| Abstract | Cilj istraživanja
Primarni cilj istraživanja je utvrditi utjecaj intervencije kliničkog farmaceuta na adherenciju
kroničnih bolesnika pri otpustu iz bolnice. Specifični ciljevi su utvrditi najčešće razloge
neadherencije kod kroničnih bolesnika, utvrditi učestalost i vrstu terapijskih problema kod
kroničnih bolesnika, utvrditi prihvaćenost intervencije kliničkog farmaceuta od strane
liječnika te vrstu i učestalost različitih kategorija interakcija lijekova.
Ispitanici i metode
Ovo intervencijsko istraživanje provedeno je na Klinici za unutarnje bolesti s centrom za
dijalizu u sklopu Sveučilišne kliničke bolnice Mostar u trajanju od dva mjeseca. U istraživanje
je uključeno stotinu ispitanika. U svrhu prikupljanja podataka, korišten je anketni upitnik i
strukturirani razgovor s pacijentom. Farmaceut je imao uvid u karton bolesnika, propisanu
terapiju, postavljene dijagnoze i laboratorijske nalaze. Anketa i strukturirani razgovor
provedeni su s pacijentima koji su pristali sudjelovati u istraživanju te su potpisali informirani
pristanak. Kriteriji uključivanja kronični su bolesnici koji su boravili najmanje jedan dan u
bolnici i oni koji imaju tri ili više lijekova u propisanoj terapiji. Pacijenti su randomizirani u
dvije skupine od po 50 ispitanika, jednu intervencijsku i drugu kontrolnu. Iz zdravstvenog
kartona pacijenta dobiveni su podaci o dobu, spolu, dijagnozama, propisanim lijekovima te
nalazima laboratorijskih pretraga. Kod intervencijske skupine bolesnika, pri otpustu iz bolnice
klinički farmaceut pregledao je propisanu terapiju te proveo strukturirani razgovor s
pacijentom. Prije samog razgovora, provedena je analiza podataka propisane farmakoterapije
i utvrđeni su prisutni terapijski problemi. Strukturirani razgovor, uključivao je i prikupljanje
podatka o dodacima prehrani i OTC lijekovima koje pacijent trenutno koristi, edukaciju
bolesnika o ciljevima i načinima praćenja uspješnosti terapije, važnosti pridržavanja
propisanoj terapiji te davanje jasnih uputa o ispravnoj primjeni pojedinih lijekova. Za izradu
prijedloga intervencija korištena je baza podataka Lexi-comp, Sažetak opisa svojstava lijeka i
ostala dostupna stručna literatura. Prijedlog farmaceutske intervencije sadržavao je
literaturni navod, temeljem kojeg se predlagala određena intervencija. Ponovni razgovor s
pacijentima zakazan je unutar 30 - 60 dana po otpustu. U ponovnom razgovoru pacijentima
je postavljeno 8 pitanja iz Moriskyjeve ljestvice adherencije. Kontrolnu skupinu sačinjava 50
ispitanika koji su došli u bolnicu na kontrolni pregled, a s kojima pri otpustu nije izvršen
razgovor s kliničkim farmaceutom. Svim pacijentima iz kontrolne skupine postavljeno je
također, 8 pitanja iz Moriskyjeve ljestvice adherencije
Rezultati
Ukupno je utvrđeno 203 terapijska problema od strane farmaceuta. Ukupno je pronađena 91
vrsta interakcije lijek-lijek. Najčešće su bile interakcije stupnja kliničkog značaja C i D i čine
44% utvrđenih terapijskih problema. Kontraidikacija odnosno interakcija stupnja kliničkog
značaja X uočena je kod 2 ispitanika i čini 1% terapijskih problema. Interakcije lijek – hrana
utvrđene su kod 18% ispitanika, interakcije lijek- dodatak prehrani utvrđene su kod 6%
ispitanika, interakcija lijek bolest utvrđena je kod 10% ispitanika. Dupliciranje terapije
utvrđeno je kod 2% ispitanika, kod 1% ispitanika uočene su nuspojave lijeka. Nerazumijevanje
rasporeda doziranja lijekova utvrđeno je kod 10% ispitanika. Interakcije lijek-dodatak prehrani
utvrđene su kod 12 ispitanika. Neodgovarajući interval doziranja uočen je kod 3% ispitanika,
nepostojanje jasne indikacije za primjenu lijeka utvrđeno je kod 3% ispitanika, dupliciranje
terapije utvrđeno je kod 2% ispitanika. Nepropisivanje lijeka unatoč postojanju indikacije za
primjenu lijeka uočeno je kod 0,5% ispitanika.
Ukupno je utvrđen 151 terapijski problem koji je zahtijevao intervenciju farmaceuta
usmjerenu prema pacijentu. Svim pacijentima (100%) intervencijske skupine dati su savjeti o
pravilnom doziranju i učinku lijekova koji su im propisani u terapiji. Kod 24% ispitanika
intervencijske skupine uočena je interakcija lijeka – hrana, kod 19% ispitanika izrađen je
raspored doziranja dnevne terapije. 8% ispitanika informirano je o interakciji lijek – dodatak
prehrani, 7% ispitanika podijeljene su tabela za praćenje krvnog tlaka, te kod 3% ispitanika
tabela za praćenje šećera u krvi. Informiranje pacijenta o mogućim nuspojava lijeka
provedeno je kod 6% pacijenata. 1% ispitanika upućeno je na ponovni liječnički pregled.
Ukupno je utvrđeno 52 terapijska problema koji su zahtijevali intervenciju farmaceuta
usmjerenu prema liječniku. Od predloženih intervencija najčešće su informiranje liječnika o
interakcijama (35%), ukidanje lijeka (25%), upućivanje na pojačano praćenje (21%), izmjena
intervala doziranja (13%), zamjena jednog lijeka drugim (6%), informiranje o kombinacijama
više aktivnih tvari u jednoj tableti (2%), uvođenje novog lijeka u terapiju (2%), izmjena doze
lijeka (2%). Od ukupno 52 intervencije farmaceuta usmjerene prema liječniku, prihvaćeno je
njih 46 ili 88,5%. Odbijeno je 11,5% od ukupnog broja intervencija.
Najveći broj ispitanika intervencijske skupine pokazao je umjerenu adherentnost njih 56%,
dok je 26% ispitanika pokazao visoku adherentnost, a kod 18% ispitanika utvrđena je slaba
adherentnost. Najčešći uzrok neadherentnosti je opterećenost bolesnika propisanom
terapijom, tj. 82% bolesnika je na pitanje br. 7 Moriskyjeve ljestvice odgovorilo sa DA. Najveći
broj ispitanika kontrolne skupine pokazao je umjerenu adherentnost njih 52%, dok je 38%
ispitanika pokazao slabu adherentnost, a kod 10% ispitanika utvrđena je visoka adherentnost.
Najčešći uzrok neadherentnosti kontrolne skupine (80%) je također opterećenost bolesnika
propisanom terapijom.
Zaključak
U ovom istraživanju utvrđena su ukupno 203 terapijska problema od kojih su interakcije
lijekova činile 44,8 %. Izvršene su 52 intervencije farmaceuta usmjerene prema liječniku,
prihvaćeno je njih 88,5%. Ukupno je utvrđen 151 terapijski problem koji je zahtijevao
intervenciju farmaceuta usmjerenu prema pacijentu.
Najveći broj ispitanika intervencijske skupine pokazao je umjerenu adherentnost (56%), a vrlo
sličan postotak umjerene adherentnosti je i kod kontrolne skupine (52%). Međutim velika
razlika je u postotku visoke i slabe adherentnosti. Naime, 26% ispitanika intervencijske skupine
pokazao visoku adherentnost, a kod 18% ispitanika utvrđena je slaba adherentnost. Dok je
postotak visoko adherentnih u kontrolnoj skupini 18%, a slabo adherentnih znatno veći u
odnosu na intervencijsku skupinu, čak 38%. Najčešći uzrok neadherentnosti i jedne i druge
skupine je opterećenost bolesnika propisanom terapijom odnsono veliki broj lijekova u
terapiji.
U ovom ispitivanju prikazana je veća adherentnost ispitanika kod kojih je klinički farmaceut
imao intervenciju po otpustu iz bolnice. Međutim potrebna su daljnja istraživanja na većem
uzorku te kroz duži vremenski period kako bi se pratili učinci intervencija kliničkog farmaceuta
na adherenciju pacijenata po otpustu iz bolnice, poboljšanje terapijskih ishoda te
farmakoekonomski učinci takvih intervencija. |
| Abstract (english) | Objectives
The primary objective of the research is to determine the impact of a clinical pharmacist’s intervention
on the adherence of chronic patients on discharge from the hospital. The specific objectives are to
determine the most common causes of non-adherence in chronic patients, to determine the
frequency and type of therapeutic problems in chronic patients, to determine the acceptance of
clinical pharmacist intervention by physicians and to determine the type and frequency of different
categories of drug interactions.
Patients and methods
This intervention study was conducted at the Clinic for Internal Medicine with a dialysis center within
the University Clinical Hospital Mostar for two months. One hundred patients were included in the
research. For the purpose of data collection, a survey questionnaire and a structured interview with
the patient were used. The pharmacist had an insight into the patient's card, prescribed therapy,
diagnoses and laboratory findings. The survey and structured interview were conducted with patients
who agreed to participate in the study and signed informed consent. One of the criteria for inclusion
in the study was a stay in the hospital for at least one night. Patients were randomized into two groups
of 50 subjects, one interventional group and the other control group. From the patient's medical
record were obtained data on age, sex, diagnoses, prescribed medications and laboratory test results.
In the intervention group of patients, upon discharge from the hospital, the clinical pharmacist
reviewed the prescribed therapy and conducted a structured interview with the patient. Before the
interview, a data analysis of the prescribed pharmacotherapy was performed and the present
therapeutic problems were identified. The structured interview included collecting data on dietary
supplements and OTC drugs currently used by the patient, educating patients about the goals and
ways to monitor the success of therapy, the importance of adhering to prescribed therapy and giving
clear instructions on the proper use of certain drugs. The Lexi-comp database, the Summary of Product
Characteristics and other available professional literature were used to prepare the proposed
intervention. The proposal of the pharmaceutical intervention contained a literature citation, on the
basis of which a certain intervention was proposed. Re-interview with patients was scheduled within
30-60 days after discharge. In the re-interview, patients were asked 8 questions from the Morisky
Adherence Scale. The control group consists of 50 patients who came to the hospital for a check-up
and who were not interviewed by a clinical pharmacist at discharge. All patients from the control
group were also asked, 8 questions from the Morisky adherence scale.
Results
203 therapeutic problems were identified by pharmacist. 91 types of drug-drug interactions were
found. Interactions of clinical grade C and D were the most common and accounted for 44% of
identified therapeutic problems. Contraindication or interaction of the degree of clinical significance
X was observed in 2 patients and accounts for 1% of therapeutic problems. Drug-food interactions
were found in 18% of patients, drug-supplement interactions were found in 6% of patients, drug-drug
interactions were found in 10% of patients. Duplication of therapy was found in 2% of patients, in 1%
of patients side effects of the drug were observed. Misunderstanding of the drug dosing schedule was
found in 10% of patients. Drug-dietary drug interactions were found in 12 patients. Inadequate dosing
interval was observed in 3% of patients, the absence of a clear indication for drug use was found in
3% of patients, duplication of therapy was found in 2% of patients. Non-prescribing of the drug despite
the existence of an indication for the use of the drug was noted in 0.5% of patients.
A total of 151 therapeutic problems were identified that required patient-directed pharmacist
intervention. All patients (100%) of the intervention group were given advice on the correct dosage
and effect of the drugs prescribed to them in therapy. Drug-food interaction was observed in 24% of
the patients in the intervention group, and the dosing schedule of daily therapy was developed in
19% of the subjects. 8% of patients were informed about the drug-supplement interaction, 7% of
patients were given a table for monitoring blood pressure, and 3% of patients were given tables for
monitoring blood sugar. Informing the patient about possible side effects of the drug was performed
in 6% of patients. 1% of patients were referred to re-examination.
A total of 52 therapeutic problems were identified that required a physician-directed pharmacist
intervention. Of the proposed interventions, the most common are informing physicians about
interactions (35%), discontinuing the drug (25%), referring to enhanced monitoring (21%), changing
the dosing interval (13%), replacing one drug with another (6%), informing about combinations more
active substances in one tablet (2%), introduction of a new drug into therapy (2%), change of drug
dose (2%). Out of a total of 52 physician-directed pharmacist interventions, 46 or 88.5% were accepted
(Figure 2). 6 or 11.5% of total interventions were rejected.
The largest number of patients in the intervention group showed moderate adherence, 56%, while
26% of patients showed high adherence, and 18% of patients showed poor adherence. The most
common cause of inadequacy is the burden of patients with prescribed therapy, i.e. 82% of patients
answered YES to question no. 7 of Morisky scale. The largest number of patients in the control group
showed moderate adherence, 52%, while 38% of patients showed poor adherence, and 10% of
patients showed high adherence. The most common cause of non-adherence of the control group
(80%) is also the burden of patients with prescribed therapy.
Conclusion
A total of 203 therapeutic problems were identified in this study, of which drug interactions accounted
for 44.8%. 52 physician-directed pharmacist interventions were performed, 88.5% of them were
accepted. A total of 151 therapeutic problems were identified that required patient-directed
pharmacist intervention.
The largest number of patients in the intervention group showed moderate adherence (56%), and a
very similar percentage of moderate adherence was in the control group (52%). However, the big
difference is in the percentage of high and low adherence. Namely, 26% of the patients in the
intervention group showed high adherence, and 18% of the patients showed poor adherence. While
the percentage of highly adherent in the control group is 18%, and poorly adherent is significantly
higher compared to the intervention group, as much as 38%. The most common cause of inadequacy
of both groups is the burden of patients with prescribed therapy or a large number of drugs in therapy.
In this study, greater adherence was shown in subjects in whom a clinical pharmacist had an
intervention after discharge from the hospital. However, further research is needed on a larger sample
and over a longer period to monitor the effects of clinical pharmacist interventions on patient
adherence after discharge, improvement of therapeutic outcomes and pharmacoeconomic effects of
such interventions. |
