Early identification of long-term poor adherence in ambulatory patients.
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Biomedical subjects
Marcel L Bouvy
Publications and source records attributed to Marcel L Bouvy.
Improving pharmacotherapy after myocardial infarction by group academic detailing using feedback data on a patient level.
STUDY OBJECTIVE: To develop and evaluate a peer review group (PRG) meeting using feedback data on a patient level to improve the quality of drug therapy for prevention of recurrent myocardial infarction. DESIGN: Prospective follow-up study. DATA SOURCE: General practitioners' computerized patients records (intervention patients) and the PHARMO record linkage system (controls). PATIENTS: Forty patients in the intervention group and 1030 control patients; both groups had documented myocardial infarction. INTERVENTION: The intervention, which was based on the principles of group academic detailing, consisted of scoring current cardiovascular treatment on separate forms for each patient, presenting an overview of, and discussing, evidence-based treatment after myocardial infarction, defining the target population, formulating a binding consensus, and identifying patients who were eligible for improvement of pharmacotherapy. MEASUREMENTS AND MAIN RESULTS: Drug therapy and adherence to the newly formulated PRG consensus were assessed at baseline and 1 year after the intervention. Of the patients who received the intervention and were not treated according to the PRG consensus at baseline, 40% received treatment according to the consensus 12 months after the PRG meeting. In the control group, the proportion of patients was 9.5% (prevalence ratio 4.2, 95% confidence interval 1.8-9.7). CONCLUSION: Peer review group meetings can be a valuable tool for improving pharmacotherapy after myocardial infarction.
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Collaborative services among community pharmacies for patients with diabetes.
BACKGROUND: Patients performing self-monitoring of blood glucose (SMBG) may benefit from community pharmacy services. However, wide-scale implementation of these services is limited. Many pharmacy characteristics (eg, physical layout of the pharmacy, knowledge and competence of the pharmacy team) are reported to be relevant when implementing these services. Still, the importance of local agreements on the division of roles with, for example, local general practitioners or diabetes nurses, is less clear. OBJECTIVE: To study the association between local collaboration and the level of services provided by community pharmacies to patients performing SMBG. METHODS: In 2004, we performed a cross-sectional survey among all 1692 Dutch community pharmacies. Data were gathered on provision of services for SMBG, local agreements, and pharmacy characteristics. Data were analyzed using logistic regression. Associations were adjusted for pharmacy characteristics. RESULTS: About 44% (724) of the community pharmacies returned the questionnaire. Pharmacies that were not involved in local collaborative services on patient counseling reported to provide fewer services compared with those that were involved in such agreements (OR 0.26, 95% CI 0.13 to 0.53). Similar findings were observed for agreements on calibration of SMBG equipment (0.17, 0.04 to 0.71). The associations remained after adjusting for pharmacy characteristics. CONCLUSIONS: Local collaboration on the division of roles in diabetes care between healthcare professionals is independently associated with the number of pharmacy services provided to patients performing SMBG.
Blood Glucose Self-Monitoring↗
Preventive drug use in patients with a history of nonfatal myocardial infarction during 12-year follow-up in The Netherlands: a retrospective analysis.
BACKGROUND: Myocardial infarction (MI) is a common cause of death in developed countries. Long-term preventive pharmacotherapy has been shown to decrease mortality and morbidity after MI. Based on a literature search, studies of these therapies to date have estimated the use of monotherapy, whereas many patients are prescribed combination therapy. Thus, assessment of long-term combination drug use after MI is timely. OBJECTIVE: The aim of this study was to assess the use of oral antithrombotics, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, hydroxymethyl-glutaryl coenzyme A reductase inhibitors ("statins"), and their combinations after MI at discharge and during 12-year follow-up. METHODS: This community-based, retrospective data analysis was conducted at Utrecht University, Utrecht, The Netherlands. Data from patients aged > or =18 years at hospital admission who experienced nonfatal acute MI between 1991 and 2000 and had a duration of follow-up > or =30 days were included in the analysis. Data were retrieved from the Pharmo Record Linkage System database, which links pharmacies' dispensation records to hospitals' discharge records on an individual patient level, allowing the investigator to observe individual patients' medication use over time. Primary outcome measures were the use of preventive medicines (oral antithrombotics, beta-blockers, ACE inhibitors, and statins) at discharge, overall use, and persistence during 12-year follow-up. RESULTS: Of 330,000 patients in the database, 4007 were included in the analysis (2828 men, 1179 women; mean [SD] age, 63.5 [12.5] years). Use at discharge and overall use of oral antithrombotics and statins increased significantly between 1991 and 2000, whereas use of beta-blockers and ACE inhibitors increased mainly in patients discharged in the latter years of the follow-up period. Therapy with any combination of drugs increased strikingly from 1991 to 2000, from 47% to 90%. At 1 year after discharge, 32% of patients had discontinued their first-prescribed combination treatments. At 5 years after discharge, this rate increased to 57%, suggesting a low rate of persistence CONCLUSIONS: Based on the results of this retrospective data analysis, the use of MI-preventive drug treatment at and after discharge increased significantly in this population in The Netherlands during the 1990s. Combination therapy increased strikingly. However, persistence with combination therapy was low.
Adrenergic beta-Antagonists↗
Dramatic change in prescribing of hormone replacement therapy in The Netherlands after publication of the Million Women Study: a follow-up study.
AIMS: To estimate the diffusion of new safety information concerning postmenopausal hormonal replacement therapy (HRT) into prescribing practice in The Netherlands and to assess the impact of revised guidelines on the long-term treatment of HRT. DESIGN: Cross-sectional study. SETTING: Community pharmacy dispensing data from a population of approximately 450,000 patients in the northern and eastern part of The Netherlands. POPULATION: Women aged 45-69 years to whom at least one HRT prescription was dispensed between 1 January 2000 and 1 January 2004. MAIN OUTCOME MEASURES: Annual and quarter prevalences of HRT and the proportion of new HRT users, switchers and continuous HRT users per quarter. RESULTS: The prevalence of HRT prescribing decreased significantly from 107/1000 [95% confidence interval (CI) 104, 110] in 2000 to 87/1000 (95% CI 84, 89) in 2003. The decreasing prevalence was especially evident among the younger age groups and was most pronounced among users of oestrogen/progestagen combinations. The publication of the Women Health Initiative Study (WHI) was followed by a modest decrease in prescribing of HRT, whereas prescribing of HRT declined dramatically after publication of the Million Women Study (MWS) in August 2003. Among the continuous HRT users in the 4th quarter of 2002, 55% used HRT longer than 3 years. This percentage was 53 in the 4th quarter of 2003. CONCLUSIONS: In contrast to the release of the WHI study results, publication of the MWS was followed by a dramatic fall in prescribing of HRT in The Netherlands. Despite the new recommendation that long-term HRT use should be discouraged, the proportion of long-term users did not change after the publication of the MWS.
Age Factors↗
Drug related problems identified by European community pharmacists in patients discharged from hospital.
INTRODUCTION: Drug related problems (DRPs) are perceived to occur frequently when patients are discharged from the hospital. Community pharmacists' interventions to detect, prevent and solve DRPs in this population are scarcely studied. OBJECTIVE: To examine the nature and frequency of DRPs in community pharmacies among patients discharged from hospitals in several countries, and to examine several variables related to these drug related problems. METHOD: The study was performed in 112 community pharmacies in Europe: Austria, Denmark, Germany, The Netherlands, Portugal and Spain. Community pharmacists asked patients with a prescription after discharge from hospital between February and April 2001 to participate in the study. A patient questionnaire was used to identify drug related problems. Pharmacists documented drug related problems, pharmacy interventions, type of prescriber and patient and pharmacy variables. RESULTS: 435 patients were included in the study. Drug related problems were identified in 277 patients (63.7%). Uncertainty or lack of knowledge about the aim or function of the drug (133; 29.5%) and side effects (105; 23.3%) were the most common DRPs. Practical problems were reported 56 times (12.4%) by patients. Pharmacists revealed 108 problems (24.0%) concerning dosage, drug duplication, drug interactions and prescribing errors. Patients with more changes in their drug regimens (drugs being stopped, new drugs started or dosage modifications) and using more drugs were more likely to develop DRPs. Community pharmacists recorded 305 interventions in 205 patients with DRPs. Pharmacists intervened mostly by patient medication counselling (39.0%) and practical instruction to the patient (17.7%). In 26.2% the intervention was directed towards the prescriber. In 28 cases (9.2%) the pharmacists' intervention led to a change of the drug regimen. CONCLUSION: This study shows that a systematic intervention by community pharmacists in discharged patients, or their proxies, is able to reveal a high number of DRPs that might be relevant for patient health outcomes. There should be more initiatives to insure continuity of care, since DRPs after discharge from hospital seem to be very common.
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Patterns of pharmacotherapy in patients hospitalised for congestive heart failure.
BACKGROUND: In the 1990s, a number of cardiovascular drugs were evaluated in randomised clinical trials. Treatment guidelines for heart failure were modified to include these evidence-based treatments. AIM: To evaluate the impact of new medical treatments for heart failure between 1990 and 1998. METHODS AND RESULTS: A retrospective cohort study of 2764 patients with a first hospital admission for heart failure between 1990 and 1998. The percentage of patients treated with different cardiovascular drugs after hospitalisation was calculated and compared over time. Use of loop diuretics remained steady approximately 80%, digoxin decreased from 57.6 to 42.7%, angiotensin converting enzyme (ACE) inhibitors showed a slight increase from 49.8 to 54.8%, beta-blockers almost tripled from 11.3 to 28.7%, low dose prophylactic acetylsalicylic acid quadrupled from 9.9 to 39.9%. Kaplan-Meier survival estimates showed highest continuation rates of drug treatment for antithrombotics and diuretics, intermediate for digoxin and ACE inhibitors and low for beta-blockers. More than a quarter of the users discontinued beta-blockers in the first year after hospitalisation. CONCLUSIONS: We observed an increase in the prescribing of several important drug classes, reflecting changes in treatment guidelines during the study period. However, our findings show that not all patients were receiving optimal treatment. More research into the reasons for this is warranted.
Adrenergic beta-Antagonists↗
Determinants for successful smoking cessation with bupropion in daily practice.
OBJECTIVE: To describe the patterns of use of bupropion in daily clinical practice and factors which determine successful smoking cessation. METHODS: Retrospective follow-up study in 36 pharmacies in the Netherlands. Patients who received at least one prescription for bupropion between January and April, 2000 were included. The pharmacists noted several characteristics relating to the patient, use of bupropion and co-medication. Patients were interviewed by telephone about their current and former smoking habits, the success of their smoking cessation and their experiences with bupropion. MAIN OUTCOME MEASURE: Abstinence rate and factors determining successful abstinence after six months. RESULTS: 322 patients with a least one prescription for bupropion were identified. In 93.5% of patients bupropion was prescribed by the general practitioner. Half of the patients were dispensed 30 or fewer tablets. Pharmacists interviewed 215 (66.8%) patients by telephone. Of these patients 58 (27.0%) still did not smoke six months after the prescription for bupropion. The number of tablets used, lack of co-morbidity, less than two previous attempts to stop smoking and private-insurance were associated with a higher rate of successful abstinence. CONCLUSION: Most patients do not use bupropion in accordance with the recommended period and did not receive the same degree of additional support provided in clinical trials. Nevertheless 27.0% of patients reported to have stopped smoking six months after the prescription for bupropion. This self-reported abstinence rate is only slightly lower than is reported in literature. This might be partly related to the fact that we did not validate smoking cessation by carbonmonoxide monitoring. Bupropion is not reimbursed in the Netherlands. It is difficult to assess whether patients' self-payment has led to the selection of motivated patients, or has been a barrier to finishing using bupropion.
Adult↗
Effect of a pharmacist-led intervention on diuretic compliance in heart failure patients: a randomized controlled study.
BACKGROUND: Noncompliance is a major factor in the morbidity and unnecessary hospital readmissions for patients with heart failure. Several studies have aimed to reduce rehospitalizations in heart failure patients through a comprehensive, multidisciplinary approach. Medication compliance was rarely measured in these studies or, when it was measured, the method employed was seldom valid. We aimed at determining the effect of a pharmacist-led intervention on medication compliance in patients with heart failure. METHODS: We conducted a randomized controlled trial into the effect of a pharmacist-led intervention on medication compliance in patients with heart failure (predominantly New York Heart Association [NYHA] II and III) treated with loop diuretics, presenting to a cardiology outpatient clinic or admitted to hospitals in The Netherlands. Patients in the intervention group received monthly consultations from their community pharmacist during a 6-month period. Patients in the control group received usual care. Primary endpoint was medication compliance, assessed with a medication event monitoring system, an electronic pill bottle that registers time of opening. Secondary endpoints were the number of rehospitalizations, death, and quality of life. RESULTS: A total of 152 patients were randomized: 74 patients to the intervention arm and 78 patients to the usual care arm. Over the 6-month study period, patients in the intervention group had 140/7656 days without use of loop diuretics compared with 337/6196 days in the usual care group (relative risk 0.33 [confidence interval (CI) 95% 0.24-0.38]). Two consecutive days of nondosing occurred on 18/7656 days in the intervention group compared with 46/6196 days in the usual care group (relative risk 0.32 [CI 95% 0.19-0.55]). There were no significant differences in rehospitalizations, mortality, or disease-specific quality of life between groups. CONCLUSIONS: A pharmacy-led intervention can improve medication compliance in patients with moderate to severe heart failure, even in those with relatively high compliance. Future interventions should also focus at less compliant patients.
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Drug therapy for prevention of recurrent myocardial infarction.
OBJECTIVE: To provide an evidence-based overview of drug treatment for long-term secondary prevention of myocardial infarction (MI). DATA SOURCES: We conducted searches of MEDLINE (1966-August 2002), the Cochrane Controlled Trial Register, and the reference list of each identified study. STUDY SELECTION/DATA EXTRACTION: Trials and meta-analyses were included using the following criteria: (1) randomized trials, (2) description of identification procedure, inclusion criteria, outcome measures, and statistical methods, (3) confirmed MIs, (4) treatment continued for at least 1 month, and (5) all-cause mortality as primary outcome; other events as secondary outcomes. All authors interpreted the results from trials that met the inclusion criteria. DATA SYNTHESIS: In randomized clinical trials, low-dose aspirin, high-intensity oral anticoagulants, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and statins decreased the risk of mortality and reinfarction after MI. Randomized clinical trials using calcium-channel blockers, antiarrhythmics, and hormone replacement therapy did not show benefits in patients with prior MI. Effects of the combined use of aspirin or oral anticoagulants with beta-blockers or ACE inhibitors plus statins must be derived from subgroup analysis of trials, but seem to be beneficial. CONCLUSIONS: The use of at least aspirin or an oral anticoagulant, a beta-blocker or an ACE inhibitor, plus a statin should be incorporated in the treatment routine. Clopidogrel treatment might be an alternative to aspirin. Standard addition of a beta-blocker to ACE inhibitor-treated patients without reduced left-ventricular ejection fraction seems to be untimely.
Evidence-Based Medicine↗
Effects of NSAIDs on the incidence of hospitalisations for renal dysfunction in users of ACE inhibitors.
INTRODUCTION: Although relatively safe, both NSAIDs and ACE inhibitors can cause renal dysfunction in patients with compromised renal function. Case reports indicate that the combined use of ACE inhibitors and NSAIDs increases the risk of renal dysfunction. It is not known how often and when renal dysfunction occurs in patients using a combination of ACE inhibitors and NSAIDs. OBJECTIVE: The objective of the study was to investigate the effects of NSAIDs on the incidence of hospitalisations due to renal dysfunction in patients treated with ACE inhibitors. STUDY DESIGN: Case-control study nested within a cohort of users of ACE inhibitors. PARTICIPANTS: All participants had at least two consecutive prescriptions for an ACE inhibitor. One hundred and forty-four cases were admitted to hospital for renal insufficiency during use of ACE inhibitors. There were 1189 randomly sampled control patients who did not have any hospital admission for renal dysfunction during use of ACE inhibitors. MAIN OUTCOME MEASURES: The risk for hospitalisation for renal dysfunction associated with exposure to NSAIDs in patients receiving ACE inhibitors was expressed as odds ratios (OR). RESULTS: Of 144 cases, a total of 32 (22.2%) received NSAIDs in the 90 days before hospital admission for renal dysfunction. Recent start (<90 days) of an NSAID was associated with an increased risk of admission for renal dysfunction (adjusted OR 2.2; 95% CI 1.1-4.5). The increased risk was most pronounced in patients aged >70 years (adjusted OR 2.7; 95% CI 1.0-7.2). For patients who started NSAIDs and were dispensed at least three prescriptions in the 90 days preceding hospitalisation an adjusted OR of 7.1 (95% CI 1.8-28.7) was observed. CONCLUSIONS: This study strongly suggests an increased risk for hospitalisation for renal insufficiency in patients receiving ACE inhibitors who start using NSAIDs. Elderly patients receiving several prescriptions for NSAIDs in a short period of time are particularly at risk. Renal function should be closely monitored in these patients.
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Patients' drug-information needs: a brief view on questions asked by telephone and on the Internet.
OBJECTIVE: To compare patient characteristics and types of questions from individuals who consulted a toll-free telephone number with individuals who consulted a free information site on the Internet. METHOD: Characteristics of all individuals and the questions they asked on both services in the month of February 2000 were analysed. RESULTS: There were several differences between individuals who consulted both services. Individuals who asked questions through the Internet were younger and consisted of a relatively higher percentage of men than individuals who used the telephone. CONCLUSION: Different services can meet the needs of different patient groups.
Adolescent↗
Amiodarone-induced thyroid dysfunction associated with cumulative dose.
PURPOSE: To obtain risk estimates of thyroid disorder in patients starting amiodarone. METHODS: We followed a cohort of 5522 patients with a first prescription for an anti-arrhythmic drug and no previous use of thyroid drugs. Within this cohort we conducted a nested case-control analysis. Cases were defined as all patients who started a thyreomimetic or thyreostatic drug no sooner than 3 months after the start of an anti-arrhythmic drug. Controls were patients with a comparable follow-up period not receiving any thyroid drugs during the observation period. RESULTS: We identified 123 cases who had started thyreostatic drugs and 96 cases who had started a thyreomimetic drug. In users of amiodarone we found an adjusted odds ratio of 6.3 (3.9-10.2) for hyperthyroidism and 6.6 (3.9-11.1) for hypothyroid disease compared to users of other antiarrhythmics. Patients who were exposed to a cumulative dose exceeding 144 g of amiodarone had an adjusted odds ratio of 12.9 (6.1-27.3) for the development of hyperthyroid disease. The dose response for development of hypothyroidism was less pronounced. CONCLUSIONS: We observed an increased risk for thyroid disorder at the high end of that reported in the literature. The risk of thyroid disorder increased with exposure to higher cumulative doses. Clinicians should keep in mind the possibility of development of thyroid disorders in patients on treatment with amiodarone even after several years of use.
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