Forum

European Society of Clinical Pharmacy

Pharmacists from many parts of the world attended the spring conference of the European Society of Clinical Pharmacy, held in Malta, from May 2 to 5. The theme of the conference was “Pharmacy practice to meet patients' needs”

Pharmaceutical care can make drug therapy safe and effective in the elderly
Pharmacists see global view of antibiotic prescribing and resistance
Pharmaceutical care should be routine and integrated
Pharmacists frustrated by responsibility without authority
Post-MI prescribing interventions improve guideline adherence

Pharmaceutical care can make drug therapy safe and effective in the elderly

Pharmacists involved in the development of trial protocols should query why upper-age limits are set, as there is usually no good reason to do so, according to Dr ANTHONY BAYER, senior lecturer in geriatric medicine, University of Wales college of medicine. He argued: “If you keep on asking, eventually they will disappear.”

Moreover, excluding older patients from trials allows advisory bodies, such as the National Institute for Clinical Excellence in the United Kingdom, room for scepticism in recommending drug treatments. And if investigators can be persuaded to include older people in their trials, the results will be applicable to greater numbers of patients.

Dr Bayer agreed that evidence-based prescribing is currently not always straightforward in elderly patients because of the practice of imposing upper-age limits in trials. The lack of evidence does not necessarily imply a lack of efficacy, he emphasised.

Existing evidence tends to be from trials involving relatively young, male, white and well-educated patients who are not the patients who will be taking the drugs in practice. They also tend to be functionally independent, and tend neither to have co-morbidities nor to be taking other medicines.

For example, trials evaluating treatment of acute myocardial infarction often exclude patients over the age of 65, even though 70 per cent of all acute MIs occur in this age group.

Also, trials of anticholinesterases for treatment of Alzheimer's disease have been conducted mainly in patients in their 60s and early 70s. However, clinical practice suggests that these drugs can have a significant impact on day-to-day functioning of patients in their 90s. Greater attention to outcomes, such as maintenance of independence that are meaningful to older people, should help to optimise a patient's quality of life.

Dr Bayer warned that elderly patients should not be treated as one homogeneous group and that treatment decisions should be based on appropriate outcome measures. “Effective drug management should add life to years, rather than merely years to life,” he concluded.

Drug related morbidities

Dr Bayer's views were echoed by Professor DOUGLAS HEPLER, college of pharmacy, University of Florida, United States, who said that safe and effective drug therapy is as feasible in elderly patients as it is in younger patients.

Advanced age is often thought to be a risk factor for drug-related morbidity but data does not confirm this, he said. Professor Hepler proposed that patient specific characteristics are probably more important than age with regard to drug-related morbidity although he conceded advanced age could be an indicator of primary risk factors.

Early studies of medicine use in older people concentrate on prescribing appropriateness with a preoccupation with the choice of drug. However, it is important to think about other criteria, such as directions and duration of treatment. The criteria and standards set within prescribing guidelines should have something to do with the outcomes that are required and should not just be a list of drugs that can and cannot be prescribed. “For prescribing to be understood in context, prescribing outcomes have to be considered,” said Professor Hepler. “This is rarely done in prescribing reviews,” he added.

Professor Hepler also called for systems to be put in place to address the problem of patients being admitted to hospitals because of drug-related morbidity. These systems should include pharmacists, he said.

By recording clinical indicators it would be possible to determine whether the therapeutic purpose of prescribing has been achieved at an individual patient level; if not, drug therapy could be adjusted or continued until it had. This process can be used to lay the foundation of a “programme-level” system using prescribing indicators to improve prescribing in general.

Pharmacists see global view of antibiotic prescribing and resistance

Pharmacists need to be involved in managing microbial resistance to antibiotics, according to Dr STEPHANIE NATSCH, clinical pharmacist at the university medical centre in Nijmegen, the Netherlands.

Antibiotic resistance will always be with us, and is one of the most challenging problems in health care today, she said. But pharmacists can play an important role in managing this resistance as they have training in microbiology, are familiar with the clinical syndromes involved, and are already playing a role in prevention studies, and in developing guidelines.

Appropriate use of antibiotics should not be interpreted simply as reduced use. It is also the misuse, including underuse, of antibiotics that can help spread resistance.

Pharmacists can be more objective than physicians in seeing the global view, and should persuade physicians to think about the effects of treatment on future patients. “But be prepared to face opposition to changing drug combinations,” said Dr Natsch.

Surveillance data on resistance patterns and patterns of antibiotic use are needed to define problems at local, national, and international levels, she said. Microbiologists and pharmacists at local levels should join their databases and evaluate their own data. This would create a basis on which to formulate local guidelines on the use of antibiotics and support the selection process for prescribing. Comparing antibiotic use with levels of resistance in neighbouring institutions would allow outbreaks to be identified early, which would make them more manageable.

However, surveillance is more than just data collection, she said. Data has to be analysed closely and then interpreted, and the information disseminated. The scientific community is not geared up for this, with data never being published soon enough to tackle the problem.

Pharmaceutical care should be routine and integrated

Joined-up care is a concept that has resonances in many countries, and, according to participants in a round table discussion, pharmaceutical care is an example of the concept in which different health care professionals work together for the benefit of patients.

Mr RUUD DESSING, a community pharmacist from the Netherlands, said that pharmaceutical care should be a part of integrated care and it should be routine.

Mr Dessing described schemes that were improving pharmaceutical care within his community. Some hospitals had established an in-hospital transfer desk to support the discharge of patients. This means that by the time a patient goes home, the community pharmacist has the necessary information to support patients.

Collaboration between primary and secondary health care systems allows pharmaceutical care to be targeted at specific groups. For example, community pharmacists can collaborate with general practitioners and cardiologists to identify patients at risk from drug-related morbidities. A decision can then be made as to who should take responsibility for the pharmaceutical care of these patients.

Intensive counselling of patients taking new medicines has also been integrated into Mr Dessing's community practice. Patients are asked about their experiences with a new medicine, including whether the medicine was easy to use, if they experienced any adverse drug reactions, and whether they had any specific problems. As part of this management of medicines, patients are visited in their own homes. Computers allow a record of the patient's experiences to be kept. “We should be working in the same way as general practitioners, recording experiences to develop a patient dossier,” he said.

Professor DOUGLAS HEPLER, college of pharmacy, University of Florida, United States, said that the management of drug therapy is too complicated for one professional to do alone. Studies have shown that adding a pharmacist to the treatment systems in hospitals reduces drug morbidity and the patient's length of stay.

“The greatest contribution that pharmacists can make is in evaluating prescribing,” he said. Putting pharmacists on ward rounds is expensive but effective. And, if a patient's stay in hospital can be reduced, so, too, is the cost of admission.

Mrs CHRISTINE GLOVER, health care consultant in Edinburgh, Scotland, (and also President of the Royal Pharmaceutical Society), said that pharmacists need to persuade the people who “run the money” of the value of pharmaceutical care. Linking adverse drug events to hospital admissions will drive money into this area, she said.

Pharmaceutical care was only just starting in German hospitals and direct interaction between pharmacists and patients was not usual, Ms HANNELORE KRECKEL, deputy director of the pharmacy department at University Hospital Giessen, said. However, there was a shift from distributive tasks to patient-orientated tasks with pharmacists starting to take patients' drug histories. “Pharmacists can do this well,” she said.

Another area that pharmacists in Germany are starting to become involved with is discharge counselling.

Doctors often only spend a few minutes with each patient during their ward rounds and the discharge process involves talking about patients rather than to patients. Pharmacists have a greater opportunity to spend time with patients and for patients to tell them about any problems they might have with their drug therapy, she said.

Pharmacists frustrated by responsibility without authority

Pharmacists are frustrated because they have a great deal of responsibility, but, because they lack authority, can only ever react to challenging situations, according to Dr SAM SALEK, director of the Welsh School of Pharmacy, Cardiff. Traditionally, the burden of decision making falls on physicians, but “some pharmacists want this to change”, he said. Pharmacists take a re-active role in responding to prescribing errors, often with little clinical knowledge of the patient involved. This way, a pharmacist's knowledge is not used when it is most useful, but this can change if pharmacists demand authority.

Retrospective reviews of medication orders can intercept errors but there would be a greater impact if input is made at the time of prescribing. Consultation with physicians can result in savings and can prevent errors occurring. This, in turn, reduces the rate of preventable adverse drug events (ADEs).

In a study to evaluate the impact of pharmacists on ward rounds, preventable ADEs were reduced by 66 per cent, Dr Salek said. Of 400 interventions made by the pharmacists over six months, 366 were related to medication errors. Other health care professionals responded positively to the interventions and physicians accepted 99 per cent of the pharmacists' recommendations. “The impact we can make as part of the health care team is substantial,” Dr Salek concluded.

Post-MI prescribing interventions improve guideline adherence

Dr Mohamad Haniki, school of pharmaceutical sciences, Sains University, Malaysia, and colleagues have demonstrated that pharmacist intervention improves prescribing of discharge medicines for post-myocardial infarction patients.

Dr Haniki presented the results of the study as an oral communication at the conference. The researchers conducted a four-month, prospective study to identify drug-related problems in a cardiac rehabilitation ward in a large Malaysian hospital. They compared prescribing habits with the ACC/AHA Task Force practice guidelines (American College of Cardiologists/American Heart Association guidelines) to identify whether the guidelines were being followed.

They detected non-compliance to the guidelines in 17 out of 36 patients and made recommendations to the prescribing physicians. Interventions were accepted in 10 out of 17 cases. The accepted interventions were the inclusion of lipid-lowering agents to patients' discharge medication (eight patients), to prescribe a beta-blocker (one patient), and to prescribe an angiotension-converting enzyme inhibitor (one patient). The interventions that were not accepted were the addition of nitrates in the discharge medication of seven patients.

After the interventions had been made, the discharge medication of 29 of the 36 patients was compliant to the ACC/AHA guidelines.

Dr Haniki commented that the guidelines are posted in the cardiac rehabilitation unit and prescribing was, in general, good. “However, in specific cases, such as prescribing of lipid-lowering agents, adherence to the guidelines is more relaxed.”