An evaluation of medication review reports across different settings

Background There is a growing body of evidence which supports that a pharmacist conducted medication review increases the health outcomes for patients. A pharmacist integrated into a primary care medical centre may offer many potential advantages in conducting medication reviews in this setting however research describing this is presently limited. Objective To compare medication review reports conducted by pharmacists practicing externally to a medical centre to those medication review reports conducted by an integrated practice pharmacist. The secondary objective was to compare medication review reports conducted by pharmacists in the patient’s home to those conducted in the medical centre. Setting A primary care medical centre, Brisbane, Australia Method A retrospective analysis of pharmacist conducted medication reviews prior to and after the integration of a pharmacist into a medical centre. Main outcome measures Types of drug related problems identified by the Pharma cists, recommended intervention for drug related problems made by the pharmacist, and the extent of implementation of pharmacist recommendations by the general practitioner. Results The primary drug related problem reported in the practice pharmacist phase was Additional therapy required as compared to Precautions in the external pharmacist phase. The practice pharmacist most frequently recommended to add drug with Additional monitoring recommended most often in the external pharmacists. During the practice pharmacist phase 71 % of recommendations were implemented and was significantly higher than the external pharmacist phase with 53 % of recommendations implemented (p\0.0001). Two of the 23 drug related problem domains differed significantly when comparing medication reviews conducted in the patient’s home to those conducted in the medical centre.

Translational approaches to medication development

Alcohol accounts for major disability worldwide and available treatments are insufficient. A massive growth in the area of addiction neuroscience over the last several decades has not resulted in a corresponding expansion of treatment options available to patients. In this chapter, we describe our experience with building translational research programs aimed at developing novel pharmacotherapies for alcoholism. The narrative is based on experience and considerations made in the course of building these programs, and work on four mechanisms targeted by our libraries: cholinergic nicotine receptors, receptors for corticotropin-releasing hormone (CRH), neurokinin 1 (NK1) receptors for substance P (SP) and hypocretin/orexin receptors. Around this experience, we discuss issues we believe to be critical for successful translation of basic addiction neuroscience into treatments, and complementarities between academic and other actors that in our assessment need to be harnessed in order to bring treatments to the clinic.

Crushed tablets : does the administration of food vehicles and thickened fluids to aid medication swallowing alter drug release?

Purpose. To evaluate the influence of co-administered vehicles on in vitro dissolution in simulated gastric fluid of crushed immediate release tablets as an indicator for potential drug bioavailability compromise. Methods. Release and dissolution of crushed amlodipine, atenolol, carbamazepine and warfarin tablets were tested with six foods and drinks that are frequently used in the clinical setting as mixers for crushed medications (water, orange juice, honey, yoghurt, strawberry jam and water thickened with Easythick powder) in comparison to whole tablets. Five commercial thickening agents (Easythick Advanced, Janbak F, Karicare, Nutilis, Viscaid) at three thickness levels were tested for their effect on the dissolution of crushed atenolol tablets. Results. Atenolol dissolution was unaffected by mixing crushed tablets with thin fluids or food mixers in comparison to whole tablets or crushed tablets in water, but amlodipine was delayed by mixing with jam. Mixing crushed warfarin and carbamazepine tablets with honey, jam or yoghurt caused them to resemble the slow dissolution of whole tablets rather than the faster dissolution of crushed tablets in water or orange juice. Crushing and mixing any of the four medications with thickened water caused a significant delay in dissolution. When tested with atenolol, all types of thickening agents at the greatest thickness significantly restricted dissolution, and products that are primarily based on xanthan gum also delayed dissolution at the intermediate thickness level. Conclusions. Dissolution testing, while simplistic, is a widely used and accepted method for comparing drug release from different formulations as an indicator for in vivo bioavailability. Thickened fluids have the potential to retard drug dissolution when used at the thickest levels. These findings highlight potential clinical implications of the addition of these agents to medications for the purpose of dose delivery and indicate that further investigation of thickened fluids and their potential to influence therapeutic outcomes is warranted.

Tensions between policy and practice : reconciliation agendas in the Australian curriculum English

In various parts of the world, Indigenous and non-Indigenous peoples are actively working towards Reconciliation. In Australia, the context in which we each undertake our work as educationalists and researchers, the Reconciliation agenda has been pushed into schools and English teachers have been called on to share responsibility for facilitating the move towards a new national order. The recently introduced Australian Curriculum mandates that Aboriginal and Torres Strait Islander Histories and Cultures be embedded with “a strong” but “varying presence” into each learning area (Australian Curriculum, Assessment and Reporting Authority, 2013). In this paper we consider the tensions between policy and practice, when discourses external to education are recontextualised into the discipline of English. We do so by applying an analytical framework based on Bernstein’s (1990, 1996,2000) sociological theories about the structure of instructional and regulative discourses. Our findings suggest that the space to exert Reconciliatory agendas in the Australian Curriculum English is ambiguous and thus holds the potential to not only marginalise Indigenous knowledges but also to create tensions between policy and practice for non-Indigenous teachers of English.

Impact of community pharmacist intervention discussing patients’ beliefs to improve medication adherence

Background Adherence to evidence based medicines in patients who have experienced a myocardial infarction remains low. Individual’s beliefs towards their medicines are a strong predictor of adherence and may influence other factors that impact on adherence. Objective To investigate if community pharmacists discussing patients’ beliefs about their medicines improved medication adherence at 12 months post myocardial infarction. Setting This study included 200 patients discharged from a public teaching hospital in Queensland, Australia, following a myocardial infarction. Patients were randomised into intervention (n = 100) and control groups (n = 100) and followed for 12 months. Method All patients were interviewed between 5 to 6 weeks, at 6 and 12 months post discharge by the researcher using the repertory grid technique. This technique was used to elicit the patient’s individualised beliefs about their medicines for their myocardial infarction. In the intervention group, patients’ beliefs about their medicines were communicated by the researcher to their community pharmacist. The pharmacist used this information to tailor their discussion with the patient about their medication beliefs at designated time points (3 and 6 months post discharge). The control group was provided with usual care. Main outcome measure The difference in non-adherence measured using a medication possession ratio between the intervention and control groups at 12 months post myocardial infarction. Results There were 137 patients remaining in the study (intervention group n = 72, control group n = 65) at 12 months. In the intervention group 29 % (n = 20) of patients were non-adherent compared to 25 % (n = 16) of patients in control group. Conclusion Discussing patients’ beliefs about their medicines for their myocardial infarction did not improve medication adherence. Further research on patients beliefs should focus on targeting non-adherent patients whose reasons for their non-adherence is driven by their medication beliefs.

Pharmaceutical company influences on medication prescribing and their potential impact on quality use of medicines

Background Pharmaceuticals are big business, reporting strong market growth year after year. The ‘gatekeepers’ of this market are prescribers of medicines, who are the major target of pharmaceutical companies, utilizing direct and indirect influences. Methods This paper draws on previous research investigating pharmaceutical company prescribing influences to develop a qualitative model demonstrating the synergism between commercial influences on prescribing. The generic model was used to explore a realistic but hypothetical scenario to ascertain the applicability of the model. Results and Discussion A generic influence model was developed. The model was readily able to be adapted to reflect a realistic practice scenario. Conclusion Prescriber awareness of the linkages between various seemingly separate marketing techniques could potentially improve medicines usage in an evidence-based practice paradigm.

Supporting family caregivers with palliative symptom management: A qualitative analysis of the provision of an emergency medication kit in the home setting

Purpose The purpose of this qualitative analysis was to examine the experiences of family caregivers supporting a dying person in the home setting. In particular, it explores caregivers’ perceptions of receiving palliative care at home when supplied with an emergency medication kit (EMK). Results Most family caregivers described preexisting medication management strategies that were unable to provide timely intervention in symptoms. The EMK was largely viewed as an effective strategy in providing timely symptom control and preventing readmission to inpatient care. Caregivers reported varying levels of confidence in the administration of medication. Conclusion The provision of an EMK is an effective strategy for improving symptom control and preventing inpatient admissions of home-dwelling palliative care patients.

The use of emergency medication kits in community palliative care: An exploratory survey of views of current practice in Australian home-based palliative care services

Improving symptom management for palliative care patients has obvious benefits for patients and advantages for the clinicians, as workload demands and work-related stress can be reduced when the emergent symptoms of patients are managed in a timely manner. The use of emergency medication kits (EMKs) can provide such timely symptom relief. The purpose of this study was to conduct a survey of a local service to examine views on medication management before and after the implementation of an EMK and to conduct a nationwide prevalence survey examining the use of EMKs in Australia. Most respondents from community palliative care services indicated that EMKs were not being supplied to palliative care patients but believed such an intervention could improve patient care.

Reconciliation and Early Childhood Education for Sustainability : Broadening the Environmental Paradigm

The uptake of sustainability initiatives in early childhood education curricula continues to gain momentum in Australia and internationally. Growing awareness about the fragility of natural environments in local and global contexts, along with prioritising sustainability in educational policy, has resulted in more broad-scale responses to sustainability in early years settings. To address issues of sustainability, many childcare centres and schools focus on environmental initiatives such as garden projects, recycling and water conservation. While important, such initiatives respond to just one dimension of sustainability. With expanding focus on sustainability initiatives in early childhood education, it is timely to consider why the environmental dimension receives the most attention and what this means for social, political and economic areas of concern.

Wheeze, asthma diagnosis and medication use : a national adult survey in a developing country

Background As relatively little is known about adult wheeze and asthma in developing countries, this study aimed to determine the predictors of wheeze, asthma diagnosis, and current treatment in a national survey of South African adults. Methods A stratified national probability sample of households was drawn and all adults (>14 years) in the selected households were interviewed. Outcomes of interest were recent wheeze, asthma diagnosis, and current use of asthma medication. Predictors of interest were sex, age, household asset index, education, racial group, urban residence, medical insurance, domestic exposure to smoky fuels, occupational exposure, smoking, body mass index, and past tuberculosis. Results A total of 5671 men and 8155 women were studied. Although recent wheeze was reported by 14.4% of men and 17.6% of women and asthma diagnosis by 3.7% of men and 3.8% of women, women were less likely than men to be on current treatment (OR 0.6; 95% confidence interval (CI) 0.5 to 0.8). A history of tuberculosis was an independent predictor of both recent wheeze (OR 3.4; 95% CI 2.5 to 4.7) and asthma diagnosis (OR 2.2; 95% CI 1.5 to 3.2), as was occupational exposure (wheeze: OR 1.8; 95% CI 1.5 to 2.0; asthma diagnosis: OR 1.9; 95% CI 1.4 to 2.4). Smoking was associated with wheeze but not asthma diagnosis. Obesity showed an association with wheeze only in younger women. Both wheeze and asthma diagnosis were more prevalent in those with less education but had no association with the asset index. Independently, having medical insurance was associated with a higher prevalence of diagnosis. Conclusions Some of the findings may be to due to reporting bias and heterogeneity of the categories wheeze and asthma diagnosis, which may overlap with post tuberculous airways obstruction and chronic obstructive pulmonary disease due to smoking and occupational exposures. The results underline the importance of controlling tuberculosis and occupational exposures as well as smoking in reducing chronic respiratory morbidity. Validation of the asthma questionnaire in this setting and research into the pathophysiology of post tuberculous airways obstruction are also needed.

Medication Management of Adult Patients Admitted to Hospital with Epilepsy, Seizure or Convulsion

Background: An inpatient medication chart review at the Gold Coast Hospital identified shortcomings with the prescribing and monitoring of antiepileptic medications. Aim: To evaluate medication management of patients with epilepsy, seizure or convulsion; to map their transition through the health system; and to identify lifestyle behaviours that may lead to overt risks for seizure occurrence. Method: A retrospective observational audit of adult patients (16 years and over) admitted to hospital with a diagnosis of epilepsy, seizure or convulsion from 1 to 31 January 2012. Results: Majority of the 62 episodes of care investigated involved patients who were discharged directly from the ED (68%). Only 30% of all patients discharged from an inpatient unit received a discharge medication record from a pharmacist. Non-adherence with antiepileptic medications, alcohol and/ or recreational drug use and prescription medication misuse were identified as overt risks for seizure occurrence. Conclusion: Valuable insights were gained into the management of seizure patients. The role of the ED pharmacist was reviewed to focus on high-risk seizure patients. An increase in the provision of discharge medication records and patient education on the overt risks for seizure occurrence is needed.

Prevalence of swallowing difficulties and medication modification in customers of community pharmacists

Background People may alter their solid oral medication dosage forms to make it easier to swallow. However, modification of solid medication dosage forms can lead to adverse effects, and people may alter the dosage forms without informing the health professionals involved in their care. Aim To estimate the prevalence of swallowing difficulties and medication dosage form modification among community pharmacy consumers, and to investigate consumer views, attitudes and interactions with health professionals regarding such issues. Method Consumers were recruited from five community pharmacies in Brisbane, Australia and invited to participate in a structured interview. Results A total of 369 consumers participated in the study. Overall, 16.5% of people reported experiencing swallowing difficulties, and 10.6% of all respondents reported modifying medication dosage forms. Almost half (44.2%) of those surveyed did not think there would be issues with modifying medication dosage forms. Some consumers would not seek advice from health professionals if they experienced swallowing problems and/or would not seek advice from health professionals before modifying their medication dosage forms, regardless of their thoughts about any problems associated with this practice. Conclusion Some consumers appeared to be accustomed to modifying medication dosage forms, even when there was no apparent or obvious need. People were also reluctant to seek advice from health professionals regarding swallowing difficulties, or modifying medication dosage forms. Health professionals must be assertive in educating consumers about swallowing problems, and medication dosage form modification.