Improve patient safety and clinical outcomes Optimise medication therapy Provide patient care

Transcription

1 Hospital Pharmacy Department of Stem Cell Transplantation 46th ESCP Symposium on Clinical Pharmacy Nr. 2 Improve patient safety and clinical outcomes Optimise medication therapy Provide patient care 1

2 Nr. 3 Clinical Pharmacist core competencies (ACCP 2017) Direct patient care Pharmacotherapy knowledge System-based care and population health Communication Professionalism Continuing professional development Saseem et al., Pharmacotherapy 2017 Nr. 4 Clinical Pharmacist core competencies (ACCP 2017) Direct patient care Assess patients (patient problems, medication-related needs) Evaluate drug therapy for appropriateness, effectiveness, safety, adherence, and afforability Develop/initiate therapeutic plans and address medication-related problems Pharmacotherapy knowledge System-based care and population health Communication Professionalism Continuing professional development Saseem et al., Pharmacotherapy

3 Nr. 5 Clinical Pharmacist core competencies (ACCP 2017) Direct patient care Pharmacotherapy knowledge Demonstrate and apply in-depth knowledge of pharmacology, pharmacotherapy, pathophysiology, and the clinical signs, symptoms, and natural history of diseases and/or disorders Locate, evaluate, interpret and assimilate scientific/clinical evidence and other relevant information from the biomedical, clinical, epidemiological and social-behvioural literature Use scientific/clinical evidence as the basis for therapeutic decision-making System-based care and population health Communication Professionalism Continuing professional development Saseem et al., Pharmacotherapy 2017 Nr. 6 Clinical Pharmacist core competencies (ACCP 2017) Direct patient care Pharmacotherapy knowledge System-based care and population health Use health care delivery systems and and health care informatics to optimise the care of individual patients and patient populations Resolve medication-related problems to improve patient/population health and quality metrics Participate in developing processes to improve transition of care Communication Professionalism Continuing professional development Saseem et al., Pharmacotherapy

4 Nr. 7 ACCP Clinical Pharmacist Competencies Ensure, that clinical pharmacists posess the knowledge skills, attitudes, and behaviours necessary to deliver comprehensive medication management Saseem et al., Pharmacotherapy 2017 Nr. 8 Information overload? 4

5 Nr. 9 Medical and pharmaceutical knowledge Data source: Nr. 10 Appropriate prescribing and medication management 5

6 Nr. 11 The challenge of appropriate prescribing and medication management Drug approval - Effectiveness - Safety - Harmlessnes Guidelines Patient Nr. 12 The challenge of appropriate prescribing and medication management Drug approval - Effectiveness - Safety - Harmlessnes Guidelines - Development methodology - Level of recommendation - consistency Patient 6

7 Nr. 13 Guideline inconsistencies Nr. 14 Guideline inconsistencies Example: hypertension management in diabetes First line treatment in the presence of chronic kidney disease: ACEI or ARB (consistency Association among guidelines) Year RR target American Diabetes Association (ADA) /90 Joint National Committee 8 (JNC8) /90 American Society of Hypertension / International Society of Hypertension (ACC/AHA) /90 European Society of Cardiology (ESC) /90 Canadian Guideline /80 American Association of Clinical Endocrinologists and American College of Endocrinology (AACE) /80 National Institute of Health and Care Excellence (NICE) 2014 < 140/80 Ganda et al., Curr Cardiol Rep

8 Nr. 15 The challenge of appropriate prescribing and medication management Drug approval - Effectiveness - Safety - Harmlessnes Guidelines - Development methodology - Level of recommendation - consistency Patient - preferences - Comorbidities, allergies, life-style - multimorbidity Nr. 16 What about multimorbidity? Process of medication 1. Anamnesis drug history morbidities/complaints Adherence 2. Structured assessment of mediation MAI (including undersupply!) 3. Coordination with the patient 4. Proposal of medication 5. Communication dispensing application - monitoring 8

9 Nr. 17 Explicit tools How developed? Explicit (criterion-bsed) Literature reviews, expert opinions, consensus techniques Implicit (judgment-based) Rely on expert professional judgment Contents Drug/disease specific lists of drugs and dosages known to cause harmful effects Pro - Applicable with little/no clinical judgement - Low cost Con Implcit - Comorbidities, (judgement-based) patient preferences - - Rely not addressed on expert professional judgment Regular updates needed -- Focus Country-specific on the patient, adaption address needed entire Examples medication regimen Beers, Priscus, START-STOPP, FORTA, Pregnancy risk categories (e.g. FDA) Questions to assess - Focus on the patient - Address entire medication regimen - Time comsuming - Low reliability MAI, Cipolle-Strand (DRP), Naranjo scale (ADR), DIPS Nr. 18 Example for an explicit tool: EU(7)PIM Renom-Guiteras et al., EurJClinPharmacol

10 Nr. 19 Overlap of different PIM classification systems 200 patients (admission via emergency department) 3 explicit tools to evaluate PIM FORTA PRISCUS STOPP Wickop et al., Drugs real world outcomes, 2016 Nr. 20 Overlap of different PIM classification systems Wickop et al., Drugs real world outcomes,

11 Nr. 21 GERAS The UKE-PIM-Tool illustrated on just one page more a guidance for clinical situations than a list of single substances % Percentage of patients with zopiclone 7.5 mg during hospital stay Before GERAS After GERAS Wickop et al., Drugs real world outcomes, 2016 Nr. 22 Anticholinergic burden scales 11

12 Nr. 23 Explicit and implicit tools How developed? Explicit (criterion-bsed) Literature reviews, expert opinions, consensus techniques Implicit (judgment-based) Rely on expert professional judgment Contents Drug/disease specific lists of drugs and dosages known to cause harmful effects Pro - Applicable with little/no clinical judgement - Low cost Con Implcit - Comorbidities, (judgement-based) patient preferences - - Rely not addressed on expert professional judgment Regular updates needed -- Focus Country-specific on the patient, adaption address needed entire Examples medication regimen Beers, Priscus, START-STOPP, FORTA, Pregnancy risk categories (e.g. FDA) Questions to assess - Focus on the patient - Address entire medication regimen - Time comsuming - Low reliability MAI, Cipolle-Strand (DRP), Naranjo scale (ADR), DIPS Nr. 24 Example for an implicit tool: DIPS Horn et al., AnnPharmacother

13 Nr. 25 Electronic support Nr. 26 Computerised physician order entry (CPOE) Expanding the use of electronic prescribing by doctors and nurses in hospitals will help the NHS saves lives and save money. Professor Sir Bruce Keogh, Medical Director of NHS England, May 2013 Successful if Integrated in the clinical workflow Decision support at the time and place of decision making Automatic output of a clear guidance Use of computer technology 50% reduction of prescribing errors* *Tully BrJClinPm 2012, Gillaizeau Cochrane Database Syst Rev 2013, Radley JAMIA 2013, Westbrook PLoS Med 2012, Reckmann JAMIA

14 Nr. 27 Digital revolution Nr. 28 CPOE/CDSS in European hospitals EAHP survey report 2015/16 ( 14

15 Nr. 29 UKE Hamburg: Closed loop medication administration (CLMA) Electronic prescribing on the ward (physician) Documentation of application (nurses) Unit Dose production in the hospital pharmacy Validation of prescriptions by clinical pharmacists Nr. 30 Drug information in the CPOE/CDSS 15

16 Nr. 31 Drug information in the CPOE/CDSS: pharmacovigilance Nr. 32 Drug information in the CPOE/CDSS: drug interactions CAVE: Overalert vs. underreporting Differences in drug interaction databases (pharmacist s) judgement is important for clinical relevance in individual patients 16

17 Nr. 33 Drug-drug interaction databases: are they helpful? Prospective cohort study Three drug-drug interaction databases Lexicomp Online Drug Interaction Checker (Drugs.com) Complete Drug Interaction (Micromedex) Clinically relevant DDI-related ADR were identified by 3 members of the multidisciplinary team using DIPS 20,447 drug pair combinations 50 severe, clinically relevant DDI detected Muhic et al, EurJClinPharmacol, 2017 Nr. 34 Drug-drug interaction databases: are they helpful? Muhic et al, EurJClinPharmacol,

18 Nr. 35 Clinical decision support systems (CDSS) Includes drug data (e.g. SPC) Dose check, interaction check, double-prescription check Regulatory information on pharmacovigilance ( Rote-Hand-Brief ) Aut-idem or aut-simile switch (to hospital formulary and back) Crushing; feeding-tubes; incompatibilities Implemented into the electronic patient record Age, gender Lab data (kidney, liver, etc.) Morbidities, allergies Clinical pathways (?) Usually, several explicit tools are included for decision making Nr. 36 Levels of medication review Geurts et al. BrJClinPharm

19 Nr. 37 Clinical pharmacists interventions (PI) with CPOE/CDSS Daily individual monitoring of prescriptions 3809 PI during 854 ward visits 4.5 PI per ward and day Acceptance rate: 93 % Important contribution to Medication safety Economic efficiency Quality gain Langebrake et al, KHP 2013 Nr. 38 And without CDSS? Paper-based Publications of explicit and implicit tools Guidelines Web-based Guidelines (AWMF (German), Medical and pharmaceutical associations) Drug information (Specialist pharmacy service, NHS; AM-Info-Datenbank) Trip Database Dosing.de, thecaddy.de, Apps (FORTA, UpToDate, ) 19

20 Nr. 39 Apps Nr. 40 Are tools useful? helpful as a supporting instrument for clinical pharmacy not advisable to use them as a substitute for professional decision making 20

21 Nr. 41 Hospital Pharmacy Department of Stem Cell Transplantation Martinistraße 52 D Hamburg PD Dr. Fachapothekerin für Klinische Pharmazie Phone: +49 (0)