Nordic social pharmacy and health services research conference & the nordic networking group of clinical pharmacy : june 3-5, 2015, tartu, estonia.

Int J Clin Pharm (Suppl 2015) 37:1–34 DOI 10.1007/s11096-015-0121-4

ABSTRACTS

Nordic Social Pharmacy and Health Services Research Conference & The Nordic Networking Group of Clinical Pharmacy June 3–5, 2015, Tartu, Estonia

Ó Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015 This publication contains abstracts of the oral and poster presentations on the field of social pharmacy, clinical pharmacy and health services research presented at the Nordic Social Pharmacy and Health Services Research Conference & Nordic Networking Group of Clinical Pharmacy Conference, held in Tartu, Estonia, June 3–5, 2015. Abstracts have been published as a supplement to the International Journal of Clinical Pharmacy. This supplement has been prepared for distribution to participants in the conference research topic sessions and a poster session. For NSPC&NNGCP 2015, 80 abstracts were submitted, 30 abstracts were accepted for oral and 39 for poster presentations. Authors were asked to limit the length of their contribution to allow each abstract to fit on to a single page of this supplement. However, a few abstracts exceeded the specified maximum length and have had to be compressed in order to fit onto one page. Abstracts of oral and poster presentations have been classified according to the conference programme and content of abstracts into seven categories: (1) Medication use and drug behaviour (13 abstracts); (2) Professional and inter-professional issues and pharmacy education (11 abstracts); (3) Patient safety, pharmacoepidemiology and pharmaceutical policy (14 abstracts); (4) Clinical pharmacy (10 abstracts); (5) Health care services and pharmacists’ interventions (10 abstracts); (6) Medicines and health information (7 abstracts) and (7) Innovations in pharmacy practice and research (4 abstracts). The best oral and poster presentations will be awarded prizes.

Dr. Daisy Volmer Chair of the scientific and organising committee of the NSPC&NNGCP 2015

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Int J Clin Pharm (Suppl 2015) 37:1–34

Medication use and drug behaviour

PP II-2

The impact of curriculum reform to the professional competency of pharmacists–perceptions of MSc pharmacy students in Estonia

Oral presentations PP II-3 OP I-1 OP I-2

Administration of medicines to children Changes in antipsychotic prescribing in dementia and psychogeriatric units in New Zealand

Exploring the pharmacist’s intervention roles based on a literature survey

PP II-4

Perception of medical practitioners on antibiotic prescribing by pharmacists

OP I-3

Vitamin A, D and E intake among middle aged women in Norway

PP II-5

OP I-4

Use of antiepileptic drugs in combination with central nervous system drugs in elderly home care service and nursing home patients in Norway

Education of pharmacy technicians and their role in community pharmacies in Lithuania and Estonia— comparative analysis

PP II-6

The production of a framework of competences for pharmacy practice in the European Union: the PHAR-QA project

OP I-5

Incidence of type 2 diabetes and use of oral antidiabetic drugs in the elderly population in Norway

Poster presentations PP I-1

Asthma management practices in Finnish children and adolescents: a register-based follow-up study

PP I-2

Case study on medicine education in Finnish families

PP I-3

Management of chemotherapy side effects in breast cancer patients

PP I-4

Once daily gentamicin dosing in the intensive therapy unit

PP I-5 PP I-6

Patient safety, pharmacoepidemiology and pharmaceutical policy Oral presentations OP III-1

Recent prescribing patterns of psycholeptics in Norwegian nursing homes

Socio-demographic characteristics of prescribing second line lipid-lowering medicines: ezetimibe as switch from statin therapy or as add-on therapy

OP III-2

Comparison of patient knowledge regarding diabetes between health centre patients and the central Diabetic Clinic at Mater Dei Hospital

Physicians’ experiences with NORGEP criteria and the use of inappropriate medication in elderly patients in nursing home and home care service

OP III-3

The innovation that never came true-stakeholders views of the perceived effects of the reregulation of the Swedish pharmacies

OP III-4

Health impacts of cost-related prescription deferral: evidence from New Zealand

OP III-5

Register-based indicators for potentially inappropriate medication in high-cost patients with excessive polypharmacy

PP I-7

Patient benefit of a Medicines Use Review framework

PP I-8

Statin therapy patients in primary care—monitoring medication adherence

Professional and inter-professional issues and pharmacy education Oral presentations

Poster presentations

OP II-1

General practitioner’s views on pharmacists in the primary health care system in Iceland

PP III-1

OP II-2

Towards inter-professional networking in medication management: challenges and potential solutions Medical technology education for pharmacy students and practicing pharmacists in the Nordic and Baltic countries

Feasibility of a practical nurse-administered risk assessment tool for drug-related problems in home care

PP III-2

Identification of risk factors frequently associated with medication errors (PEPPAS)

PP III-3

The patterns of antibiotics drug prescription by physicians in south of Iran (Shiraz) Use of non-hormonal therapies for menopausal symptoms—The Norwegian Women and Cancer study (NOWAC) Availability of antiepileptic drugs across Europe

OP II-3

OP II-4

Interdisciplinary and structured drug reviews in primary health care–health personnel’s perceived value of participation

PP III-4

OP II-5

A qualitative study of attitudes towards treatment of nausea in pregnancy among pregnant women and general practitioners

PP III-5 PP III-6

Patient and population aspects of treatment with antiepileptic drugs for improved patient safety

PP III-7

Antiepileptic drug therapy—Is the best formulation prescribed?


PP III-8

What is dispensing? Legal cognitive requirements during dispensing in the Nordic countries

PP II-1

PP III-9

An independent non-chain community pharmacies perspective in Lithuania

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A historical, social and ethnic study of pharmacy students at the University of Tartu in 1802–2014


Clinical pharmacy

3

PP V-4

The impact of pharmacist’s intervention on the quality of life and knowledge of patients with gastroesophageal reflux disease

PP V-5

Improving medication adherence in hypertension patients through genetic risk assessment

Oral presentations OP IV-1

Quality of drug information in discharge summaries from a Norwegian hospital

OP IV-2

Use of analgesics in patients with acute pancreatitis at the intensive care units Drug related problems in patients receiving home care services—a multidisciplinary approach to integrated medicines management

OP IV-3

Medicines and health information Oral presentations

OP IV-4

Hospital pharmacists narrow the gap between health care levels by optimizing discharge letters

OP VI-1

OP IV-5

Development and content of a multifaceted medication adherence intervention for patients with hypertension in secondary care

Is physician–pharmacist interaction important for advising pregnant and breastfeeding women in pharmacies?

OP VI-2

Medicines information needs among medicine users in Finland—a population survey

OP VI-3

How to incorporate patient perspectives in health technology assessments and clinical practice guidelines—a qualitative study

OP VI-4

Associations between beliefs about medicines and teaching about medicine education

OP VI-5

Patient benefits of a pharmacy-based inhaler service

Poster presentations PP IV-1

Aseptic preparation of injectable medicines in the intensive care units of Tartu University Hospital

PP IV-2

Changes in the quality of medicines during administration—a sample of ketoprofen infusion Evaluation of prophylactic practice for venous thromboembolism

PP IV-3 PP IV-4

PP IV-5

Medication reconciliation in Norway; does a written procedure for reconciliation reduce medication discrepancies?


Medicines use at the European neonatal departments

PP VI-1

Medicines information research in Finland in 2000–2013: a systematic review

PP VI-2

A review of countries’ pharmacist–patient communication legal requirements on prescription medications and alignment with practice: comparison of Nordic countries

Health care services and pharmacists’ interventions Oral presentations OP V-1

Multi-professional medication review in home care and care homes

OP V-2 OP V-3

Medication review practices in European countries The use of myometer for early identification of statin myalgia—a pilot study among primary care patients in Tartu, Estonia Extended role for pharmacists in safe medication process on wards? Inter-professional focus group discussions on hospital wards Cardiovascular risk assessment in community pharmacy

OP V-4

OP V-5

Innovations in pharmacy practice and research Poster presentations PP VII-1

Association of the CYP2C19 *2 allele on the occurrence of in-stent restenosis in patients undergoing repeat coronary stenting

PP VII-2

Pharmacist-led CYP2C19 genotype–phenotype analysis in patients on clopidogrel therapy following percutaneous coronary intervention

Poster presentations PP V-1

Prescriptions without a written indication—a community pharmacy study in Norway

PP VII-3

PP V-2

How the role of a pharmacist has changed—the different opinions of the Estonian and Lithuanian healthcare students and teachers

The ‘‘Quality guidelines for community pharmacy services’’—a tool for harmonization of community pharmacy practice in Estonia

PP VII-4

PP V-3

The impacts of electronic prescription on the dispensing process in the community pharmacies in Finland

Heading towards safer dosing in infants— pharmacokinetic study of microtracer 14C paracetamol

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Medication use and drug behaviour OP I-1: Administration of medicines to children Elin Høien Bergene1,2, Marikken Høiseth3, Ole Andreas Alsos4, Jonas Asheim5 1 Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), N-7491 Trondheim, Norway, [email protected]; 2 Trondheim Hospital Pharmacy; 3Department of Product Design, NTNU; 4Department of Computer and Information Science, NTNU; 5 Nice Industridesign

Background and objectives: Many children object to different forms of medical treatment like having a mask placed over their nose and mouth. Parents and healthcare professionals often restrain non-cooperative children during the administration of medicines. Restraint is perceived as very distressing by those involved and may reduce the effect of the medical treatment. The objective of this study was to identify and validate key steps in the process of giving medicines to children. Methods: The study consisted of two parts; identification of key steps in the process of giving medicines to children and validation of these steps. To identify the key steps, the members of the BLOPP group used their own experiences (from parenting, pharmacy and pediatric hospital, child-centered design and research) and collected data through literature search, nurses and parents’ experiences of giving medicines to children, and examination of successful children’s TVprograms and computer games. The collected data was used in an analysis workshop where the BLOPP group identified four key steps in the process of giving medicines to children. The validation of these steps was done by: (1) Observing children’s nebulization treatment, (2) interviewing parents and healthcare workers, (3) arranging workshops with children that were experienced nebulizer users and their parents, and (4) arranging workshops with psychiatrists, nurses, children’s theatre performers, a pediatrician, preschool teacher, hospital clown, and play-specialist nurse. Results: We categorized the process of giving medicines to children into four steps: (1) Prepare, (2) Motivate, (3) Distract and (4) Reward. The proposed steps were verified and given content by the user- and expert groups: Preparation before treatment should include both the child and parent and might also serve as a reminder. Motivation can be done through predictability, mirroring, empowerment and reward. Rewards could consist of both attention and praise and material things. The process of distraction received most discussions, arguing that it would be better to empower the child through active participation rather than distracting the child from the activity. These views were combined, integrating the distraction in the medication process. Conclusions: Prepare, motivate, distract and reward were identified as both relevant and usable key steps in the process of giving medicines to children. Implications for practice: Using the four key steps of administering medicine to children as a guide in the development of medication aids for children may increase children’s cooperation and empowerment during the administration of medications.

Int J Clin Pharm (Suppl 2015) 37:1–34 Background and objectives: Despite associations with cerebrovascular events and deaths [1] antipsychotics are commonly prescribed for 19–59.5 % of residents with dementia who live in care homes, in some countries [2, 3]. The objective of this study was to examine prescribing changes following the implementation of interventions to reduce antipsychotic prescribing, in 13 dementia and psychogeriatric units managed by a residential care provider (RCP) in New Zealand. Methods: An audit was undertaken in July to September 2011 (n = 228 residents) and repeated in July to September 2013 (n = 233 residents). Interventions, which were implemented in the interim period, varied between units, and were educational, managerial, environmental, recreational and resident-specific. A modified version of a tool developed by the Best Practice Advocacy Centre New Zealand (bpacnz) [4] was used to collect data on antipsychotics prescribed, the administration of ‘‘when required’’ (PRN) antipsychotic doses, and antipsychotic-related documentation (target behaviour identified, target behaviour response, directions to monitor for adverse effects, and attempts to withdraw antipsychotics in the last 3–6 months). Prescribing for some central nervous system agents and the rates of fractures/falls were examined. Data were analysed using logistic regression models. The multi-region ethics committee approved the study (MEC/10/102EXP/AM01). Results: Antipsychotic administration and the prescribing of regular doses (±PRN) decreased by about a quarter from 2011 to 2013: 50.4 % to 38.2 %, and 49.1 % to 36.5 % (ORs 0.60, 0.57, respectively, both p \ 0.001), and prescribing for any antipsychotic dose (including PRN only) decreased: 60.5 % to 50.6 % (OR = 0.67, p = 0.003). Documenting of ‘‘target behaviour identified’’ significantly increased from 54.3 % to 71.2 %, (OR = 2.9, p \ 0.001) and documenting of directions to monitor for adverse effects increased non-significantly from 30.4 % to 46.6 % (p = 0.098). However, both fell short of the 90 % goal set by bpacnz. Benzodiazepine prescribing significantly decreased from 39.0 % to 25.8 % (OR = 0.59, p \ 0.001) and cholinesterase inhibitor prescribing significantly increased from 10.1 % to 15.5 % (OR = 1.63, p \ 0.001). The number of fractures in all units decreased from 6 to 1 per annum. In 2011, residents taking antipsychotics experienced more falls per annum than those who did not (5.52 vs. 3.11, IRR = 1.78, p = 0.034) but there was no difference in fall rates in 2013 (6.32 vs. 6.50, IRR = 0.97, p = 0.899). Conclusions and implications to practice: Following a range of interventions, antipsychotic prescribing, administration and some related documentation improved in dementia and psychogeriatric units in New Zealand. Future studies should aim to identify the most effective of the interventions implemented so they can be considered for use in similar settings. References [1] [2] [3] [4]

Schneider, L.S.; Dagerman, K.S.; Insel P. JAMA. 2005, 294, 1934–43. Parsons, C.; Haydock, J.; Mathie E.; et al. BMC Geriatr. 2011, 1 (56). Tucker, M.; Hosford, I. N Z Med J. 2008, 121, 18–25. Best Practice Advocacy Centre New Zealand (2008). Retrieved from http://www.bpac.org.nz/a4d/resources/guide/guide.asp.

Acknowledgements: We thank the RCP for funding the study, and staff at the units and bpacnz for their assistance.

OP I-2: Changes in antipsychotic prescribing in dementia and psychogeriatric units in New Zealand

OP I-3: Vitamin A, D and E intake among middle aged women in Norway

June Tordoff1, Nagham Ailabouni2, Dorothy Browne2, Hesahm Al-Sallami2, Andrew Gray3

Marit Waaseth1, Vibeke Tytlandsvik2, Guri Skeie3

1

School of Pharmacy, University of Otago, PO Box 56, New Zealand, [email protected]; 2School of Pharmacy, University of Otago, PO Box 56, New Zealand; 3Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, New Zealand

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1 UiT, The Arctic University of Norway, Faculty of Health Sciences, Department of Pharmacy, N-9037 Tromsø, Norway, [email protected]; 2The Norwegian Medicines Agency, Department for Medical Information; 3UiT, The Arctic University of Norway, Faculty of Health Sciences, Department for Community Medicine

Int J Clin Pharm (Suppl 2015) 37:1–34 Background and objectives: A telephone survey from 2012 shows that Norwegians spend almost 90 € a year per capita on dietary supplements, and 70 % report having used dietary supplements during the past year [1]. Two Master’s Theses from 2012 show an association between socioeconomic status and dietary supplements use, and suggest a potential excess consumption of vitamins among middle aged women. The aims of the study were to describe the total intake of fat-soluble vitamins (A, D and E) in a general population of middle-aged women, and investigate whether vitamin intake was associated with socioeconomic status. Methods: We used questionnaire data from the Norwegian Women and Cancer study (NOWAC), a national prospective cohort comprising about 170,000 participants. Data analysed in this study is a cross-section of 3231 women, aged 46–63 years, who answered a two-page questionnaire 2003–2006, response rate 72 %. Results: Prevalence of dietary supplements use is 71.8 %. Women with a vitamin rich diet have a higher prevalence of dietary supplements use. Very few women have a potentially toxic intake of fatsoluble vitamin (A: 0.2 %, D: 0.3 % and E: 3.0 %). Fewer than 1 % is below the lower limits for recommended vitamin intake, leaving 96 % between lower and upper limit. There is a statistically significant association between intake of vitamin A, D and E and education length, with higher intake among women with higher education. No corresponding association was found for gross household income. Conclusions: The majority of Norwegian middle-aged women use dietary supplements, but very few have a worrying intake of fatsoluble vitamins. Dietary supplements use is higher among women with a vitamin rich diet, and vitamin A, D and E intake is associated with education length. Implications to practice: Clinical and community pharmacists should be aware the extent of dietary supplements use, and the fact that those in need use the least. We need tools to identify the few in real need of supplements, as well as excess users. Reference [1]

Fønnebø, V. Bruk av alternativ behandling i Norge 2012: NAFKAM 2013.

OP I-4: Use of antiepileptic drugs in combination with central nervous system drugs in elderly home care service and nursing home patients in Norway Kjell H. Halvorsen1, Cecilie Johannessen Landmark2, Anne Gerd Granas2 1

Department of Pharmacy, Faculty of Health Science, University of Tromsø, 9037 Tromsø, Norway, [email protected]; 2 Department of Life Sciences and Health, Faculty of Health Science, Oslo and Akershus University College of Applied Sciences, Oslo, Norway Background and objectives: Antiepileptic drugs (AEDs) are used to treat epilepsy, but also other diseases and symptoms such as pain, bipolar disease and migraine. A majority of AEDs are involved in drug interactions. The purpose of this study is to investigate concomitantly use of AEDs with other central nervous system (CNS)active drugs, and to identify potential drug–drug interactions in older patients. Methods: Point-prevalence study of patients in home care services and nursing homes aged C65 years receiving multi-dose dispensed drugs. At the patient level, we identified AEDs in combination with other AEDs, or with CNS-active drugs. Results We included 8268 patients in home care services (mean age 83.0 years, 69 % women) and 2986 patients in nursing homes

5 (mean age 85.3 years, 72 % women). Of these, 881 patients (7.8 %) used AEDs: 7.7 % in home care services and 8.2 % in nursing homes. The most commonly used AEDs were carbamazepine, pregabalin, lamotrigine and gabapentin, accounting for [60 % of totally 13 different AEDs. Antidepressants (6.6 %), antipsychotics (3.0 %) and opioids (2.3 %) were more frequently prescribed among AED-users compared to non-users. From the sample of 881 patients on AEDs, 45 % had one or more potential drug interactions. In total, 436 pharmacokinetic/-dynamic interactions involving AEDs were identified: 79 pharmacokinetic interactions with substantial propensity to interact with CNS-active drugs, 66 additional pharmacokinetic interactions, 278 pharmacodynamic interactions, and 13 other interactions. Conclusions Elderly patients in home care services and nursing homes use AEDs more than twice as frequently as compared to the general elderly population. AEDs in combination with other CNSactive drugs should be closely monitored for pharmacokinetic and pharmacodynamics interactions. Special attention to commonly occurring combinations is of importance to avoid unnecessary adverse effects or toxicity.

OP I-5: Incidence of type 2 diabetes and use of oral antidiabetic drugs in the elderly population in Norway Inger-Lise F. Neslein1, Anne Gerd Grana˚s1, Ellen Hagesæther1, Cecilie J. Landmark1 1

Department of Life Sciences and Health, Oslo and Akershus University College, Oslo, Norway Background and objectives: Type 2 diabetes (DT2) is a globally common metabolic disorder that results from the body’s ineffective use of insulin. Accounting for about 90 % of all diabetes cases worldwide, DT2 is strongly associated with increased body weight and a lack of physical activity [1]. Both average life expectancy and the prevalence of diabetes are continuing to rise. Amongst the elderly population, DT2 is a growing problem, and a larger proportion of newly diagnosed diabetics are older. The purpose of this study is to study changes in utilization of antidiabetic drugs except for insulin prescribed to elderly patients in Norway 2004–2013, and to correlate this to the incidence of DT2 over the same period. Methods: Anonymous data of anti-diabetic drugs; ATC-code A10B, blood glucose lowering drugs excluding insulin, were collected from the Norwegian Prescription Database. Data from both males and females aged 65–90+ for the past 10 years (2004–2013) were obtained. The patients were grouped in intervals of 5 years. Data from the entire country were used; no geographical, socioeconomic or ethnical filters were applied [2, 3]. Results: The prevalence of DT2 is higher in men than in women in all age groups, and increased by almost 40 % in males aged 65–90+, and by 29 % in females over the 10-year period. The total amount of doses (DDD) over the same period increased in total by 82 % in the males and by 45 % in females and the greatest increase in DDD was found in patients aged 65–69 years. The number of elderly persons using oral anti-diabetic drugs increased by 85 % in males and 44 % in females over the 10-year period. Males aged 65–69 diagnosed with DT2 increased by 165 % from 4997 in 2004 to 13,103 in 2013, whereas the female frequency increased by 117 % from 3873 in 2004 to 8387 in 2013. Conclusions: The considerable increase in DDDs and prevalence of DT2 from 2004 to 2013 could partly be due to intensified treatment and diagnosis frequency, but whether this accounts for it all is not clear, and further investigations are called for. The number of elderly

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people (aged 67+) in the Norwegian population was the same in 2004 as in 2013, 13 % [4]. Implication to practice: The growing number of patients require closer follow-up and more intensive monitoring and will introduce stricter demands on competence of all health personnel involved in this increasing group of patients. References [1] [2]

[3] [4]

Type 2 diabetes, Diabetes.co.uk. Retrieved 18. January 2015 from http://www.diabetes.co.uk/type2-diabetes.html. Norwegian Institute of Public Health, Facts about diabetes. Retrieved 18. January 2015 from http://www.fhi.no/eway/ default.aspx?pid=240&trg=List_6673&Main_6664=6894:0:25, 7535:1:0:0:::0:0&MainContent_6894=6671:0:25,7543:1:0:0:::0:0 &List_6673=6674:0:25,7547:1:0:0:::0:0. Norwegian Prescription Database. Retrieved 18. January 2015 from http://www.reseptregisteret.no. Kommuneprofilen—Befolkning og aldersstruktur. Retrieved 18. January 2015 from http://www.kommuneprofilen.no/Profil/ Befolkning/DinRegion/bef_alder_region.aspx.

children under four years of age, of whom 29 % had at least one fixed combination purchase in four years. Most commonly fixed combinations were used by adolescents aged 12 years and over, at which age it is considered safe and effective. Those who bought a fixed combination at least once purchased also more antibiotics and allergy drugs than those with no fixed combination purchases (p \ 0.001). The same was also observed in those who had acquired montelukast or oral corticosteroids. Conclusions: This study showed that the use of fixed combinations is common in the treatment of childhood asthma, also in children under four years of age. However, neither Finnish nor any international guidelines recommend using fixed combinations for young children. Our results highlight the need for interventions that could improve the treatment practices of childhood asthma. References [1]

[2] [3] PP I-1: Asthma management practices in Finnish children and adolescents: a register-based follow-up study Kati Sepponen1, Johanna Jyrkka¨2, Susanna Pieska¨1, Jaana E. Martikainen3, Hannes Enlund2, Kristiina Malmstro¨m4, Mika Ma¨kela¨4

Ma¨ki, P. et al. [eds.]. Child Health—Results of the LATE-study on growth, development, health, health behavior and growth environment [in Finnish, with English abstract]. National Institute for Health and Welfare. Report 2/2010. Helsinki, 2010. GINA (Global Initiative for Asthma). Global strategy for asthma management and prevention, 2014. Asthma Current Care Guideline [in Finnish, with English summary]. Working group appointed by the Finnish Medical Society Duodecim, the Finnish Respiratory Society, the Finnish Paediatric Society and the Finnish Society of Clinical Physiology. Finnish Medical Society Duodecim, 2012.

1

University of Eastern Finland, Faculty of Health Sciences, School of Pharmacy, Social Pharmacy, BOX 1627, FIN-70211 Kuopio, Finland, [email protected]; 2Finnish Medicines Agency, Assessment of Pharmacotherapies, Kuopio, Finland; 3Social Insurance Institution, Research Department, Helsinki, Finland; 4Helsinki University Central Hospital, Department of Allergy, Helsinki, Finland Background and objectives: Asthma is the most common long-term disease in children and adolescents. In Finland, it has been diagnosed in 5 % of children under school age and in 7 % of school aged children and adolescents [1]. Based on asthma guidelines short-acting beta2-agonists and inhaled corticosteroids should be the first-line medication for asthma treatment in children and adolescents [2, 3]. Leukotriene receptor antagonists and long-acting beta2-agonists can be additionally used. The aim of this study was to evaluate the asthma management practices in Finnish children and adolescents. Special emphasis was placed on the prescribing of inhaled corticosteroids in fixed combinations with long-acting beta2-agonists. Methods: In Finland, patients with chronic asthma are entitled to a higher rate of refund, i.e. special reimbursement, for their medicinal costs. Our study cohort (n = 13,526) included children under 18 years of age who were entitled to special reimbursements for asthma medication for the first time during the years 2006–2009. Data on their asthma drug purchases was obtained from the registers maintained by the Social Insurance Institution of Finland. In addition, reimbursed antibiotic and allergy drug purchases were obtained from the registers. Individual four-year follow-up time for drug purchases of each child was defined as a period of two years before and after the entitlement to special reimbursement. Results: Medication was most commonly started with inhaled corticosteroids and short-acting beta2-agonist (48 % of the subjects). Altogether 16 % of children and adolescents started asthma medication with a fixed combination and one-third had at least one fixed combination purchase in four years. These medications were bought more often after the entitlement to special reimbursement than before it (p \ 0.001). The use of fixed combinations was common in

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PP I-2: Case study on medicine education in Finnish families Johanna Hokkanen1, Anna-Liisa Kosonen1, Kirsti Vainio2, Katri-Ha¨meen-Anttila3, Tuula Keinonen1 1 School of Applied Educational Science and Teacher Education, University of Eastern Finland, P.O. Box 86, 57101 Savonlinna, Finland, [email protected]; 2School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland; P.O. Box 1627, 70211, Kuopio, Finland; 3Fimea P.O. Box 55, 00034 FIMEA, Helsinki, Finland

Background and objectives: Medicine education can be seen as a cooperation between children, parents, teachers, and health care professionals. The purpose of the study is to describe medicine education at home and medicine use interact with the socio-cultural environments. The research approach orientates for Home economics and the theoretical framework is Human Ecology Theory (Bubolz & Sontag 1993). Methods: The research was conducted as a case study for the students and their parents of a primary school in Eastern Finland between 2011 and 2013. Mixed method research was used where in the first stage the students’ parents answered a questionnaire (n = 250). The second stage of the research included medicine education intervention for the 4th and 7th graders after which the children and their parents were interviewed at their home. 12 mothers and 12 children of whom two were girls participated in the half structured interviews concerning home medicine education. As part of the interview was also conducted medicine cabinet study using participant observation method for those who gave a permission (n = 10). Results: Based on the data from both questionnaires and interviews, the respondents (mothers) were divided into different categories as health and medicine educators: A questioner (n = 7), a medicine criticiser (n = 54), a home caretaker (n = 45), and believer of a doctor (n = 55). All of the children who participated in the study (n = 12) stated that their mother usually took care of them while they


7

were sick. The mother was also generally in charge of giving the medication. Conclusions: At home medicines are discussed consciously when the child, family member, relative or a friend has a long-term illness, when being sick and while taking medication. In addition, parents and other people in the close circle passed on models of medicine use even unconsciously by using medication themselves. Since home cannot be studied as a separate entity disregarding the environment, children’s upbringing is also influenced by formal school education and informal learning environments, such as television and internet. Moreover, health professionals provide support to home medicine education.

[2]

PP I-3: Management of chemotherapy side effects in breast cancer patients

PP I-4: Once daily gentamicin dosing in the intensive therapy unit

Danika Caruana, Lilian M. Azzopardi, Anthony Serracino-Inglott

Annalisa Thake, Lilian.M. Azzopardi, Anthony Serracino-Inglott

Department of Pharmacy, Faculty of Medicine and Surgery, University of Malta, Msida, Malta, [email protected]

Mean Sample Score

Background and objectives: Chemotherapy side effects are often overshadowed by the objective to ensure clinical efficacy. The scope of this study was to assess the incidence and management of FEC (combination regimen of 5-fluorouracil, epirubicin and cyclophosphamide)—induced nausea and vomiting (CINV), diarrhoea and oral mucositis and to evaluate the quality-of-life (QoL). Methods: Approval from the University Research Ethics Committee was granted. Informed consent was obtained from all patients participating in the study. Patients were recruited from Sir Paul Boffa Oncology Hospital, between August 2013 and August 2014, according to the inclusion criteria of newly diagnosed or relapsed, breast cancer patients, initiating FEC or FEC-T (usually 3 cycles FEC followed by 3 cycles docetaxel). QoL was assessed before chemotherapy initiation and following Cycle 3 utilizing EORTC-QLQ-C30 v.3 [1]. Incidence of side effects following Cycle 1 and Cycle 3 was evaluated using Morrow Assessment of Nausea and Emesis [2] for CINV and tools developed for oral mucositis and diarrhoea. Prior to implementation, the developed tools were psychometrically evaluated. The preventive regimen prescribed was assessed. Results: 37 female patients completed the study (mean age = 54.32 years). Breakthrough nausea was greatly experienced in both cycles (Cycle 1 = 26 patients; Cycle 3 = 27 patients). A discrepancy in the dexamethasone dosage regimen prescribed was observed; 2 mg t.d.s. = 13 patients, 4 mg b.d. = 24 patients. Yet, no relationship between the dexamethasone daily dose and incidence of nausea was sustained (p value [ 0.05). For Cycle 1 and Cycle 3, 9 patients and 6 patients respectively reported oral mucositis. Only a few patients (Cycle 1 = 5 patients; Cycle 3 = 3 patients) reported vomiting while no episodes of diarrhoea were recorded. Overall a statistical decrease in QoL (p value = 0.000) was recorded (Fig. 1). Conclusions: The high incidence of nausea despite preventive treatment indicates that CINV is a substantial problem which must not be ignored.

100 90 80 70 60 50 40 30 20 10 0

96.7

95.3

Cycle 0

80.2 69.4 59

References [1]

Aaronson, N.K.; Ahmedzai, S.; Bergman, B.; Bullinger, M.; Cull, A.; Duez, N.J. et al. J. Natl. Cancer Inst. 1993, 85, 365–376. Morrow, G.R.Br. J. Cancer. 1992, 66(19), S72–S74.

Department of Pharmacy, Faculty of Medicine and Surgery, University of Malta, Malta, [email protected] Background and objectives: Gentamicin, used to treat serious infections in ITU, is given as a once daily 7 mg/kg dose in 100 ml 5 % dextrose or 0.9 % sodium chloride solution administered over 30–60 min by IV infusion [1]. The aim of the study was to assess dosing and drug blood levels of gentamicin and to propose guidelines for once daily gentamicin dosing applicable for the local scenario. Methods: Following ethical approval, a data collection form was developed and validated by 8 health care professionals. A total of 42 critically ill adult patients were collected by convenience sampling for patients satisfying inclusion and exclusion criteria and receiving treatment during the study period. A scenario analysis of gentamicin dosing in ITU was carried out. Patient medical records and drug treatment charts were reviewed for data related to gentamicin therapy. Drug blood levels of gentamicin, serum creatinine levels and sensitivity results were reviewed. Data was analyzed using SPSS version 20. Guidelines were proposed and validated by health care professionals. Results: A total of 42 critically ill adult patients (32 males and 10 females) with a mean age of 54 years were eligible for once daily gentamicin treatment and all had a baseline creatinine clearance of [20 ml/min. The treatment doses resulted in 36 % underdosing, 59 % correct dosing and 6 % overdosing (n = 198). Six patients had treatment stopped due to high gentamicin levels and renal issues. Validation of developed guidelines indicated that they were userfriendly, comprehensive, practical and beneficial. Conclusion: Underdosing or overdosing is still occurring and this highlights the relevance of the developed guidelines. Incorrect dosing occurred most frequently either because the patient’s weight and height were not taken or due to incorrect weight and height estimation, incorrect dosage adjustments and use of an inaccurate or outdated weight in medical records. Both patient’s weight and height are important information to calculate the appropriate dose [2]. References

Cycle 3

[1]

61.5 41.7

47.7 33.3 9.6

Emotional Social Physical Functioning Functioning Functioning

41.1

Fatigue

28.8

23.3

21.6

Global Health Status

Practical implications: Chemotherapy side effects should never be underestimated. Many advances have been made in the prevention of CINV and clinical pharmacists’ intervention should ensure individualised anti-emetic treatment.

8.6

13.5 3.1

Pain

Insomnia

Fig. 1 Mean scores for EORTC scales (n = 37)

9

Appetite Loss

Financial Difficulties

[2]

Calderdale and Huddersfield NHS Foundation Trust Antibiotic Guidelines [Internet]. 2007. Available from: http://www.formulary. cht.nhs.uk/pdf,_doc_files_etc/MMC/066_Antibiotic%20Guidelines %20-%20Dr%20Booklet/Gentamicin.pdf. Qureshi, I.; Habayeb, H.; Grundy, C. Improving the correct prescription and dosage of gentamicin. BMJ Quality Improv Report. 2012; 1. doi:10.1136/bmjquality.u134.w317.

Acknowledgements: Staff at the Intensive Therapy Unit.

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PP I-5: Recent prescribing patterns of psycholeptics in Norwegian nursing homes

Department of Pharmacy, Faculty of Medicine and Surgery, University of Malta, Msida, e-mail: [email protected]

Vibeke Lunden, Frode Skjold, Kjell H. Halvorsen

Background and objectives: Malta has 40,000 registered diabetic patients. The rate of diabetes and its complications have been on the increase which takes a huge toll on the patient, the patient’s families and the healthcare system [1]. The aims of this study were to recognize and to compare the motivation, drug treatment, biological markers and the current patient knowledge regarding lifestyle modifications of type 2 diabetes of patients visiting the Diabetes and Endocrine Clinic at Mater Dei Hospital (MDH) and 3 health centre diabetic clinics. Methods: An ethical approval for the study methodology was obtained from the University Research Ethics Committee. The selected patients received information about the study, were invited to participate and asked to sign the informed consent. One hundred type 2 diabetic patients were recruited by convenience sampling from each of the healthcare settings. Each patient was presented a questionnaire in order to obtain the required patient details, drug treatment, current knowledge and motivation regarding diet, physical activity, monitoring of blood glucose and blood pressure and undergoing cardiovascular, feet and eye examinations [2]. Fasting blood glucose level, total: high-density lipoprotein cholesterol (HDL-c), HbA1c and triglycerides (TG) were recorded from the computerized records. Results: A total of 193 patients completed this study; 98 patients from MDH and 95 patients from the 3 healthcare centres, with a mean age of 65 years old. 21.4 % visiting MDH and 8.4 % visiting health centres were smokers. 67.4 % of the patients visiting the health centres included physical activity in their daily regimen while only 32.7 % of the patients visiting MDH exercise regularly. Only 29.3 % from both healthcare settings always follow a nutritionist’s diet plan. Overall 74.6 % of the patients are on oral hypoglycaemic agents mainly metformin 500 mg or gliclazide 80 mg, 10.9 % on insulin and 7.8 % on both. By using the independent t-test, Table 1 was compiled which demonstrates a significant difference between the biological markers; HbA1c and fasting glucose level of patients visiting the 2 healthcare settings. 54 % recognize that the best eating plan is eating frequent small meals spaced throughout the day. 98 % are aware that fruits are vegetables should be included in their diet however 95 % also think that they should include high carbohydrate foods. 47 % are aware regarding the hypoglycaemic effect caused by anti-diabetic therapy and only 51 % carry a source of sugar at all times. Conclusions: There was no significant difference between the 2 healthcare settings with respect to patient knowledge. A significant difference was recognised in motivation and biological markers. Patients visiting the health centres were more motivated and biological markers values were more optimal. From the HbA1c and fasting glucose levels it was shown that blood glucose management was not optimal for patients from both settings indicating the need for pharmacists to participate in focused patient education for improving outcomes.

Department of Pharmacy, UiT The Arctic University of Norway, e-mail:[email protected] Background and objectives: Data from the Norwegian Prescription Database shows that about 90 % of the Norwegian population aged C70 years used prescription drugs in the period 2009–2013. In the same period, nervous system drugs (ATC-group N) was the third most frequently used drug class [1]. Approximately 40,000 patients live in Norwegian nursing homes [2]. A study investigating psycholeptic drug use (ATC-group N05) in older nursing home patients reported an increased drug load of these drugs during 1997–2009 [3, 4] Nursing home patients have also a more extensive drug load compared to patients receiving home care services [5]. At least one psycholeptic drug was used by 71 % of the nursing home patients in 2009 [3]. The aim of this study was to investigate the trends of psycholeptic drug use in Norwegian nursing home patients receiving multi-dose dispensed drugs from 2009 to 2013. Methods: Longitudinal study of nursing home patients in Norway aged C65 years. Data was obtained from Farmaka AS, one of three suppliers of multi-dose dispensed drugs. Total drug use and use of psycholeptics were analyzed on the patient level. Associations between psycholeptic drug use, gender, age and total number of drugs was examined in univariate analysis. Statistical analysis was performed using SPSS 22 for Windows. Results: The study included 27,301 patients (mean age 85.8 years, 67.3 % women). From 2009 to 2013, the use of psycholeptic drugs decreased significantly from 11.4 % to 8.3 %, antipsychotics from 3.2 % to 2.3 % and anxiolytics from 4.5 % to 2.5 %. However, the use of hypnotics and sedatives did not change significantly. The most commonly used psycholeptic drug was zopiclone (27.7 %). Overall, women used significantly more psycholeptic drugs than men. Conclusions: Previous studies have reported a continuously increasing trend in the use of psycholeptic drugs among nursing home patients. Our study suggests that after 2009, this trend has reversed for both antipsychotic- and anxiolytic drugs, but not for hypnotics and sedatives. Reasons for this shift needs to be further investigated. References [1]

[2]

[3]

[4] [5]

Berg, C.; Karlstad, Ø.; Mahic, M.; Odsbu, I. Reseptregisteret 2009–2013: Nasjonalt folkeheleseinstitutt; 2014. Available from: http://www.fhi.no/eway/default.aspx?pid=239&trg=Content_ 6510&Main_6157=6261:0:25,6753&MainContent_6261=6510:0: 25,7338&Content_6510=6259:110199:25,7338:0:6250:1:::0:0. SSB. Pleie og omsorgsstjenester 2013 [13.02.15]. Available from: http://ssb.no/helse/statistikker/pleie/aar-forelopige/2014-07 -08?fane=tabell&sort=nummer&tabell=186130. Ruths, S.; Sorensen, P.H.; Kirkevold, O.; Husebo, B.S.; Kruger, K.; Halvorsen, K.H.; et al. Int J Geriatr Psychiatry 2013; 28(8):868–876. Bakken, M.S.; Ranhoff, A.H.; Engeland, A.; Ruths, S. Scand J Prim Health Care 2012;30(3):169–175. Halvorsen, K.H.; Granas, A.G.; Engeland, A.; Ruths, S. Pharmacoepidemiol Drug Saf. 2012;21(9):929–936.

PP I-6: Comparison of patient knowledge regarding diabetes between health centre patients and the central Diabetic Clinic at Mater Dei Hospital Lilian M. Azzopardi, Leanne Bason, Anthony Serracino-Inglott

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References [1] [2]

Formosa, C. et al. Int. J Diabetes and Metab. 2012, 20, 25–29. Goldfine, A., Goldfine, H. Cardiovascular Disease in the Diabetic Patient Circulation. 2003, 107, 14–16.

Table 1 Mean values and p values of HbA1c and fasting glucose of patients visiting the 2 healthcare settings Health centre Mater Dei Hospital P value HbA1c

7%

Fasting glucose level 8.2 mmol/l

8% 9.3 mmol/l

\0.001 0.04

Int J Clin Pharm (Suppl 2015) 37:1–34 PP I-7: Patient benefit of a Medicines Use Review framework Anthony Serracino-Inglott, Matthew Camilleri, Lilian M. Azzopardi Department of Pharmacy, Faculty of Medicine and Surgery; University of Malta, Msida, Malta, [email protected] Background and objectives: Medicines Use Reviews (MUR) have been implemented in a number of countries with the aim to improve patients’ overall medication knowledge, identify drug related problems and promote quality use of both prescription and over-thecounter medicines. The objectives of the study were to propose a framework to identify and manage drug related problems for patients receiving medication for chronic conditions. Methods: Five validated and reliability-tested tools were developed for the scope of the study. Inclusion criteria were developed to include patients who are considered more at risk of developing drug related problems, namely patients of 60 years of age and over, patients taking more than 3 different medications, patients taking narrow therapeutic index drugs, patients taking insulin or insulin analogues and patients using inhalers. Ten community pharmacies in Malta were selected via stratified random sampling. Pharmacies were required to have a private area where the review could take place. Ethical approval was granted from the University Research Ethics Committee. A time frame of 3 months was allocated to contact patients within the inclusion criteria via convenience sampling when patients collected their medicinal products from their chosen pharmacy. If within the inclusion criteria, the patient was referred to the investigator (MC) by the dispenser. The study was explained and if signed consent was given, the MUR was undertaken. A yearly follow-up was done to assess impact of the service. Results: A total of 120 patients were recruited from all pharmacies during the first MUR. The patients consisted of 61 males and 59 females with 81 % being over the age of 51 years. The average number of medicines was of 5 medicines per patient (range 1–12 medicines). During the first interview, 662 interventions were made averaging 5.5 per patient. The most common intervention was found to be providing first time information regarding side-effects which amounted to 57 % of all the interventions carried out followed by non-compliance (8 %) and providing first time information regarding drug indications (8 %). In the follow-up, 317 interventions were made in the 95 patients who accepted to re-participate. A 30 % decrease in the number of interventions was observed during the follow-up. Conclusions: The developed framework was shown to be applicable and practical for the local community pharmacies scenario. The number of interventions undertaken indicates the significance of the service to ensure patient safety.

9 Methods: Approval from the Ethics Committee of the University of Tartu was granted. Ambulatory patients starting statin therapy (atorvastatin, rosuvastatin, simvastatin) in primary care setting in Tartu, Estonia, are recruited to participate in the study. Currently 24 patients are involved in the on-going pilot study. Of the study patients, 75 % are using polypharmacotherapy. The medication adherence is evaluated by using a combined study method: pre-structured interview, calculation of pill count adherence and electronic prescription claims data adherence (both at 1, 3, 6, 9 and 12 months) and taking blood samples for blood cholesterol (at 0, 6 and 12 months) and creatine kinase (at 0–12 months). Pre-structured interview was designed to provide information about general perceptions towards the use of medicines and medication adherence of the patients (at 0 month) and to evaluate the use of statins and possible factors for non-adherence of this therapy (at 1, 3, 6, 9, and 12 months). Results: Initial interview results demonstrate that negative general perception towards the use of medicines and medication adherence, asymptomatic disease and experienced malaise considered as possible side effect of statins has strong influence to the treatment compliance. More frequently described side effects are pain in legs and hands, itching skin, tiredness, sleep problems, leg cramps and dry mouth. Among the study patients 8.3 % (n = 2) have stopped taking statins and 20.8 % (n = 5) could be considered to the intermittent statin users group (e.g. stopped treatment temporarily). Among patients claimed regular use of statins (n = 17), the pill count adherence varied from 72–100 % at month 1 and 24–100 % at month 3, and electronic prescription claims data adherence varied from 57–100 % at month 1 and 64–100 % at month 3. Of the concomitantly used prescription medicines warfarin was identified as well-known medicine interacting with statins and may lead to the clinically relevant side effects. Conclusions: Negative beliefs about medicines and experience of potential side effects are some of the reasons for low adherence to statin therapy. About 1/3 of the study patients would benefit from the regular communication with healthcare specialists to understand better the need for compliance in statin therapy. Practice implications: Evaluation of medication adherence in primary care setting could be linked to the set of analysis evaluating statin related side effects or employed independently to identify potential risks to medication adherence of individual patients using statins.

Professional and inter-professional issues and pharmacy education

PP I-8: Statin therapy patients in primary care—monitoring medication adherence

OP II-1: General practitioners’ views on pharmacists in the primary health care system in Iceland

Triin Durejko1, Maia Gavronski2,3, Daisy Volmer1

Anna Bryndı´s Blo¨ndal1, Anna Birna Almarsdo´ttir2

1

Department of Pharmacy, Faculty of Medicine, University of Tartu, 1 Nooruse Str., 50411 Tartu, Estonia, [email protected]; 2General Practitioners Rauam and Gavronski, Medicum Tartu, 2 Turu Str., Tartu, Estonia; 3Department of Pharmacology, Centre of Excellence for Translational Medicine, Faculty of Medicine, University of Tartu, 19 Ravila Str., Tartu, Estonia

1

Faculty of Pharmaceutical Sciences and Research Institute for Pharmaceutical Outcomes and Policy, University of Iceland, Hagi, Hofsvallagata 53, 107 Reykjavı´k, Iceland, [email protected]; 2Institute of Public Health, Research unit of Clinical Pharmacology, University of Southern Denmark, J.B. Winsløws Vej 19/2DK-5000 Odense C, Denmark

Background and objectives: Treatment of atherosclerosis aims to prevent the condition from escalating to a serious cardiovascular disease by employing statins. Compliance among patients receiving statin treatment, however, has been relatively low. The objectives of this study are to monitor medication adherence of ambulatory patients who have started statin therapy and evaluate factors influencing the treatment compliance.

Background and objective: Interprofessional collaboration in the healthcare system involves different health care professionals using their specialized training to make significant contributions to patient care. General practitioners and pharmacist are examples of two such groups. Research to date has tended to focus on the effect of general practitioners–pharmacist collaboration on how the drug therapy changes and patient outcomes. However, little is known about general

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practitioners’ perspective on pharmacists’ provision of pharmaceutical care (medication review). Gaining insight into this aspect is important due to the necessity of close collaboration between these two healthcare providers. What are general practitioners’ perspectives on pharmacists as a healthcare profession, pharmaceutical care and the need for pharmacists providing pharmaceutical care in primary care in Iceland? Methods: Semi-structured in-depth interviews were conducted with twenty general practitioners from different Health Care Clinics in Iceland. All interviews were recorded and transcribed verbatim. The transcripts were categorized by concepts and then analyzed using a Grounded Theory methodology. Results: There are several unmet needs regarding medicines and patient monitoring in the Icelandic health care system. General practitioners suggested ways in which these gaps may be addressed and pharmacist-provided pharmaceutical care was one of the suggestions. Currently their communication with pharmacists in the primary sector solely surrounds practical non-clinical issues. Due to polypharmacy and various other drug related problems they find that pharmacists should be more involved in patient care. Conclusions and public health implications: Before establishing a service of pharmaceutical care in Icelandic primary health care clinics it is important to study whether the service is found to be needed by key collaborators. General practitioners believe that pharmacist-led pharmaceutical care can increase the quality of therapy in addition to improving drug treatment counseling to patients and other health care professionals.

hectic work and problems with patient record systems. At the individual and team level, problems related the most commonly to communication and the attitudes. As a solution, the interviewees considered that the responsibilities and tasks of each profession should be determined. Pharmaceutical expertise should be added to all over the healthcare. Interviewees perceived that interprofessional meetings and education could enhance collaboration between different professions. Conclusions: When developing interprofessional medication management of the aged, it is important to examine the challenges at the micro, meso and macro levels. A comprehensive operational program on the macro level is a prerequisite for taking the rational medication management to daily healthcare. Some challenges can be solved by clarifying responsibilities and enhancing communication between the actors. Information technology based solutions can also be utilized. Interprofessional collaboration should be systematically added to all healthcare education programs. The results can be utilized when developing the national guideline to optimize the rational medicines use of the aged.

OP II-2: Towards inter-professional networking in medication management: challenges and potential solutions

1

Sonja Kallio1, Anne Kumpusalo-Vauhkonen2, Timo Ja¨rvensivu3, Antti Ma¨ntyla¨2, Marika Pohjanoksa-Ma¨ntyla¨1, Marja Airaksinen1 1

Clinical Pharmacy Unit, Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Viikinkaari 9 C (PO Box 56), 00014 University of Helsinki, Finland, [email protected]; 2Finnish Medicines Agency, PO Box 55, 00301 Helsinki, Finland; 3Aalto University School of Business, Helsinki, Finland Background and objectives: Finnish Medicines Agency Fimea started a program in 2012 for enhancing interprofessional networking in medication management of the aged. The goal is to learn from experiences of existing interprofessional healthcare teams and to develop a national guideline for interprofessional medication management of seniors which is planned to be launched in 2015. Interviews of different healthcare professionals provided a basis for the national network of interprofessional teams. The objective of this study was to explore challenges and potential solutions experienced by healthcare teams in managing medications of the aged (1) at the individual and team level (micro level), (2) organizational level (meso level) and (3) structural level (macro level). Networking was used as a theoretical framework of the study. Methods: This qualitative study based on theme interviews (n = 15) of different healthcare professionals (n = 55). The interviews included group discussions (n = 10), pair interviews (n = 3) and individual interviews (n = 2) among teams involved in medication management of the aged and individuals interested in working interprofessionally. The interviews were conducted by Fimea in the formation phase of the network. Abductive content analysis combining both data and theory was applied for the analysis. Results: Challenges on interprofessional collaboration cited in the interviews occurred at all the levels. At the organizational and the structural levels, the main challenges included economic limitations,

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OP II-3: Medical technology education for pharmacy students and practicing pharmacists in the Nordic and Baltic countries Daisy Volmer1, Aleksandra Sokirskaja1, Raisa Laaksonen2, Kirtsi Vainio3, Niklas Sandler4, Kjell H. Halvorsen5, Reidun Kjome6, Sveinbjo¨rn Gizurarson7, Ruta Muceniece8, Baiba Maurina9, Jurgita Dauksiene10, Lilian Ruuben11, Ingunn Bjo¨rnsdottir12, Jyrki Heina¨ma¨ki1 Department of Pharmacy, Faculty of Medicine, University of Tartu, 50411 Tartu, Estonia, [email protected]; 2Division of Clinical Pharmacology, Faculty of Pharmacy, FI-00014, University of Helsinki, Helsinki, Finland; 3School of Pharmacy, University of Eastern Finland, FI-70211 Kuopio, Finland; 4Pharmaceutical ˚ bo Akademi University, FI-20520 Turku, Finland; Sciences, A 5 Department of Pharmacy, Faculty of Health Science, UiT The Arctic University of Norway, 9037 Tromsø, Norway; 6Department of Global Public Health and Primary Care, University of Bergen, 5018 Bergen, Norway; 7Faculty of Pharmaceutical Sciences, University of Iceland, 107 Reykjavik, Iceland; 8Department of Pharmacy, Faculty of Medicine, University of Latvia, LV-1050 Riga, Latvia; 9Faculty of Pharmacy, Riga Stradins University, LV-1007 Rı¯ga, Latvia; 10 Department of Drug Technology and Social Pharmacy, Faculty of Pharmacy, Medical Academy, Lithuanian; University of Health Sciences, 44307 Kaunas, Lithuania; 11Chair of Pharmacy, Tallinn Health College, 13418 Tallinn, Estonia; 12School of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, 0316 Oslo, Norway Background and objectives: Community and hospital pharmacists provide important counselling to patients using medical devices (MDs) and drug-delivery products (DDPs). The aim of this study was to assess the current medical technology education of MDs and DDPs for pharmacy students and pharmacists in Estonia, Finland, Iceland, Latvia, Lithuania and Norway. Methods: The questionnaire was completed by academic staff members, by B.Sc. or M.Sc. Pharm students and representatives of professional organizations of community and hospital pharmacy from May to October 2014 using an internet based study platform eFormular. Results: Total 50 responses were collected: 34 from academia and 16 from professional organizations. Seventy-four percent of the respondents considered professional knowledge about MDs as important for pharmacists. Of practicing pharmacists, 77 % reported to never participated in any continuing education courses about MDs and DDPs. At universities, the knowledge on MDs and DDPs was in most cases

Int J Clin Pharm (Suppl 2015) 37:1–34 obtained in the courses of medicine and pharmaceutical technology. In these courses, more theoretical than practical aspects were covered. Specialists of MDs or medical technology industry were more involved in the courses for practicing pharmacists (45 %) than for pharmacy students (28 %). More than the representatives of academia, the practicing pharmacists underlined the need for increasing the education about MDs for pharmacy students (53 % vs. 17 %) and importance of international courses about MDs (53 % vs. 18 %). Conclusions: There is an increasing need for professional knowledge about MDs and DDPs among pharmacy students and practicing pharmacists in the Nordic and Baltic countries. Networking for the effective exchange of existing knowledge on medical technology would foster to improve the competency of pharmacists in the field of MDs and DDPs in the future.

OP II-4: Interdisciplinary and structured drug reviews in primary health care–health personnel’s perceived value of participation Hege Therese Bell1,2, Ragnhild Omli R3,4, Anne Gerd Granas5, Ingela Enmarker4,6,7, Aslakk Steinsbekk2 1

Department of Pharmacy, Faculty of Health Sciences, Nord-Trondelag University College, Namsos, Norway, [email protected]; 2 Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway; 3 Department of Nursing, Faculty of Health Sciences, Nord-Trondelag University College, Namsos, Norway; 4Centre of Care Research, Steinkjer, Mid-Norway; 5Department of Life Sciences and Health, Faculty of Health Sciences, Oslo and Akershus University College, Oslo, Norway; 6Department of Health Sciences, Nord-Trondelag University College, Namsos, Norway; 7Department of Health Science, ¨ stersund, Sweden Mid-Sweden University, O Background and objectives: The Norwegian Patient Safety Programme [1] aims to establish interdisciplinary teams to initiate drug reviews in nursing homes and home care services in all Norwegian municipalities. Learning networks were established in each county. Our study is based upon the experiences from 6 interdisciplinary network teams. The aim of the study was to explore the perceived value of participation in structured interdisciplinary drug reviews in primary health care for different health care professionals. Methods: We recruited 3 focus groups [2] representing a small, a medium and a large municipality with a total of 13 participants from 6 teams (10 nurses, one pharmacist and two social educators). Interviews were digitally recorded, transcribed verbatim and analysed using systematic text condensation [3]. Results: The interdisciplinary systematic drug reviews were perceived to promote increased interprofessional knowledge, a raised awareness of appropriate drug use, a more holistic view on the patient and an increased sense of professional confidence. The main boundary reported was mixed motivation amongst physicians to take part in the drug reviews. Conclusion: The informants expressed that the interdisciplinary systematic drug reviews produced new clinical knowledge, which they would not have achieved as individual health care professionals. Further research must be performed to show whether this new clinical knowledge leads to more appropriate drug use. References [1] [2] [3]

Helsedirektoratet. I trygge hender. Oslo. http://www.pasientsikkerhetsprogrammet.no/no/I+trygge+hender Kitzinger, J. BMJ. 1995;311:299–302 Malterud, K. Scan J Public Health. 2012;40(8):795–805

11 OP II-5: A qualitative study of attitudes towards treatment of nausea in pregnancy among pregnant women and general practitioners Kristine Heitmann, Hans Christian Svendsen, Ingvild H. Sporsheim, Lone Holst University of Bergen; Department of global public health and primary care, Post Box 7804, N-5018 Bergen, [email protected] Background and objectives: Nausea and vomiting during pregnancy (NVP) is one of the most common pregnancy related complaints. NVP has great impact on a woman’s life with dramatic effects on the women’s social and occupational functioning [1]. The aim of this study was to explore thoughts and attitudes among Norwegian pregnant women and GPs on treatment of NVP, and to identify potential barriers against optimal care for women with NVP. Methods: Two separate focus group discussions were conducted with pregnant women and two with GPs in accordance with an interview guide to facilitate open discussion on pre-defined themes. In total, ten pregnant women and ten GPs were included. The transcripts were analysed according to the principles of systematic text condensation as described by Malterud [2]. The study was approved by the Regional Committee for Ethics in Medical Research, Region West, and the Norwegian Data Inspectorate. Results: This study identifies attitudes among both GPs and pregnant women that may act as obstacles to appropriate care of women suffering from NVP. The pregnant women experienced that their NVP had a big influence on their daily life, but was not taken seriously by their GPs. In general, they did not want to take medicines during pregnancy, but found sick leave to be helpful to be able to cope with NVP. The GPs found it very important to normalise NVP, telling the women that it is natural and nothing to worry about. They were uncertain about treatment, when advice on diet and lifestyle did not solve the problem. Sick leave was often a solution. The Thalidomide tragedy was brought up in all four discussions as an argument against taking/giving medicines in pregnancy. Conclusions: GPs need to acknowledge the extent of the problem of NVP and to gain the necessary knowledge about treatment options and recommendations. The pregnant women need good information from their GP before they will choose to take medicines when needed. References [1]

[2]

Attard, C.L.; Kohli, M.A.; Coleman, S.; Bradley, C.; Hux, M.; Atanackovic, G.; Torrance, G.W. Am J Obstet Gynecol 2002, 186:S220–S227. Malterud, K. Scand J Public Health 2012, 40:795–805.

PP II-1: A historical, social and ethnic study of pharmacy students at the University of Tartu in 1802–2014 Ain Raal1, Toivo Hinrikus1, Karmen Kapp1,2 1 Department of Pharmacy, University of Tartu, 1 Nooruse Str., 50411 Tartu, Estonia, [email protected]; 2Division of Pharmaceutical Biosciences, Faculty of Pharmacy, University of Helsinki, Viikinkaari 5E, 00014 Helsinki, Finland

Background and objectives: The University of Tartu was founded in 1632 by Gustav II Adolf, the King of Sweden. The history of the university can be divided into three periods: the founding period (1632–1800), the Russian imperial period (1800–1918) and the Estonian-language university (1918-present). In 1842, the first separate chair of pharmacy was opened. The aim of the study was to perform a

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historical, social and ethnic study of pharmacy students at the University of Tartu in the years 1802–2014. Methods: The data was collected from the student roll books in the Estonian Historical Archives and additional sources such as the Tartu University Archives, books ‘‘Report on the Students of Tartu University’’ and ‘‘The Oldest Pharmacies of Livonia and Estonia’’. The electronic database was tabulated using the computer program MS Excel. The database contains student roll number; name; year of birth; place of birth; parents’ social standing; nationality, years of entrance and exit or graduation; ethnicity; school formerly graduated [1]. Results: In the years 1802–2014, 6925 students studied pharmacy at the University of Tartu and 4309 graduated in the speciality. No data about the graduation or exit of 1969 students could be found in the archives. The most common place of birth was Tartu and the Tartu region (14 %). 42 % of the students were 21–25 years old. The majority (95 %) of the students were Estonians. At the end of the 19th century, russification of the university resulted in Russian being made the official language of teaching. This resulted in a decrease of ethnically German and an increase in ethnically Estonian students. Changes in admissions policies have led to an increased number of Russian speaking students among graduates since the year 2004. Of the total 6925 students, 2441 were females. Since the year 1926, women have constituted the majority among students. Conclusions: During the years 1802–2014, students with diverse ethnical and social background have studied pharmacy at the University of Tartu. The collected data reflects the geopolitical and social changes in University of Tartu and Estonia. Reference [1]

Kapp, K.; Talv, S.; Hinrikus, T.; Raal, A. Pharmazie 2012, 67, 658–664.

PP II-2: The impact of curriculum reform to the professional competency of pharmacists–perceptions of MSc pharmacy students in Estonia Marianne To˜kke1, Daisy Volmer1, Ain Raal1 1 Department of Pharmacy, Faculty of Medicine, University of Tartu, 1 Nooruse Str., 50411 Tartu, Estonia, e-mail: [email protected]

Background and objectives: At the University of Tartu, Estonia, the pharmacy curriculum was last modified in 2007 with increase of pharmaceutical technology related, medicinal subjects and introduction of clinical pharmacy concept. The current pharmacy curriculum is pharmaceutical product oriented, based on medicinal subjects and designed to prepare the future pharmacists for cooperation in healthcare team. The objectives of this research were to evaluate perception of MSc pharmacy students at the University of Tartu towards pharmacy education and professional competency related to curriculum reforms. Methods: A descriptive, questionnaire-based study was conducted amongst all 4th year MSc pharmacy students in between 2005–2013. Results: In total 309 MSc pharmacy students participated in the study. The mean age of the respondents was 24 years and majority of the students were female (85 %). Majority of the students described perceived theoretical knowledge as broad and diverse. They recognized the curriculum reforms and introduction of disciplines supporting their better professional competency as future pharmacists. On the other hand, in the future they would expect more intertwined approach of theory and practice within all five study years. To fill in the current gap, about 35 % of the students have been working as supportive staff mainly at community pharmacies during their studies.

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Pharmacy students’ understanding about the professional role of pharmacists has changed—pharmacist is primarily seen as a recognized member of healthcare team and a professional about medicines and healthcare issues (p \ 0.01). Within all study years about 50 % of all students have considered professional career at community pharmacy. In 2010–2013 the interest towards working at hospital pharmacy or pharmaceutical industry has considerably increased, being every year 53 % and 57 %, respectively. Described change could be connected with curriculum reform. As the number of named positions is limited in Estonia, pharmacy students could be more guided about how to employ the perceived professional knowledge at community pharmacy—the largest employment possibility for pharmacists in Estonia. Conclusions and implications to practice: Curriculum reforms have given encouragement to MSc pharmacy students to act as full members of healthcare team. In the future they would like to see theoretical professional knowledge more connected to practice. MSc pharmacy students’ feedback to the curriculum reforms is a valuable source of information and could be used in redesigning the pharmacy curriculum at the University of Tartu in the future.

PP II-3: Exploring the pharmacist’s intervention roles based on a literature survey Bilge So¨zen Sahne, Selen Yegenoglu Hacettepe University, Faculty of Pharmacy, Department of Management, Sıhhiye-Ankara, Turkey 06100, [email protected] Background: In today’s world pharmacists roles expanded heavily compared to past and went beyond merely dispensing the medicine. However pharmacists those provide healthcare services directly to the people are more intensely located in community pharmacies and in hospitals. In the light of this fact, they perform various healthcare services changing from medication management therapy to educating patients as well as healthcare professionals. Objectives: Pharmacist’s intervention roles in healthcare services may differ from country to country. Yet exploring these roles has not been an aim of a study involving the recent years. Thus the aim of this study is to present the current interventions performed by pharmacists in various countries based on a literature survey. Methods: We conducted a literature survey via PubMed by using the keyword ‘‘healthcare services pharmacist intervention’’ for the last five years. Selection of the articles were in the light of the followings: Inclusion criteria of the articles were based on: (1) direct intervention of pharmacist, (2) reaching the full text, (3) research studies published in English. Afterwards we classified the studies according to their origin of the country, setting, type of targeted disease/health condition and outcome. Results: Pharmacist’s intervention studies vary from country to country. Of the 259 articles 109 were eligible for our study concerning our inclusion and exclusion criteria. Most studies are US origined and intervention studies were in a wide range like cardiovascular, diabetes, respiratory diseases, etc. For instance, with an appropriate intervention, after discharging patients’ compliance to their medicines improve on their recovery period. However, there are examples of interventions without improvement as well. Conclusions: Pharmacists have various intervention roles in order to help improving the healthcare status of the community members. On the other hand sometimes these intervention studies do not make any difference on patients’ health. But generally it can be concluded that as a healthcare professional most of their interventions have a positive impact on patients’ health and are of value. For a good intervention, pharmacists have to present their communication skills and clinical

Int J Clin Pharm (Suppl 2015) 37:1–34 knowledge. Also, teach-back method will be helpful for the success of the interventions.

PP II-4: Perception of medical practitioners on antibiotic prescribing by pharmacists Lilian M. Azzopardi, Maresca Attard-Pizzuto, Anthony Serracino-Inglott University of Malta, Department of Pharmacy, Faculty of Medicine and Surgery, Msida, Malta, [email protected] Background and objectives: Optimising antimicrobial use through appropriate selection, driven by a multidisciplinary team, improves patient safety by achieving a desired clinical outcome, reducing harm to patients and decreasing potential for selection of resistant strains of pathogens [1]. This study aims to assess medical practitioners’ perceptions on antibiotic prescribing by pharmacists. Methods: A questionnaire to study medical practitioners’ perceptions on antibiotic prescribing by pharmacists and to establish pharmacists’ contribution in prescribing and dispensing antibiotics was developed. The questionnaire was validated using the Delphi technique [2] and disseminated to 376 medical practitioners practising in primary and secondary care in Malta. Questions asked include rating pharmacists’ competence to prescribe broad-spectrum antibiotics to treat common infections on a 5-point Likert scale and identifying potential problems should antibiotic prescribing rights be given to pharmacists. Results: One hundred fifty-four medical practitioners answered the questionnaire, obtaining a response rate of 41 %. Pharmacists are regarded as being competent to treat common infections by 8 % of practitioners, 37 % have no opinion and 14 % think pharmacists are not competent at all. Medical practitioners think that the topical antibiotics fusidic acid and mupirocin are the most appropriate to be prescribed by pharmacists for bacterial skin infections at 24 % and 22 % respectively. This is followed by gentamicin and chloramphenicol drops for bacterial conjunctivitis both at 15 %. The majority of respondents (68 %) do not agree that pharmacists are given prescribing rights. Reasons given are that pharmacists are not qualified to clinically examine patients (78 %), pharmacists do not have access to patient medical records (60 %) and lack of privacy in local pharmacies (49 %). When asked whether practitioners will experience a potential decrease in the number of patients if pharmacists were to prescribe antibiotics and thus be affected financially, 16 % strongly agreed with the statement. Conclusions: The results indicate that a number of medical practitioners do not have an opinion on pharmacist prescribing of antibiotics. Relevant patient risks if prescribing is undertaken by the pharmacist as opposed to other prescribers are not clearly outlined by evidence-based justifications. References [1]

[2]

Glowacki, R.C.; Schwartz, D.N.; Itokazu, G.S.; Wisniewski, M.F.; Kieszkowski, P.; Weinstein, R.A. Clin. Infect. Dis. 2003, 37, 59–64. Attard Pizzuto, M; Serracino Inglott, A.; Azzopardi, L.M. ACCP Conference Abstract. 2014, May.

PP II-5: Education of pharmacy technicians and their role in community pharmacies in Lithuania and Estonia— comparative analysis Dovydas Daunys1, Edita Kizeviciene1, Jonas Grincevicius1,2, Regina Motien_e1, Jurgita Dauksiene1,2, Alar Sepp3

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Kaunas University of Applied Sciences, Faculty of Medicine, 44162, Kaunas, Lithuania, [email protected]; 2Department of Drug Technology and Social Pharmacy, Faculty of Pharmacy, Medical Academy, Lithuania; University of Health Sciences, 44307 Kaunas, Lithuania; 3Tallinn Health Care College, 13418 Tallinn, Estonia Background and objectives: The pharmaceutical service in community pharmacies cannot exist without pharmacy specialists. Pharmacist and pharmacy technician demonstrate team work skills in order to provide high quality services to the community pharmacy patients. The experience of other countries shows that a pharmacy technician provides essential support to the pharmacist in areas including prescription entry, third party insurance management, staff/patient scheduling and inventory control. Delegating these responsibilities to the technician allows the pharmacist to focus on prescription accuracy, interact with patients more intensively while providing medication therapy management services and fulfill administrative duties. The study aim was to compare the education of pharmacy technicians (assistant pharmacist) and their role in community pharmacies in Lithuania and Estonia. Methods: The methods of anonymous Internet survey and document analysis were applied. The questionnaire was completed by 640 respondents (students and teachers): 313 from Tallinn Health Care Collage and 327 from Kaunas University of Applied Sciences, faculty of Medicine. The age ranged from \20 to 61 years or more. The education systems, pharmacy technician’s functions in community pharmacies in Lithuania and Estonia were observed. Results: Pharmacy technician (assistant pharmacist) education in Lithuania and Estonia is similar, but it has some differences as well. In both countries specialists must study for 3 years and have approximately the same 180 of ECTS credits for all subjects. Estonian students of pharmacy technique have more practice and pharmacotherapy lectures than Lithuanian students. However, Lithuanian students have more study hours in pharmaceutical technology. There are also some differences in pharmacy regulation fields: e-prescription system and special queue management system have already been introduced in Estonia, however in Lithuanian community pharmacies it is only on planning level yet. However, all pharmacy specialists (both in Lithuania and Estonia) are participating in the public health strengthening and improvement. Pharmacy technicians (assistant pharmacists) are competent advisers for the citizens, drugs and disease experts. More than half of respondents in both countries rate the assistant pharmacist’s (pharmacy technician’s) knowledge related to prescription medicines as good or very good. In Lithuania approximately of respondents (24 %) and 30 % of Estonian respondents rate the pharmacy technician’s (assistant pharmacist’s) knowledge on prescription medicines as very good. 65 % of Lithuanian and 60 % of Estonia respondents rate pharmacy technician’s knowledge on prescription medicines as good. Almost the same numbers were indicated concerning non-prescription medicines, what means that our pharmacy specialists are really good and competent in both countries. In Lithuania approximately 2/3 of respondents while only more than of Estonian respondents use family doctor. Conclusions: In both countries respondents usually ask pharmacy technician (assistant pharmacist) for support, and they are always ready to help the respondents. The respondents in both countries rate pharmacy technicians’ (assistant pharmacists’) knowledge on nonprescription and prescription medicines as very good or good. The biggest difference was in the opinion of respondents on who is the primary source of medical information: Lithuanian respondents named the general practitioner as the main source of medical information while Estonian colleagues admitted that pharmacy technician is the primary source of this kind of information.

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14 PP II-6: The production of a framework of competences for pharmacy practice in the European Union: the PHAR-QA project Jeffrey Atkinson1, Kristien De Paepe2, Antonio Sa´nchez Pozo3, Dimitrios Rekkas4, Daisy Volmer5, Jouni Hirvonen6, Borut Bozic7, Agnieska Skowron8, Constantin Mircioiu9, Annie Marcincal10, Andries Koster11, Keith Wilson12 1 Pharmacolor Consultants Nancy, 12 rue de Versigny, Villers 54600, France, [email protected]; 2Vrije Universiteit Brussel, Laarbeeklaan 103, Brussels 1090, Belgium; 3University of Granada, Campus Universitario de la Cartuja s/n, Granada 18701, Spain; 4 National and Kapodistrian University Athens, Panepistimiou 30, Athens 10679, Greece; 5University of Tartu, Nooruse 1, Tartu 50411, Estonia, [email protected]; 6University of Helsinki, Yliopistonkatu 4, P.O. Box 33-4, Helsinki 00014, Finland; 7University of Ljubljana, Askerceva cesta 7, Ljubljana 1000, Slovenia; 8Jagiellonian University, Golebia 24, Krakow 31-007, Poland; 9University of Medicine and Pharmacy ‘‘Carol Davila’’ Bucharest, Dionisie Lupu 37, Bucharest 020021, Romania; 10Universite´ de Lille 2 (UL), Lille 59000, France; 11European Association of Faculties of Pharmacy, Utrecht University, PO Box 80082, 3508 TB Utrecht, The Netherlands; 12Aston University, Birmingham, B4 7ET, UK

Background and objectives: The goal of the PHAR-QA (Quality assurance in European pharmacy education and training) project is the production of a European framework of competences for pharmacy practice. This PHAR-QA framework (www.phar-qa.eu) will be European and consultative i.e. it will be used for harmonization—but will not to replace existing national QA systems. Methods: Using the proposals for competences produced by the previous PHARMINE (Pharmacy education in Europe; www.pharmine.eu ) project, together with those of other sources, the authors produced a list of 68 personal and patient care competencies. Using internet survey tools the stakeholders—European pharmacy community (university department staff and students, community, hospital and industrial pharmacists, as well as pharmacists working in clinical biology and other branches, together with representatives of chambers and associations)—were invited to rank the proposals and add comments. Results and conclusions: Pharmacology and pharmacotherapy together with competences such as ‘‘supply of appropriate medicines taking into account dose, correct formulation, concentration, administration route and timing’’ ranked high. Other topics such as ‘‘current knowledge of design, synthesis, isolation, characterisation and biological evaluation of active substances’’ ranked lower. Implications for practice: In the short term, it is anticipated that this survey will stimulate a productive discussion on pharmacy education and practice by the various stakeholders. In the long term, this framework could serve as a European model framework of competences for pharmacy practice. Acknowledgements: With the support of the Lifelong Learning programme of the European Union: 527194-LLP-1-2012-1-BEERASMUS-EMCR. This publication reflects the views only of the authors; the Commission cannot be held responsible for any use which may be made of the information contained therein.

Patient safety, pharmacoepidemiology and pharmaceutical policy OP III-1: Socio-demographic characteristics of prescribing second line lipid-lowering medicines: ezetimibe as switch from statin therapy or as add-on therapy

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Int J Clin Pharm (Suppl 2015) 37:1–34 Helle Wallach Kildemoes, Ebba Holme Hansen University of Copenhagen, Department of Pharmacy, Section of Social and Clinical Pharmacy, Universitetsparken 2, 2100 Copenhagen Ø, Denmark, [email protected] Background: Ezetimibe, a newer type of lipid lowering medicine (LLM), has been introduced as an alternative to statin therapy when statins are not tolerated (switch) or as add-on to statin therapy to reach lipid goals. Yet, while ezetimibe reduces lipid-levels, the evidence on reducing the risk of cardiovascular events has not been established. Objective: The aim of this cohort study was to investigate sociodemographic factors as predictors for dispensing ezetimibe as switch from statin therapy or as add-on therapy. Methods: A cohort of all Danish inhabitants aged C30 years who redeemed at least one statin prescription and no ezetimibe prescription in 2010 was followed during January 1, 2011 to December 31, 2012 in the Danish individual-level registries on prescriptions, inhospital and socio-demographic informations. Prevalent statin users with and without statin discontinuation within 365 days after the first statin prescription in 2011 were followed for redeemed ezetimibe prescription during this period. Logistic regression analyses was used to explore socio-demographic predictors i.e. gender, age and socioeconomic position (education and household income) for redeeming ezetimibe as switch or add-on therapy. Statin type dispensed (medium versus high-potency) and indication for LLM-therapy were applied as additional explanatory variables. Odds ratios (OR) with 95 % confidence intervals (CI) were calculated. Results: Among 442.761 prevalent statin users, 2.8 % redeemed ezetimibe as add-on therapy Women were more likely than men to be prescribed ezetimibe both as add-on therapy (OR: 1.37; CI: 1.21–1.54), and as switch (1.65; 1.40–1.93). While odds for add-on therapy decreased with age in men, odds in women were independent of age until the age of 75. After adjustment for education, odds for both add-on and switch tended to increase with income. Use of higher-potency statins (atorvastatin or rosuvastatin) mediated the effect of education and was the most important predictor both for ezetimibe as add-on therapy (5.56; 4.95–6.24) and as switch (4.53–4.83). Conclusions: Being female in higher age was a more important predictor for redeeming ezetimibe than socioeconomic factors; both for switch and add-on therapy. The most important predictor was use of higher-potency statins; especially for add-on therapy.

OP III-2: Physicians’ experiences with NORGEP criteria and the use of inappropriate medication in elderly patients in nursing home and home care service Mari-Ann Gaup, Kjell H. Halvorsen Department of Pharmacy, Faculty of Health Science, University of Tromsø, 9037 Tromsø, Norway, [email protected] Background and objectives: Previous studies have revealed a range of problems in nursing home and home care service patients [1, 2]. The NORGEP (The Norwegian General Practice) criteria [3] aim at detecting potentially inappropriate prescribing in older people. NORGEP criteria is an assessment tool designed for physicians. The tool is list of adverse drugs and drug combinations for the elderly over 70 years. The list consists of 36 criteria, criteria based on Beers criteria, Swedish recommendations and other Norwegian studies. NORGEP criteria was developed in 2009 and was adapted to elderly population in Norway. The aim of this study was to investigate how nursing home physicians and general practitioners’ cope with inappropriate prescribing, their own experiences of using NORGEP criteria in clinical work, and how inappropriate prescribing could be reduced.


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Design: We conducted semi-structured individual interviews of five nursing home physicians and five general practitioners within the municipality of Tromsø. Data was analyzed using systematic text condensation. Four researchers independently quoted and created categories for emerging themes. Results: Organizational problems in the health care system often hindered physicians to keep track of patients prescribing, and thus resulted in inappropriate medication. Most physicians were familiar with the NORGEP criteria, but did not use them systematically. Physicians described it was challenging treating elderly patients with physiological age changes, multimorbidity and polypharmacy, and found that it led to the use of inappropriate medications. To reduce inappropriate prescribing, physicians suggested implementing the NORGEP criteria within the computerized clinical decision support systems. They also expressed that interdisciplinary collaboration could be helpful to deal with inappropriate medications. Conclusions: Physicians have different strategies to cope with suboptimal prescribing. They presented different ideas how to improve good prescribing including computerized clinical decision support systems and interdisciplinary collaboration.

Amongst the professional organization representatives, one important rationale for the reregulation was to get better use of the pharmacists’ knowledge. All the professional organization representatives, and some of the patient organization representatives, thought that after the reregulation the counseling in the pharmacies has deteriorated. None of the political organization representatives thought that the reform had improved the use of medicines. A perceived effect of the reregulation was, by all the stakeholder groups, less availability to prescription medicines in the pharmacies. As expected in the interviews, the post-reregulation pharmacy sector consists of more pharmacies. However, one assumption in the interviews was that the amount will decrease in the future. Conclusions: This study shows that the political organization representatives had an ideological basis for their argumentation. The political stakeholders did not have a clear view about what the reregulation should lead to, apart from abolishing the state owned monopoly. The perceived effects are quite similar in the different stakeholder groups, and not as positive as the expectations.

References

[1]

[1] [2]

[3]

Halvorsen, K.H.; Granas, A.G.; Engeland, A.; Ruths, S. Pharmacoepidemiol Drug Saf. 2012; 21(9):929–936. Larsen, J. Correct use of drugs in elderly in nurse home and home care service within the municipality of Tromsø. Development Center for nurse home and home care service, Troms: 2012. Rognstad, S.; Brekke, M.; Fetveit, A.; Spigset, O.; Wyller, TB; Straand, J. Scand J Prim Health Care. 2009; 27(3):153–159.

OP III-3: The innovation that never came true-stakeholders views of the perceived effects of the reregulation of the Swedish pharmacies Kristin Wisell1, Sofia Ka¨lvemark Sporrong2, Ulrika Winblad3 1 Department of Pharmacy, Uppsala University, SE-751 23 Uppsala, Sweden, [email protected]; 2Department of Pharmacy, University of Copenhagen, Universitetsparken 2, 2100 Copenhagen, Denmark; 3Department of Public Health and Caring Sciences, Uppsala University, SE-751 22 Uppsala, Sweden

Background and objectives: The Swedish pharmacies were prior to 2009 organized in a state owned monopoly. In 2009, a reregulation of the Swedish pharmacy sector took place, where a majority of the pharmacies were sold to private owners. The rationales for this reregulation changed profoundly during the preparatory work [1], making it probable that other rationales than the ones first expressed existed for this reform. This study explores key stakeholders’ views and arguments on the reregulation. Other objectives are to reveal perceived unpredicted effects of the reregulation, and ideas about possible future developments in the Swedish pharmacy market. Methods: A semi-structured interview design was chosen. Interviews were conducted with representatives from key stakeholder organizations; i.e. political, patient and professional organizations. The analysis was performed in steps, inspired by Malterud [2]. Results: One expectation about the reregulation amongst the political organization representatives was that the reregulation would create opportunities for ideas. The competition introduced in the market was supposed to lead to a more diversified pharmacy sector. After the reregulation, the informants in favor of a reregulation were surprised that the pharmacies were so similar to each other.

References

[2]

Wisell, K.; Winblad,U.; Ka¨lvemark Sporrong, S. Reregulation of the Swedish pharmacy sector—a qualitative content analysis of the political rationale. [Article in Manuscript]. Malterud, K. Scand J. Public Health. 2012, 40: 795.

OP III-4: Health impacts of cost-related prescription deferral: evidence from New Zealand Pauline Norris1, Santosh Jatrana2, Ken Richardson3, Peter Crampton4 1 University of Otago, School of Pharmacy, Box 56, Dunedin, New Zealand, [email protected]; 2Alfred Deakin Research Institute, Deakin University Waterfront Campus, Geelong, Victoria3220, Australia; 3Department of Public Health, Wellington School of Medicine and Health Sciences, University of Otago, PO Box 7343, Wellington, New Zealand; 4Division of Health Sciences, University of Otago, Box 56, Dunedin, New Zealand

Background and objectives: The amount patients pay for their medicines and the design of copayment systems vary substantially between countries. In New Zealand almost all patients pay $5 (3.13 Euro) per medicines for almost all medicines. There is international evidence that prescription charges can reduce use of medicines [1, 2], and can lead to higher use of other health services [3, 4]. In New Zealand 6.4 % of adults reported deferring picking up one or more prescription items because of cost [5]. This study aimed to examine the association between cost-related non-collection of prescription medication and health status. Methods: We data from Statistics New Zealand’s SoFIE-(Survey of Family, Income and Employment) Health. SoFIE is an 8 year (2002–2010) longitudinal household panel survey that includes a wide range of socio-economic and demographic questions. 17,363 participants with at least two observations in three waves were included in our analyses. We examined the relationship between not collecting a prescription because of cost, and three health measures: self-rated health (SRH: 1–5 where 1 is ‘‘excellent’’), physical health (PCS: 0–100 where 100 indicates no limitations) and mental health summary scores (MCS: 0–100, where 100 indicates no problems). We modelled health outcomes using a linear fixed effects model. Ethnicity, age, and gender were treated as timeinvariant covariates, and labour force status, marital status, family structure, both small area and individual measures of socio-economic deprivation were treated as time-varying confounders.

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Results: After adjusting for time-varying confounders, non-collection of prescription(s) was associated with declines of 0.11 (95 % CI 0.07–0.15) in SRH, 1.00 (95 % CI 0.61–1.40) in PCS, and 1.69 (95 % CI 1.19–2.18) in MCS. Non-collection of prescriptions due to cost was associated with a greater decline in SRH for males than for females and a greater decrease in MCS for males. The interaction of the main exposure with age was significant for SRH. Non-collection of prescriptions due to cost was associated with a decline in SRH for those aged 15–24 year olds and 25–64, but for respondents aged 65 years and over non-collection of prescriptions had no significant effect on SRH. Conclusions and implications to practice: Even very small prescription charges can prevent some people (presumably those with poor health and low incomes) accessing medicines that are important to the maintenance of their health. Healthcare professionals and policy makers should be aware that for some patients even a small charge can be a barrier to accessing healthcare.

psychotropics more often simultaneously (20.4 % vs. 3.8 %, p \ 0.001) than all drug users. Conclusions: The drug users of at least 10 different drugs with high drug costs account for over one fifth of the total pharmaceutical expenditures but only 3 % of all the drug users. Over half of the highcost polypharmacy drug users have a drug-related problem according to chosen indicators of inappropriate drug use, whereas the same is true for about one in ten of all the drug users. Implications to practice: The patients with excessive polypharmacy and high drug costs provide a most interesting group for containing pharmaceutical costs via medication reviews. References [1] [2]

References [1] [2] [3] [4] [5]

Joyce, G., et al. JAMA, 2002. 288(14):1733–1739. Lexchin, J. and P. Grootendorst. Int J Health Serv. 2004. 34(1):101–122. Tamblyn, R., et al., JAMA, 2001. 285(4):421–429. Goldman, D., G. Joyce, and Y. Zheng. JAMA, 2007. 298(1): 61–69. Jatrana, S., P. Crampton, and P. Norris. J Epidemiol Community Health, 2010. 65(5): p. 454–460.

[3] [4]

Saastamoinen, L.K.; Verho, J. Eur J Health Econ 2013, 14(3), 495–502. Fialova, D.; Topinkova, E.; Gambassi, G. et al. JAMA 2005, 293(11), 1348–1458. Buck, M.; Atreja, A.; Brunker, C.P. Am J Geriatr Pharmacother 2009, 7(2), 84–92. Lau, D.T.; Mercaldo, N.D.; Harris, A.T. et al. Alzheimer Dis Assoc Disord 2010, 24(1), 56–63.

PP III-1: Feasibility of a practical nurse-administered risk assessment tool for drug-related problems in home care Maarit S Dimitrow1, Saija NS Leikola2, Sirkka-Liisa Kivela¨1, Sanna Passi3, Pirjo Lukkari3, Marja SA Airaksinen1

OP III-5: Register-based indicators for potentially inappropriate medication in high-cost patients with excessive polypharmacy Leena Saastamoinen, Jouko Verho The Social Insurance Institution, Research Department, P.O. Box 450, 00101 Helsinki, Finland, [email protected] Background and objectives: Drug expenditures are heavily skewed, with 5 % of the Finnish population accounting for nearly half of the total costs of reimbursed drugs [1]. A considerable share of patients in the top 5 % of the cost distribution has excessive polypharmacy. Excessive polypharmacy is often associated with inappropriate drug use [2–4]. The aim of this study was to review the quality of drug use in patients with extremely high costs and excessive polypharmacy and to compare them with all drug users. Methods: This is a nation-wide register study including all patients in Finland over 15 years of age (n = 3,303,813) using reimbursed medicines in 2011. Patients in the top 5 % of the cost distribution with over 10 drugs used within a three months’ period were included. The data were extracted from the Finnish Prescription Register. Patients with high costs and polypharmacy were compared to all drug users based on annual total drug costs, the average drug costs per patient, and the number of patients. The background characteristics included gender, age, morbidity, the active substance of the drug, and indicators for potentially inappropriate drug use, for example, Beer’s criteria and anticholinergic use based on the recommendation of the National Board of Health and Welfare in Sweden. Results: The patients with high costs and excessive polypharmacy accounted for 22 % (365 million euros in 2011) of the total pharmaceutical expenditures but only 3 % of drug users.. One third of these patients were elderly, compared to 11.3 % of all drug users (p \ 0.001). Almost all of them, 93.6 %, had at least one chronic disease compared to 34.0 % of all the drug users (p \ 0.001). The high-cost polypharmacy patients used more potentially inappropriate (28.0 % vs. 19.9 %, p \ 0.001) and anticholinergic drugs (26.7 % vs. 9.6 %, p \ 0.001) and

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University of Helsinki, Faculty of Pharmacy, Clinical Pharmacy Group, PL 56, 00014 Helsingin yliopisto, Helsinki, Finland, [email protected]; 2Association of Finnish Pharmacies, Pieni Roobertinkatu 14 C, 00120 Helsinki, Finland; 3The Finnish Pharmacists’ Association, Ma¨kela¨nkatu 2 A, 00500 Helsinki, Finland Background and objectives: The demand for long-term home health care services for the aged is increasing. Practical nurses (PNs) are the health care providers who most often visit home care (HC) clients and thus, are in a key position to monitor the risks and benefits of medication. We developed and content validated a drugrelated problem (DRP) risk assessment tool to be used by PNs caring for home-dwelling clients aged C65 years [1]. The Tool consists of 18 items that assess highest priority risks for DRPs. It is divided into 4 sections: (1) basic client data, (2) potential risks for DRPs in medication use, (3) characteristics of the client’s care and adherence, and (4) recommendations for actions to resolve DRPs. This study aims to evaluate the feasibility of the Tool among PNs in HC. Methods: The study was conducted during March and June 2011. Altogether 36 PNs participated in the study. They were trained about the purpose and use of the DRP Risk Assessment Tool. The training consisted of a day long interactive workshop and involved reviewing four self-selected clients’ medications using the Tool (one as a preassignment before, and three as post-assignments after the workshop). The data of this study were collected during the training. Triangulation, i.e., combination of methods and data was used to evaluate the feasibility of the Tool. Quantitative data were gathered from completed post-assignments and qualitative data from face-to-face discussions during the workshop and open questions in the feedback forms. Results: The time reported by the PNs having spent in completing the Tool varied from 10–45 min (median 20, mean 20.3 ± 8.). They had identified reliably most (88 %) of the risk medicines used by the clients listed in the Tool. According to the returned feedback forms (n = 23) almost half of the respondents (43 %) reported that they felt

Int J Clin Pharm (Suppl 2015) 37:1–34 it easy or quite easy to answer the questions of the Tool. Generic names of medicines, time constraints, home-care workers’/client’s remissness to client’s pharmacotherapy and short client contacts were the most common barriers to use the Tool. Conclusions: The DRP Risk Assessment Tool turned out to be feasible among PNs. The brief training on the content and use of the Tool seems to be sufficient for assuring reliable use of the Tool. Reference [1]

Dimitrow, M.; Mykka¨nen, S.; Leikola, S.N.S.; Kivela¨, S-L.; Lyles, A.; Airaksinen, M. Eur J Clin. Pharmacol. 2014, 70, 991–1002.

17 causes were identified as: lack of knowledge (43), communication failure/problem (30) and technology (11). There is only a small bias in the system, caused by the reporting colleagues. They have to decide, which errors to report. Conclusions: Based on our present data we are already able to identify a number of risk factors that most likely cause medication errors. With this information we have a means to develop specific strategies to avoid medication errors while keeping human and financial resources at an optimum by sharing the knowledge all over Europe. The database should be enrolled in the future in more European countries.

PP III-3: The patterns of antibiotics drug prescription by physicians in south of Iran (Shiraz) PP III-2: Identification of risk factors frequently associated with medication errors (PEPPAS) Pamela Kantelhardt1, Andras Su¨le2, Thorunn K Gudmundsdottir3, Marika Saar4 1

University Hospital of Mainz, Neurosurgery, Langenbeckstrasse 1, 55129 Mainz, Germany, [email protected]; 2Peterfy Hospital and Trauma Center, Hospital Pharmacy, Budapest, Hungary; 3Landspitali The National University Hospital of Iceland (LSH), Hospital Pharmacy, Reykjavik, Iceland; 4Tartu University Hospital, Hospital Pharmacy, Tartu, Estonia Background and objectives: Medication errors are a major problem for patient safety all over Europe. To avoid medication errors a better knowledge about the respective risk factors as well as the type of an error and the cause of it is necessary. It is therefore essential to document medication errors and later on to identify the risk factors out of these data. To learn from other countries as well as to share strategies to avoid medication errors we invented the PEPPAS (PanEuropean Project for Patient Safety). Methods: We invented the German medication error reporting system DokuPIK (Dokumentation Pharmazeutischer Interventionen im Krankenhaus = Documentation of pharmaceutical interventions in hospitals, developed by the German Association of Hospital Pharmacists) in Iceland, Estonia and Hungary. DokuPIK is a critical incident reporting system to collect data in the field of medication errors. The medication error reports could be submitted online. Apart from a stand-alone-use in a single hospital the reporting system can also be used nationwide as well as international to detect major risks. The anonymity of the users is ensured by a restricted access excluding database fields from the analysis that might contain user specific information. The present pilot study is based on analysis of 101 records stored in the medication error reporting system DokuPIK (14 January 2015). These records were putted in the database by pharmacists and pharmaceutical technicians out of the involved countries. They were free to put in all errors they think are worth to be reported. Data were exported into MS Excel and screened independently by a hospital pharmacist. Entries were categorised for frequency of type of error, cause of error and the degree of severity caused by the medication error. Results: The medication error reporting system DokuPIK is a very useful tool to identify risk factors for medication errors. We identified the most common types of errors as well as the causes for medication errors. Most of the errors were classified as ‘‘An error occurred that reached the patient but did not cause patient harm’’. A preliminary analysis (101 entries) revealed the following rank order of type of error: Inappropriate or unsuitable drug formulation in terms of indication (14), (wrong) dose (13) and prescription/documentation incomplete/incorrect (12). The most common

Payam Peymani1, Saba Afifi1, Hassan Joulaie1, Hashem Montaseri2, Hossein Niknahad3, Mustafa Ghaemi Nia3, Kamran B Lankarani1 1

Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran, [email protected]; 2Departments of Pharmaceutics, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran; 3Vice-chancellors for Food and Drug, Shiraz University of Medical Sciences, Shiraz, Iran Background and objectives: This study was performed to evaluate the pattern of antibiotics prescription by physicians in Fars province, Iran from 2000 to 2014. Obtaining antibiotics In Iran is not possible unless by a physician’s prescription. The prescriptions were in paper format. In our region antibiotic are used for: bacterial infection, cold and fever and sometimes mis-prescribed for viral infections, parasitic infections and non-infectious diseases. Only physicians and in special cases pharmacists can prescribe antibiotics. Methods: In this cross-sectional study, we included all medical prescriptions consisting of antibiotics in Fars province. We examined the prescriptions which belonged to social security insurance foundation which is an insurance company in the field of healthcare. We extracted all variables using the Data Bank at Division of Research & Development. Our information was categorized into three groups: (1) data about physicians, (2) data about content of prescriptions (3) data about patients. Results: There has been a fluctuation in the rate of patients who were prescribed anti-microbial drugs from 2000 to 2012—the minimum rate (38.10 %) in 2004 and the maximum rate (50.59 %) in 2008. For instance, amoxicillin, metronidazole, penicillin, cefixime, penicillin, azithromycin, ceftiraxone, ciprofloxacin, cephalexin, co-amoxiclav were among the most prescribed antimicrobial drugs. In 2006, 51 % of patients received antibiotics and the rates for 2007 and 2008 were 48 % and 50.59 %, respectively. The rate of Beta-Lactam antimicrobial prescription was 4.26 %. This rate decreased to 3.59 % in recent years. 12.51 % patients received Beta-Lactam antibiotics in 2000 and this rate declined to 3.98, then to 4.03 and finally to 3.59. Conclusion: The mean numbers of antibiotics per prescription by physicians in Fars province of Iran were not in agreement with WHO standards for drug use. The high rate of using different types of antibiotics needs a comprehensive reassessment by the medical management staff of infectious diseases.

PP III-4: Use of non-hormonal therapies for menopausal symptoms—The Norwegian Women and Cancer study (NOWAC) Eirin Karlsen1, Kjersti Bakken2, Marit Waaseth3 1 Department of Pharmacy, Faculty of Health Sciences, UiT, The Arctic University of Norway, 9037 Tromsø, [email protected];

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Department of Community Medicine, Faculty of Heath Science, UiT, The Arctic University of Norway; 3Department of Pharmacy, Faculty of Health Sciences, UiT, The Arctic University of Norway Background and objectives: Hormone therapy (HT) has been used in the treatment of menopausal symptoms for several decades. HT is the most effective treatment of vasomotor symptoms. However, several studies in the early 2000s reported that the risk of side effects exceeded the benefits, and the use of HT greatly decreased. It is reasonable to believe that alternative therapies are used to a greater extent now than before. The aim of this study is to describe the use of alternatives to HT, prevalence of use and whether such use is related to previous hormone use, lifestyle, education and menopausal status. Methods: A cross-sectional analysis will be performed, based on data from the Norwegian Woman and Cancer study (NOWAC). NOWAC is a population based prospective cohort study which relies on information obtained from questionnaires. Since 1991 about 172 000 women were enrolled. The analyzed data in this study were collected during 2010–2011 and include responses from 17,561 women, aged 52–69 years. The women answered an 8 page questionnaire about health, diet and lifestyle, including use of alternative therapies against menopausal symptoms. Results: A total of 3714 women had ever used alternatives to HT, where soy and relaxation techniques/exercise were most commonly used. Univariate analyses show that women who had gone through surgical menopause used less alternatives (18.8 %) compared to women with natural menopause (23.0 %). Women with close relatives (mother, sister or daughter) with breast cancer used less HT, but their use of alternatives was not significantly different from women without relatives with breast cancer. Women with higher education used more alternatives, compared to women with lower education. The women with poor health used more alternatives (25.3 %) compared to those who considered their health to be good (22.4 %). Results from adjusted analyses are pending and will be presented at the conference. Conclusions: According to univariate analyses, use of alternative therapies to HT for menopausal symptoms is associated with type of menopause, education length and self-reported health, but not with familial breast cancer. However, some of these results may be confounded by for instance HT-use. A conclusion will be presented at the conference, when all analyses are finalized.

PP III-5: Availability of antiepileptic drugs across Europe Arton Baftiu1, Cecilie Johannessen Landmark1, Inger-Lise Neslein1, Svein I. Johannessen2, Emilio Perucca3 1 Department of Pharmacy and Biomedical Science, Faculty of Health Sciences, Oslo and Akershus University College of Applied Sciences, Oslo, Norway, [email protected]; 2National Center for Epilepsy, Sandvika and Oslo University Hospital, Norway; 3University of Pavia, Italy

Background and objectives: There is a pronounced diversity in economic status and political, educational and healthcare systems in Europe. Data from WHO show major gaps in quality of epilepsy care across Europe. It provides recommendations to improve access and quality of care and understanding of epilepsy, and reduce stigmatization to help bring epilepsy ‘out of the shadows’. The purpose of this study was to investigate the availability on the marked and accessibility of antiepileptic drugs (AEDs) in different European countries. Method: An electronic questionnaire was submitted in 2012 to all 43 member countries of the organization International League against Epilepsy in Europe, to the president or organization office in each country. The questions concerned availability of AEDs for epilepsy and non-epilepsy disorders, availability of generics, reimbursement

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Int J Clin Pharm (Suppl 2015) 37:1–34 rules, and reasons for shortcomings. The AEDs were divided into older, newer and newest drugs. The European countries were divided and compared according to economic status (high income, upper and lower middle/low income countries) as defined by the World Bank. Good availability of AEDs and especially of the newer ones, and favorable reimbursement rules were considered as important factors for optimal treatment possibilities. Results: 34/43 (79 %) countries (22 high-, 6 upper-middle and 6 lowmiddle/low-income) replied. One or more of the newest AEDs (eslicarbazepine acetate, lacosamide, rufinamide, stiripentol) were not available in 43 % of high-income countries and in none of the uppermiddle and low-middle/low-income countries. Lamotrigine has regulatory approval for psychiatric indications and pregabalin/gabapentin for neuropathic pain in almost all countries. Reimbursement by national healthcare systems was available in 75 % of high-income countries in contrast to 30 % and 10 % of upper-middle and low-middle/low-income countries, respectively. Conclusions: There are important AED accessibility gaps across Europe, especially for the newest AEDs. This is mostly due to lack of regulatory approval, high cost and reimbursement restrictions. The reimbursement of AEDs varies from no to full reimbursement. These results raise major concerns related to quality of treatment in epilepsy across Europe, as patients in different countries do not have equal opportunities for optimal treatment.

PP III-6: Patient and population aspects of treatment with antiepileptic drugs for improved patient safety Cecilie Johannessen Landmark1,2, Arton Baftiu1, Svein I. Johannessen2 1

Department of Life Sciences and Health, Programme for Pharmacy, Oslo and Akershus University College, Oslo, Norway; 2Department of Pharmacology, The National Centre for Epilepsy, Oslo University Hospital, Oslo, Norway Background: Most patients with epilepsy have a life-long need for treatment with antiepileptic drugs (AEDs). One third do not achieve satisfactory seizure control, and adverse effects are common. We use therapeutic drug monitoring (TDM) for individualization of treatment of AEDs for improved patient safety [1–3]. At the population level, analysis from the Norwegian Prescription Database (NorPD) shows that the use of newer AED in epilepsy and other indications increases every year, which calls for close surveillance [4, 5]. The objective of this study is to describe two methodologies for improved patient safety: at the patient and population levels, respectively, and elucidate clinical implications. Methods: TDM-data from 546 individual patients treated at The National Centre for Epilepsy were used to study pharmacokinetic variability for selected AEDs (clobazam, lacosamide, eslicarbazepine acetate). Data from NorPD was used to explore the use of newer AEDs for epilepsy vs non-epilepsy indications in the whole population ([100,000 patients per year). Results: At patient level, TDM-data reveal extensive pharmacokinetic variability between patients of up to 100-fold changes in concentration/dose-ratios of the three selected AEDs. Variability between age groups and drug interactions are main factors for variability. Analysis of data from NorPD show that newer AEDs are increasingly used in non-epilepsy indications; bipolar disorder and neuropathic pain, accounting for 51 % of the total use of AEDs in 2012. The increasing use of gabapentin and pregabalin in the elderly needs special attention. Thus, each year many new patients are exposed to AEDs, where detailed knowledge is needed to provide optimal treatment.

Int J Clin Pharm (Suppl 2015) 37:1–34 Conclusions: Safety aspects of AEDs are elucidated at the patient and population levels. The use of TDM of newer AEDs reveal a need for individualization of therapy by adjusting the dose according to serum levels to avoid lack of efficacy or excessive adverse effects. Increased focus on changes in drug utilization in special patient groups as the elderly contributes to improved pharmacovigilance. Implication to practice: The extensive pharmacokinetic variability between individuals, and increased use of newer AEDs in the population as a whole, calls for the development and use of methodologies to improve monitoring and surveillance at the patient and population levels. References [1]

[2] [3] [4] [5]

Johannessen, Landmark C.; Baftiu, A., Tysse, I.; Valsø, B.; Larsson, P.G.; Rytter, E., Johannessen, S.I. Ther Drug Monit. 2012, 34(4), 440–445. Johannessen, Landmark C.; Johannessen, S.I.; Tomson, T. Adv Drug Deliv Rev. 2012, 64: 896–910. Johannessen, Landmark C.; Johannessen, S.I. Pharmacoepid Drug Saf. 2012, 21(1):11–20. Johannessen, Landmark C.; Fossmark, H.; Larsson, P.G.; Rytter, E.; Johannessen, S.I. Epilepsy Res. 2011; 95: 51–59. Johannessen, Landmark C.; Larsson, P.G.; Rytter, E.; Johannessen, S.I. Epilepsy Res. 2009, 87: 31–39.

19 the period. Multiparticulates are easier to swallow, and are considered to behave more predictably in the gastro-intestinal tract. For children using levetiracetam, the prescriptions of oral solutions have increased steadily to about 45 %. For comparison, this number was only about 1 % in the elderly, although this age group may also benefit from flexible dosing and easiness to swallow. The amount of elderly using gastro-resistant formulations increased from about 2300 patients to about 3200 patients (a * 40 % increase) during the period. The reason may be to reduce gastro-intestinal discomfort, but we raise a concern connected to the slowing of the gastric emptying time with increasing age, which is likely to increase the pharmacokinetic variability. Conclusions: The results showed decreasing and minimal use of generic substitution. The use of multiparticulate prolonged release formulations increased on the extent of monolithic ones. The use of oral solutions increased among children. These trends may contribute to increased adherence and reduced pharmacokinetic variability for most patients. However, for the elderly, we suspect that there are still some room for improvement, connected to the low use of oral solutions and increasing use of gastro-resistant formulations. This has to be confirmed by complementary studies, though.

PP III-8: What is dispensing? Legal cognitive requirements during dispensing in the Nordic countries Karin Svensberg1, Ingunn Bjo¨rnsdottir1, Sofia Ka¨lvemark Sporrong2

PP III-7: Antiepileptic drug therapy—Is the best formulation prescribed? Ellen Hagesaether1, Pa˚l G. Larsson2, Svein I. Johannessen3, Cecilie Johannessen Landmark1,3 1

Department of Life Sciences and Health, Oslo and Akershus University College of Applied Sciences, Postboks 4 St. Olavs Plass, 0130 OSLO, [email protected]; 2Department of Neurosurgery, Oslo University Hospital; 3Department of Pharmacology, National Centre for Epilepsy, Oslo University Hospital Background and objectives: Antiepileptic drug therapy is complicated due to large intra- and inter-patient variability. Finding the right drug is crucial, ensuring good efficacy with tolerable adverse effects. High adherence and low pharmacokinetic fluctuations are equally important. Therefore, choosing the right formulation for each individual patient is of great value. The aim of this work was to study changes of possible clinical importance in the use of different antiepileptic drug formulations in Norway from the period 2004–2012. Methods: The Norwegian Prescription registry enables detailed studies of changes in drug prescriptions in a population-based database to be performed. The variables ‘‘number of patients’’ and ‘‘drug use in defined daily doses (DDD)’’ (divided into age groups: 0–10 years, 11–59 years and B60 years) were identified for different trade names and formulations, annually for the period 2004–2012. The study was approved by the National Institute of Public Health. Results and discussion: About 9 % of the patients (10904 patients in total) used a generic formulation in 2008. This number decreased to about 4 % in 2012 (4781 patients in total). Thus, a clear preference for the original drug over the generic counterpart was observed. This is probably an advantage for minimizing the pharmacokinetic variability and a result of the policy of ‘‘restricted generic substitution’’ in Norway. For prolonged release OrfirilÒ (sodium valproate), the DDD prescription of multiparticulates increased with 89 % and the DDD prescription of monolithic formulations decreased with 34 % during

1

University of Oslo, School of Pharmacy, Post Box 1068, N-0316 Oslo, [email protected]; 2University of Copenhagen, School of Pharmaceutical Sciences, Universitetsparken 2, D-2100 København Background and objectives: Dispensing medications is among the core tasks of community pharmacists. Dispensing can be defined as the distribution of medications according to a prescription. Nevertheless, the dispensing can also include important clinical and cognitive elements, i.e. identifying clinical errors and undertaking interventions to optimize outcomes. Here a pharmacist’s professional competence and judgment is needed to ensure optimal outcome and patient safety. Pharmacists’ individual dispensing practice varies regarding i.e. kinds and amount of prescription interventions undertaken. However, legislation constitutes a basis for the pharmacy professional’s work and independence. The aim was to explore the Nordic countries of Denmark, Finland, Iceland, Norway and Sweden legislation regarding dispensing in community pharmacies: focusing on cognitive issues. Methods: A descriptive analysis of legislative documents was undertaken [1]. Documents regulating cognitive and clinical tasks and also technical controls (checking prescriptions for completeness and compliance with legislation) included in dispensing were collected in the spring 2014, by using online legislative databases. Regulating authorities were contacted to gather supplementary information. Results: In the Nordic countries only pharmacists (master and bachelor) are allowed independently to dispense medications. The prescription should be dispensed as ‘‘intended’’ by the prescriber. The countries’ dispensing rules include a detailed regulated control of prescriptions for completeness and compliance with legislation i.e. technical issues regarding for example prescriber and patient standard information, verification of the authenticity. The countries legal cognitive requirements of the prescription review process and handling of interventions are few and more or less homogenous. Mentioned areas are dosage accuracy and checking for interactions. In all countries, identified clinical or other prescription errors should be checked with the prescriber before implementing a change. For example, the pharmacists cannot independently adapt prescriptions for

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the purpose of optimizing a drug therapy or change a potentially inappropriate dosage. Nevertheless, all the countries allow pharmacists to some extent to dispense medications in emergency situations e.g. if the prescriber is unreachable. Conclusions: Nordic community pharmacists’ cognitive practices during dispensing of prescriptions seem to be strongly linked to the prescribers. It also appears to limit the pharmacists’ contribution to patients’ medication use. Policy makers could consider potential benefits from allowing pharmacists’ to do more independent adaptions of prescriptions and investigate tools to enable this practice. References [1]

Sarantakos, S. Social Research. 3rd ed. Hampshire: Palgrave Macmillan; 2005. Chapter 13, the study of documents; pp. 292–320.

PP III-9: An independent non-chain community pharmacies perspective in Lithuania

main difficulties in the management of an independent pharmacy are specific lack of knowledge, financial deprivation, which leads to the late payments of State Patient Fund. The main competitors of independent pharmacies are pharmacy chains. The result showed, that individual non-chain pharmacies from chain community pharmacies varies given pharmacist professional autonomy. The content analysis method revealed that individual non-chain pharmacies are experiencing difficulties in competition with network pharmacies on medicament’s price terms, but by provided pharmaceutical services quality—in the lead. The research showed that the main factors that restrict the development of pharmacies are: a large number of pharmacies in country, the possibility of unequal competition, laws base which is regulating pharmacy, financial dependency on states institutions, too big marketing price. Conclusions: Although a number of negative factors for independent non-chain community pharmacies expansion were defined, but also (based on 5 expert interview) a theoretical, a competitive non-chain pharmacy model was established. This could be a niche pharmacy, which provides specific services, that makes it easier to adapt to the current market. Further studies on this should be continued.

Jurgita Dauksiene1,2, Artu¯ras Nastaravicˇius1 Department of Drug Technology and Social Pharmacy, Faculty of Pharmacy, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; [email protected]; 2 Kaunas University of Applied Sciences, Faculty of Medicine, 44162, Kaunas Lithuania Background and objectives: The traditional model of a pharmacist owning his/her own pharmacy has given way to the chains and multinational operators. It is undeniable that an operator having the status of pharmacist pursues, like other persons, the objective of making a profit. However, as a pharmacist by profession, he is presumed to operate the pharmacy not with a purely economic objective, but also from a professional viewpoint. ‘‘Dual loyalty’’ of pharmacists (to the employer and to the patient) is present in all sectors of pharmacy practice, not just community pharmacies. Community pharmacies are widely used for obtaining medications as well as to get health advice. Pharmacists are the easiest accessible health care professionals who are able to provide consultation on rational medication use and help to prevent serious health problems. Despite of a huge job what pharmacist do as health care system workers, their practice are often valuated as profit seeking activity. In Lithuania, there are 1442 community pharmacies and population of 2.9 million. Lithuania former soviet republic and present EU member, has survived a number of legislation change in field pharmacy ownership. The aim of this study is to evaluate the economic perspectives of independent non-chain pharmacies in Lithuania. Methods: This study was based on an empirical qualitative method. The investigation started in November, 2012 and finished in March, 2013. The participants of the study were 5 selected experts non-chain pharmacies owners who agreed to take part in this study had with experience more than 20 years of ownership and also all of them more than 30 years of professional activity. The selected data collection method was semi-structured interview and which consists of 17 open questions. The questions were about experience in everyday professional activity, pharmacist’s ethics, professional autonomy and practical aspects; strengths; weaknesses and future expectations of non-chain pharmacies were included. Our respondents had a high level of homogeneity among the population, the number was sufficient to enable development of meaningful themes and useful interpretations and led to a saturated data and allow analysed the results by grounded theory methodology. Results: All participants claimed that the number of community pharmacies in Lithuanian pharmaceutical market is too high. The

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Clinical pharmacy OP IV-1: Quality of drug information in discharge summaries from a Norwegian hospital Beate H. Garcia1, Berit D. Svendsen1, Trine I. Aag2 1

Department of Pharmacy, UiT The Arctic University of Norway, 9037 Tromsø, Norway, [email protected]; 2Helgelandssykehuset HF, Postboks 601, 8607 Mo i Rana Background and objectives: The Norwegian patient safety program (NPSP) strongly focuses on safe use of drugs [1]. One of the main focuses is medication reconciliation (MR) at discharge from hospital. MR should finally lead to a correct medication list including essential information, comprehensive for both patients and the next caregiver. The NPSP has developed an 8-criteria scoring tool to evaluate the quality of drug information in discharge summaries compiled at hospitals [1]. The aim of this study was to evaluate whether drug information included in discharge summaries is in adherence with the scoring tool criteria. Methods: We retrospectively collected randomly selected discharge summaries compiled during 2013 at Helgelandssykehuset Mo i Rana, Norway. We evaluated drug information using the scoring tool from the NPSP, where a total sum of 0–16 could be achieved, depending on whether all criteria could be applied. We used Excel and SPSS for Windows and applied the Independent sample t-test. A P value \0.05 was considered significant.

Criteria adherence (%)

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XXV Nordic-Baltic Congress of Cardiology. Tallinn, Estonia, June 4-6, 2015: Abstracts.

Pharmacy Practice Research Abstracts: Canadian Pharmacists Conference 2015.

Social Pharmacy and Clinical Pharmacy-Joining Forces.

Abstracts of Papers Presented at the Health Services Research & Pharmacy Practice Conference, 16-17 April 2015, Riddel Hall, Queen's University Belfast.

Pharmacists's Q's & A's: reimbursement for clinical pharmacy services.

Emergency physicians group supports ED clinical pharmacy services.

The 11th NORDIC NUTRITION CONFERENCE NNC2016.

Social psychology in an evolving profession: a research agenda for advancing clinical pharmacy services.

Abstracts of the Papers Presented at the Health Services Research & Pharmacy Practice Conference, 3-4 April 2014, University of Aberdeen, Aberdeen, UK.

Rural access to clinical pharmacy services.

Professional fees for clinical pharmacy services.

47th Nordic Lung Congress - Oslo 2015.

A Nordic data base on somatic chromosome damage in humans. Nordic Study Group on the Health Risk of Chromosome Damage.

Canadian Pharmacists Conference 2017 pharmacy practice research highlights.

The Implementation of Pharmacy Competence Teaching in Estonia.

Pharmacy students' experiences in provision of community pharmacy mental health services.

2015: The state of pharmacy in Canada.

Executive leadership: Critical to developing clinical pharmacy programs and services.

A comprehensive review of the impact of clinical pharmacy services on patient outcomes in mental health.

Change management in pharmacy: a simulation game and pharmacy leaders' rating of 35 barriers to change.

Expansion of inpatient clinical pharmacy services through reallocation of pharmacists.

Social Pharmacy Research in Copenhagen-Maintaining a Broad Approach.

Economic evaluations of clinical pharmacy services: 2006-2010.

Implementation of clinical pharmacy services in a pediatric dialysis unit.