(1) Background: In general, it is known that continuity of care can contribute to an increase in patient satisfaction, reduce health care costs, and improve patient outcomes. A guarantee of continuity in pharmacotherapy is a big challenge facing Japanese health care as a system that encourages cooperation/collaboration for pharmacists with other health care professions is currently lacking. (2) Method: This is a narrative review. (3) Results: The Lund Integrated Medicine Management (LIMM) model describes a systematic approach to individuals and was developed in Sweden to optimize pharmacotherapy among elderly inpatients. The aim of the LIMM model is to provide patients with continuous pharmacotherapy at different levels of care. The LIMM model, in which a clinical pharmacist is the catalyst and leads other health care professions in completing the process, has the potential to reduce potentially inappropriate prescriptions, reduce rehospitalization risk, unscheduled hospital revisits due to problems related to medications, reduce total medical expenditure, and provide a comprehensive understanding of patients' conditions of taking medicine. (4) Conclusions: Introducing a framework such as Sweden's LIMM model, anchored by clinical pharmacists, could provide a good opportunity to promote collaborations among different health care professionals and improve continuity in pharmacotherapy.

Background Medication discrepancies in care transitions and medication non-adherence are problematic. Few interventions consider the entire process, from the hospital to the patient’s medication use at home.

Aim In preparation for randomised controlled trials (RCTs), this study aimed (1) to investigate the feasibility of recruitment and retention of patients and data collection to reduce medication discrepancies at discharge and improve medication adherence and (2) to explore the outcomes of the interventions.

Method Participants were recruited from a hospital and a residential area. Hospital patients participated in a pharmacist-led intervention to establish a correct medication list upon discharge and a follow-up interview two weeks post-discharge. All participants received a person-centred adherence intervention for three to six months. Discrepancies in the medication lists, the Beliefs about Medicines Questionnaire (BMQ-S), and the Medication Adherence Report Scale (MARS-5) were assessed.

Results Of 87 asked to participate, 35 were included, and 12 completed the study. Identifying discrepancies, discussing discrepancies with physicians, and performing follow-up interviews were possible. Conducting the adherence intervention was also possible using individual health plans for medication use. Among the seven hospital patients, 24 discrepancies were found. Discharging physicians agreed that all discrepancies were errors, but only ten were corrected in the discharge information. Ten participants decreased their total BMQ-S concern scores, and seven increased their total MARS-5 scores.

Conclusion Based on this study, conducting the two RCTs separately may increase the inclusion rate. Data collection was feasible. Both interventions were feasible in many aspects but need to be optimised in upcoming RCTs.

Ordination av läkemedel börjar oftast hos en läkare och då inleds en komplex process där flera olika professioner, framför allt sjuksköterskor och farmaceuter, bidrar med sin kompetens till en helhetssyn för att optimera läkemedelsbehandling. Detta är fokus i denna bok, Farmakologi och farmakoterapi. Här presenteras den teoretiska bakgrunden som ger förståelse i hur läkemedel omsätts och fungerar i kroppen, men även farmakoterapi (läkemedelsbehandling) och vanliga läkemedelsrelaterade problem beskrivs. Boken är uppdelad i tre delar. Den första delen beskriver olika aspekter på praktisk läkemedelsanvändning i vården och av patienten. Speciellt fokus läggs på utvärdering av läkemedelsbehandling och samarbete mellan vårdens olika professioner. Den andra delen beskriver basalfarmakologiska principer och tillämpningar där teori och praktiska utföranden varvas. Del tre är uppbyggd enligt ATC-systemet och fokuserar på farmakoterapi vid olika sjukdomstillstånd där rekommendationer samt nytta och eventuella risker med läkemedel beskrivs. Boken vänder sig till studenter på sjuksköterskeprogrammet och till yrkesverksamma sjuksköterskor. Den kan även användas av andra professioner inom hälso- och sjukvården, såväl i undervisning som i informationssökande.

Introduction: Beliefs about medicines is one of the strongest determinants of adherence. It’s plausible that adherence interventions can be effective by changing patients’ beliefs about medicines.

Aim: To describe how a pharmaceutical care intervention affected beliefs about medicines and adherence.

Methods: In the Motivational Interviewing and Medication review in Coronary heart disease (MIMeRiC) trial, 316 patients were randomized to a pharmaceutical care intervention during around 6 months, or standard care. Key secondary outcome was a combination of persistence (at least one refill in the period 12–16 months) and a self-report instrument at 15 months. Beliefs about medicines specific (BMQ-S) was used as a process measure.

Results: At follow up, 88% and 77% (P = 0.033) of patients were adherent in the intervention and control group respectively. Patients who had received the intervention had a more positive necessity–concern differential (NCD) than patients with standard care, 7.9 (5.7) vs. 6.3 (5.8); P = 0.022. Patients in the intervention group who were adherent had a mean NCD of 8.8 (5.6), while intervention patients who were not adherent had mean NCD 5.4 (5.5); P = 0.046. In patients receiving standard care, the mean NCD was 6.7 (5.5) and 6.3 (5.9); P = 0.746 among patients who were adherent and not adherent at follow-up.

Conclusion: The intervention seemed to increase adherence through an effect on patients’ medication beliefs.

Background After completing university education, biomedical laboratory scientists work in clinical laboratories, in biomedical research laboratories, in biotech, and in pharmaceutical companies. Laboratory diagnostics have undergone rapid development over the recent years, with the pace showing no signs of abatement. This rapid development challenges the competence of the staff and will most certainly influence the education of future staff. This study aimed to examine what was considered the necessary competencies needed to pursue a career as a biomedical laboratory scientist. Methods A modified Delphi technique was used, with the panel of experts expressing their views in a series of three questionnaire. Consensus was defined as the point which 75 % or more of the panel participants agreed that a particular competency was necessary. Results The study highlights the perceived importance of mostly generic competencies that relate to quality, quality assurance, and accuracy, as well as different aspects of safety, respect, trustworthiness (towards patients/clients and colleagues), and communication skills. The results also stress the significance of self-awareness and professionality. Conclusions We identified important competencies for biomedical laboratory scientists. Together with complementary information from other sources, i.e., guidelines, laws, and scientific publications, the competencies identified can be used as learning outcomes in a competency-based education to provide students with all the competencies needed to work as professional biomedical laboratory scientists.

Aim: Describe, and between regions, compare the services provided, and the pharmacists’ perceptions of their role and its importance.

Method: Online survey involving active clinical pharmacists in Sweden.

Result: The survey was completed by 118 pharmacists (66%), half of whom had at least 1 year’s formal training in clinical pharmacy, and work experience in excess of 5 years. Admission medication reconciliation and medication review are provided in most regions and often on a daily basis. The most important services were: making suggestions to physicians regarding drug changes, medication review, medication reconciliation, and patient communication. On a five-point Likert-scale (where 1 = negative and 5 = positive) very few respondents scored less than 4 on the role, acceptance and skills questions.

Discussion: Our study confirms the strong position of clinical pharmacy and clinical pharmacists in Sweden. There were some differences regarding the services provided between regions but clinical pharmacists’ patient-centred work in the clinical setting as part of the care team is well established, accepted and important. Respondents believed they could take on additional responsibilities for prescription changes without the need for further education.

Conclusion: Patient-centred clinical pharmacy work in a clinical setting as part of the care team is well established, accepted and important.

BACKGROUND: In the treatment of coronary heart disease, secondary prevention goals are still often unmet and poor adherence to prescribed drugs has been suggested as one of the reasons. We aimed to investigate whether pharmaceutical care by a pharmacist at the cardiology clinic trained in motivational interviewing improves clinical outcomes and patient adherence.

METHODS: This was a prospective, randomized, controlled, outcomes-blinded trial designed to compare pharmaceutical care follow-up with standard care. After standard follow-up at the cardiology clinic, patients in the intervention group were seen by a clinical pharmacist two to five times as required over seven months. Pharmacists were trained to use motivational interviewing in the consultations and they tailored their support to each patient's clinical needs and beliefs about medicines. The primary study end-point was the proportion of patients who reached the treatment goal for low-density lipoprotein cholesterol by 12 months after discharge. The key secondary outcome was patient adherence to lipid-lowering therapy at 15 months after discharge, and other secondary outcomes were the effects on patient adherence to other preventive drugs, systolic blood pressure, disease-specific quality of life, and healthcare use.

RESULTS: 316 patients were included. The proportion of patients who reached the target for low-density lipoprotein cholesterol were 37.0% in the intervention group and 44.2% in the control group (P = .263). More intervention than control patients were adherent to cholesterol-lowering drugs (88 vs 77%; P = .033) and aspirin (97 vs 91%; P = .036) but not to beta-blocking agents or renin-angiotensin-aldosterone system inhibitors.

CONCLUSIONS: Our intervention had no positive effects on risk factors for CHD, but it increased patient adherence. Further investigation of the intervention process is needed to explore the difference in results between patient adherence and medication effects. Longer follow-up of healthcare use and mortality will determine if the increased adherence per se eventually will have a meaningful effect on patient health.

TRIAL REGISTRATION: ClinicalTrials.gov NCT02102503, 03/04/2014 retrospectively registered.

BACKGROUND: The Lund Integrated Medicines Management model offers a systematic approach for individualising and optimising patient drug treatment. Clinical, economical and humanistic outcomes have been shown as well as results from the medication reconciliation process. There is a need also to describe the medication review process.

OBJECTIVE: To describe the frequency and types of drug-related problems (DRPs) identified during medication reviews and to evaluate the actions of the pharmacists and the physicians regarding the identified DRPs.

METHOD: Structured medication reviews were conducted by a multi-professional team on top of standard care for 719 patients in two internal medicine wards in a Swedish University Hospital. The medication reviews were studied retrospectively to classify DRPs and actions taken.

RESULTS: A total of 573 (80%) of patients had at least one actual DRP; an average of three DRPs per patient and in total 2164. Wrong drug and adverse drug reaction were the most common types of DRPs. The most frequent medication groups involved in DRPs were drugs for the cardiovascular system and the nervous system and the most frequent substances were warfarin, digoxin, furosemide and paracetamol. The 10 most common medications accounted for 27% of the actual DRPs. Of the identified DRPs, a total of 1740 (80%) were acted on. The three most common types of adjustments made were withdrawal of drug therapy, change of drug therapy and initiation of drug therapy. When the pharmacist suggested an adjustment, the physician implemented 88% (1037/1174) of the recommendations.

CONCLUSION: DRPs are common among elderly patients who are admitted to hospital. Systematic identification of high-risk medications and common DRP types enables targeting of prioritised patients for medication reviews.

Background The Lund Integrated MedicinesManagement model offers a systematic approach forindividualising and optimising patient drug treatment.Clinical, economical and humanistic outcomes havebeen shown as well as results from the medicationreconciliation process. There is a need also to describethe medication review process.Objective To describe the frequency and types of drug-relatedproblems (DRPs) identified during medicationreviews and to evaluate the actions of the pharmacistsand the physicians regarding the identified DRPs.Method Structured medication reviews were conductedby a multi-professionalteam on top of standard care for719 patients in two internal medicine wards in a SwedishUniversity Hospital. The medication reviews were studiedretrospectively to classify DRPs and actions taken.Results A total of 573 (80%) of patients had at leastone actual DRP; an average of three DRPs per patientand in total 2164. Wrong drug and adverse drug reactionwere the most common types of DRPs. The most frequentmedication groups involved in DRPs were drugs forthe cardiovascular system and the nervous system andthe most frequent substances were warfarin, digoxin,furosemide and paracetamol. The 10 most commonmedications accounted for 27% of the actual DRPs. Ofthe identified DRPs, a total of 1740 (80%) were actedon. The three most common types of adjustments madewere withdrawal of drug therapy, change of drug therapyand initiation of drug therapy. When the pharmacistsuggested an adjustment, the physician implemented88% (1037/1174) of the recommendations.Conclusion DRPs are common among elderly patientswho are admitted to hospital. Systematic identificationof high-riskmedications and common DRP types enablestargeting of prioritised patients for medication reviews.

Objective To present evidence for healthcare-provided medication adherence interventions on clinical, economic and humanistic outcomes among patients. Methods Literature search of systematic reviews in Medline, Embase and CINAHL (2007–2017), validation of quality using A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 and Preferred Reporting Items for Systematic Reviews and Meta-Analyses questionnaires and, finally, extraction, combination and tabulation of results for included studies. Results From eight systematic reviews with medium to high AMSTAR 2 score, 37 randomised controlled studies involving 28 600 participants were extracted. Patient education and counselling showed some positive effects on medication adherence. Patient education also showed some positive effects on morbidity, healthcare utilities and patient satisfaction. Counselling had some benefit on mortality and healthcare utilisation. Simplifying doses was shown to have some benefit on morbidity and patient satisfaction. Interventions delivered by pharmacists and nurses showed a better result in improving adherence and outcomes than interventions delivered by general practitioners. Conclusions Some interventions were found to have positive effect on adherence and outcomes, but no single strategy showed improvement in all settings. For future research patients should be screened for non-adherence to reveal both if they are non-adherent and type of nonadherence, as well as bigger sample sizes and longer duration of follow-up.

Background Adverse drug events from preventable medication errors can result in patient morbidity and mortality, and in cost to the healthcare system. Medication reconciliation can improve communication and reduce medication errors at transitions in care. Objective Evaluate the impact of medication reconciliation and counselling intervention delivered by a pharmacist for medical patients on clinical outcomes 30 days after discharge. Setting Sultan Qaboos University Hospital, Muscat, Oman. Methods A randomized controlled study comparing standard care with an intervention delivered by a pharmacist and comprising medication reconciliation on admission and discharge, a medication review, a bedside medication counselling, and a take-home medication list. Medication discrepancies during hospitalization were identified and reconciled. Clinical outcomes were evaluated by reviewing electronic health records and telephone interviews. Main outcome measures Rates of preventable adverse drug events as primary outcome and healthcare resource utilization as secondary outcome at 30 days post discharge. Results A total of 587 patients were recruited (56 ± 17 years, 57% female); 286 randomized to intervention; 301 in the standard care group. In intervention arm, 74 (26%) patients had at least one discrepancy on admission and 100 (35%) on discharge. Rates of preventable adverse drug events were significantly lower in intervention arm compared to standard care arm (9.1 vs. 16%, p = 0.009). No significant difference was found in healthcare resource use. Conclusion The implementation of an intervention comprising medication reconciliation and counselling by a pharmacist has significantly reduced the rate of preventable ADEs 30 days post discharge, compared to the standard care. The effect of the intervention on healthcare resource use was insignificant. Pharmacists should be included in decentralized, patient-centred roles. The findings should be interpreted in the context of the study's limitations.

Objective To investigate pharmacists' involvement in medication reconciliation (MedRec) and the quality of MedRec processes throughout Europe. Methods A survey with six questions was sent to delegates from the 30 countries participating in the EAHP Academy Seminar Camp focusing on MedRec. The questionnaire included four questions regarding the status of MedRec on a national level including the prevalence of MedRec, available educations, requirements of the pharmacists and training of new staff. Results 52 delegates from 29 countries responded (response rate 90%). Only the participants from the UK stated that MedRec is implemented as standard practice in the country. For most countries MedRec is implemented in some hospitals for some patients (13) or as projects (12). In 11 countries a systematic approach was in place for training new staff and 13 countries have courses teaching MedRec. Only five countries had prerequisites for pharmacists performing MedRec. Conclusions There is great heterogeneity in the implementation rate and standards of practice of MedRec processes including pharmacists in Europe.

Background: Trials of complex interventions are often criticized for being difficult to interpret because the effects of apparently similar interventions vary across studies dependent on context, targeted groups, and the delivery of the intervention. The Motivational Interviewing and Medication Review in Coronary heart disease (MIMeRiC) trial is a randomized controlled trial (RCT) of an intervention aimed at improving pharmacological secondary prevention. Guidelines for the development and evaluation of complex interventions have recently highlighted the need for better reporting of the development of interventions, including descriptions of how the intervention is assumed to work, how this theory informed the process evaluation, and how the process evaluation relates to the outcome evaluation. Objective: This paper aims to describe how the intervention was designed and developed. The aim of the process evaluation is to better understand how and why the intervention in the MIMeRiC trial was effective or not effective. Methods: The research questions for evaluating the process are based on the conceptual model of change processes assumed in the intervention and will be analyzed by qualitative and quantitative methods. Quantitative data are used to evaluate the medication review in terms of drug-related problems, to describe how patients' beliefs about medicines are affected by the intervention, and to evaluate the quality of motivational interviewing. Qualitative data will be used to analyze whether patients experienced the intervention as intended, how cardiologists experienced the collaboration and intervention, and how the intervention affected patients' overall experience of care after coronary heart disease. Results: The development and piloting of the intervention are described in relation to the theoretical framework. Data for the process evaluation will be collected until March 2018. Some process evaluation questions will be analyzed before, and others will be analyzed after the outcomes of the MIMeRiC RCT are known. Conclusions: This paper describes the framework for the design of the intervention tested in the MIMeRiC trial, development of the intervention from the pilot stage to the complete trial intervention, and the framework and methods for the process evaluation. Providing the protocol of the process evaluation allows prespecification of the processes that will be evaluated, because we hypothesize that they will determine the outcomes of the MIMeRiC trial. This protocol also constitutes a contribution to the new field of process evaluations as made explicit in health services research and clinical trials of complex interventions.

Background: Preventive treatment goals for blood pressure and cholesterol levels continue to be unmet for many coronary patients. The effect of drug treatment depends on both its appropriateness and the patients' adherence to the treatment regimen. There is a need for adherence interventions that have a measurable effect on clinical outcomes. Objective: This study aims to evaluate the effects on treatment goals of an intervention designed to improve patient adherence and treatment quality in secondary prevention of coronary heart disease. A protocol for the prespecified process evaluation of the trial is published separately. Methods: The Motivational Interviewing and Medication Review in Coronary heart disease (MIMeRiC) trial is a prospective, randomized, outcomes-blinded trial designed to compare individualized follow-up by a clinical pharmacist using motivational interviewing (MI) and medication review with standard follow-up. Patients were randomized to 2 groups after stratification according to their beliefs about medicines. After standard follow-up at the cardiology clinic, patients in the intervention group are seen individually by a clinical pharmacist 2 to 5 times as required over 7 months, at the clinic. The pharmacist reviews each patient's medication and uses MI to manage any problems with prescribing and adherence. The primary study outcome is the proportion of patients who have reached the treatment goal for low-density lipoprotein cholesterol by 12 months after discharge. Secondary outcomes are the effects on patient adherence, systolic blood pressure, disease-specific quality of life, and health care use. Results: The protocol for this study was approved by the Regional Ethics Committee, Linkoping, in 2013. Enrollment started in October 2013 and ended in December 2016 when 417 patients had been included. Follow-up data collection will conclude in March 2018. Publication of the primary and secondary outcome results from the MIMeRiC trial is anticipated in 2019. Conclusions: The MIMeRiC trial will assess the effectiveness of an intervention involving medication reviews and individualized support. The results will inform the continued development of support for this large group of patients who use preventive medicines for lifelong treatment. The design of this adherence intervention is based on a theoretical framework and is the first trial of an intervention that uses beliefs about medicines to individualize the intervention protocol.

Background: Medication errors occur frequently at transitions in care and can result in morbidity and mortality. Medication reconciliation is a recognized hospital accreditation requirement and designed to limit errors in transitions in care. Objectives: To identify beliefs, perceived roles and responsibilities of physicians, pharmacists and nurses prior to the implementation of a standardized medication reconciliation process. Methods: A survey was distributed to the three professions: pharmacists in the pharmacy and physicians and nurses in hospital in-patient units. It contained questions about the current level of medication reconciliation practices, as well as perceived roles and responsibilities of each profession when a standardized process is implemented. Value, barriers to implementing medication reconciliation and the role of information technology were also assessed. Analyses were performed using univariate statistics. Results: There was a lack of clarity of current medication reconciliation practices as well as lack of agreement between the three professions. Physicians and pharmacists considered their professions as the main providers while nurses considered physicians followed by themselves as the main providers with limited roles for pharmacists. The three professions recognize the values and benefits of medication reconciliation yet pharmacists, more than others, stated limited time to implement reconciliation is a major barrier. Obstacles such as unreliable sources of medication history, patient knowledge and lack of coordination and communication between the three professions were expressed. Conclusions: The three health care professions recognize the value of medication reconciliation and want to see it implemented in the hospital, yet there is a lack of agreement with regard to roles and responsibilities of each profession within the process. This needs to be addressed by the hospital administration to design clear procedures and defined roles for each profession within a standardized medication reconciliation process.

A new curriculum is planned for the medical school at Lund University, Sweden. Pharmacology, in a broad sense, has been identified as a subject that needs to be strengthened based on needs in the healthcare system. The aim was to identify the competencies in basic and clinical pharmacology that a newly qualified physician needs. Using a modified three-round Delphi technique, 31 physicians were invited to list necessary competencies (round 1). After content analysis, these panel members classified the list by importance on two occasions (rounds 2 and 3) using a 4-point scale (4 = necessary, 3 = desirable, 2 = useful, 1 = not necessary). Competencies with the highest ranks based on necessity were retained. Thirty physicians accepted the invitation and 25 (83%) of them completed all three rounds. Round 1 resulted in 258 suggestions, which were subsequently reduced to 95 competencies. Of these 95 competencies, 40 were considered necessary by at least 75% of the panel members. The degree of consensus increased between round 2 and round 3. Using a modified Delphi technique, we identified 40 competencies that could be transferred to learning outcomes for a new curriculum in basic and clinical pharmacology at medical school.

Den farmaceutiska professionen håller snabbt på att förändras och våra lärosäten är inte tillräckligt snabba i sina omställningar för att möte nya behov i samhället. Det behövs ökad tydlighet av vad receptarie- respektive apotekarkompetensen, professionerna och yrkena inkluderar. Vetenskapsområdet farmaci behöver alltså diskuteras och uppdateras. Kompetens inom naturvetenskaper som kemi och biologi är självklart nödvändigt för apotekare och även för receptarier men detta är stödjande kompetenser inte kärnkompetenser.

Jag har skrivit denna bok för att dela med mig av min resa och erfarenheter för att etablera farmacin som en viktig komponent i patientvården och i vårdteamet runt patienten för bättre läkemedelsanvändning. Denna roll har varit intressant för studenter och yrkesverksamma under flera decennier men har inte fått genomslag i grundutbildningarna. Under min resa har jag fått kompetenser och erfarenheter inom kemi, farmaci, farmakologi, läkemedelsutveckling, farmakoterapi, evidensbaserad medicin, klinisk farmaci och pedagogik, som praktiker, produkt-, tjänste- och verksamhetsutvecklare, lärare och utbildningsansvarig, akademiker, forskare och internationell expert till myndigheter och organisationer, som beskrivs i författarpresentationen.