphine-equivalent amount of Schedule II opioid per individual obtained per year was threefold to sixfold higher for doctor shoppers than for the general population across different age and gender groups., Conclusions: Age and gender differences in opioid use were relatively small, whereas the trends for use of opioids and multiple providers grew at a disquieting rate., (Copyright © 2013 John Wiley & Sons, Ltd.)

Background: Criteria to assess the appropriateness of prescriptions might serve as a helpful guideline during professional training and in daily practice, with the aim to improve a patient's pharmacotherapy., Objective: To create a comprehensive and structured overview of existing tools to assess inappropriate prescribing., Method: Systematic literature search in Pubmed (1991-2013). The following properties of the tools were extracted and mapped in a structured way: approach (explicit, implicit), development method (consensus technique, expert panel, literature based), focused patient group, health care setting, and covered aspects of inappropriate prescribing., Results: The literature search resulted in 46 tools to assess inappropriate prescribing.Twenty-eight (61%) of 46 tools were explicit, 8 (17%) were implicit and 10 (22%) used a mixed approach. Thirty-six (78%) tools named older people as target patients and 10 (22%) tools did not specify the target age group. Four (8.5%) tools were designed to detect inappropriate prescribing in hospitalised patients, 9 (19.5%) focused on patients in ambulatory care and 6 (13%) were developed for use in long-term care. Twenty-seven (59%) tools did not specify the health care setting. Consensus methods were applied in the development of 19 tools (41%), the others were based on either simple expert panels (13; 28%) or on a literature search (11; 24%). For three tools (7%) the development method was not described., Conclusion: This overview reveals the characteristics of 46 assessment tools and can serve as a summary to assist readers in choosing a tool, either for research purposes or for daily practice use.

Purpose: A Web-based application for coordinating medication-use evaluation (MUE) initiatives within the Veterans Affairs (VA) health care system is described., Summary: The MUE Tracker (MUET) software program was created to improve VA's ability to conduct national medication-related interventions throughout its network of 147 medical centers. MUET initiatives are centrally coordinated by the VA Center for Medication Safety (VAMedSAFE), which monitors the agency's integrated databases for indications of suboptimal prescribing or drug therapy monitoring and adverse treatment outcomes. When a pharmacovigilance signal is detected, VAMedSAFE identifies "trigger groups" of at-risk veterans and uploads patient lists to the secure MUET application, where locally designated personnel (typically pharmacists) can access and use the data to target risk-reduction efforts. Local data on patient-specific interventions are stored in a centralized database and regularly updated to enable tracking and reporting for surveillance and quality-improvement purposes; aggregated data can be further analyzed for provider education and benchmarking. In a three-year pilot project, the MUET program was found effective in promoting improved prescribing of erythropoiesis-stimulating agents (ESAs) and enhanced laboratory monitoring of ESA-treated patients in all specified trigger groups. The MUET initiative has since been expanded to target other high-risk drugs, and efforts are underway to refine the tool for broader utility., Conclusion: The MUET application has enabled the increased standardization of medication safety initiatives across the VA system and may serve as a useful model for the development of pharmacovigilance tools by other large integrated health care systems.

The objective of this study was to assess the impact on carbapenems use of a program combining pre-authorization requirement and systematic post-prescription review of carbapenems prescriptions. The program was implemented in a 1,230-bed teaching tertiary hospital. Monthly carbapenems consumption was analyzed using a controlled interrupted time-series method and compared to that of vancomycin before and after implementation of the intervention. Compared to the pre-intervention period (14 monthly points), a significant and sustained decrease of carbapenems consumption [1.66 defined daily doses (DDD)/1,000 patient-days; p = 0.048] was observed during the intervention period (12 monthly points), despite an increasing trend in incidence of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) isolates (0.02/1,000 patient-days per month; p = 0.093). As expected, vancomycin consumption was unaffected by the intervention. A total of 337 prescriptions were reviewed in the intervention period; most were microbiologically documented (81.3%; ESBL-PE: 39.2%). Three of four (76.6%) carbapenems prescriptions were modified within a median [interquartile range] of 2 [1; 4] days, either after infectious disease physician (IDP) advice (48.4%) or by ward physicians (28.2%). Most changes included de-escalating (52.2%) or reducing the planned duration (22.2%), which resulted in a median duration of treatment of only 3 [2; 7] days. The median length of stay and mortality rate were not influenced by the intervention. This reasonably practicable antimicrobial stewardship program including controlled delivery and systematic reevaluation of carbapenems prescriptions was able to reduce their use in our hospital, despite a rising ESBL-PE incidence.

What Is Known and Objective: Limited and conflicting evidence exists on the effect of a multicomponent pharmaceutical care intervention (i.e. medication review, involving collaboration between general practitioners (GPs), pharmacists and patients) on medication-related hospitalizations, survival, adverse drug events (ADEs) and quality of life. We aimed to investigate the effect of a multicomponent pharmaceutical care intervention on these outcomes., Methods: An open controlled multicentre study was conducted within primary care settings. Patients with a high risk on medication-related hospitalizations based on old age, use of five or more medicines, non-adherence and type of medication used were included. The intervention consisted of a patient interview, a review of the pharmacotherapy and the execution and follow-up evaluation of a pharmaceutical care plan. The patient's own pharmacist and GP carried out the intervention. The control group received usual care and was cared for by a GP other than the intervention GP. The primary outcome of the study was the frequency of hospital admissions related to medication within the study period of 12 months for each patient. Secondary outcomes were survival, quality of life and ADEs., Results and Discussion: 364 intervention and 310 control patients were included. Less medication-related hospital admissions were found in the intervention group (n = 6; 1·6%) than in the control group (n = 10; 3·2%) but the overall effect was not statistically significant (hazard ratio (HR) 0·50, 95% confidence interval (CI) 0·12-1·59). The secondary outcomes were not statistically significantly different either. The study was underpowered, which may explain the negative results. A post hoc analysis showed that the effect of the intervention was statistically significant for patients with five diseases or more: five diseases, HR 0·28 (95% bootstrap CI: 0·056-0·73) and eight diseases, HR 0·11 (95% CI: 0·013-0·34)., What Is New and Conclusion: A multicomponent pharmaceutical care intervention does not prevent medication-related hospital admissions. Whether this is true for such interventions in general is unknown, because the PHARM study was underpowered. The intervention may significantly reduce medication-related hospitalizations in patients with five or more comorbidities, but this is only based on a post hoc analysis and thus needs confirmation in large controlled trials., (© 2013 Erasmus MC.)

The frail elderly populations of nursing homes frequently use drugs and suffer from considerable comorbidities. Medication reviews are intended to support evidence based prescribing and optimise therapy. However, literature is still ambiguous regarding the optimal method and the effects of medication reviews. Innovative computerised systems may support the medication reviews in the future. We are developing a clinical decision support system (CDSS) that, independently of the prescribing software, continuously monitors all prescribed drugs while taking into account co-medication, laboratory-data and co-morbidities. The CDSS will be developed in five phases: (1) development of the computerised system, (2) development of the clinical rules, (3) validation of the CDSS, (4) randomised controlled trial, and (5) feasibility for implementation in different nursing homes. The clinical decision support system aims at supporting the traditional medication review.

Background: The aim of this study is to evaluate in-house antibiotic use in a state hospital in Turkey with its cost, using the ATC/DDD index, which is an accepted standard method., Methods: This study was performed as a point prevalence study in a state hospital with 372 beds. All in-house patients using antibiotics on July 19, 2011 were included in the study. Indications for antibiotic use and information about the patients were recorded on special forms. Antibiotic use and cost analysis were evaluated using the ATC/DDD index, which is also suggested by the WHO to be used in similar studies., Findings: 147 patients out of 308 patients who were in-house were identified to use antibiotics with appropriate indications for prophylaxis or treatment in 61% of the patients. The rate of appropriate antibiotic use was identified to be in 78%, while this rate was 38.9% in surgical clinics. The daily cost of the antibiotics consumed on the date of the study was calculated as 4104.79 TL (=2476.80 USD)., Discussion: The rate of inappropriate use of antibiotics seems to be high in our hospital. This will result in both increased costs and also increased nosocomial infection rates with resistant species. Infectious disease specialists should take more active roles in the in-house antibiotic use, hospitals should prepare and implement their own principles of antibiotic use, and microbiology laboratories should be used more effectively. These measures would decrease the conspicuous shortcomings in the antibiotic use.

Purpose: This paper aimed to assess the prescription of medications during pregnancy by primary care physicians in the UK., Methods: We identified both completed pregnancies and pregnancies losses (ectopic pregnancies, miscarriages, terminations, and stillbirths) in women aged 13-49 years enrolled in The Health Improvement Network (THIN) between 1996 and 2010 following an algorithm with three sequential cycles that searched for Read Code groups in hierarchical order: (1) indicators of conception; (2) delivery or pregnancy loss; and (3) other codes suggestive of pregnancy. Completed pregnancies were linked to liveborn infants by means of the family identification number and date of birth. Prescription of specific drugs during the first trimester and time trends during the last decade were calculated., Results: A total of 191 000 pregnancies were identified, including 148 544 completed pregnancies and 42 456 (22.2%) pregnancies losses (ectopic pregnancies, miscarriages, terminations, and stillbirths). Of the completed pregnancies, 131670 (88.6%) were successfully linked with the offspring. The most commonly prescribed drugs were antibiotics, antimycotics, asthma/allergy medications, and analgesics. From 1996 to 2010, the proportion of completed pregnancies with at least one prescription during the first trimester increased for antidepressants (1.8% to 4.2%), thyroid hormones (0.7% to 1.6%), and opiods (1.5% to 2.6%), among other drugs., Conclusion: In conclusion, the prescription of several medications by primary care physicians during the first trimester of pregnancy has risen in the UK during the last decade. We discuss how, when important challenges are considered, THIN may be a promising resource to study specific therapies during pregnancy., (Copyright © 2013 John Wiley & Sons, Ltd.)

We evaluated 222 hospitalized patients whose clinical isolates were tested using standard methods and matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF). MALDI-TOF could have reduced time to appropriate therapy for 28.8% and 44.6% patients based on the treating physician's choices and stewardship team recommendations, respectively. Clinicians should be aware of scenarios in which MALDI-TOF can optimize antibiotic therapy.

Aim: To evaluate the clinical appropriateness and safety of nurse and midwife prescribing practice., Background: The number of countries introducing nurse and midwife prescribing is increasing; however, concerns over patient safety remain., Design: A multi-site documentation evaluation was conducted using purposeful and random sampling. The sample included 142 patients' records and 208 medications prescribed by 25 Registered Nurse Prescribers., Methods: Data were extracted from patient and prescription records between March-May 2009. Two expert reviewers applied the modified Medication Appropriate Index tool (8 criteria) to each drug. The percentage of appropriate or inappropriate responses for each criterion was reported. Reviewer concordance was measured using the Cohen's kappa statistic (inter-rater reliability)., Results: Nurse or midwife prescribers from eight hospitals working in seventeen different areas of practice were included. The reviewers judged that 95-96% of medicines prescribed were indicated and effective for the diagnosed condition. Criteria relating to dosage, directions, drug-drugs or disease-condition interaction, and duplication of therapy were judged appropriate in 87-92% of prescriptions. Duration of therapy received the lowest value at 76%. Overall, reviewers indicated that between 69 (reviewer 2)-80% (reviewer 1) of prescribing decisions met all eight criteria., Conclusion: The majority of nurse and midwife prescribing decisions were deemed safe and clinically appropriate. However, risk of inappropriate prescribing with the potential for drug errors was detected. Continuing education and evaluation of prescribing practice, especially related to drug and condition interactions, is required to maximize appropriate and safe prescribing., (© 2012 Blackwell Publishing Ltd.)

Context: Morphine has been considered the gold standard for treating moderate-to-severe pain, although many new opioid products and formulations have been marketed in the last two decades and should be considered when examining opioid consumption. Understanding opioid consumption is improved by using an equianalgesic measure that controls for the strengths of all examined opioids., Objectives: The research objective was to use a morphine equivalence (ME) metric to determine the extent that morphine consumption relates to the total consumption of all other study opioids., Methods: An ME metric was created for morphine and the aggregate consumption of each study opioid (Total ME), adjusted for country population to allow for uniform equianalgesic comparisons. Graphical and statistical evaluations of morphine use and Total ME consumption trends (between 1980 and 2009) were made for the global and geographic regional levels and selected developed and developing countries., Results: Global morphine consumption rose dramatically in the early 1980s but has been significantly outpaced by Total ME since 1996. As expected, the extent of morphine and Total ME consumption varied notably among regions, with the Americas, Europe, and Oceania regions accounting for the highest morphine use and Total ME in 2009. Developing and least developed countries, compared with developed countries, demonstrated lower overall Total ME consumption., Conclusion: Generally, worldwide morphine use has not increased at the rate of Total ME, especially in recent years. Examining a country's ability to effectively manage moderate-to-severe pain should extend beyond morphine to account for all available potent opioids., (Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Purpose: In Japan, a national surveillance study of antimicrobial consumption has never been undertaken. This study aimed to describe antimicrobial consumption and resistance to Pseudomonas aeruginosa in 203 Japanese hospitals, to identify targets for quality improvement., Methods: We conducted an ecological study using retrospective data (2010). Antimicrobial consumption was collected in the World Health Organization (WHO) anatomical therapeutic chemical/defined daily dose (ATC/DDD) format. Rates of imipenem (IPM), meropenem (MEPM), ciprofloxacin (CPFX), or amikacin (AMK) resistance were expressed as the incidence of non-susceptible isolates. Additionally, hospitals were asked to provide data concerning hospital characteristics and infection control policies. Hospitals were classified according to functional categories of the Medical Services Act in Japan., Results: Data were collected from 203 Japanese hospitals (a total of 91,147 beds). The total antimicrobial consumption was 15.49 DDDs/100 bed-days (median), with consumptions for penicillins, carbapenems, quinolones, and glycopeptides being 4.27, 1.60, 0.41, and 0.49, respectively. The median incidences of IPM, MEPM, CPFX, and AMK resistance were 0.15, 0.10, 0.13, and 0.03 isolates per 1,000 patient-days, respectively. Antimicrobial notification and/or approval systems were present in 183 hospitals (90.1 %). In the multivariate analysis, the piperacillin/tazobactam, quinolones, and/or total consumptions and the advanced treatment hospitals showed a significant association with the incidence of P. aeruginosa resistant to IPM, MEPM, CPFX, and AMK [adjusted R (2) (aR (2)) values of 0.23, 0.30, 0.22, and 0.35, respectively)., Conclusion: This is the first national surveillance study of antimicrobial consumption in Japan. A continuous surveillance program in Japan is necessary in order to evaluate the association among resistance, antimicrobial restriction, and consumption.

Background: Polypharmacy in older people should be addressed by an annual review of the chronic medication. In the PIL-study this was done by an integrated approach by GP, practice nurse, pharmacist, specialist and patient. All patients were first visited at home by the practice nurse., Research Questions: What 'over the counter' (OTC) medications do polypharmacy patients use? Do they know the indications of the prescribed medication? Does medication use according to the patient match with medication use according to the records of GP and pharmacist?, Method: Inclusion criteria were: age 60 years or older, daily use of five or more chronic medications, mental competence, and adequate command of the Dutch language. All patients were visited at home by the practice nurse, who made an inventory of the actual drug use., Results: Five hundred fifty patients used a total of 5576 drugs, including 527 (9.4%) OTC medication. Patients knew the indication of 64% of the prescribed medication. The number of prescribed drugs that a patient actually used did not match the numbers known to GP and pharmacist. In 60.4% of all medication prescriptions there was complete agreement between GP, pharmacist and patient. On a patient level agreement was 18.7%., Conclusions: Home visits by the nurse practitioner to make an inventory of the medication as reported by the patient seem to have an added value.

Purpose: To evaluate the quality of data reporting and statistical methods performed in drug utilization studies in the pediatric population., Methods: Drug utilization studies evaluating all drug prescriptions to children and adolescents published between January 1994 and December 2011 were retrieved and analyzed. For each study, information on measures of exposure/consumption, the covariates considered, descriptive and inferential analyses, statistical tests, and methods of data reporting was extracted. An overall quality score was created for each study using a 12-item checklist that took into account the presence of outcome measures, covariates of measures, descriptive measures, statistical tests, and graphical representation., Results: A total of 22 studies were reviewed and analyzed. Of these, 20 studies reported at least one descriptive measure. The mean was the most commonly used measure (18 studies), but only five of these also reported the standard deviation. Statistical analyses were performed in 12 studies, with the chi-square test being the most commonly performed test. Graphs were presented in 14 papers. Sixteen papers reported the number of drug prescriptions and/or packages, and ten reported the prevalence of the drug prescription. The mean quality score was 8 (median 9). Only seven of the 22 studies received a score of ≥10, while four studies received a score of <6., Conclusions: Our findings document that only a few of the studies reviewed applied statistical methods and reported data in a satisfactory manner. We therefore conclude that the methodology of drug utilization studies needs to be improved.

Purpose: Medication overuse is a serious concern in healthcare as it leads to increased expenditures, side effects, and morbidities. Identifying overuse is only possible through excluding appropriate indications that are primarily mentioned in unstructured notes. We developed a framework for automatic identification of medication overuse and applied it to proton pump inhibitors (PPIs)., Methods: We first created an indications knowledge base using data from drug labels, clinical guidelines, expert opinion, and other sources. We also obtained the list of current problems for 200 randomly selected inpatients who received PPIs using a natural language processing system and the discharge summaries of those patients. These problems were checked against the indications knowledge base to identify overuse candidates. Two gastroenterologists manually reviewed the notes and identified cases of overuse. Results from the automated framework were compared with the manual review., Results: Reviewers had high interrater reliability in finding indications (agreement = 92.1%, Cohen's κ = 0.773). In 137 notes included in the final analysis, our system identified indications with a sensitivity of 74% (95%CI = 59-86) and specificity of 95% (95%CI = 87-98). In cases of appropriate use where the automated system also found one or more indications, it always included the correct indication., Conclusions: We created an automated system that can identify established indications of medication use in electronic health records with high accuracy. It can provide clinical decision support for identifying potential overuse of PPIs and could be useful for reducing overuse and encouraging better documentation of indications., (Copyright © 2012 John Wiley & Sons, Ltd.)

This study aimed to determine the clinical course of patients and the quality of antibiotic use using a systematic and unsolicited post-prescription antibiotic review. Seven hundred and fifty-three adult patients receiving antibiotic therapy for 3-5 days were randomized to receive either a post-prescription review by the infectious disease physician (IDP), followed by a recommendation to the attending physician to modify the prescription when appropriate, or no systematic review of the prescription. In the intervention group, 63.3% of prescriptions prompted IDP recommendations, which were mostly followed by ward physicians (90.3%). Early antibiotic modifications were more frequent in the intervention group (57.1% vs. 25.7%, p <0.0001), including stopping therapy, shortening duration and de-escalating broad-spectrum antibiotics. IDP intervention led to a significant reduction of the median [IQR] duration of antibiotic therapy (6 [4-9] vs. 7 days [5-9], p <0.0001). In-hospital mortality, ICU admission and new course of antibiotic therapy rates did not differ between the two groups. Fewer patients in the intervention group were readmitted for relapsing infection (3.4% vs. 7.9%, p 0.01). There was a trend for a shorter length of hospital stay in patients suffering from community-acquired infections in the intervention group (5 days [3-10] vs. 6 days [3-14], p 0.06). This study provides clinical evidence that a post-prescription antibiotic review followed by unsolicited IDP advice is effective in reducing antibiotic exposure of patients and increasing the quality of antibiotic use, and may reduce hospital stay and relapsing infection rates, with no adverse effects on other patient outcomes., (© 2012 The Authors Clinical Microbiology and Infection © 2012 European Society of Clinical Microbiology and Infectious Diseases.)

The study developed and tested collaboration models for home medication reviews (HMR) between community pharmacies and general practitioner (GP)s. Three pairs (each comprising one pharmacist and one GP) developed a collaboration agreement on the patient group, content and place for HMR, responsibilities, continuation etc. The collaboration models were evaluated by the pairs and by a project group. The models were very different - adjusted to the GP's and the pharmacist's individual wishes. The entering of collaboration agreements is a good platform for effective cooperation between the pharmacist and the GP and leads to successful HMRs. We recommend that others develop collaboration models too.

Background: Antibiotic surveillance is mandatory to optimise antibiotic therapy. Our objectives were to evaluate antibiotic use in our pediatric intensive care unit (PICU) and to implement a simple achievable intervention aimed at improving antibiotic therapy., Method: Prospective, 3 months surveillance of antibiotic use on PICU (phase I) and evaluation according to the CDC 12-step campaign with development of an attainable intervention. 3 months surveillance (phase II) after implementation of intervention with comparison of antibiotic use., Results: Appropriate antibiotic use for culture-negative infection-like symptoms and targeted therapy for proven infections were the main areas for potential improvement. The intervention was a mandatory checklist requiring indication and recording likelihood of infection at start of antibiotic therapy and a review of the continuing need for therapy at 48 h and 5 days, reasons for continuation and possible target pathogen. The percentage of appropriate empiric antibiotic therapy courses for culture-negative infection-like symptoms increased from 18% (10/53) to 74% (42/57; p<0.0001), duration of therapy <3 days increased from 18% (10/53) to 35% (20/57; p=0.05) and correct targeting of pathogen increased from 58% (7/12) to 83% (20/24; p=0.21)., Conclusions: Antibiotic surveillance using the CDC 12-step campaign can help to evaluate institutional antibiotic therapy. Development of an attainable intervention using a checklist can show improved antibiotic use with minimal expense.

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 hospitalized in three internal medicine wards in a university hospital, between 1 January 2006 and 31 May 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 and Discussion: 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 with 1416 (51.3%) control patients. In total, 716 intervention (58.9%) and 1688 (61.2%) control patients experienced any event (ED visit, hospitalization 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, re-hospitalizations or mortality over 6-month follow-up., (© 2012 Blackwell Publishing Ltd.)

What Is Known and Objective: To determine to what extent patient interviews contribute to the identification of drug-related problems (DRPs) in home medication reviews, in terms of number, type and clinical relevance., Methods: We performed a cross-sectional study within the intervention arm of a randomized controlled trial. Patients were recruited from 10 Dutch community pharmacies. Patients were eligible if they were home-dwelling, aged 65 years and over and used five or more different drugs, including at least one cardiovascular or antidiabetic drug. The community pharmacist interviewed the patient at home about the medicines and identified potential DRPs in combination with medication and clinical records. This medication review was assessed and modified by an independent pharmacist reviewers' panel. Outcomes were the number and type of DRPs and recommendations and percentage of clinical relevant DRPs. Clinical relevance of DRPs was assessed by DRPs assigned a high priority, DRPs followed by recommendations for drug change and DRPs followed by implemented recommendations for drug change., Results: A total of 1565 potential DRPs and recommendations (10 per patient).were identified for 155 patients (median age, 76 years; 54% women). Fifty-eight per cent of all recommendations involved a drug change; 27% of all DRPs were identified during patient interviews and 74% from medication and clinical records. Compared to DRPs identified from patient medication and clinical records, DRPs identified during patient interviews were more frequently assigned a high priority (OR = 1.8 [1.4-2.2]), were more frequently associated with recommendations for drug change (OR = 2.4 [1.9-3.1]) and were implemented recommendations for drug change (OR = 2.8 [2.1-3.7])., What Is New and Conclusion: This study shows that more than a quarter of all DRPs were identified during patient interviews. DRPs identified during patient interviews were more frequently assigned a higher clinical relevance., (© 2012 Blackwell Publishing Ltd.)

A standardised methodology for a combined point prevalence survey (PPS) on healthcare-associated infections (HAIs) and antimicrobial use in European acute care hospitals developed by the European Centre for Disease Prevention and Control was piloted across Europe. Variables were collected at national, hospital and patient level in 66 hospitals from 23 countries. A patient-based and a unit-based protocol were available. Feasibility was assessed via national and hospital questionnaires. Of 19,888 surveyed patients, 7.1% had an HAI and 34.6% were receiving at least one antimicrobial agent. Prevalence results were highest in intensive care units, with 28.1% patients with HAI, and 61.4% patients with antimicrobial use. Pneumonia and other lower respiratory tract infections (2.0% of patients; 95% confidence interval (CI): 1.8–2.2%) represented the most common type (25.7%) of HAI. Surgical prophylaxis was the indication for 17.3% of used antimicrobials and exceeded one day in 60.7% of cases. Risk factors in the patient-based protocol were provided for 98% or more of the included patients and all were independently associated with both presence of HAI and receiving an antimicrobial agent. The patient-based protocol required more work than the unit-based protocol, but allowed collecting detailed data and analysis of risk factors for HAI and antimicrobial use.

Introduction: Increasing antimicrobial costs, reduced development of novel antimicrobials, and growing antimicrobial resistance necessitate judicious use of available agents. Antimicrobial stewardship programs (ASPs) may improve antimicrobial use in intensive care units (ICUs). Our objective was to determine whether the introduction of an ASP in an ICU altered the decision to treat cultures from sterile sites compared with nonsterile sites (which may represent colonization or contamination). We also sought to determine whether ASP education improved documentation of antimicrobial use, including an explicit statement of antimicrobial regimen, indication, duration, and de-escalation., Methods: We retrospectively analyzed consecutive patients with positive bacterial cultures admitted to a 16-bed medical-surgical ICU over 2-month periods before and after ASP introduction (April through May 2008 and 2009, respectively). We evaluated the antimicrobial treatment of positive sterile- versus nonsterile-site cultures, specified a priori. We reviewed patient charts for clinician documentation of three specific details regarding antimicrobials: an explicit statement of antimicrobial regimen/indication, duration, and de-escalation. We also analyzed cost and defined daily doses (DDDs) (a World Health Organization (WHO) standardized metric of use) before and after ASP., Results: Patient demographic data between the pre-ASP (n = 139) and post-ASP (n = 130) periods were similar. No difference was found in the percentage of positive cultures from sterile sites between the pre-ASP period and post-ASP period (44.9% versus 40.2%; P = 0.401). A significant increase was noted in the treatment of sterile-site cultures after ASP (64% versus 83%; P = 0.01) and a reduction in the treatment of nonsterile-site cultures (71% versus 46%; P = 0.0002). These differences were statistically significant when treatment decisions were analyzed both at an individual patient level and at an individual culture level. Increased explicit antimicrobial regimen documentation was observed after ASP (26% versus 71%; P < 0.0001). Also observed were increases in formally documented stop dates (53% versus 71%; P < 0.0001), regimen de-escalation (15% versus 23%; P = 0.026), and an overall reduction in cost and mean DDDs after ASP implementation., Conclusions: Introduction of an ASP in the ICU was associated with improved microbiologically targeted therapy based on sterile or nonsterile cultures and improved documentation of antimicrobial use in the medical record.

Recent years have seen a formalization of medication review by pharmacists in all settings of care. This article describes the different types of medication review provided in primary care in the UK National Health Service (NHS), summarizes the evidence of effectiveness and considers how such reviews might develop in the future. Medication review is, at heart, a diagnostic intervention which aims to identify problems for action by the prescriber, the clinician conducting the review, the patient or all three but can also be regarded as an educational intervention to support patient knowledge and adherence. There is good evidence that medication review improves process outcomes of prescribing including reduced polypharmacy, use of more appropriate medicines formulation and more appropriate choice of medicine. When 'harder' outcome measures have been included, such as hospitalizations or mortality in elderly patients, available evidence indicates that whilst interventions could improve knowledge and adherence they did not reduce mortality or hospital admissions with one study showing an increase in hospital admissions. Robust health economic studies of medication reviews remain rare. However a review of cost-effectiveness analyses of medication reviews found no studies in which the cost of the intervention was greater than the benefit. The value of medication reviews is now generally accepted despite lack of robust research evidence consistently demonstrating cost or clinical effectiveness compared with traditional care. Medication reviews can be more effectively deployed in the future by targeting, multi-professional involvement and paying greater attention to medicines which could be safely stopped., (© 2012 The Authors. British Journal of Clinical Pharmacology © 2012 The British Pharmacological Society.)

Objective: There is a lack of knowledge regarding recipients' experiences with, perceptions of, and willingness to reuse the Home Medicines Review (HMR) programme in Australia. In addition, little is known about eligible non-recipients' awareness of and willingness to use the HMR service. The aim of the study was therefore to explore perceptions of, and willingness to use, HMRs., Methods: A cross-sectional questionnaire was conducted with recipients and eligible non-recipients of HMRs. Eligible non-recipients were defined as those who had not had an HMR and were at risk of medication misadventure. The questionnaire was distributed by 264 practising pharmacists throughout Australia., Results: A total of 595 out of 1893 (31%) HMR recipients and 293 out of 1829 (16%) eligible non-recipients completed the questionnaires. Overall, 91% of recipients were satisfied with the service. Compared with eligible non-recipients, recipients were more willing to have an HMR if their general practitioner (GP) suggested it (91% versus 71%, P < 0.001) and more willing to ask for an HMR if they were having concerns about their medicines (82% versus 63%, P < 0.001). Among eligible non-recipients, 23% were aware of HMRs. Predominantly pharmacists (68%) and GPs (36%) provided awareness of HMRs, which was associated with increased willingness to have an HMR if their GP suggested it (83% versus 67%, P < 0.014)., Conclusions: An overwhelming majority of patients were satisfied with the HMR programme. Experience with HMR, and to a lesser extent, prior awareness, increased willingness to use HMR. Therefore, pharmacists and GPs who introduce HMR to eligible non-recipients may increase their willingness to use this service., (© 2011 The Authors. IJPP © 2011 Royal Pharmaceutical Society.)

Background: Polypharmacy has been shown to influence outcomes in elderly patients. However, the impact of medication regimen complexity, quantified by the Medication Regimen Complexity Index (MRCI), on health outcomes after discharge of elderly patients has not been studied., Objective: Our aim was to test the convergent, discriminant, and predictive validity of the MRCI in older hospitalized patients with varying functional and cognitive levels., Methods: We retrospectively applied the MRCI to the medication regimen of 212 hospitalized patients and assessed its validity., Results: The mean (SD) MRCI scores for medication regimens and number of medications at discharge were 30.27 (13.95) and 5.95 (2.40), respectively. The MRCI scores were strongly correlated with the number of medications (r=0.94, P<0.001) and the number of daily doses (r=0.87, P<0.001) and increased as the number of medications taken ≥3 times daily increased (27.35, 34.45, and 43.00 for none, 1, and 2 drugs, respectively; P<0.001). Positive correlations were observed between the Cumulative Illness Rating Scale-Geriatrics score and both the number of medications and the MRCI score (r=0.40, r=0.46, P<0.001, respectively). No relationship was found between MRCI scores and the number of medications and age, sex, and postdischarge medication modifications. Patients nonadherent to at least 1 drug were discharged with a higher MRCI score and higher number of medications compared with medication-compliant patients (33.3 and 7.0 vs 27 and 5.8, respectively; P<0.01). An inverse correlation was found between overall adherence 1 month after discharge and the MRCI score (r=-0.188, P= 0.028); however, no such correlation was found regarding the number of medications at discharge., Conclusions: The MRCI showed satisfactory validity and good evidence of classifying regimen complexity over a simple medication count. The MRCI demonstrated application in clinical research and practice in the elderly. However, more studies are needed to investigate its advantage over the number of medications for identifying patients with complex medication regimens and directing interventions to simplify their medication regimen complexity., (Copyright © 2012 Elsevier HS Journals, Inc. All rights reserved.)