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Biomedical subjects

Carmel M Hughes

Publications and source records attributed to Carmel M Hughes.

At least 19 recordsLinked to original sources
PubMed2006

Development and implementation of pharmaceutical care planning software for nursing homes based on the Fleetwood Model.

PURPOSE: The effectiveness of pharmaceutical care planning software for nursing homes and the extent to which the software assisted in the implementation of the Fleetwood Model are described. METHODS: During the study, one long-term-care pharmacy identified 13 nursing homes to participate in the intervention group of a study evaluating the effectiveness of the Fleetwood Model. To successfully implement the Fleetwood Model, which demands prospective drug regimen review and collaborative practices between dispensing and consultant pharmacists, a software system that exchanged information between these pharmacists was deemed necessary. Pharmacists' self-reported assessments of the use of the software and the technical difficulties reported with its use were collected. The number of interventions performed by pharmacist type, the proportion of residents receiving interventions by multiple pharmacists, and the extent to which the interventions were prospective and performed before the mandated 30-day review were estimated from data documented in the software. The consistency of software use by the pharmacists was also estimated. RESULTS: Seventy-one percent of dispensing pharmacists and 40% of consultant pharmacists reported using the software most or all of the time. Fourteen percent of dispensing pharmacists and 40% of consultant pharmacists reported technical difficulties with the software. Over half of newly admitted or readmitted residents received a Fleetwood intervention within 3 days of admittance into the nursing home-71.2% occurred in less than 30 days of admission. CONCLUSION: The use of information technology to increase communication among health care professionals and assist in providing prospective drug regimen review in long-term-care facilities is feasible. Collaboration and extensive field testing with end users, realistic expectations, appropriate training, and technical support are necessary when implementing new technology.

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PubMed2006

Pharmacotherapy interventions undertaken by pharmacists in the Fleetwood phase III study: the role of process control.

BACKGROUND: The Fleetwood Model incorporates prospective review, direct communication with the prescriber, and formalized pharmacotherapy planning in patients at highest risk for medication-related problems. OBJECTIVES: To describe the intervention activities performed by consultant pharmacists and dispensing pharmacists in the context of the Fleetwood Phase III Study. METHODS: We report on a total of 4272 residents living in 12 nursing homes included in the intervention arm of the demonstration project. The intervention period was January through December 2004. Using pharmacotherapy planning software with a Web-based interface, daily interchange of information from the commercial pharmacy software, as well as laptop-based software for use in the nursing homes, pharmacists documented the reason for the intervention, the level of service, and the extent to which the recommendations were accepted. RESULTS: There were 2118 Fleetwood interventions performed on 4272 residents (intervention rate: 9.48/100 resident months), with 81% of interventions performed by consultant pharmacists. The top 5 reasons for Fleetwood interventions by dispensing pharmacists were: missing information/clarification needed (19.8%), drug-age precautions (14.4%), excessive duration alert (9.5%), suboptimal regimen (8.7%), and laboratory test needed (7.3%). The top 5 reasons for involvement of the consultant pharmacists were: laboratory test needed (13.1%), missing information/clarification needed (13%), unnecessary drug (10.3%), product selection opportunity (10.3%), and excessive duration alert (9.1%). CONCLUSIONS: Extending the federally mandated medication review process in nursing homes to incorporate elements of the Fleetwood Model is possible. The recommendation acceptance rates for pharmacist interventions are high.

Community Pharmacy Services↗
PubMed2006

Considering the employee point of view: perceptions of job satisfaction and stress among nursing staff in nursing homes.

OBJECTIVE: To document job satisfaction and sources of stress among nursing staff working in nursing homes and to evaluate the extent to which the reasons of stress differ by type of nursing staff. DESIGN: Cross-sectional study. SETTING: Twenty-five nursing homes in North Carolina participating in a demonstration project of a new model of long-term care pharmacy. PARTICIPANTS: Nurses and nursing assistants employed at the time of the survey in the spring and summer of 2002 (n = 1283). MEASUREMENTS: Health Professional Stress Inventory modified for use in the nursing home setting and ratings of job satisfaction. RESULTS: The situations most stressful for nurses were not having enough staff, having too much work to do, interruptions, having non-health professionals determine how to do their job, poor pay, and ultimately being responsible for patient outcomes. The top most stressful situations for nursing assistants included poor pay, not enough staff, and too much work to do. Nursing assistants were more likely than nurses to report stress because they do not have adequate information regarding a patient's condition. Nurses were more likely than nursing assistants to report stress because non-health professionals (eg, surveyors) determine how they must do their job. CONCLUSIONS: The findings of this study support the need to improve recognition for nursing, improve staffing, and provide competitive compensation in nursing homes.

Attitude of Health Personnel↗
PubMed2006

Nurses' and nursing assistants' perceptions of patient safety culture in nursing homes.

OBJECTIVE: To evaluate whether perceptions of patient safety in nursing homes vary by length of employment, type of employee, and shift worked. DESIGN: Cross-sectional study. SETTING: Twenty-six nursing homes in Ohio participating in a randomized trial to test the effectiveness of a clinical informatics tool to improve patient safety during the medication monitoring. PARTICIPANTS: Nurses (n = 367) and nursing assistants (n = 636) employed at the time of the survey in the summer and fall of 2003. MAIN OUTCOME MEASUREMENTS: Resident safety questions included 34 items on different aspects of resident safety (overall safety perception, teamwork within and between departments, communication openness, feedback and communication about error, non-punitive response to error, organizational learning, management expectations, and actions promoting safety, staffing, and management support for patient safety). RESULTS: Overall perceptions of resident safety by employees were acceptable, with clear management communication of safety goals. Approximately 40% of nursing staff found it difficult to make changes to improve things most or all of the time; similar proportions indicated that management seriously considered staff suggestions to improve resident safety; only half reported management discussions with staff to prevent recurrence of mistakes. Regardless of staff type, one in five reported feeling punished and two in five reported that reporting of errors was seen as a 'personal attack'. CONCLUSIONS: Interventions to change the safety culture in nursing homes are warranted. Nursing homes need guidance on how to use information to implement safety improvement projects in the context of a strict regulatory environment which may prohibit innovative system change.

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PubMed2006

Use of medication technicians in US nursing homes: part of the problem or part of the solution?

OBJECTIVES: To determine the relation between organizational characteristics and medication technician (MT) use and quantify the impact of MTs on increasing the likelihood of using medications, employing the example of antiosteoporosis medications. DESIGN: Cross-sectional study. SETTING: The setting included 6344 Medicare/Medicaid certified nursing homes in 23 states. PARTICIPANTS: Residents older than 65 years of age. MEASUREMENTS: On-line Survey and Certification of Automated Records (OSCAR) provided facility characteristics information including structural, resource, and staffing levels. The Minimum Data Set (MDS) provided information regarding use of antiosteoporosis medications and resident factors. Adjusted estimates of MT use on antiosteoporosis medication use were derived using logistic regression with generalized estimating equations. RESULTS: MT use varied by state (6.7% in Alaska vs 85% in Kansas). Homes with greater nursing staffing levels per 100 beds (CNA, RN, LPN) were less likely to use MTs, while larger homes, homes using physician extenders, and contracting pharmacy services were more likely to use MTs. Homes with MTs were more likely to have medication error rates of at least 5% (10.1% vs 7.3%) than homes without MTs. After adjustment for resident and facility factors, residents in MT facilities were not more likely to receive antiosteoporosis treatment relative to those in homes without MTs. CONCLUSION: These data call into question the use of MTs in nursing homes. Use of MTs may lead to more errors, yet not increase use of medications that are labor intensive to administer.

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PubMed2006

The implementation of a harm minimisation model for the identification and treatment of over-the-counter drug misuse and abuse in community pharmacies in Northern Ireland.

OBJECTIVE: This study tested an intervention model which sought to minimise over-the-counter (OTC) drug misuse and abuse in community pharmacies. METHOD: Pharmacists in six community pharmacies in the Greater Belfast area volunteered to participate in the study. The intervention model consisted of client identification and recruitment, treatment and referrals, and finally follow-up data collection and outcome measurements. All pharmacists participated in semi-structured interviews to explore their views and experiences of the study. RESULTS: Pharmacists identified 196 cases of suspected abuse/misuse. Pharmacists approached 70 of the identified clients during the six-month study; some clients agreed to stop using the product of abuse/misuse, used an alternative, or had been switched to a maintenance prescription under general practitioner (GP) supervision. No client proceeded to completion of the follow-up phase (e.g. health-related quality of life). Analysis of the interviews revealed that pharmacists had encountered some difficulties in approaching potential clients, but had used skills gained in the study in other aspects of their practice. CONCLUSIONS: Some difficulties were encountered in implementing the harm minimisation model, but these may be alleviated by further training and greater collaborative working. PRACTICE IMPLICATIONS: Notwithstanding the challenges faced in the study, this approach to harm minimisation should be considered for wider implementation in community pharmacy.

Adult↗
PubMed2006

Did the introduction of a prospective payment system for nursing home stays reduce the likelihood of pharmacological management of secondary ischaemic stroke?

BACKGROUND: Since 1998, a prospective payment system (PPS) for Medicare services provided by nursing homes in the US has been in operation. Concerns have been expressed that the PPS may affect the quality of care delivered to residents. This study evaluates the impact of the PPS on pharmacological secondary ischaemic stroke prevention in nursing homes. STUDY DESIGN: The nationally mandated Minimum Data Set and Online Survey Certification and Automated Record data system from 1997 and 2000 for four states were used. We conducted a quasi-experimental study comparing the pharmacological treatment rates for secondary stroke prevention in the pre-PPS period (1997) with those in the post-PPS period (2000) in residents who experienced an ischaemic stroke within 6 months (n1997 = 5008; n2000 = 5243) of living in nursing facilities (n1997 = 1226; n2000 = 1092) in Kansas, Maine, Mississippi or Ohio. The sample was stratified according to recommendations for use of warfarin. Logistic regression models adjusting for clustering effects of residents residing in homes using generalised estimating equations provided estimates of the PPS effect on use of antiplatelets and the use of warfarin. RESULTS: The unadjusted proportion of use of pharmacological agents for the secondary prevention of stroke was similar for warfarin in both time periods and increased for antiplatelets in 2000. Relative to the pre-PPS era, the likelihood of use of antiplatelets increased in the post-PPS era (adjusted odds ratio 1.26; 95% CI 1.15, 1.38); there was no effect on the use of warfarin. CONCLUSION: Although the lack of a PPS effect on pharmacological management of secondary ischaemic stroke is encouraging, there is still room for improvement in overall stroke management.

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PubMed2006

Job satisfaction and stress among pharmacists in the long-term care sector.

OBJECTIVE: To provide normative information regarding levels of job satisfaction and stress between consulting and dispensing pharmacists in the long-term care arena. DESIGN: Cross-sectional. SETTING: United States. PARTICIPANTS: All current members of the American Society of Consultant Pharmacists as of March 2005. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Health Professional Stress Inventory. RESULTS: More than 90% of consultant pharmacists were satisfied with their jobs. The most frequently reported source of stress among the pharmacists was short staffing, affecting their ability to perform their duties. More than one-third of dispensing pharmacists were often stressed, frequently because of the need to keep up with developments to maintain professional competence. CONCLUSION: Pharmacists serving the long-term care sector are very satisfied. Methods to assist dispensing pharmacists to keep up with practice developments must be explored. Whether or not new models of long-term care pharmacy improve job satisfaction must be explored.

Consultants↗
PubMed2005

The impact of depressive symptoms and psychosocial factors on medication adherence in cardiovascular disease.

OBJECTIVE: This study sought to determine the influence of depression and psychosocial factors on medication adherence in cardiovascular disease. METHODS: A questionnaire including measures of depression, beliefs about medicines, health locus of control and adherence to medication (self-report) was completed by 122 outpatients attending a cardiac clinic. RESULTS: Analysis revealed that 14.8% of participants were non-adherent with their cardiovascular medication and 41.7% had scores indicative of depressive symptoms as determined by the Center for Epidemiological Studies Depression Scale (CES-D). Higher scores on this scale and strong concern scores on the Beliefs about Medicines Questionnaire about the potential adverse effects of using medication as prescribed were found to be associated with self-reported non-adherence. DISCUSSION AND CONCLUSION: These findings imply that the relationship between depressive symptoms in cardiovascular patients, together with certain psychosocial factors, could have negative consequences for adherence to medication. PRACTICE IMPLICATIONS: Given that there is emerging evidence to suggest an association between depression and medication non-adherence, healthcare professionals should consider this when dealing with cardiovascular patients.

Attitude to Health↗
PubMed2005

Societal perspectives on over-the-counter (OTC) medicines.

BACKGROUND: Over-the-counter (OTC) medicines are increasingly used for self-medication, but such products can be misused/abused. OBJECTIVES: The aim of this study was to investigate the general public's opinion and perceptions of OTC medicines, including the misuse/abuse of such preparations. METHODS: Data were collected using a survey administered to 1000 members of the public in 10 study sites in Northern Ireland, using a structured interview technique. The questionnaire was divided into four sections addressing: (a) attitudes towards community pharmacy and patients' contact with pharmacies; (b) attitudes towards the use of OTC medicines; (c) views on OTC medicines in terms of safety, potency and effectiveness; and (d) knowledge and opinion of abuse/misuse of OTC medicines. Data were coded and entered into a custom designed SPSS database for statistical analysis. RESULTS: The majority of participants (74.6%) visited a community pharmacy at least once per month. Almost one-third (32.2%) of participants reported buying OTC drugs at least once per month and the majority (86.4%) would always or often follow the directions on the product. The general public in Northern Ireland were highly aware of the abuse potential of some OTC drugs, with the majority naming painkillers as the products most liable for abuse. Almost one third of the participants reported having personally encountered cases of OTC abuse. CONCLUSIONS: This survey revealed that the general public had a high level of awareness of the abuse potential of OTC medicines. These findings indicate that pharmacists could be more proactive in the management of inappropriate OTC drug use.

Attitude to Health↗
PubMed2005

Managing urinary tract infections in nursing homes: a qualitative assessment.

OBJECTIVE: To elucidate the steps in the management of urinary tract infections (UTIs) in elderly nursing home residents, in order to derive data which would assist in an economic evaluation of such infections. METHOD: Maximum variation sampling was used to recruit General Practitioners (GPs) and nurses (who worked in nursing homes), into the study. Using semi-structured interviews, a topic guide was used to explore diagnosis, treatment and the role of GPs and nurses in the management of UTIs in nursing home residents. Thematic analysis was employed to identify the main themes. MAIN OUTCOME MEASURES: A comprehensive description of the management of UTIs in nursing home residents that will be used in a future economic evaluation of the costs of this prevalent infection in this setting. RESULTS: Ten GPs and nurses respectively took part in the interviews. Three overarching themes emerged from the interviews: information, processes and decision-making. Health care professionals described the key symptoms for diagnosis (information), testing procedures to confirm the presence of an infection (processes); many variations in management pathways were described. The nurse was central to decision-making in treatment i.e. prescribing of an antibiotic. Most GPs reported that they accepted the nursing staff's assessment of the resident and seldom visited a patient in a nursing home for a UTI. CONCLUSIONS: The management approach to UTIs varied greatly and was a more complex process than anticipated. Identification of the component steps will be used to perform an economic evaluation of UTIs in nursing homes.

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PubMed2005

Administrative initiatives for reducing inappropriate prescribing of psychotropic drugs in nursing homes: how successful have they been?

The quality of nursing home care has been subject to intense investigation and scrutiny, particularly in the US. In particular, there has long been concern about the extensive use of psychotropic agents, notably antipsychotics, hypnotics and anxiolytics, in this setting. These drugs have been described as 'chemical restraints', in that they were used to sedate and subdue patients, partly to compensate for poor staffing levels and to minimise staff contact with patients. However, following a damning Institute of Medicine report to the US Congress, use of such drugs became regulated under a unique administrative initiative: the Nursing Home Reform Act, embedded within the Omnibus Budget Reconciliation Act 1987 (OBRA 87). Research has indicated that psychotropic drug use in nursing homes has declined markedly following the implementation of this regulation. In addition, explicit criteria for potentially inappropriate medication use were incorporated within the guidelines for nursing home inspectors from 1 July 1999. Because regulations have targeted poor prescribing, rather than promoting the use of effective drugs in older residents, it has been difficult to determine whether outcomes have improved for nursing home residents as a result. However, US government agencies have responded to continuing concerns about nursing home care through the implementation of quality indicators which are used to guide and plan inspections of such facilities and to compare nursing homes within the same state. Although there are a limited number of quality indicators relating to prescribing, this represents a move away from adversarial regulation, which focuses on poor practice, and attempts to improve quality of care. An important role for educational initiatives and interventions has been advocated by some commentators and these have proved to be successful in the nursing home environment. Other countries have not implemented such restrictive prescribing regulation in nursing homes. Exemplars of innovative prescribing models, involving pharmacists and encouraging resident-centred care, may offer a more palatable approach to improving drug use in this vulnerable population.

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PubMed2004

Providing pharmacy services to care homes in Northern Ireland: a survey of community pharmacists' views.

OBJECTIVE: This study sought to explore the views of community pharmacists as to their present and potential role in providing care to the residents of nursing and residential home in Northern Ireland. METHOD: A structured questionnaire was developed and mailed to all community pharmacists in Northern Ireland (n = 508) on 2 occasions. RESULTS: A response rate of 50% was achieved. Over 40% of responding pharmacists (42.1%) were currently providing medication-related services to care homes for the elderly and 57.9% were not. Of those who were providing services, 50 to 80% were already providing advice to care homes regarding record-keeping, compliance devices, storage and administration of medicines and the use of more appropriate formulations. More than 75% of pharmacists who were not providing services to care homes for the elderly supported all services detailed in a checklist provided on the questionnaire. For pharmacists who were providing services to care homes, 89% agreed that they required access to an up-to-date medical history of care home residents. Over 60% of pharmacists who worked with care homes had experienced difficulties when ordering prescriptions from general practice surgeries. Just over 75% of all respondents stated that they wanted to be more involved in providing pharmaceutical services to care homes to the elderly. CONCLUSION: Community pharmacists expressed enthusiasm for provision of services to care home residents. On-going developments in community pharmacy practice in the UK may facilitate the development of this role and may guide policy development for long-term care in other countries.

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PubMed2004

Development of a community pharmacy-based model to identify and treat OTC drug abuse/misuse: a pilot study.

OBJECTIVE: The aim of this study was to develop and pilot a harm-minimisation model for the identification and treatment of over-the-counter (OTC) drug abuse/misuse by community pharmacists. METHOD: Extensive consultation was conducted during the development of the model. This included an exploratory conference involving an interdisciplinary group of delegates and detailed individual consultation with a range of healthcare practitioners. Consultation with a psychologist specialising in communication skills allowed development of the communication aspects of the model. A comprehensive manual detailing the model was prepared. RESULTS: The model is designed to be used by community pharmacists in conjunction with other healthcare professionals. It focuses on the abuse/misuse of opioids, laxatives and antihistamines and can be broadly divided into three phases, namely: patient identification and recruitment, treatment/referrals and data collection/outcome measurement. Client identification is via record-keeping which is implemented alongside an information campaign promoting safe use of OTC medicines. Once identified, the pharmacist aims to recruit clients using the developed communication strategies. Treatment depends on whether the problem is misuse or abuse and on the product. Several treatment paths are available including treatment according to an agreed protocol and referring to the GP or community addiction team (CAT). Two pharmacists were recruited and trained to pilot the model. Of the clients, 18 were identified as abusing/misusing OTC products over a one-month period. The subject of inappropriate OTC use was raised with 14 of these clients. Some success was noted in that clients agreed to stop using the product and/or to try safer alternatives. As expected, some sales had to be refused, as the client was unwilling to accept the pharmacist's intervention. CONCLUSION: This study represents the first reported structured attempt by community pharmacists in the UK to address the abuse/misuse of OTC medication. Work is now ongoing to modify this model in light of the pilot study findings.

Algorithms↗
PubMed2004

Which organizational characteristics are associated with increased management of depression using antidepressants in US nursing homes?

BACKGROUND: There is universal agreement that organizational characteristics of nursing facilities can and do influence the quality of care and resident outcomes. OBJECTIVE: This study evaluated the relation between organizational characteristics and management of depression using antidepressants. RESEARCH DESIGN: This was a cross-sectional study of Medicare/Medicaid certified nursing homes in 6 states in 2000. SUBJECTS: We studied 87,907 residents with depression in 2,128 facilities. MEASURES: Minimum Data Set (MDS) provided information regarding use of antidepressants and resident factors. On-line Survey and Certification of Automated Records (OSCAR) provided facility characteristics information including structural, resource, and staffing levels. Adjusted estimates of organizational effects on antidepressant drug use were derived from generalized estimating equations. RESULTS: Increased treatment of depression with antidepressants was associated with facilities with a higher percentage of residents from payer sources other than Medicare/Medicaid (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.06) and more professional nursing staff (OR, 1.15; 95% CI, 1.05-1.26). Decreased treatment tended to be related to larger homes (OR, 0.76; 95% CI, 0.68-0.84) or if the home employed full-time physicians (OR, 0.87; 95% CI, 0.78-0.96). Once the decision to treat was made, treatment with tricyclics tended to be inversely related to larger homes, for-profit facilities, and homes with more Medicare residents. CONCLUSIONS: Facilities that are required to be more fiscally conservative, be it larger facilities with fewer private pay patients or for profit facilities, have lower rates of pharmacologic treatment. Resource and structural characteristics influence the type of antidepressant being prescribed; resident characteristics may not be the over-riding factor in prescribing.

Activities of Daily Living↗
PubMed2004

An evaluation of the impact of the prospective payment system on antidepressant use in nursing home residents.

OBJECTIVES: To determine the impact of the prospective payment system (PPS) for skilled nursing facilities on the pharmacologic treatment of depression. METHODS: We used a quasi-experimental study comparing the pharmacological treatment rates for depression in the pre-PPS period (1997) to the post-PPS period (2000) in 8149 residents with documented depression living in over 500 nursing facilities in Ohio. Logistic regression models adjusting for clustering effects of residents residing in homes using generalized estimating equations provided estimates of the PPS effect on use of any antidepressant and the use of selective serotonin reuptake inhibitors (SSRIs). We evaluated the extent to which the PPS effect was modified by organizational characteristics, including structural characteristics, resource characteristics, and staff resources available in the homes. RESULTS: Overall, there was no difference in the likelihood of any antidepressant [odds ratio (OR), 1.05; 95% confidence interval (CI), 0.93 to 1.18, resident-adjusted model] or an SSRI being used (OR, 0.98; 95% CI, 0.86 to 1.12, resident-adjusted model) after the introduction of PPS compared with 1997 when this reimbursement system was not in place (referent group). These trends did not appear to be modified substantially by organizational characteristics. CONCLUSION: Although PPS did not appear to have influenced the treatment of depression in nursing homes, systems that provide checks and balances in relation to PPS are warranted.

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PubMed2004

Medication non-adherence in the elderly: how big is the problem?

Adherence to medication is one of the most intriguing and complex behaviours demonstrated by patients. Non-adherence to a therapeutic regimen may result in negative outcomes for patients and may be compounded in populations with multiple morbidities which require multiple drug therapy. Such a population is exemplified by the elderly. However, non-adherence may not be more prevalent in older patients and there is no consensus in the literature that age is a predictor of poor adherence. Indeed, older patients may deliberately choose not to adhere to medication (intentional non-adherence) to avoid adverse effects. Furthermore, many of the studies on adherence lack commonality in terms of how adherence is measured, the definition of an 'older' patient and the range of disease states which have been examined. Adherence may also be affected by access to medications which may be restricted by the use of formularies or insurance programmes. However, non-adherence may represent a greater risk in older people resulting in poor disease control which may be compounded with multiple morbidity and polypharmacy. A range of strategies have been implemented to try and improve adherence in this patient population. The use of forgiving drugs (those which have a prescribed dosage interval that is 50% or less the duration of drug action) may facilitate occasional lapses in drug-taking. Drug holidays (deliberate, supervised non-adherence for a fixed period of time) have been used in Parkinson's disease to reduce adverse effects. Once-daily scheduling of drug administration may offer a pragmatic approach to optimising drug therapy in some patients; this may be supplemented through the use of compliance aids. What is increasingly apparent, however, is that the role of the patient (irrespective of age) is critical in decision-making about medication, together with communication between patients and healthcare professionals. This has been articulated through the concept of concordance which has been described as a therapeutic alliance between the patient and healthcare professional. In addition, interventions employed to improve adherence must be multifaceted, and together with practical approaches (reducing unnecessary drugs and simplifying dosage regimens), the patient perspective must be considered. Good adherence should be seen as a means of achieving a satisfactory therapeutic result and not as an end in itself.

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