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Sjölander, M., Lindholm, L., Pfister, B., Jonsson, J., Schneede, J., Lövheim, H. & Gustafsson, M. (2019). Impact of clinical pharmacist engagement in ward teams on the number of drug-related readmissions among Swedish older patients with dementia or cognitive impairment: an economic evaluation. Research in Social and Administrative Pharmacy, 5(3), 287-291
Open this publication in new window or tab >>Impact of clinical pharmacist engagement in ward teams on the number of drug-related readmissions among Swedish older patients with dementia or cognitive impairment: an economic evaluation
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2019 (English)In: Research in Social and Administrative Pharmacy, ISSN 1551-7411, E-ISSN 1934-8150, Vol. 5, no 3, p. 287-291Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Clinical pharmacists play an increasing role in the pharmacological treatment of hospital-admitted older patients with dementia or cognitive impairment. In an earlier randomised controlled trial, clinical pharmacist involvement in the ward team could significantly reduce drug-related readmissions in patient subgroups. However, the economic impact of the intervention has not been addressed so far.

OBJECTIVES: To evaluate the economic impact of clinical pharmacist engagement in hospital ward teams for medication therapy management in older patients with dementia or cognitive impairments.

METHODS: Economic evaluation of a randomised controlled trial conducted in two hospitals in Northern Sweden between January 2012 and December 2014. Participants included 460 hospital-admitted older patients with dementia or cognitive impairments. Patients were randomly assigned to usual care, or usual care with pharmacist intervention; the intervention consisted of medication reconciliation, medication review, and participation in ward rounds. The outcomes were measured as drug-related readmissions to hospital as assessed by a group of external experts, 180 and 30 days after discharge. Costs included pharmacists' direct labour costs for the interventions, average costs for drug-related readmissions, and from this the total cost per person was calculated.

RESULTS: The effect of the intervention on drug-related readmissions within 180 days was significant in patients without heart failure (subgroup analysis), and the intervention resulted in cost savings of €950 per person in this subgroup. Drug-related readmissions within 30 days were reduced in the total sample (post-hoc analysis), and the cost-savings in this intervention group were €460 per person.

CONCLUSIONS: Post-hoc and subgroup analyses indicate that engagement of pharmacists in hospital ward teams reduced the number of drug-related readmissions, and that the cost per person was lower in the intervention group compared to the control group. Including clinical pharmacists created savings in the subgroups of older patients with dementia or cognitive impairments.

Place, publisher, year, edition, pages
Elsevier, 2019
Keywords
Clinical pharmacy service, Dementia, Economic evaluation, Hospital readmissions, Randomised controlled trial
National Category
Social and Clinical Pharmacy Geriatrics Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-150414 (URN)10.1016/j.sapharm.2018.05.006 (DOI)000460091900007 ()29778344 (PubMedID)
Funder
Västerbotten County Council
Available from: 2018-08-07 Created: 2018-08-07 Last updated: 2019-03-27Bibliographically approved
Sönnerstam, E., Sjölander, M., Lövheim, H. & Gustafsson, M. (2019). Letter to the Editor: Clinically relevant drug-drug interactions among elderly people with dementia [Letter to the editor]. European Journal of Clinical Pharmacology, 75(9), 1321-1322
Open this publication in new window or tab >>Letter to the Editor: Clinically relevant drug-drug interactions among elderly people with dementia
2019 (English)In: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041, Vol. 75, no 9, p. 1321-1322Article in journal, Letter (Refereed) Published
Place, publisher, year, edition, pages
SPRINGER HEIDELBERG, 2019
National Category
Pharmacology and Toxicology
Identifiers
urn:nbn:se:umu:diva-163196 (URN)10.1007/s00228-019-02680-7 (DOI)000481779100015 ()31309242 (PubMedID)
Available from: 2019-10-21 Created: 2019-10-21 Last updated: 2019-11-22Bibliographically approved
Sönnerstam, E., Sjölander, M., Lövheim, H. & Gustafsson, M. (2018). Clinically relevant drug-drug interactions among elderly people with dementia. European Journal of Clinical Pharmacology, 74(10), 1351-1360
Open this publication in new window or tab >>Clinically relevant drug-drug interactions among elderly people with dementia
2018 (English)In: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041, Vol. 74, no 10, p. 1351-1360Article in journal (Refereed) Published
Abstract [en]

Purpose: Increased numbers of drugs and changes in pharmacokinetic and pharmacodynamic parameters among elderly people contribute to increased prevalence of adverse drug reactions. Drug-drug interactions (DDIs) are an important reason for admission to hospital and elderly people with dementia are particularly vulnerable. The aims of the present study were to assess the occurrence and characteristics of clinically relevant DDIs and to investigate potential risk factors associated with DDIs among elderly people with dementia.

Methods: People 65 years with dementia, admitted to two hospitals in Northern Sweden, were included. The medical records of 458 patients were reviewed. Clinically relevant DDIs were identified using the Janusmed interactions database. Pharmacological classification was conducted using Stockley's classification system.

Results: A total of 401 DDIs were identified among 43.2% of the study population, of which 98.5% had interactions that may require dose adjustment and 7.6% had drug combinations that should be avoided. Pharmacodynamic interactions were most common, of which furosemide-citalopram (n=35) were most frequently observed. Omeprazol-citalopram (n=25) was the most common drug combination among pharmacokinetic interactions. Citalopram and warfarin were the most commonly involved drug substances. An association was found between a higher number of medications being prescribed and having at least one DDI.

Conclusion: Clinically relevant drug-drug interactions are prevalent among elderly people with dementia living in Northern Sweden. Drug-drug interactions should be identified in order to manage and prevent adverse outcomes. This is particularly important among this group of people especially when multiple medications are being prescribed.

Place, publisher, year, edition, pages
Springer Berlin/Heidelberg, 2018
Keywords
Drug-drug interactions (DDIs), Drug-related problems (DRPs), Adverse drug reactions (ADRs), Adverse drug events (ADEs), Elderly people, Dementia
National Category
Pharmacology and Toxicology
Identifiers
urn:nbn:se:umu:diva-152244 (URN)10.1007/s00228-018-2514-5 (DOI)000444387700015 ()29967921 (PubMedID)
Funder
The Dementia Association - The National Association for the Rights of the DementedVästerbotten County CouncilSwedish Society of Medicine
Available from: 2018-10-04 Created: 2018-10-04 Last updated: 2018-10-04Bibliographically approved
Gustafsson, M., Sjölander, M., Pfister, B., Schneede, J. & Lövheim, H. (2018). Effects of pharmacists' interventions on inappropriate drug use and drug-related readmissions in people with dementia: a secondary analysis of a randomized controlled trial. Pharmacy, 6(1), Article ID E7.
Open this publication in new window or tab >>Effects of pharmacists' interventions on inappropriate drug use and drug-related readmissions in people with dementia: a secondary analysis of a randomized controlled trial
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2018 (English)In: Pharmacy, ISSN 2226-4787, E-ISSN 1913-4711, Vol. 6, no 1, article id E7Article in journal (Refereed) Published
Abstract [en]

Age-associated physiological changes and extensive drug treatment including use of potentially inappropriate medications (PIMs) pose a significant risk of drug-drug interactions and adverse drug events among elderly people with dementia. This study aimed at analysing the effects of clinical pharmacists' interventions on use of PIMs, risk of emergency department visits, and time to institutionalization. Furthermore, a descriptive analysis was conducted of circumstances associated with drug-related readmissions. This is a secondary analysis of data from a randomized controlled intervention study conducted in two hospitals in Northern Sweden. The study included patients (n = 460) 65 years or older with dementia or cognitive impairment. The intervention consisted of comprehensive medication reviews conducted by clinical pharmacists as part of a healthcare team. There was a larger decrease in PIMs in the intervention group compared with the control group (p= 0.011). No significant difference was found in time to first all-cause emergency department visits (HR = 0.994, 95% CI = 0.755-1.307 p = 0.963, simple Cox regression) or time to institutionalization (HR = 0.761, 95% CI = 0.409-1.416 p = 0.389, simple Cox regression) within 180 days. Common reasons for drug-related readmissions were negative effects of sedatives, opioids, antidepressants, and anticholinergic agents, resulting in confusion, falling, and sedation. Drug-related readmissions were associated with living at home, heart failure, and diabetes. Pharmacist-provided interventions were able to reduce PIMs among elderly people with dementia and cognitive impairment.

Place, publisher, year, edition, pages
Basel: MDPI, 2018
Keywords
dementia, drug-related readmissions, medication reviews, potentially inappropriate medications
National Category
Pharmacology and Toxicology Geriatrics
Identifiers
urn:nbn:se:umu:diva-145404 (URN)10.3390/pharmacy6010007 (DOI)29337859 (PubMedID)
Available from: 2018-03-01 Created: 2018-03-01 Last updated: 2019-11-19Bibliographically approved
Sönnerstam, E., Sjölander, M. & Gustafsson, M. (2017). An evaluation of the prevalence of potentially inappropriate medications in older people with cognitive impairment living in Northern Sweden using the EU(7)-PIM list. European Journal of Clinical Pharmacology, 73(6), 735-742
Open this publication in new window or tab >>An evaluation of the prevalence of potentially inappropriate medications in older people with cognitive impairment living in Northern Sweden using the EU(7)-PIM list
2017 (English)In: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041, Vol. 73, no 6, p. 735-742Article in journal (Refereed) Published
Abstract [en]

Purpose As people get older, their sensitivity to drugs and adverse drug reactions can increase due to pharmacokinetic and pharmacodynamic changes. Older people with dementia are a particularly vulnerable group of people. They are at an increased risk of being prescribed potentially inappropriate medications, which may lead to harmful consequences. The aim of this study was to investigate the prevalence of potentially inappropriate medications among older patients with cognitive impairment. Methods Medical records for patients aged ≥65 years admitted to two hospitals in Northern Sweden were reviewed. Potentially inappropriate medications were identified using the EU(7)-PIM list as an identification tool. Results Of 428 patients included in the study, 40.9% had one or more potentially inappropriate medication prescribed. The most commonly represented potentially inappropriate medication classes were hypnotics and sedatives, cardiovascular drugs and laxatives. The most commonly involved potentially inappropriate medications were zopiclone, digoxin and sodium picosulfate. There was an association seen between having a higher number of medications prescribed and having one or more potentially inappropriate medication. Conclusion Potentially inappropriate medications are prevalent among older people with cognitive impairment living in Northern Sweden. It is important to continuously evaluate the need for potentially inappropriate medications in this patient group, in order to prevent adverse drug reactions, especially among those who have a higher number of medications prescribed.

Keywords
Older people, Cognitive impairment, Potentially inappropriate medications, EU(7)-PIM list
National Category
Geriatrics
Research subject
Geriatrics
Identifiers
urn:nbn:se:umu:diva-131328 (URN)10.1007/s00228-017-2218-2 (DOI)000400999200010 ()28246889 (PubMedID)
Available from: 2017-02-12 Created: 2017-02-12 Last updated: 2019-11-27Bibliographically approved
Sjölander, M., Gustafsson, M. & Gallego, G. (2017). Doctors' and nurses' perceptions of a ward-based pharmacist in rural northern Sweden. International Journal of Clinical Pharmacy, 39(4), 953-959
Open this publication in new window or tab >>Doctors' and nurses' perceptions of a ward-based pharmacist in rural northern Sweden
2017 (English)In: International Journal of Clinical Pharmacy, ISSN 2210-7703, E-ISSN 2210-7711, Vol. 39, no 4, p. 953-959Article in journal (Refereed) Published
Abstract [en]

Background This project is part of the prospective quasi experimental proof-of-concept investigation of clinical pharmacist intervention study to reduce drug-related problems among people admitted to a ward in a rural hospital in northern Sweden. Objective To explore doctors' and nurses' perceptions and expectations of having a ward-based pharmacist providing clinical pharmacy services. Setting Medical ward in a rural hospital in northern Sweden. Method Eighteen face-to-face semi-structured interviews were conducted with a purposive sample of doctors and nurses working on the ward where the clinical pharmacy service was due to be implemented. Semi-structured interviews were digitally recorded, transcribed and analysed using thematic analysis. Main outcome measure Perceptions and expectations of nurses and doctors. Results Doctors and nurses had limited experience of working with pharmacists. Most had a vague idea of what pharmacists can contribute within a ward setting. Participants, mainly nurses, suggested inventory and drug distribution roles, but few were aware of the pharmacists' skills and clinical competence. Different views were expressed on whether the new clinical pharmacy service would have an impact on workload. However, most participants took a positive view of having a ward-based pharmacist. Conclusion This study provided an opportunity to explore doctors' and nurses' expectations of the role of clinical pharmacists before a clinical pharmacy service was implemented. To successfully implement a clinical pharmacy service, roles, clinical competence and responsibilities should be clearly described. Furthermore, it is important to focus on collaborative working relationships between doctors, nurses and pharmacists.

National Category
Social and Clinical Pharmacy
Identifiers
urn:nbn:se:umu:diva-138074 (URN)10.1007/s11096-017-0488-5 (DOI)000407126200042 ()28547729 (PubMedID)
Available from: 2017-08-07 Created: 2017-08-07 Last updated: 2018-06-09Bibliographically approved
Gustafsson, M., Sjölander, M., Pfister, B., Jonsson, J., Schneede, J. & Lövheim, H. (2017). Pharmacist participation in hospital ward teams and hospital readmission rates among people with dementia: a randomized controlled trial. European Journal of Clinical Pharmacology, 7(73), 827-835
Open this publication in new window or tab >>Pharmacist participation in hospital ward teams and hospital readmission rates among people with dementia: a randomized controlled trial
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2017 (English)In: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041, Vol. 7, no 73, p. 827-835Article in journal (Refereed) Published
Abstract [en]

Purpose: To assess whether comprehensive medication reviews conducted by clinical pharmacists as part of a healthcare team reduce drug-related hospital readmission rates among people with dementia or cognitive impairment.

Methods: This randomized controlled trial was carried out between January 9, 2012, and December 2, 2014. Patients aged ≥65 years with dementia or cognitive impairment admitted to three wards at two hospitals located in Northern Sweden were included.

Results: Of the 473 deemed eligible for participation, 230 were randomized to intervention and 230 to control group by block randomization. The primary outcome, risk of drug-related hospital readmissions, was assessed at 180 days of follow-up by intention-to-treat analysis.

During the 180 days of follow-up, 18.9% (40/212) of patients in the intervention group and 23.0% (50/217) of those in the control group were readmitted for drug-related reasons (HR = 0.80, 95% CI = 0.53–1.21, p = 0.28, univariable Cox regression). Heart failure was significantly more common in the intervention group. After adjustment for heart failure as a potential confounder and an interaction term, multiple Cox regression analysis indicated that pharmacist participation significantly reduced the risk of drug-related readmissions (HR = 0.49, 95% CI = 0.27–0.90, p = 0.02). A post-hoc analysis showed a significantly reduced risk of 30-day readmissions due to drug-related problems in the total sample (without adjustment for heart failure).

Conclusion: Participation of clinical pharmacists in healthcare team conducting comprehensive medication reviews did not significantly reduce the risk of drug-related readmissions in patients with dementia or cognitive impairment; however, post-hoc and subgroup analyses indicated significant effects favoring the intervention. More research is needed.

Trial registration: Clinical trials NCT01504672.

Place, publisher, year, edition, pages
Springer, 2017
Keywords
Medication reviews, Clinical pharmacists, Drug-related readmissions, Dementia, Old people
National Category
Geriatrics Social and Clinical Pharmacy
Identifiers
urn:nbn:se:umu:diva-118307 (URN)10.1007/s00228-017-2249-8 (DOI)000405666100005 ()
Available from: 2016-03-15 Created: 2016-03-15 Last updated: 2018-06-07Bibliographically approved
Gustafsson, M., Sjölander, M. & Gallego, G. (2017). Where there is no pharmacist: doctors' and nurses' expectations on the implementation of clinical pharmacy services in rural Sweden. Paper presented at 45th ESCP-NSF international symposium on clinical pharmacy: clinical pharmacy tackling inequalities and access to health care. Oslo, Norway, 5–7 October 2016. International Journal of Clinical Pharmacy, 39(1), 216-216, Article ID HP-PC011.
Open this publication in new window or tab >>Where there is no pharmacist: doctors' and nurses' expectations on the implementation of clinical pharmacy services in rural Sweden
2017 (English)In: International Journal of Clinical Pharmacy, ISSN 2210-7703, E-ISSN 2210-7711, Vol. 39, no 1, p. 216-216, article id HP-PC011Article in journal, Meeting abstract (Refereed) Published
Place, publisher, year, edition, pages
SPRINGER, 2017
National Category
Social and Clinical Pharmacy
Identifiers
urn:nbn:se:umu:diva-132818 (URN)000394437100046 ()
Conference
45th ESCP-NSF international symposium on clinical pharmacy: clinical pharmacy tackling inequalities and access to health care. Oslo, Norway, 5–7 October 2016
Available from: 2017-05-04 Created: 2017-05-04 Last updated: 2018-06-09Bibliographically approved
Gustafsson, M., Sjölander, M., Pfister, B., Jonsson, J., Schneede, J. & Lövheim, H. (2016). Drug-related hospital admissions among old people with dementia. European Journal of Clinical Pharmacology, 72(9), 1143-1153
Open this publication in new window or tab >>Drug-related hospital admissions among old people with dementia
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2016 (English)In: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041, Vol. 72, no 9, p. 1143-1153Article in journal (Refereed) Published
Abstract [en]

PURPOSE: Drug treatment associated problems are common and are the cause of a large proportion of hospitalizations in oldpeople. People with dementia are especially at risk of drug-related problems. The objectives of this study were to assess the occurrence and character of drug-related problems that lead to acute hospital admissions among old people (≥65 years) with dementia or cognitive impairment.

METHODS: This study was conducted in orthopedic and internal medicine wards in two hospitals in Northern Sweden. Information about acute admissions was collected from the medical records. A total of 458 people aged 65 years or older with dementia or cognitive impairment were included in the study. The contribution of drug-related problems to each hospitalization was assessed.

RESULTS: Of 458 acute hospital admissions, 189 (41.3 %) were determined to be drug-related. The most common drug-relatedproblem (86/189; 45.5 %) was an adverse drug reaction. In total, 264 drugs were judged to be involved in 189 drug-relatedadmissions, of which cardiovascular (29.5 %) and psychotropic (26.9 %) drugs were the most commonly involved drug classes. The relationship between the drug-related problem and the admission was judged certain in 25 cases, probable in 78 cases, and possible in 86 cases. Drug-related admissions were more common among people taking more drugs (p = 0.035) and among younger patients (p = 0.031).

CONCLUSION: Drug-related problems appear to be responsible for a major proportion of hospitalizations among old peoplewith dementia or cognitive impairment. Targeted interventions such as education and medication reviews may be warranted to reduce drug-related problems.

Keywords
Old people, Dementia, Drug-related problems, Drug-related hospitalizations
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-123949 (URN)10.1007/s00228-016-2084-3 (DOI)000381585400014 ()27377393 (PubMedID)
Available from: 2016-07-06 Created: 2016-07-06 Last updated: 2018-06-07Bibliographically approved
Sönnerstam, E., Sjölander, M. & Gustafsson, M. (2016). Inappropriate Prescription and Renal Function Among Older Patients with Cognitive Impairment. Drugs and aging, 33(12), 889-899
Open this publication in new window or tab >>Inappropriate Prescription and Renal Function Among Older Patients with Cognitive Impairment
2016 (English)In: Drugs and aging, ISSN 1170-229X, Vol. 33, no 12, p. 889-899Article in journal, Editorial material (Refereed) Published
Abstract [en]

Background Older people are more sensitive to drugs and adverse drug reactions than younger people because of age-related physiological changes such as impaired renal function. As people with dementia are particularly vulnerable to the effects of drugs, it is especially important to evaluate the dosages of renally cleared medications in this group.

Objective The aim of this study was to estimate the prevalence of impaired renal function and inappropriate prescriptions on the basis of renal function among older patients with dementia or cognitive impairment. Methods The medical records of 428 patients aged ≥65 years who were admitted to two hospitals in northern Sweden were reviewed and renally cleared medications were identified. The Cockcroft–Gault equation was used to evaluate renal function. Doses were evaluated according to the Geriatric Dosage Handbook.

Results Renal function was impaired (estimated glomerular filtration rate <60 ml/min) in 65.4 % of the study population. Impaired renal function was associated with increasing age. Among 547 prescriptions identified as renally cleared medications, 9.1 % were inappropriate based on the patient’s renal function; 13.5 % of the 326 patients prescribed renally cleared medications had inappropriate prescriptions. Inappropriate prescriptions were more common among patients living in nursing homes.

Conclusions Impaired renal function is common and inappropriate prescription is prevalent among old people with cognitive impairment in northern Sweden. Continuous consideration of renal function is important when prescribing medications to this group.

Place, publisher, year, edition, pages
Springer, 2016
National Category
Pharmaceutical Sciences
Identifiers
urn:nbn:se:umu:diva-126825 (URN)10.1007/s40266-016-0408-8 (DOI)000388987000004 ()27734278 (PubMedID)
Available from: 2016-10-14 Created: 2016-10-14 Last updated: 2018-06-09Bibliographically approved
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Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-8364-6290

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