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Pharm World Sci (2006) 28:239–247DOI 10.1007/s11096-006-9023-9 Drug-related problems in patients with angina pectoris, type 2diabetes and asthma – interviewing patients at home Lotte Stig Haugbølle Æ Ellen Westh Sørensen Received: 12 January 2006 / Accepted: 12 April 2006 / Published online: 26 October 2006Ó Springer Science+Business Media B.V. 2006 ‘‘Other problems’’ (such as limited knowledge of the illness, inappropriate lifestyle, fear of medication, lack of study was to create a foundation for improving the information, etc.) were the two most common DRP sub- quality of counselling practice in pharmacies. The categories identified in all three patient groups.
research question addressed in this sub-study was to describe drug-related problems (DRPs) in terms of macy-based population of 414 patients visiting the frequency as well as type in people with angina pectoris, pharmacy, all of whom are at high risk of experiencing type 2 diabetes and asthma, as the problems were iden- drug-related problems. Pharmacy staff needs to take tified through medication reviews and home interviews.
this high rate of DRPs in people with angina pectoris, asthma and type 2 diabetes into account when dis- ships, fourth-year pharmacy students collected data for pensing medicines to and advising patients from the the study in 1999, 2000 and 2001 by carrying out medi- three groups, especially when explaining how to use cation reviews, conducting home interviews and regis- tering DRPs for 414 patients. Data were collected fromthe following patient groups in the years indicated: in Angina pectoris Æ Asthma Æ Type 2 diabetes Æ 1999, 123 angina pectoris patients; in 2000, 192 type 2 Drug-related problems Æ Home interviews Æ Medication diabetes patients, and in 2001, 99 asthma patients. The review Æ Patient perspective Æ Diabetes Æ DRP interviews dealt with the patient’s drug-related experi-ences, knowledge, perceptions, problems and actions.
Short statements on the impact of the article on The DRPs were registered according to the so-called PI- • The results of the study can be used to provide qualitative interviews with the three patient groups, pharmacy staff with concrete information on the which revealed a relatively high number of DRPs com- pared to other studies. An average of 2.8 DRPs were (DRPs) experienced by angina pectoris patients, identified per angina pectoris patient; 4.1 DRPs per type asthma patients and type 2 diabetes patients.
2 diabetes patient and 4.0 DRPs per asthma patient.
• Study results can be used to increase the awareness ‘‘Inappropriate use of medicines by the patient’’ and of pharmacy staff, so that whenever they meet apatient with angina pectoris, asthma or type 2 dia-betes, they will be alert to the fact that these patients L. S. Haugbølle (&) Æ E. W. SørensenDepartment of Pharmacology and Pharmacotherapy, are likely candidates for DRPs, problems that Section for Social Pharmacy and Research Centre for Quality in Medicine Use, The Danish University of • A Danish website based on the major results from Pharmaceutical Sciences, Universitetsparken 2, DK-2100, the study has been developed and is used widely by development of pharmacy practice and pharmacy prac-tice research in the pharmaceutical care area. This article Documenting drug-related problems (DRPs) plays an will focus on a description of the DRPs (frequency and important role in the quality assurance of the pharma- type) of people with angina pectoris, asthma and type 2 ceutical care process and the quality development of diabetes as they were identified through medication re- pharmacy practice. Furthermore, documentation of views and home interviews with patients. Results on other DRPs can be used when negotiating reimbursement of study parts can be found elsewhere [17, 22, 23].
pharmacy services, discussing health policy or as a pro-cess indicator of pharmacy practice [1–4].
Numerous pieces of research have suggested that the patient’s perspective should be an important prerequisite for describing and prioritizing the patient counsellingpractices of health professionals [5–11], the reason being that patients’ perspectives on illness and medicine useoften differ from those of health professionals [8, 12–17].
Fourth-year pharmacy students serving their pharmacy This study differs from most other studies in the fol- internships produced data for the study [23]. At present lowing way: We considered that interviewing patients in 60% of all 288 Danish pharmacies have the status of their homes would provide a useful method of collecting internship pharmacies. Selection as an internship phar- data to supplement medication reviews with regard to macy is based on willingness, a professional assessment identifying DRPs. In their own homes, patients feel of each pharmacy and the supervisor’s professional more relaxed as they describe and elaborate on their qualifications. For other aspects of Danish pharmacy medication- and illness-related experiences, consider- ations, actions and problems, meanwhile displaying the The study was conducted as an action research specific contents of their medicine chest. Home inter- study. The aim of action research is to initiate action in views between pharmacists and patients have only been the local setting and create learning, in this case for used in a few other studies to identify DRPs [18–21]. In students as well as pharmacies and pharmacy practice this study, we also deal with specific pharmacy-based researchers [24–26]. A project group consisting of patient groups. Besides, neither of the other studies in community and hospital pharmacists, pharmacy stu- the area were carried out by pharmacy students as part of dents and pharmacy practice researchers planned the a larger study, aiming at contributing to quality devel- study, and developed a study protocol containing the opment of pharmacy practice and pharmacy practice Angina pectoris patients were chosen as the study’s The study on which this article is based was part of a more first patient focus group in 1999, since with only one extensive Danish study aiming at contributing to quality exception at the time [27], this patient group had lar- 1 pharmacy proprietor (a trained pharmacist), 2.2 community pharmacists and 8.6 pharmacy technicians (converted into full-timeemployees) Typically the pharmacist. About 70% of pharmacy technicians areauthorized to control prescriptions though Pharmacy proprietor, community pharmacists, pharmacy techni-cians, pharmacy technician students Takes 5 years. In their fourth year, pharmacy students complete a 6-month pharmacy internship in either a community or a hospitalpharmacy Takes 3 years (20 weeks at college, the rest in a pharmacy) gely been neglected by community pharmacy. In technique was used to select patients during one spe- addition, since the Danish Pharmaceutical Association cific week [28]. For further details on inclusion and (DPA) had designated 1999 a campaign year for cardiovascular diseases, pharmacies were already The study thus provided a profile of a pharmacy- expected to meet the requirements for participating in based population of angina pectoris patients, type 2 a study on angina pectoris patients, due to their pre- diabetics and asthma patients. The patient interviews sumed increased knowledge of the patient group that were carried out in patient’s homes on the basis of a year. The year 2000 was labelled a campaign year for semi-structured interview guide. Theories on the diabetes by the DPA, and 2001 was a campaign year self-regulation of medicine [7, 29], coping with illness for asthma. Thus the next two patient groups to be [7, 30, 31], user perspectives [5, 8, 9, 32] and DRPs included in the study were type 2 diabetes patients in [33, 34] were used as frames for developing the inter- view guide. The interviews lasted 1 h on average perinterview (ranging from 20 min–2 h), were recorded and subsequently transcribed into the interview guide,either verbatim or in the student’s own words. See Prior to data collection, the students were given edu- Table for an example of an interview guide.
cational study materials and a test to complete toprepare them for conducting patient interviews, per- forming medication reviews and documenting DRPs.
The students filled in medication profiles and con- As stated by van Mil et al. [1], as many as 14 systems ducted the patient interviews on the basis of data from for classifying DRPs are described in the international the pharmacy and the patients. See Table .
literature, although well-constructed and validatedsystems are still lacking. To ensure reliable and con- sistent documentation of the DRPs identified, theproject group developed a DRP documentation pro- Qualitative interviews were chosen as the method of tocol outlining when and how to code a DRP, based on collecting patient data, since the students were to gain the PI-Doc (Problem Intervention Documentation) in-depth knowledge about each patient’s medicine- coding form [33–35]. Developed in 1995, the PI-Doc is and illness-related knowledge, perception, problems a hierarchical system for problem-intervention docu- and actions. A non-random self-selecting sampling mentation, and the system has been used in several Table 3 Patient inclusion and exclusion criteria eryl nitratesFrom two to four patients were Patients in residential care, patients with senile dementia, patients who did not speak Danish and psychotic Course of illness, symptoms, living with angina pectoris (family, Use of medicines (dosage, storage, knowledge of effect of med- icine), perception of medicine use, side effects (experienced, fear of side effects, speculation about side effects), other problemswith medicine use, self-regulation of medicine use (rationale,arguments) Preventing angina pectoris (smoking cessation, exercise, food, etc.), strategies for staying healthy, ways of solving illness- andmedicine-related problems, current condition of health, use ofsocial network Content and form of information (from pharmacy, GP, hospital, others) expectations of health care personnel Meaningfulness, comprehensibility and manageability of anginapectoris pharmaceutical studies to pinpoint the exact nature of was used [37]. For further details see Haugbølle et al.
The protocol was developed along with all three sub-studies, based on feedback from pharmacy stu-dents, pharmacies and researchers. For instance, based on experiences from the first sub-study (on anginapectoris), a number of sub-groups matching the Described below are the most common DRPs found in relevant disease were set up for the second and third the three patient groups in sub-categories A–E in the sub-studies to enhance documentation reliability. The coding system for the project. Sub-category F ‘other protocol contained among other things general infor- problems’, which includes aspects of medicine use other mation about DRPs, concise guidelines for when and than purely technical problem is described in the results what to document as a DRP, and instructions on how section as well, since it shows a high number of DRPs to use the documentation form. The protocol also for all three diseases. Examples come from interviews contained a documentation form with examples regarding specific DRPs. See Tables and .
clarifying when to use the different sub-groups.
A total of 329 DRPs were identified for 118 patients The students returned interview transcripts, medica- with angina pectoris, corresponding to the identifica- tion profiles and completed DRP documentation tion of an average of 2.8 DRPs per patient.
forms to the project group. Two community phar- The most common DRP is the inappropriate use of macists in the group with substantial experience in medicines by the patient (72 cases). The patients said identifying and documenting DRPs analysed all they didn’t know enough about their medicines (28 interview transcripts and medication profiles for cases); for example in terms of how fast relief medicine DRPs according to suggestions by Schaefer [34]. In affected their body. Another important problem area is addition, the two pharmacists systematically reached that 23 patients made a conscious decision not to take consensus on their documentation by each year their prescription medicine; for example, they don’t crosschecking the first 5–10 cases, plus all other cases take statins because they cannot see that they work, or involving any doubt or where new sub-groups were to they do not take anti-seizure medicine or use a smaller be added. Pharmacy students in the project group amount than prescribed because it causes headaches.
entered all data into the data-processing program Inappropriate dosage is the second most common DRP NSDStat [36]; the resulting data were checked and (52 cases). In 31 cases, reports on a dosage interval that analysed by members of the project group. Two other deviates from the one prescribed are seen; for example, researchers/pharmacists from the project group group- no nitrate-free period and/or underdosage (11 cases).
coded and analysed the interview transcripts using Side effects are registered in 47 cases, fore instance specific theoretical frames of references [5, 7, 29, 30, bradycardia (due to beta blockers), nausea (due to 32, 34]. A coding strategy of meaning condensation EmconorÒ), and problems with stomach acid.
In the sub-category ‘other problems’, 127 cases of most commonly registered category of DRPs (57 DRPs were registered, for instance related to patients cases). Problems here can be inappropriate choice of themselves (81 cases) in the form of inappropriate medicine with regard to indication (29 cases), such as lifestyle choices (21 cases) such as smoking and/or BMI patients being prescribed insulin instead of tablet above 25, and/or fear of medicine (11 cases). Thirty treatment. Another problem can be if a physiological (30) patients experienced doctor-related DRPs; for contraindication is not taken into consideration when example, in the form of lack of or incomplete infor- the medicine is prescribed (27 cases); for example, elderly patients were prescribed MetforminÒ, whichdoes not follow the recommendation that this product should not be prescribed to people over the age of 70.
Side-effects is the third most common DRP (55 For the group of patients with type 2 diabetes, a total of 635 DRPs in 155 patients were identified, which In the sub-category ‘other problems’, 296 cases were corresponds to 4.1 DRPs identified per patient.
registered. Here the most commonly registered DRPs Inappropriate use of medicines by the patient was are related to patients themselves (268 cases); for the most common DRP (171 cases, corresponding to example, in the form of inappropriate lifestyle choices more than one DRP per patient in this sub-category), (130 cases), which include smoking, having a BMI for instance no or insufficient medicine monitoring (95 value over 25, lack of exercise, lack of regular visits to cases). Inappropriate choice of medicine is the second the podiatrist or eye doctor. Similarly, the interviewees had limited knowledge about the nature of their dis- study throughout the 3 years, which leads us to believe ease (103 cases); some did not know about the negative that the results were useful in a pharmacy practice influence of alcohol or chocolate on blood glucose setting. Predicting about the external validity is more level, the affect of the medicine on the disease and/or difficult, because of the sampling strategy used for complications, what causes hypoglycaemic episodes, selecting patients and pharmacies. As mentioned ear- and ways to adjust the blood glucose level by eating.
lier, Danish internship pharmacies have to live up tocertain professional and educational standards, thus the results might not be generalized to all Danishpharmacies, let alone pharmacies internationally.
A total of 349 DRPs were identified for 88 patientswith asthma, corresponding to 4.0 DRPs per patient.
Inappropriate use of medicines by the patient is the most common DRP (167 cases). Lack of monitoring A concern with the choice of the PI-Doc coding system medicine treatment is the most common problem in was the possible risk of inconsistent documentation of this sub-category (58 cases), while practical problems, DRPs due to possible confusion and misinterpretation in particular, problems with using the inhalator, arising from the split of DRPs into a large range of affected 51 patients. Some patients do not carry fast sub-groups. Nevertheless, the project group decided relief medicine around with them, they store powdered that the advantages of the detailed PI-Doc coding medicine in wet rooms, crush Bricanyl RetardÒ tablets system clearly outweighed the concerns, and that the before use, do not shake inhalation sprays before use, risk of inconsistent coding could be minimized by and do not turn turbohalers as recommended. Insuffi- modifying sub-groups, developing a thorough docu- cient knowledge about medicine use was found in 18 mentation protocol and evaluating the pharmacy cases; for example, some patients confuse the steroid students’ application of the codes. That the same two inhalator with the inhalator for use in asthma attacks.
pharmacists did the final identification and coding of The second most common DRP is inappropriate choice DRPs all 3 years, including crosschecking one another, of medicine, which was found in 66 cases, primarily contributed heavily to increased reliability of the study.
with regard to indication (44 cases). Some patients Not all documentation systems incorporate docu- were not being treated with inhalation steroids despite mentation of both actual and potential DRPs like the the use of beta-2 agonist. Side effects were registered PI-Doc system does. However, we found that a very in 52 cases, primarily in the form of tremor and heart important part of pharmacy practice is to prevent DRPs from becoming manifest and thereby harmful to A total of 46 DRPs were registered in the sub-cat- patients, and therefore find documentation of potential egory ‘other problems’, the most commonly registered DRPs is a useful source of knowledge when the DRPs are related to patients themselves (26 cases); for objective is to improve patient counselling.
example, in the form of inappropriate lifestyle choices.
Several patients do not know about the connection between asthma, smoking and indoor climate. In13 cases, patients experienced doctor-related DRPs; One disadvantage of the study design is related to the for example, in the form of lack of or incomplete large number of data collectors, which could present a information about prescription medicine.
reason to question the reliability of the data collectingpart of the study. However, all participating studentshad been trained to collect data and had been tested A fair number of studies identifying and documentingDRPs in patient groups resembling those included in We consider the internal validity of the study to be our study have been carried out over the past decade fairly high. The results have been presented to staff in [18–21, 38–44], with only a few studies including home all participating pharmacies without their questioning interviews though [18–21]. One study showed an aver- the findings of the study. A large number of the Danish age of 5.9 potential DRPs per patient [18], another internship pharmacies volunteered to participate in the study identified DRPs in 63.7% of the patients included [19]. Our data document an average of 2.8–4.1 DRPs ‘truths’ about patients’ drug utilization, since a safe and per patient, fewer than the number identified by Pau- trusting relationship is established between interviewer lino et al. [18]. In contrast, 96% of the angina pectoris and interviewee. This assumption is supported by a patients included in our study, 81% of the type 2 dia- recently published evaluation report on home medi- betes patients and 89% of the asthma patients had at least one DRP, which is more than the number of DRPs Research [8, 12–15, 17, 46] has shown that the advice identified by Titley-Lake and Barber [19]. Thus, the and information given in pharmacies is usually unso- results of our study in Danish internship pharmacies licited by patients and therefore not necessarily related document that among a pharmacy-based population of to their problems or lack of knowledge. Instead, it is 414 angina pectoris patients, asthma patients and type 2 more likely to reflect the pharmacy staff’s perception diabetes patients, DRPs are more likely to occur in all of what patients need to know. But if pharmacy staff patients than previously described in the literature, has insufficient knowledge of patients’ DRPs, how can while the individual patient is likely to experience fewer they possibly base their counselling on the patient’s perspective? Study results can thus be used to increase ‘‘Inappropriate use of medicines by the patient’’ and the awareness of pharmacy staff, so that whenever they ‘‘other problems’’ (such as limited knowledge of the meet a patient from one of the three patient groups, illness, inappropriate lifestyle, fear of medication and they will be alert to the fact that these patients are lack of information) were the two most common DRP likely candidates for DRPs. Identifying DRPs in only sub-categories identified (see Table These two sub- the first step in providing pharmaceutical care, and the categories constituted 61% of all DRPs identified in process must be continued by working to resolve or angina pectoris patients, 73% of those identified in prevent undesirable patient outcomes [47].
type 2 diabetes patients and 61% of DRPs in asthmapatients. The number of DRPs due to side effects was14.3% for angina pectoris patients, 8.7% for type 2 diabetes patients and 14.9% for asthma patients. Intwo of the other DRP studies using home interviews, The study provided a profile of a pharmacy-based the percentage of DRPs due to side effects/ADR was population of 414 patients visiting the pharmacy, all at higher than in our study, namely 29.5% in Paulino high risk of experiencing DRPs (angina pectoris et al. [18], and 84% for ADRs in Titley-Lake and patients, type 2 diabetes patients and asthma patients).
Barber [19]. The explanation for the high number of Out of this population 361 patients (87%) experienced ADRs in the Titley-Lake and Barber study [19] could one or more DRP(s). Pharmacy staff needs to take be related to the fact that the likelihood of a patient into account the high incidence of DRPs when coun- experiencing an ADR increases as the number of selling patients from these three groups. Inappropriate possible offending agents increase, which is not the use of medicines by the patient and other problems related to the patient constitute the sub-categories of The prevalence of DRPs in all the studies men- DRPs that occur most often in all three patient tioned [18–21, 38–44] varies a great deal for many reasons, such as the use of different coding systems,different data collection methods and, as described in The authors are very grateful to the entire Westerlund et al. [44], educational level and other project group, the 229 pharmacy students, the 414 patientsinterviewed and pharmacy staffs for their contribution to this characteristics of pharmacy staff and pharmacies. For study. We would also like to thank the Pharmacy Foundation of instance, previous studies on DRPs and a high level of 1991 for their financial support, and the members of the staff training have been shown to correspond with a Research Centre for Quality in Medicine Use, which provided higher DRP identification rate [44]. This may partly professional support and under whose auspices the study wasorganised.
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