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Background Adherence rates among asthma patients are generally low and decrease during adolescence, resulting in poorly controlled asthma. The aim of our study was to evaluate the effectiveness of the ADolescent Adherence Patient Tool (ADAPT), an interactive mobile health (mHealth) intervention, in supporting self-management and improving inhaled corticosteroid adherence in adolescents with asthma. Methods We conducted a cluster randomized controlled trial in 66 Dutch community pharmacies. Asthma patients aged 12–18 years were invited to participate, based on pharmacy medication refill records. The main study outcome was self-reported medication adherence, measured with the Medication Adherence Report Scale (MARS). Secondary outcomes were asthma control and quality of life. Outcomes were measured at start (t = 0 months) and at the end of follow-up (t = 6 months). Mixed-effects models were used to analyze the effect. Results In total, 234 adolescents (147 in the control group and 87 in the intervention group) completed the study; mean age 15.1 ± 1.9 years and 52.6% females. Adherence rates of patients with low baseline adherence (MARS scores ≤19; n = 76) increased with 1.42 points in the intervention group (n = 26). Adherence rates of patients in the control group (n = 50) decreased with 0.70 points. Thus there was a positive effect of the intervention on medication adherence (MARS +2.12, p = 0.04). This effect was stronger (MARS +2.52, p = 0.02) in poor adherent adolescents with uncontrolled asthma (n = 74). No effect of the intervention was observed on asthma control or quality of life. Conclusions The ADAPT intervention increases medication adherence in adolescents with asthma having poor adherence rates at baseline. Healthcare providers should consider a tailored mHealth approach to improve the asthma treatment.

Background Since January 2012 the Dutch Medicines Act has been changed to enable medication monitoring and counselling for individual patients. Prescribers of medicines are now obliged to record the indication on the prescription of medicines mentioned in this law. Objective To assess patients’ opinion about recording of the indication on prescription and to explore the uptake of alterations in the medicines act in clinical practice. Methods The study was conducted in a sample of 57 community pharmacies belonging to the Utrecht Pharmacy Practice Network for Education and Research. In total, 528 patients were interviewed in these pharmacies and automated dispensing records were obtained from 22 community pharmacies to check prescriptions for linking of diagnosis codes (indications). Results For 12.5 % of the prescriptions that required notification of the indication, a diagnosis code was mentioned. For all other medicines, 15.1 % of the prescriptions were provided with diagnosis codes. There was large variation between different drugs. Only 11.7 % of the interviewed patients were familiar with the law. The majority of patients (91.1 %) had no objections with mentioning the indication for use on the prescription. Conclusion Indications are insufficiently mentioned on prescriptions while the majority of patients are generally positive about the law.

Purpose The purpose of this study was to determine whether homecare workers can detect signs and symptoms indicative of potential adverse drug reactions (ADRs) in homecare patients, using a standardized observation list. Methods This observational study involved 115 patients cared for by 2 homecare organizations in The Netherlands between April 2011 and August 2011. During routine home visits, homecare workers filled out a standardized observation list of signs and symptoms indicative of potential ADRs, namely, gastrointestinal and other bleedings, electrolyte disturbances, renal and heart failure, digoxin intoxication, constipation, disturbances of diabetic control, and falls. Their observations were compared against the medications that the patients were using and their known side effects, by a panel of clinical pharmacology experts. Sensitivity, specificity, and positive and negative predicted values of the standardized observations were calculated. Results In total, 234 signs and symptoms indicative of potential ADRs were observed by the homecare workers, 116 (49.6%) of which were considered drug related. More than one-half of the observed signs of gastrointestinal bleeding could be considered as drug related. Observed dizziness (64.1%) and drowsiness (53.3%) could be drug related in most cases, as could most cases (71.4%) of fainting spells (indicative of renal or heart failure). Seventeen of 20 observed falls could be drug related. The specificity of the standardized observation list was high, varying from 0.70 (confidence interval 0.62–0.77) to 0.97 (confidence interval 0.95–0.98). Conclusions Signs and symptoms indicative of potential ADRs recorded by homecare workers using a standardized observation list can aid in the early recognition of ADRs in homecare patients.

Adolescents are becoming more independently responsible for their medication regimen; therefore, adolescence is a crucial period to address medication beliefs, as many of the beliefs may persist into adulthood and can impair adherence and willingness to continue a prescribed therapy. Within this study, we aimed to explore adolescents’ general perceptions towards medicines. Adolescent students attending secondary schools in the Netherlands were invited through the school’s virtual learning environment to fill in an online questionnaire. Medication beliefs were assessed using the Beliefs About Medicines Questionnaire—General assessing general harm and general overuse beliefs. Within a 2-week period, 434 adolescent students responded to the questionnaire; 47.2 % thought that doctors overprescribed medication, and 20.5 % perceived medication as harmful in general. Being religious was associated with stronger harm (odds ratio (OR) 2.0, 95 % confidence interval (CI) 1.2–3.2) and overuse beliefs (OR 1.4, 95 % CI 0.9–2.1). Adolescents of native background had less concerns about overuse (OR 0.4, 95 % CI 0.2–0.8). Adolescents who actually consulted physicians had lower overuse beliefs (OR 0.6, 95 % CI 0.4–1.0). Conclusion: Adolescents more strongly believe in the general overuse of medicines than in general harm. Religious and ethnic background influence medication beliefs, as does previous experiences with the health-care system. Gaining more insight in adolescent patients’ medication use behavior and identifying patients at risk for negative medication beliefs associated with poor adherence in clinical practice might be a first step towards a lifelong good medication use.

Background & study aims Adjuvant endocrine therapy effectively prevents recurrence and progression of estrogen-receptor positive breast cancer. However, studies reveal substantial non-adherence. The objective was therefore to identify the nature of the experiences and beliefs of women treated with endocrine therapy in an attempt to find potential determinants of non-adherence. Method Online Focus Groups (OFGs) and individual interviews were conducted with 37 women who were treated with endocrine therapy. Sixty-three statements derived from the OFGs and 11 belief items from the Beliefs about Medicines Questionnaire (BMQ) were used in a Q-sorting task conducted with 14 of the women. The quantitative Q-sorting data were statistically analyzed with Hierarchical Cluster Analysis. Results A six cluster solution was revealed that included the clusters ‘information’, ‘efficacy’, ‘tenacity’, ‘coping’, ‘side effects’ and ‘usage’. Women's own experiences and perceptions were not clearly delineated from the beliefs measured with the BMQ. However, women judged their own experiences and perceptions with regard to endocrine therapy as more relevant for adherence than the BMQ beliefs. Conclusion In order to understand and to improve women's adherence to endocrine therapy, women's own perceptions and experiences about endocrine therapy should be targeted in addition to common beliefs that apply to a wide range of medicines.

Objective Medicine packages can cause problems in daily practice, especially among older people. This study aimed to investigate the prevalence of problems experienced by older people when opening medicine packaging and to investigate how patients manage these problems. Methods A convenience sample of 30 community pharmacies participated in this study. They selected a systematic sample of 30 patients over 65 years old with a recent omeprazole prescription, and a questionnaire was administered by telephone for at least 10 patients per pharmacy. Key findings A total of 317 patients completed the questionnaire. They received their omeprazole in a bottle (n = 179, 56.5%), push-through blister pack (n = 102, 32.2%) or peel-off blister pack (n = 36, 11.4%). Some 28.4% of all patients experienced one or more problems with opening their omeprazole packaging; most problems occurred with peel-off blisters (n = 24, 66.7% of all respondents using peel-off blisters), followed by push-through blisters (n = 34, 33.3%) and finally bottles (n = 32, 17.9%). The risk of experiencing problems with peel-off blisters and push-through blisters was higher [relative risk 3.7 (95% confidence interval 2.5–5.5) and 1.9 (1.2–2.8), respectively] than the risk of experiencing problems with opening bottles. Two-thirds of respondents reported management strategies for their problems. Most were found for problems opening bottles (n = 24, 75%), followed by push-through blisters (n = 24, 70.6%) and peel-off blisters (n = 14, 58.3%). Conclusions One in four patients over 65 experienced difficulties opening their omeprazole packaging and not all of them reported a management strategy for their problems. Manufacturers are advised to pay more attention to the user-friendliness of product packaging. In addition, it is important that pharmacy staff clearly instruct patients on how to open their medicine packaging, or assist them in choosing the most appropriate packaging.

Background Poor adherence to oral antidiabetics has a negative influence on glycaemic control in type 2 diabetes patients. Real Time Medication Monitoring (RTMM) combines real time monitoring of patients' medication use with SMS reminders sent only if patients forget their medication, aiming to improve adherence. This study aimed to investigate the effect of these SMS reminders on adherence to oral antidiabetics in patients using RTMM and investigate patients' experiences with RTMM. Methods Data were collected in a RCT involving 104 type 2 diabetes patients with suboptimal adherence to oral antidiabetics. Fifty-six patients were randomised to receive SMS reminders if they forgot their medication, 48 patients received no reminders. Primary outcome measure was adherence to oral antidiabetics registered with RTMM, measured as: (1) days without dosing; (2) missed doses; (3) doses taken within predefined standardized time windows. Patients' experiences were assessed with written questionnaires. Results Over the six-month study period, patients receiving SMS reminders took significantly more doses within predefined time windows than patients receiving no reminders: 50% vs. 39% within a 1-h window ( p =0.003) up to 81% vs. 70% within a 4-h window ( p =0.007). Reminded patients tended to miss doses less frequently than patients not reminded (15% vs. 19%, p =0.065). Days without dosing were not significantly different between the groups. The majority of patients reported positive experiences with RTMM and SMS reminders. Conclusion RTMM with SMS reminders improves adherence of type 2 diabetes patients, especially the precision with which patients follow their prescribed regimen, and is well accepted by patients. Trial registration Netherlands Trial Register NTR1882.

Objective To evaluate, among new users of inhaled corticosteroids that did not persist treatment, knowledge of inhaled corticosteroids' actions and whether they were instructed on the use of their inhaler. Setting Fifteen community pharmacies in The Netherlands. Methods Patients were interviewed by telephone. Their general practitioners provided diagnostic information and automated dispensing records were retrieved. Main outcome measures Knowledge of patients about the actions of inhaled corticosteroids. Results 230 (80.1%) of 287 patients were willing to participate. The majority (79.1%) of 230 patients was not aware of the anti-inflammatory actions of inhaled corticosteroids. Most patients were instructed on the use of their inhaler, predominantly by their physician (53%) or pharmacy (35.2%). Conclusions Although most patients reported inhaler instruction by at least one health care provider, the majority was unaware of inhaled corticosteroids' actions. Physicians and pharmacists should reconsider the instructions they provide especially to patients who should continuously use inhaled corticosteroids.

Objective To assess the extent to which patients feel they have received enough information on cardiovascular drugs and experienced counseling at the pharmacy. In addition, to identify factors that are predictors for patient satisfaction with the information received. Methods Fifteen community pharmacies participated. New and chronic users of cardiovascular medication received a questionnaire containing sociodemographic and health questions, a measure of satisfaction with information received (SIMS), beliefs about medication (BMQ), and frequency of pharmacy counseling. Results Of the 578 respondents, 335 (58%) indicated to be unsatisfied with the information received on 3 or more SIMS items. Patients’ age, beliefs about medication, duration of cardiovascular treatment and use of antithrombotics predicted patients’ satisfaction with information received. Two-thirds of patients reported ‘never’ to have experienced 5 of 8 counseling activities at the pharmacy. Conclusions A considerable proportion of patients are unsatisfied with the information received on cardiovascular medication. The majority of patients have only received a limited scope of medication counseling at the pharmacy. Practice implications Information and counseling should be tailored to patients’ needs and concerns about cardiovascular medication and the experience patients already have with treatment. Pharmacists could enhance their role in supporting patients using cardiovascular medication.

Background Community pharmacy is in the middle of a paradigm shift from provider of medication to provider of care around medication. Much of this care involves giving information to patients so as to maximize pharmacotherapy outcomes; however, this is not necessarily recognized by patients. The initiation of chronic medication for diseases, such as type 2 diabetes mellitus (T2DM), arouses much uncertainty in patients, and it is not certain how information provision roles by pharmacists are viewed. Objectives To obtain insight in the information needs of patients who have recently started treatment with oral antidiabetics and to investigate the opportunities for pharmacy regarding the provision of information for patients with T2DM. Methods A qualitative study with both semistructured telephone interviews and patient focus group discussions was conducted. Individual patients' comments were categorized and used in a strengths, weaknesses, opportunities, and threats (SWOT) analysis exploring the role of the community pharmacist in the field of providing information at the moment of initiation of T2DM oral medication. Results From interviews with 42 patients and 2 focus groups, discussions emerged that the general practitioner (GP) does not fulfill all information needs. For the pharmacist, there is an opportunity, as patients feel a need for information and like to discuss drug-related issues. SWOT analysis revealed main strengths of the pharmacy as “expertise” and “service and kindness.” Together with more cooperation with GPs and nurse practitioners, these strengths give the pharmacist the opportunity to further develop pharmaceutical care activities. Conclusion Pharmacists are challenged to increase their visibility as health care provider while keeping logistic service on a high level and improving cooperation with other health care providers.

Background: Despite the well-known beneficial effects of statins, many patients do not adhere to chronic medication regimens. Objective: To implement and assess the effectiveness of a community pharmacy-based pharmaceutical care program developed to improve patients' adherence to statin therapy. Methods: An open-label, prospective, randomized controlled trial was conducted at 26 community pharmacies in the Netherlands. New users of statins who were aged 18 years or older were randomly assigned to receive either usual care or a pharmacist intervention. The intervention consisted of 5 individual counseling sessions by a pharmacist during a 1-year period. During these sessions, patients received structured education about the importance of medication adherence, lipid levels were measured, and the association between adherence and lipid levels was discussed. Adherence to statin therapy was assessed as discontinuation rates 6 and 12 months after statin initiation, and as the medication possession ratio (MPR), and compared between the pharmaceutical care and usual care groups. Results: A total of 899 subjects (439 in the pharmaceutical care group and 460 in the usual care group) were evaluable for effectiveness analysis. The pharmaceutical care program resulted in a significantly lower rate of discontinuation within 6 months after initiating therapy versus usual care (HR 0.66, 95% CI 0.46 to 0.96). No significant difference between groups was found in discontinuation at 12 months (HR 0.84, 95% CI 0.65 to 1.10). Median MPR was very high (>99%) in both groups and did not differ between groups. Conclusions: These results demonstrate the feasibility and effectiveness of a community pharmacy–based pharmaceutical care program to improve medication adherence in new users of statins. Frequent counseling sessions (every 3 months) are necessary to maintain the positive effects on discontinuation. Although improvements are modest, the program can be applied easily to a larger population and have a large impact, as the interventions are relatively inexpensive and easy to implement in clinical practice.

Practical issues such as ease of use and packaging appear to cause significant problems in daily use of medicines, but there are only few published studies about these aspects of medicine use.To assess the type of experiences related to practical aspects of medicine use reported to an Internet-based medicine reporting system (www.meldpuntmedicijnen.nl).All reports submitted from May 2004 to December 2007 to an Internet-based medicine reporting system in the Netherlands related to practical aspects of drug use were analyzed. The experiences were grouped into the following categories: difficulty with opening the package, other difficulties with use, and problems with printed text on packages and the information leaflet.Of the 5175 individuals who submitted a report, 530 submitted 611 reports on practical aspects of medicine use. More than half of the reports concerned difficulties with the opening of packages, mostly about opening blister packages (46.2%). One third of the reports were related to other problems with use, mainly package size (13.0%) and preference for different packaging (8.5%). About 1 in 10 reports was related to the printing and information on packages, mostly about unclear and confusing text print on the primary package (5.7%). In all, 25.2% of the reporters informed their prescribing physician of the problem and 38.2% informed the pharmacist or pharmacy staff.Some medicine users experience considerable difficulties with the packaging of their drugs; one of the major issues is opening a blister package. Packaging of pharmaceuticals needs more attention; issues need to be addressed by the pharmaceutical manufacturers, registration authorities, and, most immediately, community pharmacists.

Purpose STOPP and START criteria identify potential inappropriate prescribing and potential prescribing omissions. It is unknown whether STOPP/START criteria identify all drug-related problems. This study aims to determine to what extent STOPP/START correspond to drug-related problems (DRPs) identified during a full clinical medication review. Methods In 13 Dutch community pharmacies, 457 community-dwelling patients aged ≥65 years and using ≥5 drugs, received a full clinical medication review. Community pharmacists identified potential DRPs and recommendations by implicit criteria. After completion, all identified DRPs and recommendations were compared with STOPP and START criteria by investigators. Results The total number of potential DRPs identified by community pharmacists was 1656 in 457 patients (mean 3.6 per patient). Eighty-one percent of DRPs were not associated with STOPP/START criteria. The percentage of START criteria present in identified DRPs was higher than the percentage of STOPP criteria (13 vs. 5.7 %, p

SUMMARY Introduction: Opioid-induced constipation is a common problem and can cause serious compli- cations. It is widely advised that laxatives should be started concurrently with opiates, unless there is a clear indication not to do so. Objective: This study was undertaken to estimate how often laxatives were started concurrently with opiates and to describe the effect of phar- macy-based interventions to promote the use of laxatives in patients starting opioids. Methods: Twenty-six community pharmacies identified all patients who received a first pre- scription for a strong opioid during January and February of 1998, 1999 or 2000. Pharmacists collected information on patient, drug and pre- scriber characteristics (age, gender, use of opiates and laxatives). A separate questionnaire was used to collect data on pharmacy-based interventions to promote the simultaneous prescribing of laxa- tives with the opiates. Results: Overall, 37% of the patients receiving an opioid started taking laxatives within 5 days. The percentage of patients who received laxatives simultaneously with opioids increased from 31% in 1998 to 35% in 1999 and 42% in 2000. In 117 (43%) of the opioid prescriptions, pharmacy- based intervention had taken place before the prescription date. Of these, 48AE7% was accompanied by a laxative. Opioid prescriptions (n ¼ 152) without a pharmacy based intervention were accompanied in 27AE6%. After adjustment for covariates (including time trends), pharmacy- based intervention increased the probability of concomitant laxative use 1AE9 (95% CI 1AE1-3AE3) times. Discussion: This study shows that the widely used guideline to start a laxative when prescri- bing an opioid is not always followed in daily practice. In addition, we showed that pharmacy- based intervention contributed to increasing laxative use in patients receiving opiods.

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. Copyright © 2002 John Wiley & Sons, Ltd.

Contains fulltext : 169807.pdf (Publisher’s version ) (Closed access) Background Medication waste has undesirable economic and environmental consequences. This waste is partly unavoidable, but might be reduced by redispensing medicines unused by patients. However, there is little knowledge of stakeholders' views on the redispensing. Objective To identify the stakeholders' views on the redispensing of medicines unused by patients. Setting Dutch healthcare system. Method Semi-structured interviews were conducted with 19 Dutch stakeholders from September 2014 until April 2015. The interview guide included two themes: medication waste and redispensing of unused medicines. The latter included qualitative-, legal- and financial aspects and stakeholder involvement, with specific attention to the patient. Interview transcripts were subjected to thematic content analysis. Main outcome measure Requirements related to the redispensing of unused medicines. Results All stakeholders considered the redispensing of medicines desirable if the implementation is feasible and the requirements for the safe redispensing are met. All of them pointed out that the product quality of redispensed medicines should be guaranteed and that it should be clear who is responsible for the quality of redispensed medicines. The stakeholders stated that transparent communication to patients is essential to guarantee trust in the redispensing system and that patients should be willing to use redispensed medicines. Moreover, the redispensing system's benefits should outweigh the costs and a minimal economic value of medicines suitable for redispensing should be determined. Conclusion Redispensing unused medicines could decrease medication waste if several requirements are met. For successful implementation of a redispensing system, all relevant stakeholders should be involved and cooperate as a joint-force.

Summary What is known and objectives Little is known about the ability of community pharmacists who are inexperienced in medication review to identify drug-related problems (DRPs). The objective of our study was to investigate the completeness of DRPs in terms of number, type and clinical relevance identified by community pharmacists when performing home medication reviews (HMRs). Methods This is a cross-sectional study within the intervention arm of a randomized controlled trial among community-dwelling patients (≥65 years, ≥5 drugs) in ten Dutch community pharmacies. Community pharmacists, who were inexperienced in medication review, received 2-day training in medication review. These pharmacists interviewed patients at home about their medicines, identified potential DRPs and made recommendations in combination with medication and clinical records. Expert reviewers completed the number of potential DRPs and recommendations by reviewing all available information, including patient interview reports. Results and discussion In 155 patients, community pharmacists identified a mean of 3·6 (SD 2·8) potential DRPs per patient and expert reviewers added 6·5 (SD 3·2) DRPs. Community pharmacists formulated 2·6 (SD 2·3) recommendations per patient and reviewers added 7·5 (SD 3·3) recommendations. Community pharmacists identified a higher proportion of clinically relevant DRPs compared with expert reviewers, as assessed by DRPs with high priority [OR = 1·8 (95% CI 1·4–2·2)], DRPs associated with recommendations for drug change [OR = 1·9 (95% CI 1·5–2·3)] and implemented recommendations for drug change [OR = 2·1 (95% CI 1·6–2·7)]. What is new and conclusion This study shows that the completeness of medication reviews by inexperienced community pharmacists with limited training could be improved, although they identified a higher proportion of potentially clinically relevant DRPs compared with expert reviewers. The results suggest that community pharmacists with limited experience in medication review may need more intensive post-graduate training.

BackgroundIn previous research, lapses in dosing of paroxetine or sertraline were associated with significantly more discontinuation symptoms and deterioration of depressive symptomatology compared with fluoxetine.AimsTo evaluate dosing lapses in patients chronically treated with selective serotonin reuptake inhibitors (SSRIs) in uncontrolled circumstances.MethodIn a prospective observational study we evaluated compliance data in chronic users of SSRIs using electronic drug exposure monitors.ResultsDuring a 3-month follow-up we found that 50/69 (72.5%) patients missed at least one dosing day and 20/69 (29.0%) missed two or more consecutive days.ConclusionsAbout 30% of patients treated with short-acting SSRIs had dosing lapses of 2 or more days, which, as described in prior studies, is long enough to result in clinically relevant deterioration of mental status.

Background: There is substantial nonadherence to effective adjuvant endocrine therapy for breast cancer prevention. We therefore examined patients' trade-offs between the efficacy, side-effects, and regimen duration, and whether trade-offs predicted nonadherence. Patients and methods: Trade-offs from 241 women were assessed with an Adaptive Conjoint Analysis (ACA) choice task that was customized to each individual patient. From the estimated ACA utilities, the relative importance of each treatment property was calculated and a benefit/drawback ratio between the importance of the efficacy versus that of the side-effects and other treatment properties. Nonadherence was assessed through composites of validated self-report measures. Results: Efficacy was most important. The side-effects joint and muscle pain and risk of endometrial cancer were almost as important. The benefit/drawback ratio showed 16% of the women to value the efficacy less than the side-effects and other treatment properties. A higher benefit/drawback ratio was associated with decreased nonadherence [adjusted odds ratio (OR) 0.1, 95% confidence interval 0.03-0.3]. Conclusions: One in six women do not consider the efficacy of endocrine therapy to outweigh its drawbacks. Knowing women's trade-offs is likely to identify women at risk for nonadherence and to help clinicians in tailoring their communication and care to different needs of individual women. (aut. ref.)

OBJECTIVE we compared the self-reported medication adherence and knowledge of older patients receiving their drugs via multidose drug dispensing (MDD users) with patients receiving manually dispensed drugs (non-MDD users). METHODS MDD users (≥ 65 years, ≥ 5 oral chronic drugs) were randomly selected from eight Dutch community pharmacies. Non-MDD users (≥ 5 oral chronic drugs) were matched on age and gender. Medication adherence was assessed by using the Medication Adherence Reporting Scale (MARS) and medication knowledge by asking the indication of drugs. Cognitive function was measured with Mini-Mental State Examination (MMSE) for a sub selection of patients. RESULTS the percentage of patients being adherent to all drugs was higher for MDD users (n = 119, 81%) compared with non-MDD users (n = 96, 58%, P < 0.001).The percentage of patients with adequate knowledge was lower for MDD users (40%) compared with non-MDD users (79%, P < 0.001). The differences in adherence were independent of knowledge and MMSE scores. CONCLUSION this study shows that older patients receiving their drugs via MDD reported a higher medication adherence compared with patients receiving manually dispensed drugs, despite a lower knowledge and lower cognitive function among patients receiving MDD.

Adherence to the generally complex regimen of coumarin derivatives is vital in order to keep patients in the adequate International Normalized Ratio range. Patients' beliefs about medicines are associated with the level of therapy adherence. Our first aim was to assess beliefs about coumarins. Secondly, we compared the beliefs about coumarins with the beliefs about other cardiovascular drugs.The Beliefs about Medicines Questionnaire was used to assess medication beliefs. The questionnaire was completed by new users of coumarins indicated for venous thromboembolism or atrial fibrillation. A necessity score and a concerns score were calculated for all patients. The analyses were repeated for users of antihypertensive drugs or statins (not using coumarins).Three hundred and twenty patients were included in the analysis of the beliefs about coumarins. The mean necessity score was 15.3, the concerns score 12.3 and the necessity-concerns differential 3.0. Patients with venous thromboembolism (n = 71) had higher necessity scores than patients with atrial fibrillation (n = 249; 16.8 vs. 14.9, P0.001). The mean necessity score in 493 users of other cardiovascular drugs was 16.1, the concerns score 13.5 and the necessity-concerns differential 2.6. The necessity score was higher in chronic cardiovascular drug users (n = 192) than in new users (n = 301; 17.9 vs. 14.9, P0.001).Coumarin users score higher on the necessity scale than on the concerns scale, which is also the case in users of other cardiovascular drugs. Patients with atrial fibrillation have a less positive attitude towards these drugs than patients with venous thromboembolism, and could therefore benefit more from specific attention.

Background: Poor understanding of medical instructions or misinterpretations can be a cause for not using medication as prescribed. Previous studies reported misunderstanding of instructions and warnings on drug labels by up to 50 % of the adult population. Objective: The aim of this study was to assess interpretation of drug label instructions in different migrant populations living in the Netherlands. Methods: Interpretation of drug label instructions was examined in four populations of first-generation immigrants from the Antilles (n = 168), Iran (n = 180), Surinam (n = 155), and Turkey (n = 188). Participants were recruited at meeting places (e.g., mosques and educational or cultural centers) for the particular ethnic group. First-year pharmacy students (n = 153) born in the Netherlands were included as reference group. Correct interpretation of drug label instructions was assessed using a survey with questions about five instructions. Results: Only two out of five presented instructions were interpreted correctly by the majority of the respondents of all groups. Higher levels of education, longer duration of stay, and native ethnicity were positively associated with correct interpretation of drug labels (p

PurposeConsiderable variability in adherence over time exists. The aim of this study was to investigate to what extent deviations from the prescribed regimen in type 2 diabetes patients can be explained by characteristics of the individual ‘medication intake moments’ and the patient.MethodsMedication intake of 104 non-adherent type 2 diabetes patients from 37 community pharmacies was electronically monitored for 6 months. The primary outcome measures were: (1) whether or not the intake occurred and (2) whether or not the intake occurred within the agreed-upon time period (correct timing). Multilevel logistic regression analyses were performed to account for the nested structure of the data.ResultsMedication intakes in the evening and during weekends and holidays were more likely to be incorrectly timed and also more likely to be completely missed. Irrespective of timing, most intakes occurred in the mornings of Monday through Thursday (96 %), and least intakes occurred on Saturday evening (82 %). Correctly timed intakes most often occurred on Monday and Tuesday mornings (61 %) in contrast to Sunday evenings (33 %). A patient’s medication regimen was significantly associated with adherence.ConclusionBased on our results, among patients who already have difficulties in taking their oral antidiabetic medication, interruptions in the daily routine negatively influence the intake of their medication. Professionals need to be aware of this variation in adherence within patients. As regular medication intake is important to maintain glycaemic control, healthcare professionals and patients should work together to find strategies that prevent deviations from the prescribed regimen at these problematic dosing times.Keywords: Medication adherence, Oral antidiabetics, Multilevel modelling, Electronic monitoring

Item does not contain fulltext PURPOSE: Our purpose was to investigate the feasibility of pharmacy-initiated pharmacogenetic (PGt) screening in primary care with respect to patient willingness to participate, quality of DNA collection with saliva kits, genotyping, and dispensing data retrieved from the pharmacy. METHODS: Polypharmacy patients aged >60 years who used at least one drug with Anatomical Therapeutic Chemical (ATC) code N06AA01-N06AX19 (antidepressants), A02BC01-A02BC05 (proton-pump inhibitors), N05AA01-N05AH04 (antipsychotics), or C07AB02 (metoprolol) in the preceding 2 years were randomly selected. DNA was collected with saliva kits and genotyped for CYP2D6 and CYP2C19 with the AmpliChip. Pharmacy dispensing records were retrieved and screened for drugs interacting with the patient's CYP2D6 and CYP2C19 genotype by using the evidence-based PGt guidelines from the Dutch Pharmacogenetics Working Group. RESULTS: Out of the 93 invited patients, 54 (58.1%) provided informed consent. Nine saliva samples (16.7%) contained too little DNA. Call rates for CYP2D6 and CYP2C19 were 93.3% and 100%, respectively. Frequencies of genotype-predicted phenotype were 2.4%, 38.1%, 54.8%, and 4.8% for CYP2D6 poor metabolizers (PM), intermediate metabolizers (IM), extensive metabolizers (EM), and ultrarapid metabolizers (UM) respectively. For CYP2C19 genotype-predicted phenotype, frequencies were 2.2%, 15.6%, and 82.2% for PM, IM, and EM, respectively. CONCLUSIONS: This study shows that pharmacy-initiated PGt screening is feasible for a primary care setting.

Objective. To evaluate the internal reliability, factor structure and construct validity of the Pharmacy Safety Climate Questionnaire (PSCQ) when applied to a pan-European sample of community pharmacies. Design. A cross-sectional survey design was used. Setting. Community pharmacies in Denmark, Germany, the Netherlands, Portugal and Great Britain. Participants. A total of 4105 members of the community pharmacy workforce, all drawn from one of the five participating countries. Main outcome measures. Each participant completed a copy of the Pharmacy Safety Climate Questionnaire in his or her respective language and rated the perceived safety of the pharmacy in which he or she worked. Results. Exploratory and confirmatory factor analyses of the data identified four factors that accounted for item responses, with 24 of the original 34 items loading onto them. They were labelled organizational learning, blame culture, working conditions and safety focus. These factors were found to have an acceptable level of reliability (with Cronbach’s alpha values ranging from 0.70 to 0.92) and to predict the rating of pharmacy safety. Conclusions. This study provided information on the PSCQ’s psychometric properties when used in community pharmacies in different European countries. A modified version of the original PSCQ (known as PSCQ-4) is presented, and further work is proposed to demonstrate its application to safety improvements in pharmacies.

Background Estimates of statin discontinuation rates are generally high but show large variations. Discontinuation rates are possibly influenced by unrecognized supplies from previous prescriptions and the operational definitions of statin discontinuation. Objective: To investigate whether the outcome (discontinuation) was affected by (1) the operational definition used to calculate statin exposure and (2) the operational definition and different cutoff values used to calculate discontinuation. Methods: Data for this study were obtained from the PHARMO medical record linkage system in the Netherlands. Participants were patients with a new statin and no statin prescription in the preceding year. The outcome, discontinuation, was defined based on a variable number of days without medication after exposure (gaps) or based on the availability of supplies 12 months after the inclusion date (at 1 year). Exposure to statins was assessed by 2 methods. The method termed No Overlap accounted for only the supplies of the last prescription to calculate exposure, and the method termed Overlap accounted for all supplies from previous prescriptions. We investigated the effect of 4 exposure outcome combinations on statin discontinuation estimates. Results: The exposure outcome combinations, including overlap, resulted in a 7% unit lower discontinuation rate. At gap lengths of 90 days and longer, no significant differences between No Overlap and Overlap were observed. Shorter minimum gap lengths gave higher discontinuation rates compared to longer minimum gap lengths and ranged from as high as 86% to 21%. Conclusions: If previous supplies are accounted for in the calculation of exposure to statins, lower discontinuation rates are observed, The influence of previous supplies on discontinuation rates is less pronounced than the influence of gap lengths. The calculation of exposure does not influence discontinuation if gaps longer than 90 days are used to assess discontinuation.

BACKGROUND There are concerns that automated drug dispensing may increase inappropriate drug use. Automated dispensing could lead to perpetual repeating of drug therapies without the necessary re-evaluation. OBJECTIVE The aim of this study was to examine the effect of a pharmacist-led medication review on drug-related problems (DRPs) in older patients receiving their drugs via automated dispensing. METHODS This was a pragmatic randomized controlled study conducted in primary care. Patients were recruited from six Dutch community pharmacies. They were eligible if they lived at home, were aged ≥ 65 years, and used five or more different drugs, of which at least one had to be dispensed via an automated system. Patients were randomly allocated to receive a medication review at the start of the study (intervention group) or after 6 months (waiting-list group). Each patient was independently reviewed by two pharmacist reviewers. The results of these medication reviews were sent to the community pharmacist to be discussed with the patient's general practitioner (GP). The primary outcome measure was the number of DRPs leading to a recommendation for drug change. Secondary outcomes were the total number of drug changes and the number of drug changes related to a recommendation. In order to analyse drug changes, medication records were collected 6 months after the medication review or index date in the waiting-list group. Potential DRPs were classified using the DOCUMENT classification. RESULTS There were no baseline differences between the 63 patients in the intervention group and the 55 patients in the waiting-list group with respect to age, sex, number of drugs per patient and type of drug prescribed. The mean number of DRPs per patient at baseline in the intervention group and waiting list combined was 8.5, with no difference between the groups. At baseline, the mean number of DRPs leading to a recommendation for drug change was 4.5 per patient and did not differ between the two groups. After 6 months, the number of DRPs leading to a recommendation for drug change decreased by 29% in the intervention group versus 5% in the waiting-list group (p < 0.01). Recommendations for cessation of a drug were more frequently accepted than recommendations to add a new drug (82% vs 44%, p = 0.01). CONCLUSIONS This study shows that patients using automated drug dispensing have a high number of DRPs. Medication review decreases the number of DRPs among these patients. We recommend that all patients with automatic drug dispensing should have a thorough medication review by pharmacists and prescribers.

Objective To analyze information and communication in the community pharmacy when patients collect a first dispensing for chronic medication. Methods In 3 pharmacies in the South-West of the Netherlands, counter-based communication with patients receiving a first dispensing for chronic medication was observed and audiotaped. Each contact was analyzed by two observers using an observation checklist. An 11-item questionnaire was given to the patients. Results 72 Patients were included. Only pharmacy technicians provided information. Average contact lasted approximately 2 min. A computer checklist to support information giving was closely followed. Interactions were structured with introduction and closure. Mostly, information was given without exploring needs of the patient. Questioning showed open-ended questions (26%); check-questions and questions asking feedback (57%). A mean general score given was 5.8 (range 1–9). Of 46 responders who filled in a questionnaire, the majority felt that information was useful, clear and understandable. Conclusion Our results show a concise and efficient way of information giving, closely related to a computer checklist. Technicians dominate the interaction. They ask few questions. Patients are satisfied about provided information and the contact. Practice implications We suggest a more patient-centered way of communication to increase patients’ participation and to meet patients’ needs for information.

Subjects using functional foods with approved health claims may be more likely to be non-adherent with prescribed drug therapy. This study aimed to assess the influence of the use of phytosterol/-stanol-enriched functional foods on adherence to statin therapy among patients initiating treatment.We used data from the statin intervention research project, a randomized controlled trial aimed at improving adherence to statins. In the trial, new statin users were randomized to receive either usual care or extensive pharmaceutical care consisting of five individual counseling sessions. Customary use of phytosterol/-stanol-enriched products was identified by questionnaires filled out by all participants. Automated pharmacy-dispensing records were used to assess adherence in terms of discontinuation of therapy and the medication possession ratio. Analyses were performed for the overall population, as well as stratified for receiving pharmaceutical or usual care.The use of functional foods enriched with phytosterols/-stanols was not related to discontinuation of statin therapy, neither in the overall population (overall population adjusted hazard rate ratio (HR(adj)): 0.80 [95%CI: 0.59-1.08]), nor when stratified by randomization arm (pharmaceutical care HR(adj): 0.77 [95%CI: 0.49-1.23]); usual care HR(adj): 0.81 [95%CI: 0.54-1.21]). The median medication possession ratio was significantly lower in users of phytosterols/-stanols in the usual care group, but the difference was not clinically relevant.Customary use of phytosterol/-stanol-enriched functional foods did not affect adherence to statins in new users that are well informed on the beneficial effects of statin therapy. In daily medical practice, general practitioners and pharmacists should urge subjects not to take phytosterol/-stanol-enriched functional foods as replacement for their prescribed medication.

The benefits of intensive and continuous antihyperglycemic drug therapy have been extensively described. Data on long-term patterns and modifications of antihyperglycemic drug use are scarce however. Moreover randomized controlled studies may not reflect actual drug use in daily clinical practice.The aim of this study is to describe the longitudinal patterns of antidiabetic drug modifications after initiation of oral antidiabetic therapy in a large cohort of type 2 diabetes patients. The study will focus specifically on differences between patients who initiate treatment with metformin compared to patients who initiate treatment with sulfonylureas.An observational study of longitudinal patterns of use and modification of oral antidiabetic drug therapy in 3323 patients who started with oral antidiabetic treatment between 1999 and 2007. Drug dispensing data were extracted from pharmacy information systems.This study shows that changes in international guidelines recommending metformin as first choice initial drug therapy in all patients were rapidly followed by prescribers. Patients starting diabetes treatment with metformin showed fewer modifications to treatment compared to patients initiating treatment with sulfonylureas. After correction for duration of follow-up, Cox regression analysis showed a hazard ratio of 0.84 for any modification in the metformin group compared to the sulfonylureas group.This study shows that adherence to type 2 diabetes treatment guidelines for initial treatment is implemented on a large scale. Longitudinal patterns show that the majority of patients receive a small number of modifications to their drug regimen. Discontinuation rates were relatively low.

Background: When patients visit a community pharmacy for the first time, the creation of an electronic patient record (EPR) with relevant and up-to-date data is a prerequisite for adequate medication surveillance and patient counseling. Objective: To investigate the level of completeness of documentation in the EPR after a patient's first visit to a Dutch community pharmacy. Methods: In each participating pharmacy, newly enlisted (Results: Of 403 selected patients, 154 (38.2%) could be interviewed by telephone. Poor documentation of telephone numbers in the EPR was the main reason for nonresponse (134/249). Interviewers found that 67.7% of prescription drugs, 0% of over-the-counter drugs, 19.6% of diseases, 3.7% of intolerabilities, and none of the specific conditions reported by patients had been documented in the EPR. Nonmandatory data (personal experiences and habits, drug use problems) reported during the patient interview had not been documented in the EPR. Conclusions: The EPR after a patient's first visit to the community pharmacy is often incomplete. For new patients, the pharmacist should more proactively and systematically gather patient information, and all relevant information should be recorded, preferably in coded form, in the pharmacy information system to allow more adequate clinical risk management.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • Early discontinuation of treatment in new users of inhaled corticosteroids (ICS) has been widely discussed, but patients' reasons for this have not been investigated in depth. WHAT THIS STUDY ADDS • In contrast to what might have been expected, the majority of patients mentioned a wide range of symptoms or conditions as the reason for the start of ICS therapy. • There is no clear indication for prescribing ICS in these patients. • Most of these conditions are self limiting and may be expected to be of short duration, consequently a decrease in symptoms was the main and justifiable reason for discontinuing ICS. • However, a non-negligible proportion of patients has significant residual symptoms and seems to be in need of continuous ICS use. AIM Although early discontinuation of treatment in new users of inhaled corticosteroids (ICS) has been widely discussed, the reasons for stopping have not been investigated in depth. We aimed to describe reasons for discontinuation from a patient's perspective in relation to their experience of symptoms at the time of the investigation. METHODS A cross-sectional study among new users that discontinued ICS use in the Netherlands was performed. Patients were interviewed by telephone, aiming to identify the symptoms for which they were prescribed ICS, the reasons for discontinuing treatment and the respiratory symptoms patients still experienced at the time of the survey. In addition, automated dispensing records of all patients were retrieved. RESULTS From 287 eligible patients, 230 (80.1%) were interviewed. Only 22 patients (9.6%) mentioned asthma as the reason for a first ICS prescription. A decrease in symptoms was the main reason for discontinuation (45%). Thirty patients (13%) reported clinically significant residual symptoms. These patients reported more seasonal variation of symptoms and were more often prescribed short-acting β2-agonists. CONCLUSIONS The majority of patients mentioned a wide range of symptoms and conditions, other than asthma or chronic obstructive pulmonary disease, as the reason for the start of ICS therapy. Most of these conditions may be expected to be of short duration. Not surprisingly a decrease in symptoms was the main, and justifiable, reason for discontinuing ICS. However, a non-negligible proportion of patients reported residual symptoms that suggest the need of continued ICS use. Physicians and pharmacists could cooperate in identifying those patients for which ICS are really indicated and motivate them to continue the use of ICS.

Objective To monitor the amount of unused drugs and the cost to the public health system. Setting A random sample of community pharmacies in Barcelona, Spain. Method The drugs were collected from 38 community pharmacies over a period of 7 consecutive working days (excluding Sundays). A questionnaire was designed to evaluate each returned medicine. The resulting data were analyzed and evaluated. Main outcome measure The number of drugs collected at the pharmacy, the characteristics of the clients and the reasons why they returned the drugs, and finally the economic value of the drugs returned and the cost to the public health system. Results A total of 227 clients (54.6% women, 64 ± 20 years-old) returned 1,176 packages to the pharmacy. The number of packages collected in one return ranged from 1 to 121. The number of packages collected per pharmacy ranged from 0 to 188. In more than half of the cases (52.4%) the patients returned their drug in person and in 32.2% of the cases a relative returned it on their behalf. The main reason (28.2%) why drugs were returned was the expiry date. In 24.9% of the cases the patient's condition had improved and there was no further need for the drug. In 20.8% the patient had died. The estimated total cost of the collected drugs was €8,539.9. Over 75% of this amount (€6,463.9) had been paid by the public health system. Conclusion This study confirms the importance of analyzing the return of unwanted medicines to reduce unnecessary health expenditure. It also highlights the inadequacies of the Spanish health system in the areas of prescription, dispensing and use of medicines. Establishing strategies to reduce the wastage of unused medicines is necessary.

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.Cross-sectional study.Community pharmacy dispensing data from a population of approximately 450,000 patients in the northern and eastern part of The Netherlands.Women aged 45-69 years to whom at least one HRT prescription was dispensed between 1 January 2000 and 1 January 2004.Annual and quarter prevalences of HRT and the proportion of new HRT users, switchers and continuous HRT users per quarter.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.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.

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.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.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.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.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.

To describe the patterns of use of bupropion in daily clinical practice and factors which determine successful smoking cessation.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.Abstinence rate and factors determining successful abstinence after six months.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.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.

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.

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 ( 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.

Objective: To develop a comprehensive and easily applicable prognostic model predicting mortality risk in patients with moderate to severe heart failure. Design: Prospective follow up study. Setting: Seven general hospitals in the Netherlands. Patients: 152 outpatients with heart failure or patients admitted to hospital because of heart failure, who were included in a randomised trial to assess the impact of a pharmacist led intervention to improve drug compliance. Duration of follow up was at least 18 months. Main outcome measures: Multivariable logistic regression modelling was used to evaluate information from history, physical examination (for example, blood pressure), drug use, and quality of life questionnaires that independently contributed to the prediction of death. The area under receiver operating characteristic curves (AUC) was used to estimate the predictive ability of the prognostic models. Results: During the 18 months of follow up, 51 patients (34%) died. Independent predictors of mortality were diabetes mellitus, a history of renal dysfunction (or higher creatinine), New York Heart Association (NYHA) functional class III or IV, lower weight or body mass index, lower blood pressure, ankle oedema, and higher scores on a disease specific quality of life questionnaire. The use of β blockers was predictive of a better prognosis. These factors were used to derive various prediction formulas. A model based on medical history, weight, presence of oedema, and lower blood pressure had an AUC of 0.77. Addition of use of β blockers to this model improved the AUC to 0.80. Addition of NYHA class increased the AUC to 0.84. Data on quality of life did not improve the AUC further (AUC 0.85). Conclusions: A prognostic model produced on the basis of easily obtainable information from medical history and physical examination can adequately stratify heart failure patients according to their short term risk of death.

c Abstract 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. 2003 European Society of Cardiology. Published by Elsevier Science B.V. All rights reserved.

To the Editor: In the Netherlands, the outbreak of pandemic influenza A (H1N1) 2009 led to a 100-fold increase from 2008 in prescriptions for the antiviral neuraminidase inhibitor oseltamivir (1). The guidelines for prescribing oseltamivir during the 2009 pandemic were adapted throughout the year. After August 7, prescribers were advised to restrict prescriptions to patients with influenza symptoms plus 1 additional risk factor (2) (Table). Table Reported risk factors of patients with and without influenza symptoms who were dispensed a prescription for oseltamivir, the Netherlands, 2009–10 Community pharmacists dispensed oseltamivir as a 5-day course of sachets produced exclusively for the Dutch government program and documented all prescriptions. Our objective was to assess whether oseltamivir dispensed through community pharmacies was prescribed according to the national guideline for the pandemic virus and to investigate how patients used oseltamivir. The Institutional Review Board of the Division of Pharmacoepidemiology and Clinical Pharmacology of Utrecht University approved the study. Pharmacists in 19 pharmacies belonging to the Utrecht Pharmacy Practice Network for Education and Research (UPPER) selected all patients who had filled a prescription for oseltamivir during May 1, 2009–February 8, 2010. These patients were contacted by phone and, after giving consent, completed a structured questionnaire. The questionnaire contained questions about potential risk factors, the reason for receiving the oseltamivir prescription (influenza symptoms or other reasons), and whether the oseltamivir course was started and completed. Of the 630 patients eligible for contact, 361 (57.3%) completed the questionnaire. To assess whether the current guidelines were adhered to, because of the changes in policy throughout the year, we analyzed only the 300 respondents who had filled the oseltamivir prescription at the height of the pandemic, i.e., after August 7, 2009. A total of 156 (52.0%) participants were female patients; most participants were 18–59 years of age. Of the 212 patients >18 years of age, education level was available for 195; of these, 55 (28.2%) had a low education level, 94 (48.2%) a middle education level, and 46 (23.6%) a high education level. Of the 300 respondents, 111 (37.0%) received a prescription while they did not meet guideline criteria (Table). They had risk factors but did not experience influenza symptoms (67 [22.3%] of all respondents); had influenza symptoms but not risk factors (34 [11.3%]); or had neither influenza symptoms nor any risk factors (10 [3.3%]). Compared with respondents who had a low education level, respondents >18 years of age who had a middle or high education level were 2× more likely to receive an oseltamivir prescription that was not in accordance with guideline criteria (odds ratio 2.20; 95% CI 1.12–4.32). Sex and age were not associated with the likelihood of receiving off-guideline oseltamivir. Of the 189 respondents who received oseltamivir in accordance with guideline criteria, 184 (97.4%) started treatment and 167 (90.8%) completed the oseltamivir course. Of the 111 respondents who received a prescription for oseltamivir that was not in accordance with guideline criteria, 62 (55.9%) started treatment, and 56 (90.3%) completed the course. We showed that during the pandemic the guideline criteria were not met by nearly one third of patients who received an oseltamivir prescription. Patients with a higher education level more often received a prescription, suggesting that they are more informed or empowered than patients with a lower education level to request a prescription. Another explanation for the inadequate adherence to guideline criteria is that prescribers themselves were not immediately aware of the current criteria, possibly because of changes throughout the year. In addition, in nearly half of instances in which guideline criteria were not met but in which oseltamivir was prescribed, the patients did not start the oseltamivir course. These prescriptions could have been used for stockpiling, which also occurred during the influenza A (H5N1) outbreak in 2005 (3). In the Netherlands, stockpiling did not lead to drug shortages, but in countries where oseltamivir is not reimbursed by the government, stockpiling might lead to problems with availability for patients truly in need of antiviral therapy but without the necessary means to acquire it. The limited effect of oseltamivir on reducing disease duration, usually only shortening the duration by 1 day in healthy persons (4), the possibility of serious side effects (5), the possibility of the virus developing resistance to neuraminidase inhibitors (6,7), and the cost to health care of unnecessary prescriptions are reasons to strive for better adherence to prescribing guidelines. Prescribers need to be properly informed about current guidelines to reduce overprescribing caused by lack of knowledge. Furthermore, improving communication between prescribers and patients might help relieve patients’ concerns and increase awareness about the limited benefits of oseltamivir treatment in healthy persons.

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.Characteristics of all individuals and the questions they asked on both services in the month of February 2000 were analysed.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.Different services can meet the needs of different patient groups.

Background: Sympathomimetic agents have a direct positive chronotropic effect on heart rate and may cause hypokalemia, even when administered by inhalation. In selected patients (eg, patients with congestive heart failure [CHF]) this can lead to arrhythmias. Despite the potential adverse effects of these agents, they are used frequently in patients with CHF, due to a high incidence of respiratory comorbidity. This study investigates the effects of sympathomimetics on the incidence of hospitalizations for arrhythmias in patients with CHF. Methods: In a cohort of 1208 patients with a validated hospital discharge diagnosis of CHF, we identified 149 cases with a readmission for arrhythmias, and compared these in a nested matched case-control design with 149 controls from the remainder of the cohort with no hospital readmission for any cardiac cause. Conditional logistic regression was used to calculate the risk for hospitalization for arrhythmias associated with exposure to sympathomimetic agents, expressed as odds ratios. Results: Of 149 case patients, a total of 33 (22.1%) were treated with any sympathomimetic agent, and 6 patients (4.0%) were treated with systemic sympathomimetics. The use of any sympathomimetic drug was associated with an increased risk of admission for arrhythmia (odds ratio, 4.0; 95% confidence interval, 1.0-15.1). For systemic sympathomimetic drugs, the corresponding odds ratio was 15.7 (95% confidence interval, 1.1-228.0). Conclusions: The results of this study strongly suggest an increased risk of hospitalization for arrhythmias in patients with CHF treated with sympathomimetic drugs. Sympathomimetics should be given under close surveillance to patients with CHF. Arch Intern Med. 2000;160:2477-2480