Pharmacists’ role in handling problems with prescriptions for antithrombotic medication in Belgian community pharmacies

S. Desmaele; I. De Wulf; A. G. Dupont; S. Steurbaut

doi:10.1007/s11096-015-0106-3

International Journal of Clinical Pharmacy

August 2015, Volume 37, Issue 4, pp 656–668 | Cite as

Pharmacists’ role in handling problems with prescriptions for antithrombotic medication in Belgian community pharmacies

Authors
Authors and affiliations

S. Desmaele
I. De Wulf
A. G. Dupont
S. Steurbaut

Research Article

First Online: 31 March 2015

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Abstract

Background Community pharmacists have an important task in the follow-up of patients treated with antithrombotics. When delivering these medicines, pharmacists can encounter drug–related problems (DRPs) with substantial clinical and economic impact. Objective To investigate the amount and type of antithrombotic related DRPs as well as how community pharmacists handled these DRPs. Setting Belgian community pharmacies. Methods MSc pharmacy students of six Belgian universities collected data about all DRPs encountered by a pharmacist during ten half days of their pharmacy internship. Data were registered about DRPs detected at delivery and in an a posteriori setting, when consulting the medical history of the patient. Classification of the DRP, cause of the DRP, intervention and result of the intervention were registered. Main outcome measure Amount and type of antotrombitocs related DRPs occurring in community pharmacies, as well as how community pharmacists handled these DRPs. Results 3.1 % of the 15,952 registered DRPs concerned antithrombotics. 79.3 % of these DRPs were detected at delivery and 20.7 % were detected a posteriori. Most antithrombotic-related DRPs concerned problems with the choice of the drug (mainly because of drug–drug interactions) or concerned logistic problems. Almost 80 % of the antithrombotic-related DRPs were followed by an intervention of the pharmacist, mainly at the patient’s level, resulting in 90.1 % of these DRPs partially or totally solved. Conclusion Different DRPs with antithrombotic medication occurred in Belgian community pharmacies. About 20 % was detected in an a posteriori setting, showing the benefit of medication review. Many of the encountered DRPs were of technical nature (60.7 %). These DRPs were time-consuming for the pharmacist to resolve and should be prevented. Most of the DRPs could be solved, demonstrating the added value of the community pharmacist as first line healthcare provider.

Keywords

Antithrombotic medicines Belgium Drug–related problems Pharmaceutical care Pharmacy practice

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Notes

Acknowledgments

We would like to thank the participating pharmacies and students for their effort. We are also grateful to the department of statistics of APB for providing the raw data for this study.

Funding

APB supported this study by providing logistic support for this study and by developing the electronic tool for registration of the DRPs. The primary investigator was supported by an unrestricted grant from Bayer NV-SA.

Conflicts of interest

The authors declare no conflict of interests.

Appendix

See Table 3.

Table 3

Detailed overview of detected DRPs with antithrombotic medication (classification, cause, intervention and result)

	All DRPs		DRPs detected at delivery		DRPs detected a posteriori		p value^a
	Number	%	Number	%	Number	%	p value^a
Classification of the DRP
Treatment effectiveness
Effect of drug treatment not optimal	191	39.1	167	43.0	24	23.7	0.001
No effect of drug treatment/therapy failure	4	0.8	4	1.0	0	0.0	0.585
Adverse reactions
Non-allergic adverse reaction	92	18.8	55	14.2	37	36.6	<0.001
Allergic adverse reaction	2	0.4	1	0.2	1	1.0	0.371
Accessibility of the treatment
Treatment not deliverable	46	9.4	44	11.3	2	2.0	0.003
Drug treatment more costly than necessary	26	5.3	24	6.2	2	2.0	0.133
Others
Unclear problem	125	25.6	90	23.2	35	34.6	0.021
Patient dissatisfied with therapy	3	0.6	3	0.8	0	0.0	1.000
Unnecessary drug-treatment	0	0.0	0	0.0	0	0.0	/
Untreated indication	0	0.0	0	0.0	0	0.0	/
Causes of the problem
Drug selection
Inappropriate drug	6	1.2	6	1.5	0	0.0	0.353
No indication for the drug	0	0.0	0	0.0	0	0.0	/
Inappropriate combination of drugs	132	27.0	81	20.9	51	50.5	<0.001
Inappropriate duplication of therapeutic group or active ingredient	2	0.4	0	0.0	2	2.0	0.042
More cost-effective drug available	13	2.6	12	3.1	1	1.0	0.484
Synergistic/preventive drug required and not given	3	0.6	0	0.0	3	3.0	0.009
Inappropriate drug form	0	0.0	0	0.0	0	0.0	/
Indication for drug-treatment not noticed	0	0.0	0	0.0	0	0.0	/
No alternative	3	0.6	3	0.8	0	0.0	1.000
Dose selection and treatment duration
Drug dose too low	8	1.6	8	2.1	0	0.0	0.216
Drug dose too high	10	2.0	7	1.8	3	3.0	0.438
Dosage regimen not frequent enough	2	0.4	2	0.5	0	0.0	1.000
Dosage regimen too frequent	2	0.4	2	0.5	0	0.0	1.000
No therapeutic drug monitoring	4	0.8	2	0.5	2	2.0	0.190
Deterioration/improvement of disease state requiring dose adjustment	4	0.8	4	1.0	0	0.0	0.585
Duration of treatment too long	1	0.2	0	0.0	1	1.0	0.207
Duration of treatment too short	4	0.8	3	0.8	1	1.0	1.000
Drug use process
Inappropriate timing of administration and/or dosing intervals	10	2.0	8	2.1	2	2.0	1.000
Patient unable to use drug/form as directed	1	0.2	1	0.2	0	0.0	1.000
Drug underused/under administered (deliberately)	2	0.4	2	0.5	0	0.0	1.000
Drug overused/over administered (deliberately)	1	0.2	1	0.2	0	0.0	1.000
Drug not taken/administered at all	1	0.2	1	0.2	0	0.0	1.000
Wrong drug taken/administered	2	0.4	2	0.5	0	0.0	1.000
Wrong use of device/drug	5	1.0	5	1.3	0	0.0	0.589
Drug abused (unregulated overuse)	0	0.0	0	0.0	0	0.0	/
Logistic and fraudulent causes
Prescribed drug not available	28	5.7	27	7.0	1	1.0	0.027
Device not available	2	0.4	2	0.5	0	0.0	1.000
Error in earlier prescriptions/deliveries	3	0.6	3	0.8	0	0.0	1.000
Reimbursement conditions not fulfilled	36	7.4	34	8.8	2	2.0	0.030
Unreadable prescription	8	1.6	7	1.8	1	1.0	1.000
Incomplete prescription	202	41.3	168	43.3	34	33.7	0.089
Fake prescription	0	0.0	0	0.0	0	0.0	/
Incorrect prescription	29	5.9	26	6.7	3	3.0	0.235
Drug prescribed for wrong patient	0	0.0	0	0.0	0	0.0	/
Patient-related causes
Patient forgets to use/take drugs	2	0.4	2	0.5	0	0.0	1.000
Patient uses unnecessary drug	0	0.0	0	0.0	0	0.0	/
Patient takes food that interacts	0	0.0	0	0.0	0	0.0	/
Patient stored drug inappropriately	0	0.0	0	0.0	0	0.0	/
Doubt, distrust, fear towards the drug	9	1.8	8	2.1	1	1.0	0.693
Acceptation of the drug influenced by religion	0	0.0	0	0.0	0	0.0	/
Lifestyle incompatible with treatment	2	0.4	2	0.5	0	0.0	1.000
Consultation of different physicians	1	0.2	1	0.2	0	0.0	1.000
Other causes
No obvious cause	3	0.6	2	0.5	1	1.0	0.501
Other cause	20	4.1	19	4.9	1	1.0	0.092
Interventions
No intervention	104	21.3	48	12.4	56	55.4	<0.001
At prescriber level
Prescriber informed only	6	1.2	5	1.3	1	1.0	1.000
Prescriber asked for information	25	5.1	24	6.2	1	1.0	0.039
Intervention proposed, approved by prescriber	22	4.5	19	4.9	3	3.0	0.591
Intervention proposed, not approved by prescriber, with justification	2	0.4	2	0.5	0	0.0	1.000
Intervention proposed, not approved by prescriber, without justification	1	0.2	1	0.2	0	0.0	1.000
Intervention proposed, outcome unknown	4	0.8	3	0.8	1	1.0	1.000
Prescriber contacted, no intervention needed	7	1.4	7	1.8	0	0.0	0.354
Prescriber contacted and intervention proposed by prescriber	5	1.0	5	1.3	0	0.0	0.589
At patient/carer level
Oral information provided	300	61.3	279	71.9	21	20.8	<0.001
Written information provided	109	22.3	102	26.3	7	6.9	<0.001
Patient referred to GP	7	1.4	7	1.8	0	0.0	0.354
Patient referred to prescriber	17	3.5	15	3.9	2	2.0	0.544
Patient referred to specialist	3	0.6	3	0.8	0	0.0	1.000
Patient referred to other pharmacy	0	0.0	0	0.0	0	0.0	/
Contact with family member/caregiver	5	1.0	5	1.3	0	0.0	0.589
At drug level
Drug changed	63	12.9	57	14.7	6	5.9	0.019
Dosage changed	7	1.4	7	1.8	0	0.0	0.354
Formulation changed	1	0.2	1	0.2	0	0.0	1.000
Dosage regimen changed	13	2.6	13	3.4	0	0.0	0.080
Drug stopped	4	0.8	4	1.0	0	0.0	0.585
Withdrawal plan started	0	0.0	0	0.0	0	0.0	/
New drug started	2	0.4	2	0.5	0	0.0	1.000
Other intervention or activity
Consultation of a colleague	42	8.6	33	8.5	9	8.9	1.000
Searched for additional information	31	6.3	19	4.9	12	11.9	0.014
Side effect reported to authorities	0	0.0	0	0.0	0	0.0	/
Other intervention	39	8.0	35	9.0	4	4.0	0.103
Result of the intervention
Unknown
Intervention outcome is not known	28	5.7	16	4.1	12	11.9	0.005
Solved
Problem is totally solved	310	63.4	286	73.7	24	23.8	<0.001
Partially solved
Problem is partially solved	62	12.7	41	10.6	21	20.8	0.008
Not solved
Lack of cooperation of patient	1	0.2	1	0.2	0	0.0	1.000
Lack of cooperation of prescriber	2	0.4	2	0.5	0	0.0	1.000
No intervention	41	8.4	20	5.2	21	20.8	<0.001
Intervention not effective	2	0.4	2	0.5	0	0.0	1.000
No need to solve problem	40	8.2	19	4.9	21	20.8	<0.001
No possibility to solve problem	3	0.6	1	0.2	2	2.0	0.110

Bold values are indicated p value < 0.05

^aComparison of DRPs detected at delivery versus a posteriori (χ² test or Fischer’s exact test)

References

1.
Silva MV, Dusse LM, Vieira LM, Carvalho M. Platelet antiaggregants in primary and secondary prevention of atherothrombotic events. Arq Bras Cardiol. 2013;100(6):e78–84.PubMedGoogle Scholar
2.
Alquwaizani M, Buckley L, Adams C, Fanikos J. Anticoagulants: a review of the pharmacology, dosing, and complications. Curr Emerg Hosp Med Rep. 2013;1(2):83–97.PubMedCentralPubMedCrossRefGoogle Scholar
3.
Schneeweiss S, Hasford J, Gottler M, Hoffmann A, Riethling AK, Avorn J. Admissions caused by adverse drug events to internal medicine and emergency departments in hospitals: a longitudinal population-based study. Eur J Clin Pharmacol. 2002;58(4):285–91.PubMedCrossRefGoogle Scholar
4.
Roughead EE, Gilbert AL, Primrose JG, Sansom LN. Drug-related hospital admissions: a review of Australian studies published 1988–1996. Med J Aust. 1998;168(8):405–8.PubMedGoogle Scholar
5.
Walsh D, Lavan A, Cushen AM, Williams D. Adverse drug reactions as a cause of admission to a Dublin-based university teaching hospital. Ir J Med Sci. 2014.Google Scholar
6.
Dechanont S, Maphanta S, Butthum B, Kongkaew C. Hospital admissions/visits associated with drug-drug interactions: a systematic review and meta-analysis. Pharmacoepidemiol Drug Saf. 2014;23(5):489–97.PubMedCrossRefGoogle Scholar
7.
Singer DE, Albers GW, Dalen JE, Fang MC, Go AS, Halperin JL, et al. Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6 Suppl):546S–92S.PubMedCrossRefGoogle Scholar
8.
Guidelines for pharmacotherapy of atrial fibrillation (JCS 2008): digest version. Circ J. 2010;74(11):2479–500.Google Scholar
9.
Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, et al. Guidelines for the management of atrial fibrillation: the task force for the management of atrial fibrillation of the European society of cardiology (ESC). Eur Heart J. 2010;31(19):2369–429.PubMedCrossRefGoogle Scholar
10.
Cairns JA, Connolly S, McMurtry S, Stephenson M, Talajic M. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: prevention of stroke and systemic thromboembolism in atrial fibrillation and flutter. Can J Cardiol. 2011;27(1):74–90.PubMedCrossRefGoogle Scholar
11.
Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(Suppl):e326S–50S.PubMedCentralPubMedGoogle Scholar
12.
Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al. Ocused update of the ESC guidelines for the management of atrial fibrillation: an update of the 2010 ESC guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012;33(21):2719–47.Google Scholar
13.
Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2013;15(5):625–51.PubMedCrossRefGoogle Scholar
14.
PCNE. Classification for drug related problems V6.2. [Internet] Zuidlaren, NL: Pharmaceutical care network Europe foundation; 2010 [cited 2015 2015-02-02]; Available from: http://www.pcne.org/upload/files/11_PCNE_classification_V6-2.pdf.
15.
Westerlund T, Gelin U, Pettersson E, Skarlund F, Wagstrom K, Ringbom C. A retrospective analysis of drug-related problems documented in a national database. Int J Clin Pharm. 2013;35(2):202–9.PubMedCrossRefGoogle Scholar
16.
Westerlund T, Marklund B. Assessment of the clinical and economic outcomes of pharmacy interventions in drug-related problems. J Clin Pharm Ther. 2009;34(3):319–27.PubMedCrossRefGoogle Scholar
17.
Buurma H, De Smet PA, Leufkens HG, Egberts AC. Evaluation of the clinical value of pharmacists’ modifications of prescription errors. Br J Clin Pharmacol. 2004;58(5):503–11.PubMedCentralPubMedCrossRefGoogle Scholar
18.
De Vriese C, Sansterre G, De Wulf I, Claeys C. Adaptation and validation of a drug related problem classification tool in community pharmacy. Int J Clin Pharm. 2013;35(3):497–8.Google Scholar
19.
van Noord E, van der Graaf C, de Gier J. Onderzoek naar prescriptie-interventies in een openbare apotheek. PW Wetenschappelijk Platform. 2009;3(6):6.Google Scholar
20.
WHO. ATC/DDD Index. [Internet] Oslo, Norway: WHO Collaborating Centre for Drug Statistics Methodology; 2014 [updated 2013-12-19; cited 2014 2014-03-10]; Available from: http://www.whocc.no/.

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Authors and Affiliations

S. Desmaele
- 1
I. De Wulf
- 2
A. G. Dupont
- 1
S. Steurbaut
- 1
Email author

1.Research Group Clinical Pharmacology and Clinical Pharmacy (KFAR), Centre for Pharmaceutical ResearchVrije Universiteit BrusselBrusselsBelgium
2.Centrum Wetenschappelijke Ontwikkeling voor Apothekers, Algemene Pharmaceutische BondBrusselsBelgium

Pharmacists’ role in handling problems with prescriptions for antithrombotic medication in Belgian community pharmacies

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