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Frenkel A, Smadar Shneyour R, Shiloh A, Morad M, Shimoni-Rachmilev O, Dreiher J. Adherence to monitoring of patients treated with amiodarone: a nationwide study. Front Med (Lausanne) 2024; 11:1408799. [PMID: 39036100 PMCID: PMC11257881 DOI: 10.3389/fmed.2024.1408799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/10/2024] [Indexed: 07/23/2024] Open
Abstract
Objective The aim of this study was to assess the adherence to monitoring guidelines regarding amiodarone treatment. Methods This is a retrospective cohort study of data recorded in Clalit Health Services, the largest healthcare organization in Israel. Included were individuals aged >18 years; who were prescribed amiodarone and had a documented purchase of this drug, for a minimum of 200 consecutive days; and who had less than a 100-day gap between two consecutive purchases during 2013-2021. Adherence was assessed to testing for thyroid, liver function, and electrolytes, as determined by the performance of a test every 6 months. Results The study included 24,094 individuals (mean age: 75 years, 53% male). The median follow-up was 2.3 years (total 73,727 person-years). The proportions of patients who performed baseline tests were: 43.4% for thyroid function, 58.3% for electrolytes, 48.6% for liver function, 20.6% for chest X-rays, and 14.9% for electrocardiograms. Adherence rates to semiannual monitoring of thyroid function, liver function, and electrolyte tests were: 70.4%, 79.4%, and 88.3%, respectively. In a multivariable analysis, the factors associated with higher adherence were male sex; older age; the presence of thyroid abnormalities, renal failure, and hypertension; and more frequent visits to the primary care physician. Conclusions In our country, adherence is low to monitoring risk factors for adverse effects of amiodarone therapy, especially prior to treatment initiation. Patient and primary care physicians should be educated about the importance of monitoring, particularly prior to initiation of amiodarone treatment.
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Affiliation(s)
- Amit Frenkel
- General Intensive Care Unit, Soroka University Medical Center, Beer-Sheva, Israel
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ruth Smadar Shneyour
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
- The Joyce and Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Adi Shiloh
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
- The Joyce and Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Mohammed Morad
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Risk Management and Patient Safety Unit, Kaplan Medical Center, Beer-Sheva, Israel
| | - Orly Shimoni-Rachmilev
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Pharmacy Services, Soroka University Medical Center, Beer-Sheva, Israel
| | - Jacob Dreiher
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Hospital Administration, Soroka University Medical Center, Beer-Sheva, Israel
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Brouwer JMJL, Risselada AJ, de Wit M, Lubberts J, Westerhuis H, Doornbos B, Mulder H. Lithium surveillance by community pharmacists and physicians in ambulatory patients: a retrospective cohort study. Int J Clin Pharm 2022; 44:975-984. [PMID: 35831730 PMCID: PMC9393139 DOI: 10.1007/s11096-022-01420-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Shared care agreements between clinical pharmacists and physicians can improve suboptimal lithium monitoring in in- and outpatient settings. However, it is unknown whether incorporating community pharmacists in such agreements can also improve lithium monitoring in an outpatient setting. AIM To assess the necessity for a shared care agreement for lithium monitoring in our region by investigating: intervention rates by community pharmacists and whether those are sufficient; lithium monitoring by physicians in ambulatory patients; the extent of laboratory parameter exchange to community pharmacists. METHOD Patient files of lithium users were surveyed in a retrospective cohort study among 21 community pharmacies in the Northern Netherlands. Outcome was the intervention rate by community pharmacists and whether those were deemed sufficient by an expert panel. Additionally, we investigated both the percentages of patients monitored according to current guidelines and of laboratory parameters exchanged to community pharmacists. RESULTS 129 patients were included. Interventions were performed in 64.4% (n = 29), 20.8% (n = 5), and 25.0% (n = 1) of initiations, discontinuations, and dosage alterations of drugs interacting with lithium, respectively. The expert panel deemed 40.0% (n = 14) of these interventions as "insufficient". Physicians monitored 40.3% (n = 52) of the patients according to current guidelines for lithium serum levels and kidney functions combined. Approximately half of the requested laboratory parameters were available to the community pharmacist. CONCLUSION Intervention rates by community pharmacists and lithium monitoring by physicians can be improved. Therefore, a shared care agreement between community pharmacists, clinical pharmacists, and physicians is needed to improve lithium monitoring in ambulatory patients.
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Affiliation(s)
- Jurriaan M. J. L. Brouwer
- Department of Clinical Pharmacy, Wilhelmina Hospital Assen, Mailbox: 30.001, 9400 RA Assen, The Netherlands ,grid.468637.80000 0004 0465 6592GGZ Drenthe Mental Health Services Drenthe, Assen, The Netherlands ,grid.4830.f0000 0004 0407 1981Department of Psychiatry, Research School of Behavioral and Cognitive Neurosciences, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Arne J. Risselada
- Department of Clinical Pharmacy, Wilhelmina Hospital Assen, Mailbox: 30.001, 9400 RA Assen, The Netherlands
| | - Marinka de Wit
- grid.4830.f0000 0004 0407 1981Department of Pharmacotherapy, -Epidemiology and -Economics, Department of Pharmacy and Pharmaceutical Sciences, University of Groningen, Groningen, The Netherlands
| | - Janniek Lubberts
- grid.4830.f0000 0004 0407 1981Department of Pharmacotherapy, -Epidemiology and -Economics, Department of Pharmacy and Pharmaceutical Sciences, University of Groningen, Groningen, The Netherlands
| | - Henrieke Westerhuis
- grid.4830.f0000 0004 0407 1981Department of Pharmacotherapy, -Epidemiology and -Economics, Department of Pharmacy and Pharmaceutical Sciences, University of Groningen, Groningen, The Netherlands
| | - Bennard Doornbos
- grid.4830.f0000 0004 0407 1981Lentis Psychiatric Institute, Lentis Research, Groningen, The Netherlands
| | - Hans Mulder
- Department of Clinical Pharmacy, Wilhelmina Hospital Assen, Mailbox: 30.001, 9400 RA, Assen, The Netherlands. .,Dutch Academic Network of Northern Pharmacies (ANNA), Groningen, The Netherlands.
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Albassam BA, Almutairi NM, Aldosari SF, Almodaimegh HS. Compliance with the north American Society of Pacing and Electrophysiology guidelines on amiodarone monitoring in Riyadh, Saudi Arabia: a retrospective charts review study. J Pharm Policy Pract 2020; 13:37. [PMID: 32821394 PMCID: PMC7433033 DOI: 10.1186/s40545-020-00235-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 05/31/2020] [Indexed: 11/17/2022] Open
Abstract
Background Amiodarone is known for its efficacy as an antiarrhythmic agent; however, its extensive side-effect profile requires careful selection of patients and frequent monitoring. The purpose of this study was to evaluate the performance of the baseline tests before initiating amiodarone therapy and the on-going monitoring based on the North American Society of Pacing and Electrophysiology guidelines recommendations. Methods A retrospective descriptive charts review study included all patients who are 18 years of age and older and were started on oral amiodarone with a primary diagnosis of any type of cardiac arrhythmia from January 2016 to December 2018 in King Abdualziz Medical City, Riyadh, Saudi Arabia. The medical charts were reviewed and evaluated based on the performance of the recommended baseline and follow-up of chest X-ray (CXR), liver function test (LFT), thyroid function test (TFT) and electrocardiogram (ECG). The continuous variables were analyzed and presented as mean ± SD and the categorical variables were presented as percentages. Results Over the study period, 143 eligible participants on amiodarone therapy were included, with an average of 165 ± 207 days on amiodarone. Of patients, 36.4% had the entire recommended baseline assessments before initiating amiodarone. Our results indicated optimal compliance rates to the baseline tests of CXR (79.7%), LFT (79.7%) and ECG (86.7%). However, there was a lower compliance rate to TFT recommendations (40.6%). The compliance rate to the guideline recommendations related to the follow-up tests was minimal. On-going monitoring performance rates were 47.6% of CXR, 49% of LFT, 54.5% of ECG and 22.4% of TFT. Conclusion The compliance with the guideline recommendations related to amiodarone baseline assessments was optimal for all the baseline tests, except for TFT. However, the proportion of patients who received all the recommended baseline assessments was minimal. In addition, the performance of on-going monitoring was suboptimal for all the follow-up tests. Improvements could be made by establishing a local protocol for amiodarone monitoring and pharmacists participating in amiodarone therapy assessments.
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Affiliation(s)
- Bander Ahmed Albassam
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Nouf Mohammed Almutairi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Sarah Fahad Aldosari
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Hind Saleh Almodaimegh
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Pharmacutical Care Services, King Abdualziz Medical City, Riyadh, Saudi Arabia
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Niazkhani Z, Fereidoni M, Rashidi Khazaee P, Shiva A, Makhdoomi K, Georgiou A, Pirnejad H. Translation of evidence into kidney transplant clinical practice: managing drug-lab interactions by a context-aware clinical decision support system. BMC Med Inform Decis Mak 2020; 20:196. [PMID: 32819359 PMCID: PMC7439664 DOI: 10.1186/s12911-020-01196-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 07/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Drug-laboratory (lab) interactions (DLIs) are a common source of preventable medication errors. Clinical decision support systems (CDSSs) are promising tools to decrease such errors by improving prescription quality in terms of lab values. However, alert fatigue counteracts their impact. We aimed to develop a novel user-friendly, evidence-based, clinical context-aware CDSS to alert nephrologists about DLIs clinically important lab values in prescriptions of kidney recipients. METHODS For the most frequently prescribed medications identified by a prospective cross-sectional study in a kidney transplant clinic, DLI-rules were extracted using main pharmacology references and clinical inputs from clinicians. A CDSS was then developed linking a computerized prescription system and lab records. The system performance was tested using data of both fictitious and real patients. The "Questionnaire for User Interface Satisfaction" was used to measure user satisfaction of the human-computer interface. RESULTS Among 27 study medications, 17 needed adjustments regarding renal function, 15 required considerations based on hepatic function, 8 had drug-pregnancy interactions, and 13 required baselines or follow-up lab monitoring. Using IF & THEN rules and the contents of associated alert, a DLI-alerting CDSS was designed. To avoid alert fatigue, the alert appearance was considered as interruptive only when medications with serious risks were contraindicated or needed to be discontinued or adjusted. Other alerts appeared in a non-interruptive mode with visual clues on the prescription window for easy, intuitive notice. When the system was used for real 100 patients, it correctly detected 260 DLIs and displayed 249 monitoring, seven hepatic, four pregnancy, and none renal alerts. The system delivered patient-specific recommendations based on individual lab values in real-time. Clinicians were highly satisfied with the usability of the system. CONCLUSIONS To our knowledge, this is the first study of a comprehensive DLI-CDSS for kidney transplant care. By alerting on considerations in renal and hepatic dysfunctions, maternal and fetal toxicity, or required lab monitoring, this system can potentially improve medication safety in kidney recipients. Our experience provides a strong foundation for designing specialized systems to promote individualized transplant follow-up care.
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Affiliation(s)
- Zahra Niazkhani
- Nephrology and Kidney Transplant Research Center, Urmia University of Medical Sciences, Urmia, Iran.,Department of Health Information Technology, Urmia University of Medical Sciences, Urmia, Iran
| | - Mahsa Fereidoni
- Department of Health Information Technology, Urmia University of Medical Sciences, Urmia, Iran.,Student Research Committee, Urmia University of Medical Sciences, Urmia, Iran
| | | | - Afshin Shiva
- Department of Clinical Pharmacy, Urmia University of Medical Sciences, Urmia, Iran
| | - Khadijeh Makhdoomi
- Nephrology and Kidney Transplant Research Center, Urmia University of Medical Sciences, Urmia, Iran.,Department of Adult Nephrology, Urmia University of Medical Sciences, Urmia, Iran
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Habibollah Pirnejad
- Patient Safety Research Center, Urmia University of Medical Sciences, Urmia, Iran. .,Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam, Rotterdam, the Netherlands.
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Pantoja T, Grimshaw JM, Colomer N, Castañon C, Leniz Martelli J. Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes. Cochrane Database Syst Rev 2019; 12:CD001174. [PMID: 31858588 PMCID: PMC6923326 DOI: 10.1002/14651858.cd001174.pub4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care. OBJECTIVES 1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies. SELECTION CRITERIA We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions. DATA COLLECTION AND ANALYSIS Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention. Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR -1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR -0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence). We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons). Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain. None of the included studies reported outcomes related to harms or adverse effects. AUTHORS' CONCLUSIONS Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.
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Affiliation(s)
- Tomas Pantoja
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Jeremy M Grimshaw
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramThe Ottawa Hospital ‐ General Campus501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
| | - Nathalie Colomer
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Carla Castañon
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Javiera Leniz Martelli
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
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Nilsson E, De Deco P, Trevisan M, Bellocco R, Lindholm B, Lund LH, Coresh J, Carrero JJ. A real-world cohort study on the quality of potassium and creatinine monitoring during initiation of mineralocorticoid receptor antagonists in patients with heart failure. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 4:267-273. [PMID: 29726982 DOI: 10.1093/ehjqcco/qcy019] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 04/25/2018] [Indexed: 12/28/2022]
Abstract
Aims Clinical heart failure (HF) guidelines recommend monitoring of creatinine and potassium throughout the initial weeks of mineralocorticoid receptor antagonists (MRAs) therapy. We here assessed the extent to which this occurs in our health care. Methods and results Observational study in 2007-2010 HF patients starting MRA therapy in Stockholm, Sweden. Outcomes included potassium and creatinine laboratory testing before MRA initiation and in the early (Days 1-10) and extended (Days 11-90) post-initiation periods. Exclusion criteria considered death/hospitalization within 90 days, and lack of a second MRA dispense. Of 4036 HF patients starting on MRA, 45% were initiated from a hospital, 24% from a primary care centre, and 30% from other private centres. Overall, 89% underwent pre-initiation testing, being more common among hospital (97%) than for primary care (74%) initiations. Only 24% were adequately monitored in all three recommended intervals, being again more frequent following hospital (33%) than private (21%) or primary care (17%) initiations. In multivariable analyses, adequate monitoring was more likely for hospital [odds ratio (OR) 2.85, 95% confidence interval (95% CI) 2.34-3.56] initiations, and for patients with chronic kidney disease (OR 1.79, 95% CI 1.30-2.43) and concomitant use of angiotensin-converting enzyme (OR 1.27, 95% CI 1.05-1.52), angiotensin receptor blockers (OR 1.19, 95% CI 1.01-1.40) or beta-blockers (OR 1.65, 95% CI 1.22-2.26). Age, sex, and prescribing centre explained a small portion of adequate monitoring (c-statistic 0.63). Addition of comorbidities and medications improved prediction marginally (c-statistic 0.65). Conclusion Although serum potassium and creatinine monitoring before MRA initiation for HF is frequent, rates of post-initiation monitoring remain suboptimal, especially among primary care centres.
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Affiliation(s)
- Erik Nilsson
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska Universitetssjukhuset Huddinge, Stockholm, Stockholm, Sweden.,Department of Internal Medicine, School of Medical Sciences, Örebro University, Södra Grev Rosengatan, Örebro, Örebro, Sweden
| | | | - Marco Trevisan
- Department of Medical Epidemiology and Biostatistics (MEB), Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden
| | - Rino Bellocco
- Milano Biccoca University, Milan, Italy.,Department of Medical Epidemiology and Biostatistics (MEB), Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska Universitetssjukhuset Huddinge, Stockholm, Stockholm, Sweden
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, Karolinska Universitetssjukhuset, Solna, Stockholm, Stockholm, Sweden
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, W6508, Baltimore, MD, USA
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics (MEB), Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden
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Rankin S, Elder DH, Ogston S, George J, Lang CC, Choy AM. Population-level incidence and monitoring of adverse drug reactions with long-term amiodarone therapy. Cardiovasc Ther 2017; 35. [DOI: 10.1111/1755-5922.12258] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 02/09/2017] [Accepted: 03/01/2017] [Indexed: 01/24/2023] Open
Affiliation(s)
- Stephen Rankin
- College of Medical, Veterinary Life Sciences; University of Glasgow; Glasgow UK
| | - Douglas H. Elder
- Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital and Medical School; University of Dundee; Dundee UK
| | - Simon Ogston
- Department of Public Health; University of Dundee; Dundee UK
| | - Jacob George
- Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital and Medical School; University of Dundee; Dundee UK
| | - Chim C. Lang
- Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital and Medical School; University of Dundee; Dundee UK
| | - Anna Maria Choy
- Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital and Medical School; University of Dundee; Dundee UK
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8
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Huang CJ, Tseng CL, Chu CH, Huang DF, Huang CC, Lin LY. Adherence to guidelines in monitoring amiodarone-induced thyroid dysfunction. J Eval Clin Pract 2017; 23:108-113. [PMID: 27515316 DOI: 10.1111/jep.12619] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 07/07/2016] [Accepted: 07/07/2016] [Indexed: 01/25/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES Baseline thyroid function testing and regular follow-up of thyroid function under amiodarone usage was recommended by guidelines. Little is known about the status of amiodarone monitoring in real-world clinical care in Taiwan. The objective was to determine the rate of thyroid monitoring and to assess the clinical and physicians' characteristics associated with adequate monitoring in a tertiary referral centre for arrhythmia. METHODS We reviewed the medical records of patients receiving amiodarone during the period 2008-2009 at Taipei Veterans General Hospital. The rate of baseline and follow-up thyroid function monitoring during amiodarone therapy were calculated. Factors associated with guideline adherence to monitoring were analysed. RESULTS Among the 1319 enrolled cases, 36.4% (n = 480) underwent baseline thyroid function testing and 1.1% (n = 15) received measurement of anti-thyroid peroxidase antibody before amiodarone initiation. Regular follow up of thyroid function under amiodarone usage occurred in only 8.6% (n = 114) of cases. Baseline thyroid function was more likely to be present in patients of younger age (P < 0.001), female sex (P = 0.01), and in those who received amiodarone therapy from cardiologists (P < 0.001) or electrophysiologists (P < 0.001) with fewer years of service (P < 0.001). Upon multivariate analysis, only physicians' expertise (cardiologist versus non-cardiologist, OR = 5.67, 95% CI: 2.44-13.16) and years of service (OR = 0.97, 95% CI: 0.95-0.998) were significantly associated with adequate thyroid monitoring. CONCLUSIONS The rate of thyroid monitoring with amiodarone therapy had been suboptimal. Strategies to enhance guideline adherence are needed.
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Affiliation(s)
- Chun-Jui Huang
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chi-Lung Tseng
- Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Gastroenterology, Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Huei Chu
- Division of Otology, Department of Otorhinolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - De-Feng Huang
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chin-Chou Huang
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Liang-Yu Lin
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
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9
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Cooper LB, Hammill BG, Peterson ED, Pitt B, Maciejewski ML, Curtis LH, Hernandez AF. Characterization of Mineralocorticoid Receptor Antagonist Therapy Initiation in High-Risk Patients With Heart Failure. Circ Cardiovasc Qual Outcomes 2017; 10:e002946. [PMID: 28073850 PMCID: PMC5228387 DOI: 10.1161/circoutcomes.116.002946] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 10/21/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Heart failure guidelines recommend routine monitoring of serum potassium, and renal function in patients treated with a mineralocorticoid receptor antagonist (MRA). How these recommendations are implemented in high-risk patients or according to setting of drug initiation is poorly characterized. METHODS AND RESULTS We conducted a retrospective cohort study of Medicare beneficiaries linked to laboratory data in 10 states with prevalent heart failure as of July 1, 2011, and incident MRA use between May 1 and September 30, 2011. Outcomes included laboratory testing before MRA initiation and in the early (days 1-10) and extended (days 11-90) post-initiation periods, based on setting of drug initiation and the presence of renal insufficiency. Additional outcomes included abnormal laboratory results and adverse events proximate to MRA initiation. Of 10 443 Medicare beneficiaries with heart failure started on an MRA, 19.7% were initiated during a hospitalization. Appropriate follow-up laboratory testing across all time periods occurred in 25.2% of patients with inpatient initiation compared with 2.8% of patients begun as an outpatient. Patients with chronic kidney disease had higher rates of both hyperkalemia and acute kidney failure in the early (1.3% and 2.7%, respectively) and extended (5.6% and 9.8%, respectively) post-initiation periods compared with those without chronic kidney disease. CONCLUSIONS Patients initiated on MRA therapy as an outpatient had extremely poor rates of guideline indicated follow-up laboratory monitoring after drug initiation. In particular, patients with chronic kidney disease are at high risk for adverse events after MRA initiation. Quality improvement initiatives focused on systems to improve appropriate laboratory monitoring are needed.
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Affiliation(s)
- Lauren B Cooper
- From the Inova Heart and Vascular Institute, Falls Church, VA (L.B.C.); Department of Medicine (L.B.C., E.D.P., M.L.M., L.H.C., A.F.H.) and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (B.G.H., E.D.P., L.H.C., A.F.H.); Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC (M.L.M.).
| | - Bradley G Hammill
- From the Inova Heart and Vascular Institute, Falls Church, VA (L.B.C.); Department of Medicine (L.B.C., E.D.P., M.L.M., L.H.C., A.F.H.) and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (B.G.H., E.D.P., L.H.C., A.F.H.); Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC (M.L.M.)
| | - Eric D Peterson
- From the Inova Heart and Vascular Institute, Falls Church, VA (L.B.C.); Department of Medicine (L.B.C., E.D.P., M.L.M., L.H.C., A.F.H.) and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (B.G.H., E.D.P., L.H.C., A.F.H.); Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC (M.L.M.)
| | - Bertram Pitt
- From the Inova Heart and Vascular Institute, Falls Church, VA (L.B.C.); Department of Medicine (L.B.C., E.D.P., M.L.M., L.H.C., A.F.H.) and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (B.G.H., E.D.P., L.H.C., A.F.H.); Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC (M.L.M.)
| | - Matthew L Maciejewski
- From the Inova Heart and Vascular Institute, Falls Church, VA (L.B.C.); Department of Medicine (L.B.C., E.D.P., M.L.M., L.H.C., A.F.H.) and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (B.G.H., E.D.P., L.H.C., A.F.H.); Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC (M.L.M.)
| | - Lesley H Curtis
- From the Inova Heart and Vascular Institute, Falls Church, VA (L.B.C.); Department of Medicine (L.B.C., E.D.P., M.L.M., L.H.C., A.F.H.) and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (B.G.H., E.D.P., L.H.C., A.F.H.); Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC (M.L.M.)
| | - Adrian F Hernandez
- From the Inova Heart and Vascular Institute, Falls Church, VA (L.B.C.); Department of Medicine (L.B.C., E.D.P., M.L.M., L.H.C., A.F.H.) and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (B.G.H., E.D.P., L.H.C., A.F.H.); Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC (M.L.M.)
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10
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Thomas RE, Vaska M, Naugler C, Chowdhury TT. Interventions to Educate Family Physicians to Change Test Ordering: Systematic Review of Randomized Controlled Trials. Acad Pathol 2016; 3:2374289516633476. [PMID: 28725760 PMCID: PMC5497906 DOI: 10.1177/2374289516633476] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 01/14/2016] [Accepted: 01/23/2016] [Indexed: 11/16/2022] Open
Abstract
The purpose is to systematically review randomised controlled trials (RCTs) to change family physicians’ laboratory test-ordering. We searched 15 electronic databases (no language/date limitations). We identified 29 RCTs (4,111 physicians, 175,563 patients). Six studies specifically focused on reducing unnecessary tests, 23 on increasing screening tests. Using Cochrane methodology 48.5% of studies were low risk-of-bias for randomisation, 7% concealment of randomisation, 17% blinding of participants/personnel, 21% blinding outcome assessors, 27.5% attrition, 93% selective reporting. Only six studies were low risk for both randomisation and attrition. Twelve studies performed a power computation, three an intention-to-treat analysis and 13 statistically controlled clustering. Unweighted averages were computed to compare intervention/control groups for tests assessed by >5 studies. The results were that fourteen studies assessed lipids (average 10% more tests than control), 14 diabetes (average 8% > control), 5 cervical smears, 2 INR, one each thyroid, fecal occult-blood, cotinine, throat-swabs, testing after prescribing, and urine-cultures. Six studies aimed to decrease test groups (average decrease 18%), and two to increase test groups. Intervention strategies: one study used education (no change): two feedback (one 5% increase, one 27% desired decrease); eight education + feedback (average increase in desired direction >control 4.9%), ten system change (average increase 14.9%), one system change + feedback (increases 5-44%), three education + system change (average increase 6%), three education + system change + feedback (average 7.7% increase), one delayed testing. The conclusions are that only six RCTs were assessed at low risk of bias from both randomisation and attrition. Nevertheless, despite methodological shortcomings studies that found large changes (e.g. >20%) probably obtained real change.
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Affiliation(s)
- Roger Edmund Thomas
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcus Vaska
- Knowledge Resource Service, Holy Cross Centre, Calgary, Alberta, Canada
| | - Christopher Naugler
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.,Departments of Pathology & Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tanvir Turin Chowdhury
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
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11
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Fischer SH, Tjia J, Reed G, Peterson D, Gurwitz JH, Field TS. Factors associated with ordering laboratory monitoring of high-risk medications. J Gen Intern Med 2014; 29:1589-98. [PMID: 24965280 PMCID: PMC4242891 DOI: 10.1007/s11606-014-2907-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 04/07/2014] [Accepted: 05/14/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Knowledge about factors associated with provider ordering of appropriate testing is limited. OBJECTIVE To determine physician factors associated with ordering recommended laboratory monitoring tests for high-risk medications. METHODS Retrospective cohort study of patients prescribed a high-risk medication requiring laboratory monitoring in a large multispecialty group practice between 1 January 2008 and 31 December 2008. Analyses are based on administrative claims and electronic medical records. The outcome is a physician order for each recommended laboratory test for each prescribed medication. Key predictor variables are physician characteristics, including age, gender, specialty training, years since completing training, and prescribing volume. Additional variables are patient characteristics such as age, gender, comorbidity burden, whether the medication requiring monitoring is new or chronic, and drug-test characteristics such as inclusion in black box warnings. We used multivariable logistic regression, accounting for clustering of drugs within patients and patients within providers. RESULTS Physician orders for laboratory testing varied across drug-test pairs and ranged from 9% (Primidone-Phenobarbital level) to 97% (Azathioprine-CBC), with half of the drug-test pairs in the 85-91% ordered range. Test ordering was associated with higher provider prescribing volume for study drugs and specialist status (primary care providers were less likely to order tests than specialists). Patients with higher comorbidity burden and older patients were more likely to have appropriate tests ordered. Drug-test combinations with black box warnings were more likely to have tests ordered. CONCLUSIONS Interventions to improve laboratory monitoring should focus on areas with the greatest potential for improvement: providers with lower frequencies of prescribing medications with monitoring recommendations and those prescribing these medications for healthier and younger patients; patients with less interaction with the health care system are at particular risk of not having tests ordered. Black box warnings were associated with higher ordering rates and may be a tool to increase appropriate test ordering.
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Affiliation(s)
- Shira H Fischer
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, 1330 Beacon St., Suite 400, Brookline, MA, 02446, USA,
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12
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Kennedy AG, Chen H, Corriveau M, MacLean CD. Improving population management through pharmacist-primary care integration: a pilot study. Popul Health Manag 2014; 18:23-9. [PMID: 25029631 DOI: 10.1089/pop.2014.0043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Pharmacists have unique skills that may benefit primary care practices. The objective of this demonstration project was to determine the impact of integrating pharmacists into patient-centered medical homes, with a focus on population management. Pharmacists were partnered into 5 primary care practices in Vermont 1 day per week to provide direct patient care, population-based medication management, and prescriber education. The main measures included a description of drug therapy problems identified and cost avoidance models. The pharmacists identified 708 drug therapy problems through direct patient care (336/708; 47.5%), population-based strategies (276/708; 38.9%), and education (96/708; 13.6%). Common population-based strategies included adjusting doses and discontinuing unnecessary medications. Pharmacists' recommendations to correct drug therapy problems were accepted by prescribers 86% of the time, when data about acceptance were known. Of the 49 recommendations not accepted, 47/49 (96%) were population-based and 2/49 (4%) were related to direct patient care. The cost avoidance model suggests $2.11 in cost was avoided for every $1.00 spent on a pharmacist ($373,092/$176,690). There was clear value in integrating pharmacists into primary care teams. Their inclusion prevented adverse drug events, avoided costs, and improved patient outcomes. Primary care providers should consider pharmacists well suited to offer direct patient care, population-based management, and prescriber education to their practices. To be successful, pharmacists must have full permission to document findings in the primary care practices' electronic health records. Given that many pharmacist services do not involve billable activities, sustainability requires identifying alternative funding mechanisms that do not rely on a traditional fee-for-service approach.
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Affiliation(s)
- Amanda G Kennedy
- 1 Division of General Internal Medicine, University of Vermont College of Medicine , Burlington, Vermont
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13
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Bayoumi I, Al Balas M, Handler SM, Dolovich L, Hutchison B, Holbrook A. The effectiveness of computerized drug-lab alerts: a systematic review and meta-analysis. Int J Med Inform 2014; 83:406-15. [PMID: 24793784 DOI: 10.1016/j.ijmedinf.2014.03.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 03/17/2014] [Accepted: 03/19/2014] [Indexed: 01/18/2023]
Abstract
BACKGROUND Inadequate lab monitoring of drugs is a potential cause of ADEs (adverse drug events) which is remediable. OBJECTIVES To determine the effectiveness of computerized drug-lab alerts to improve medication-related outcomes. DATA SOURCES Citations from the Computerized Clinical Decision Support System Systematic Review (CCDSSR) and MMIT (Medications Management through Health Information Technology) databases, which had searched MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, International Pharmaceutical Abstracts from 1974 to March 27, 2013. STUDY SELECTION Randomized controlled trials (RCTs) of clinician-targeted computerized drug lab alerts conducted in any healthcare setting. Two reviewers performed full text review to determine study eligibility. DATA ABSTRACTION A single reviewer abstracted data and evaluated validity of included studies using Cochrane handbook domains. DATA SYNTHESIS Thirty-six studies met the inclusion criteria (25 single drug studies with 22,504 participants, 14 targeting anticoagulation; 11 multi-drug studies with 56,769 participants). ADEs were reported as an outcome in only four trials, all targeting anticoagulants. Computerized drug-lab alerts did not reduce ADEs (OR 0.89, 95% CI 0.79-1.00, p=0.05), length of hospital stay (SMD 0.00, 95%CI -0.93 to 0.93, p=0.055, 1 study), likelihood of hypoglycemia (OR 1.29, 95% CI 0.31-5.37) or likelihood of bleeding, but were associated with increased likelihood of prescribing changes (OR 1.73, 95% CI 1.21-2.47) or lab monitoring (OR 1.47, 95% confidence interval 1.12-1.94) in accordance with the alert. CONCLUSIONS There is no evidence that computerized drug-lab alerts are associated with important clinical benefits, but there is evidence of improvement in selected clinical surrogate outcomes (time in therapeutic range for vitamin K antagonists), and changes in process outcomes (lab monitoring and prescribing decisions).
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Affiliation(s)
- Imaan Bayoumi
- Department of Family Medicine, McMaster University, Canada; Kingston Community Health Centres, Canada; Department of Family Medicine, Queen's University, Canada.
| | - Mosab Al Balas
- Department of Pharmacy, St. Joseph's Health Care Hamilton, Hamilton, Canada
| | - Steven M Handler
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System (VAPHS), Pittsburgh, PA, United States; Center for Health Equity Research and Promotion (CHERP), VAPHS, Pittsburgh, PA, United States
| | - Lisa Dolovich
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Canada; Department of Family Medicine, McMaster University, Canada; Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton, Canada
| | - Brian Hutchison
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Canada; Department of Family Medicine, McMaster University, Canada
| | - Anne Holbrook
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Canada; Division of Clinical Pharmacology & Therapeutics, Department of Medicine, McMaster University, Canada; Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton, Canada
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14
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Geerts AFJ, De Koning FHP, De Vooght KMK, Egberts ACG, De Smet PAGM, van Solinge WW. Feasibility of point-of-care creatinine testing in community pharmacy to monitor drug therapy in ambulatory elderly patients. J Clin Pharm Ther 2013; 38:416-22. [PMID: 23808548 DOI: 10.1111/jcpt.12081] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 06/05/2013] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE It is often necessary to adjust drug therapy if renal function is impaired in elderly patients taking drugs for diabetes and/or cardiovascular disease that are cleared by the kidneys. Although clinical guidelines recommend regular monitoring of renal function in these patients, in practice adherence to these recommendations varies from 28% to 75%. To determine whether drug dosing is appropriate, pharmacists need have up-to-date information about patients' renal function. In this study, the feasibility of point-of-care creatinine testing (POCCT) in a community pharmacy was evaluated as part of monitoring the drug therapy of ambulatory elderly patients. METHODS Elderly patients on maintenance therapy with renally excreted drugs for diabetes or cardiovascular disease were eligible for POCCT. After informed consent was obtained, POCCT was performed by trained personnel. A pharmacist assessed the clinical relevance of electronically generated drug alerts based on the patient's calculated renal function and the Dutch guidelines for adjusting drug dosage in patients with chronic kidney disease. If appropriate, the patient's general practitioner (GP) was consulted and adjustments to treatment were communicated to the patient. The feasibility of POCCT was evaluated by means of questionnaires completed by patients and healthcare professionals (GPs and pharmacists). RESULTS Of 338 potentially eligible patients, 149 (44%) whose renal function was not known were asked, by letter, to participate in the study. Of these individuals, 46 (31%) gave their informed consent and underwent POCCT. Response rates for completing the patient and professional questionnaires were 87% and 100%, respectively. More than half of the patients who underwent POCCT had mild-to-moderate renal impairment. On the basis of information provided by patients and healthcare professionals, POCCT would appear to be feasible in community pharmacies. WHAT IS NEW AND CONCLUSION POCCT improves the management of drug therapy by community pharmacists and is feasible in daily practice.
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Affiliation(s)
- A F J Geerts
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht, the Netherlands.
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15
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Wilbur K, Hazi H, El-Bedawi A. Drug-Related Hospital Visits and Admissions Associated with Laboratory or Physiologic Abnormalities-A Systematic-Review. PLoS One 2013; 8:e66803. [PMID: 23826139 PMCID: PMC3694970 DOI: 10.1371/journal.pone.0066803] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Accepted: 05/15/2013] [Indexed: 11/18/2022] Open
Abstract
Countless studies have demonstrated that many emergency-room visits and hospital admissions are drug-related and that a significant proportion of these drug-related visits (DRVs) are preventable. It has not been previously studied which DRVs could be prevented through enhanced monitoring of therapy. The objective of the study was to determine the incidence of DRVs attributed to laboratory or physiologic abnormalities. Three authors independently performed comprehensive searches in relevant health care databases using pre-determined search terms. Articles discussing DRV associated with poisoning, substance abuse, or studied among existing in-patient populations were excluded. Study country, year, sample, design, duration, DRV identification method, proportion of DRVs associated with laboratory or physiologic abnormalities and associated medications were extracted. The three authors independently assessed selected relevant articles according to the Strengthening the reporting of observational studies in epidemiology (STROBE) as applicable according to the studies' methodology. The initial literature search yielded a total of 1,524 articles of which 30 articles meeting inclusion criteria and reporting sufficient laboratory or physiologic data were included in the overall analysis. Half employed prospective methodologies, which included both chart review and patient interview; however, the overwhelming majority of identified studies assessed only adverse drug reactions (ADRs) as a drug-related cause for DRV. The mean (range) prevalence of DRVs found in all studies was 15.4% (0.44%–66.7%) of which an association with laboratory or physiologic abnormalities could be attributed to a mean (range) of 29.4% (4.3%–78.1%) of cases. Most laboratory-associated DRVs could be linked to immunosuppressant, antineoplastic, anticoagulant and diabetes therapy, while physiologic-associated DRVs were attributed to cardiovascular therapies and NSAIDs. Significant proportions of laboratory and physiologic abnormalities contribute to DRVs and are consistently linked to specific drugs. These therapies are potential targets for enhanced medication monitoring initiatives to proactively avert potential DRVs.
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Affiliation(s)
- Kerry Wilbur
- College of Pharmacy, Qatar University, Doha, Qatar
- * E-mail:
| | - Huda Hazi
- College of Pharmacy, Qatar University, Doha, Qatar
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16
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Fischer SH, Field TS, Gagne SJ, Mazor KM, Preusse P, Reed G, Peterson D, Gurwitz JH, Tjia J. Patient completion of laboratory tests to monitor medication therapy: a mixed-methods study. J Gen Intern Med 2013; 28:513-21. [PMID: 23229907 PMCID: PMC3599033 DOI: 10.1007/s11606-012-2271-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 10/11/2012] [Accepted: 10/23/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Little is known about the contribution of patient behavior to incomplete laboratory monitoring, and the reasons for patient non-completion of ordered laboratory tests remain unclear. OBJECTIVE To describe factors, including patient-reported reasons, associated with non-completion of ordered laboratory tests. DESIGN Mixed-Methods study including a quantitative assessment of the frequency of patient completion of ordered monitoring tests combined with qualitative, semi-structured, patient interviews. PARTICIPANTS Quantitative assessment included patients 18 years or older from a large multispecialty group practice, who were prescribed a medication requiring monitoring. Qualitative interviews included a subset of show and no-show patients prescribed a cardiovascular, anticonvulsant, or thyroid replacement medication. MAIN MEASURES Proportion of recommended monitoring tests for each medication not completed, factors associated with patient non-completion, and patient-reported reasons for non-completion. KEY RESULTS Of 27,802 patients who were prescribed one of 34 medications, patient non-completion of ordered tests varied (range: 0-24 %, by drug-test pair). Factors associated with higher odds of test non-completion included: younger patient age (< 40 years vs. ≥ 80 years, adjusted odds ratio [AOR] 1.52, 95 % confidence interval [95 % CI] 1.27-1.83); lower medication burden (one medication vs. more than one drug, AOR for non-completion 1.26, 95 % CI 1.15-1.37), and lower visit frequency (0-5 visits/year vs. ≥ 19 visits/year, AOR 1.41, 95 % CI 1.25 to 1.59). Drug-test pairs with black box warning status were associated with greater odds of non-completion, compared to drugs without a black box warning or other guideline for testing (AOR 1.91, 95 % CI 1.66-2.19). Qualitative interviews, with 16 no-show and seven show patients, identified forgetting as the main cause of non-completion of ordered tests. CONCLUSIONS Patient non-completion contributed to missed opportunities to monitor medications, and was associated with younger patient age, lower medication burden and black box warning status. Interventions to improve laboratory monitoring should target patients as well as physicians.
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Affiliation(s)
- Shira H Fischer
- Beth Israel Deaconess Medical Center, Division of Clinical Informatics, 1330 Beacon St., Suite 400, Brookline, MA 02446, USA.
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17
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Delayed antibiotic prescribing and associated antibiotic consumption in adults with acute cough. Br J Gen Pract 2012; 62:e639-46. [PMID: 22947585 PMCID: PMC3426603 DOI: 10.3399/bjgp12x653561] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Delayed antibiotic prescribing is promoted as a strategy to reduce antibiotic consumption, but its use and its effect on antibiotic consumption in routine care is poorly described. AIM To quantify delayed antibiotic prescribing in adults presenting in primary care with acute cough/lower respiratory tract infection (LRTI), duration of advised delay, consumption of delayed antibiotics, and factors associated with consumption. DESIGN AND SETTING Prospective observational cohort in general practices in 14 primary care networks in 13 European countries. METHOD GPs recorded clinical features and antibiotic prescribing for adults presenting with an acute infective illness with cough as the dominant symptom. Patients recorded their consumption of antibiotics from any source during the 28-day follow up. RESULTS Two hundred and ten (6.3%) of 3368 patients with usable consultation data were prescribed delayed antibiotics. The median recommended delay period was 3 days. Seventy-five (44.4%) of the 169 with consumption data consumed the antibiotic course and a further 18 (10.7%) took another antibiotic during the study period. 50 (29.6%) started their delayed course on the day of prescription. Clinician diagnosis of upper respiratory tract/viral infection and clinician's perception of patient's wanting antibiotics were associated with less consumption of the delayed prescription. Patient's wanting antibiotics was associated with greater consumption. CONCLUSION Delayed antibiotic prescribing was used infrequently for adults presenting in general practice with acute cough/LRTI. When used, the effect on antibiotic consumption was less than found in most trials. There are opportunities for standardising the intervention and promoting wider uptake.
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18
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Bundy DG, Marsteller JA, Wu AW, Engineer LD, Berenholtz SM, Caughey AH, Silver D, Tian J, Thompson RE, Miller MR, Lehmann CU. Electronic health record-based monitoring of primary care patients at risk of medication-related toxicity. Jt Comm J Qual Patient Saf 2012; 38:216-23. [PMID: 22649861 DOI: 10.1016/s1553-7250(12)38027-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Timely laboratory monitoring may reduce the potential harm associated with chronic medication use. A study was conducted to determine the proportion of patients receiving National Committee for Quality Assurance (NCQA)-recommended laboratory medication monitoring in a primary care setting and to assess the effect of electronic health record (EHR)-derived, paper-based, provider-specific feedback bulletins on subsequent patient receipt of medication monitoring. METHODS In a single-arm, pre-post intervention in two federally qualified community health centers in Baltimore, patients targeted were adults prescribed at least 6 months (in the preceding year) for at least one index medication (digoxin, statins, diuretics, angiotensin-converting enzyme inhibitors/ angiotensin II-receptor blockers) in a 12-month period (August 2008-July 2009). RESULTS Among the 2,013 patients for whom medication monitoring was recommended, 42% were overdue for monitoring at some point during the study. As the number of index medications the patient was prescribed increased, the likelihood of ever being overdue for monitoring decreased. Being listed on the provider-specific monitoring bulletin doubled the odds of a patient receiving recommended laboratory monitoring before the next measurement period (1-2 months). Limiting the intervention to the most overdue patients, however, mitigated its overall impact. CONCLUSIONS Recommended laboratory monitoring of chronic medications appears to be inconsistent in primary care, resulting in potential harm for individuals at risk for medication-related toxicity. EHRs may be an important component of systems designed to improve medication monitoring, but multimodal interventions will likely be needed to achieve high reliability.
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Affiliation(s)
- David G Bundy
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, USA.
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19
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McKibbon KA, Lokker C, Handler SM, Dolovich LR, Holbrook AM, O'Reilly D, Tamblyn R, Hemens BJ, Basu R, Troyan S, Roshanov PS. The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials. J Am Med Inform Assoc 2012; 19:22-30. [PMID: 21852412 PMCID: PMC3240758 DOI: 10.1136/amiajnl-2011-000304] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 07/11/2011] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The US Agency for Healthcare Research and Quality funded an evidence report to address seven questions on multiple aspects of the effectiveness of medication management information technology (MMIT) and its components (prescribing, order communication, dispensing, administering, and monitoring). MATERIALS AND METHODS Medline and 11 other databases without language or date limitations to mid-2010. Randomized controlled trials (RCTs) assessing integrated MMIT were selected by two independent reviewers. Reviewers assessed study quality and extracted data. Senior staff checked accuracy. RESULTS Most of the 87 RCTs focused on clinical decision support and computerized provider order entry systems, were performed in hospitals and clinics, included primarily physicians and sometimes nurses but not other health professionals, and studied process changes related to prescribing and monitoring medication. Processes of care improved for prescribing and monitoring mostly in hospital settings, but the few studies measuring clinical outcomes showed small or no improvements. Studies were performed most frequently in the USA (n=63), Europe (n=16), and Canada (n=6). DISCUSSION Many studies had limited description of systems, installations, institutions, and targets of the intervention. Problems with methods and analyses were also found. Few studies addressed order communication, dispensing, or administering, non-physician prescribers or pharmacists and their MMIT tools, or patients and caregivers. Other study methods are also needed to completely understand the effects of MMIT. CONCLUSIONS Almost half of MMIT interventions improved the process of care, but few studies measured clinical outcomes. This large body of literature, although instructive, is not uniformly distributed across settings, people, medication phases, or outcomes.
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Affiliation(s)
- K Ann McKibbon
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
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Park MY, Yoon D, Lee K, Kang SY, Park I, Lee SH, Kim W, Kam HJ, Lee YH, Kim JH, Park RW. A novel algorithm for detection of adverse drug reaction signals using a hospital electronic medical record database. Pharmacoepidemiol Drug Saf 2011; 20:598-607. [PMID: 21472818 DOI: 10.1002/pds.2139] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE Quantitative analytic methods are being increasingly used in postmarketing surveillance. However, currently existing methods are limited to spontaneous reporting data and are inapplicable to hospital electronic medical record (EMR) data. The principal objectives of this study were to propose a novel algorithm for detecting the signals of adverse drug reactions using EMR data focused on laboratory abnormalities after treatment with medication, and to evaluate the potential use of this method as a signal detection tool. METHODS We developed an algorithm referred to as the Comparison on Extreme Laboratory Test results, which takes an extreme representative value pair according to the types of laboratory abnormalities on the basis of each patient's medication point. We used 10 years' EMR data from a tertiary teaching hospital, containing 32,033,710 prescriptions and 115,241,147 laboratory tests for 530,829 individual patients. Ten drugs were selected randomly for analysis, and 51 laboratory values were matched. The sensitivity, specificity, positive predictive value, and negative predictive value of the algorithm were calculated. RESULTS The mean number of detected laboratory abnormality signals for each drug was 27 (±7.5). The sensitivity, specificity, positive predictive value, and negative predictive value of the algorithm were 64-100%, 22-76%, 22-75%, and 54-100%, respectively. CONCLUSION The results of this study demonstrated that the Comparison on Extreme Laboratory Test results algorithm described herein was extremely effective in detecting the signals characteristic of adverse drug reactions. This algorithm can be regarded as a useful signal detection tool, which can be routinely applied to EMR data.
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Affiliation(s)
- Man Young Park
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Korea.
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21
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Tjia J, Fischer SH, Raebel MA, Peterson D, Zhao Y, Gagne SJ, Gurwitz JH, Field TS. Baseline and follow-up laboratory monitoring of cardiovascular medications. Ann Pharmacother 2011; 45:1077-84. [PMID: 21852593 DOI: 10.1345/aph.1q158] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Laboratory monitoring of medications is typically used to establish safety prior to drug initiation and to detect drug-related injury following initiation. It is unclear whether black box warnings (BBWs) as well as evidence- and consensus-based clinical guidelines increase the likelihood of appropriate monitoring. OBJECTIVE To determine the proportion of patients newly initiated on selected cardiovascular medications with baseline assessment and follow-up laboratory monitoring and compare the prevalence of laboratory testing for drugs with and without BBWs and guidelines. METHODS This cross-sectional study included patients aged 18 years or older from a large multispecialty group practice who were prescribed a cardiovascular medication (angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, amiodarone, digoxin, lipid-lowering agents, diuretics, and potassium supplements) between January 1 and July 31, 2008. The primary outcome measure was laboratory test ordering for baseline assessment and follow-up monitoring of newly initiated cardiovascular medications. RESULTS The number of new users of each study drug ranged from 49 to 1757 during the study period. Baseline laboratory test ordering across study drugs ranged from 37.4% to 94.8%, and follow-up laboratory test ordering ranged from 20.0% to 77.2%. Laboratory tests for drugs with baseline laboratory assessment recommendations in BBWs were more commonly ordered than for drugs without BBWs (86.4% vs 78.0%, p < 0.001). Drugs with follow-up monitoring recommendations in clinical guidelines had a lower prevalence of monitoring (33.1% vs 50.7%, p < 0.001). CONCLUSIONS Baseline assessment of cardiovascular medication monitoring is variable. Quality measurement of adherence to BBW recommendations may improve monitoring.
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Affiliation(s)
- Jennifer Tjia
- Department of Medicine, Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
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22
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Roshanov PS, You JJ, Dhaliwal J, Koff D, Mackay JA, Weise-Kelly L, Navarro T, Wilczynski NL, Haynes RB. Can computerized clinical decision support systems improve practitioners' diagnostic test ordering behavior? A decision-maker-researcher partnership systematic review. Implement Sci 2011; 6:88. [PMID: 21824382 PMCID: PMC3174115 DOI: 10.1186/1748-5908-6-88] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 08/03/2011] [Indexed: 11/24/2022] Open
Abstract
Background Underuse and overuse of diagnostic tests have important implications for health outcomes and costs. Decision support technology purports to optimize the use of diagnostic tests in clinical practice. The objective of this review was to assess whether computerized clinical decision support systems (CCDSSs) are effective at improving ordering of tests for diagnosis, monitoring of disease, or monitoring of treatment. The outcome of interest was effect on the diagnostic test-ordering behavior of practitioners. Methods We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews database, Inspec, and reference lists for eligible articles published up to January 2010. We included randomized controlled trials comparing the use of CCDSSs to usual practice or non-CCDSS controls in clinical care settings. Trials were eligible if at least one component of the CCDSS gave suggestions for ordering or performing a diagnostic procedure. We considered studies 'positive' if they showed a statistically significant improvement in at least 50% of test ordering outcomes. Results Thirty-five studies were identified, with significantly higher methodological quality in those published after the year 2000 (p = 0.002). Thirty-three trials reported evaluable data on diagnostic test ordering, and 55% (18/33) of CCDSSs improved testing behavior overall, including 83% (5/6) for diagnosis, 63% (5/8) for treatment monitoring, 35% (6/17) for disease monitoring, and 100% (3/3) for other purposes. Four of the systems explicitly attempted to reduce test ordering rates and all succeeded. Factors of particular interest to decision makers include costs, user satisfaction, and impact on workflow but were rarely investigated or reported. Conclusions Some CCDSSs can modify practitioner test-ordering behavior. To better inform development and implementation efforts, studies should describe in more detail potentially important factors such as system design, user interface, local context, implementation strategy, and evaluate impact on user satisfaction and workflow, costs, and unintended consequences.
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Affiliation(s)
- Pavel S Roshanov
- Health Research Methodology Program, McMaster University, 1280 Main Street West, Hamilton, ON, Canada
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Hemens BJ, Holbrook A, Tonkin M, Mackay JA, Weise-Kelly L, Navarro T, Wilczynski NL, Haynes RB. Computerized clinical decision support systems for drug prescribing and management: a decision-maker-researcher partnership systematic review. Implement Sci 2011; 6:89. [PMID: 21824383 PMCID: PMC3179735 DOI: 10.1186/1748-5908-6-89] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 08/03/2011] [Indexed: 02/02/2023] Open
Abstract
Background Computerized clinical decision support systems (CCDSSs) for drug therapy management are designed to promote safe and effective medication use. Evidence documenting the effectiveness of CCDSSs for improving drug therapy is necessary for informed adoption decisions. The objective of this review was to systematically review randomized controlled trials assessing the effects of CCDSSs for drug therapy management on process of care and patient outcomes. We also sought to identify system and study characteristics that predicted benefit. Methods We conducted a decision-maker-researcher partnership systematic review. We updated our earlier reviews (1998, 2005) by searching MEDLINE, EMBASE, EBM Reviews, Inspec, and other databases, and consulting reference lists through January 2010. Authors of 82% of included studies confirmed or supplemented extracted data. We included only randomized controlled trials that evaluated the effect on process of care or patient outcomes of a CCDSS for drug therapy management compared to care provided without a CCDSS. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive. Results Sixty-five studies met our inclusion criteria, including 41 new studies since our previous review. Methodological quality was generally high and unchanged with time. CCDSSs improved process of care performance in 37 of the 59 studies assessing this type of outcome (64%, 57% of all studies). Twenty-nine trials assessed patient outcomes, of which six trials (21%, 9% of all trials) reported improvements. Conclusions CCDSSs inconsistently improved process of care measures and seldomly improved patient outcomes. Lack of clear patient benefit and lack of data on harms and costs preclude a recommendation to adopt CCDSSs for drug therapy management.
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Affiliation(s)
- Brian J Hemens
- Health Information Research Unit, Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, Canada
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Steinman MA, Handler SM, Gurwitz JH, Schiff GD, Covinsky KE. Beyond the prescription: medication monitoring and adverse drug events in older adults. J Am Geriatr Soc 2011; 59:1513-20. [PMID: 21797831 DOI: 10.1111/j.1532-5415.2011.03500.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Whether a person will suffer harm from a medication or how severe that harm will be is difficult to predict precisely. As a result, many adverse drug events (ADEs) occur in patients in whom it was reasonable to believe that the drug's benefits exceeded its risks. Improving safety and reducing the burden of ADEs in older adults requires addressing this uncertainty by not only focusing on the appropriateness of the initial prescribing decision, but also by detecting and mitigating adverse events once they have started to occur. Such enhanced monitoring of signs, symptoms, and laboratory parameters can determine whether an adverse event has only mild and short-term consequences or major long-term effects on morbidity and mortality. Although current medication monitoring practices are often suboptimal, several strategies can be leveraged to improve the quality and outcomes of monitoring. These strategies include using health information technology to link pharmacy and laboratory data, prospective delineation of risk, and patient outreach and activation, all within a framework of team-based approaches to patient management. Although many of these strategies are theoretically possible now, they are poorly used and will be difficult to implement without a significant restructuring of medical practice. An enhanced focus on medication monitoring will also require a new conceptual framework to re-engineer the prescribing process. With this approach, prescribing quality does not hinge on static attributes of the initial prescribing decision but entails a dynamic process in which the benefits and harms of drugs are actively monitored, managed, and reassessed over time.
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Affiliation(s)
- Michael A Steinman
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA.
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25
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Smith DH, Raebel MA, Chan KA, Johnson ES, Petrik AF, Weiss JR, Yang X, Feldstein A. An economic evaluation of a laboratory monitoring program for renin-angiotensin system agents. Med Decis Making 2011; 31:315-24. [PMID: 21393563 DOI: 10.1177/0272989x10379918] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The efficiency of patient safety interventions is not well studied, especially laboratory monitoring for drug therapy. More than one-third of preventable adverse drug events are associated with inadequate monitoring. Current knowledge of decreasing adverse drug events through expanded monitoring programs is lacking. DESIGN The authors focused on a laboratory monitoring program (above usual practice) of renin-angiotensin system (RAS) agents to prevent adverse events of hyperkalemia and acute renal failure. They used a probabilistic decision model to estimate cost savings and cost effectiveness (at $30,000 and $10,000 per quality-adjusted life-year (QALY)). Costs included the monitoring program, and offsets from reduced care in 3 populations (overall, chronic kidney disease [CKD], and diabetes). MAIN RESULTS Adverse events were most common in those with CKD. Intervening on all new users or the subset with diabetes was almost never expected to be cost saving (probability <1%). But a monitoring program restricted to patients with CKD was expected to be cost saving (probability = 95%). A strategy that intervened on all patients, or those with diabetes, was never cost effective, (probability <1%). But intervening on patients with CKD was estimated to be cost effective (at either cost-effectiveness threshold) at least 95% of the time in the base case. CONCLUSIONS The authors' findings illustrate that for laboratory monitoring to be cost effective, the patient population must be at high enough risk of adverse events. Further inquiry into the willingness to pay for patient safety interventions is needed.
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Affiliation(s)
- David H Smith
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR (DHS, ESJ, AFP, JRW, XY, AF),HMO Research Network Center for Education and Research on Therapeutics, Boston, Massachusetts (HMO CERT)
(DHS, MAR, KAC, ESJ, AFP, XY, AF)
| | - Marsha A Raebel
- Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado (MAR),HMO Research Network Center for Education and Research on Therapeutics, Boston, Massachusetts (HMO CERT)
(DHS, MAR, KAC, ESJ, AFP, XY, AF)
| | - K Arnold Chan
- Harvard School of Public Health (KAC),HMO Research Network Center for Education and Research on Therapeutics, Boston, Massachusetts (HMO CERT)
(DHS, MAR, KAC, ESJ, AFP, XY, AF),i3 Drug Safety, Boston, Massachusetts (KAC)
| | - Eric S Johnson
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR (DHS, ESJ, AFP, JRW, XY, AF),HMO Research Network Center for Education and Research on Therapeutics, Boston, Massachusetts (HMO CERT)
(DHS, MAR, KAC, ESJ, AFP, XY, AF)
| | - Amanda F Petrik
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR (DHS, ESJ, AFP, JRW, XY, AF),HMO Research Network Center for Education and Research on Therapeutics, Boston, Massachusetts (HMO CERT)
(DHS, MAR, KAC, ESJ, AFP, XY, AF)
| | - Jessica R Weiss
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR (DHS, ESJ, AFP, JRW, XY, AF),Division of Nephrology and Hypertension, Oregon Health and Science University, Portland, Oregon (JRW)
| | - Xiuhai Yang
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR (DHS, ESJ, AFP, JRW, XY, AF),HMO Research Network Center for Education and Research on Therapeutics, Boston, Massachusetts (HMO CERT)
(DHS, MAR, KAC, ESJ, AFP, XY, AF)
| | - Adrianne Feldstein
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR (DHS, ESJ, AFP, JRW, XY, AF),HMO Research Network Center for Education and Research on Therapeutics, Boston, Massachusetts (HMO CERT)
(DHS, MAR, KAC, ESJ, AFP, XY, AF)
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Bhardwaja B, Carroll NM, Raebel MA, Chester EA, Korner EJ, Rocho BE, Brand DW, Magid DJ. Improving Prescribing Safety in Patients with Renal Insufficiency in the Ambulatory Setting: The Drug Renal Alert Pharmacy (DRAP) Program. Pharmacotherapy 2011; 31:346-56. [DOI: 10.1592/phco.31.4.346] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Fischer SH, Tjia J, Field TS. Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review. J Am Med Inform Assoc 2011; 17:631-6. [PMID: 20962124 DOI: 10.1136/jamia.2009.000794] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Medication errors are a major source of morbidity and mortality. Inadequate laboratory monitoring of high-risk medications after initial prescription is a medical error that contributes to preventable adverse drug events. Health information technology (HIT)-based clinical decision support may improve patient safety by improving the laboratory monitoring of high-risk medications, but the effectiveness of such interventions is unclear. Therefore, the authors conducted a systematic review to identify studies that evaluate the independent effect of HIT interventions on improving laboratory monitoring for high-risk medications in the ambulatory setting using a Medline search from January 1, 1980 through January 1, 2009 and a manual review of relevant bibliographies. All anticoagulation monitoring studies were excluded. Eight articles met the inclusion criteria, including six randomized controlled trials and two pre-post intervention studies. Six of the studies were conducted in two large, integrated healthcare delivery systems in the USA. Overall, five of the eight studies reported statistically significant, but small, improvements in laboratory monitoring; only half of the randomized controlled trials reported statistically significant improvements. Studies that found no improvement were more likely to have used analytic strategies that addressed clustering and confounding. Whether HIT improves laboratory monitoring of certain high-risk medications for ambulatory patients remains unclear, and further research is needed to clarify this important question.
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Affiliation(s)
- Shira H Fischer
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01605, USA.
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28
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Raebel MA. Hyperkalemia Associated with Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers. Cardiovasc Ther 2011; 30:e156-66. [DOI: 10.1111/j.1755-5922.2010.00258.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Medves J, Godfrey C, Turner C, Paterson M, Harrison M, MacKenzie L, Durando P. Systematic review of practice guideline dissemination and implementation strategies for healthcare teams and team-based practice. INT J EVID-BASED HEA 2010; 8:79-89. [PMID: 20923511 DOI: 10.1111/j.1744-1609.2010.00166.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To synthesis the literature relevant to guideline dissemination and implementation strategies for healthcare teams and team-based practice. METHODS Systematic approach utilising Joanna Briggs Institute methods. Two reviewers screened all articles and where there was disagreement, a third reviewer determined inclusion. RESULTS Initial search revealed 12,083 of which 88 met the inclusion criteria. Ten dissemination and implementation strategies identified with distribution of educational materials the most common. Studies were assessed for patient or practitioner outcomes and changes in practice, knowledge and economic outcomes. A descriptive analysis revealed multiple approaches using teams of healthcare providers were reported to have statistically significant results in knowledge, practice and/or outcomes for 72.7% of the studies. CONCLUSION Team-based care using practice guidelines locally adapted can affect positively patient and provider outcomes.
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Affiliation(s)
- Jennifer Medves
- School of Nursing, Queen's University, Kingston, Ontario, Canada.
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30
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Goldman RE, Soran CS, Hayward GL, Simon SR. Doctors' perceptions of laboratory monitoring in office practice. J Eval Clin Pract 2010; 16:1136-41. [PMID: 21176004 DOI: 10.1111/j.1365-2753.2009.01282.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Laboratory monitoring has been increasingly recognized as an important area for improving patient safety in ambulatory care. Little is known about doctors' attitudes towards laboratory monitoring and potential ways to improve it. METHODS Six focus groups and one individual interview with 20 primary care doctors and nine specialists from three Massachusetts communities. RESULTS Participants viewed laboratory monitoring as a critical, time-consuming task integral to their practice of medicine. Most believed they commit few laboratory monitoring errors and were surprised at the error rates reported in the literature. They listed various barriers to monitoring, including not knowing which doctor was responsible for ensuring the completion of laboratory monitoring, uncertainty regarding the necessity of monitoring, lack of alerts/reminders and patient non-adherence with recommended monitoring. The primary facilitator of monitoring was ordering laboratory tests while the patient is in the office. Primary care doctors felt more strongly than specialists that computerized alerts could improve laboratory monitoring. Participants wanted to individualize alerts for their practices and warned that alerts must not interrupt work flow or require too many clicks. CONCLUSIONS Doctors in community practice recognized the potential of computerized alerts to enhance their monitoring protocols for some medications. They viewed patient non-adherence as a barrier to optimal monitoring. Interventions to improve laboratory monitoring should address doctor workflow issues, in addition to patients' awareness of the importance of fulfilling recommended therapeutic monitoring to prevent adverse drug events.
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Affiliation(s)
- Roberta E Goldman
- Center for Primary Care and Prevention, The Warren Alpert Medical School of Brown University and Memorial Hospital of Rhode Island, Pawtucket, RI, USA
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Nkansah N, Mostovetsky O, Yu C, Chheng T, Beney J, Bond CM, Bero L. Effect of outpatient pharmacists' non-dispensing roles on patient outcomes and prescribing patterns. Cochrane Database Syst Rev 2010; 2010:CD000336. [PMID: 20614422 PMCID: PMC7087444 DOI: 10.1002/14651858.cd000336.pub2] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The roles of pharmacists in patient care have expanded from the traditional tasks of dispensing medications and providing basic medication counseling to working with other health professionals and the public. Multiple reviews have evaluated the impact of pharmacist-provided patient care on health-related outcomes. Prior reviews have primarily focused on in-patient settings. This systematic review focuses on services provided by outpatient pharmacists in community or ambulatory care settings. This is an update of the Cochrane review published in 2000. OBJECTIVES To examine the effect of outpatient pharmacists' non-dispensing roles on patient and health professional outcomes. SEARCH STRATEGY This review has been split into two phases. For Phase I, we searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (January 1966 through March 2007). For Phase II, we searched MEDLINE/EMBASE (January 1966 through March 2008). The Phase I results are reported in this review; Phase II will be summarized in the next update. SELECTION CRITERIA Randomized controlled trials comparing 1. Pharmacist services targeted at patients versus services delivered by other health professionals; 2. Pharmacist services targeted at patients versus the delivery of no comparable service; 3. Pharmacist services targeted at health professionals versus services delivered by other health professionals; 4. Pharmacist services targeted at health professionals versus the delivery of no comparable service. DATA COLLECTION AND ANALYSIS Two authors independently reviewed studies for inclusion, extracted data, and assessed risk of bias of included studies. MAIN RESULTS Forty-three studies were included; 36 studies were pharmacist interventions targeting patients and seven studies were pharmacist interventions targeting health professionals. For comparison 1, the only included study showed a significant improvement in systolic blood pressure for patients receiving medication management from a pharmacist compared to usual care from a physician. For comparison 2, in the five studies evaluating process of care outcomes, pharmacist services reduced the incidence of therapeutic duplication and decreased the total number of medications prescribed. Twenty-nine of 36 studies reported clinical and humanistic outcomes. Pharmacist interventions resulted in improvement in most clinical outcomes, although these improvements were not always statistically significant. Eight studies reported patient quality of life outcomes; three studies showed improvement in at least three subdomains. For comparison 3, no studies were identified meeting the inclusion criteria. For comparison 4, two of seven studies demonstrated a clear statistically significant improvement in prescribing patterns. AUTHORS' CONCLUSIONS Only one included study compared pharmacist services with other health professional services, hence we are unable to draw conclusions regarding comparisons 1 and 3. Most included studies supported the role of pharmacists in medication/therapeutic management, patient counseling, and providing health professional education with the goal of improving patient process of care and clinical outcomes, and of educational outreach visits on physician prescribing patterns. There was great heterogeneity in the types of outcomes measured across all studies. Therefore a standardized approach to measure and report clinical, humanistic, and process outcomes for future randomized controlled studies evaluating the impact of outpatient pharmacists is needed. Heterogeneity in study comparison groups, outcomes, and measures makes it challenging to make generalised statements regarding the impact of pharmacists in specific settings, disease states, and patient populations.
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Affiliation(s)
- Nancy Nkansah
- University of California, San FranciscoClinical Pharmacy155 North Fresno Street, Suite 224FresnoCaliforniaUSA93701
| | - Olga Mostovetsky
- University of California, San FranciscoClinical PharmacySuite 420, Box 06133333 California StreetSan FranciscoCaliforniaUSA94118
| | - Christine Yu
- University of California, San FranciscoClinical PharmacySuite 420, Box 06133333 California StreetSan FranciscoCaliforniaUSA94118
| | - Tami Chheng
- University of California, San FranciscoClinical PharmacySuite 420, Box 06133333 California StreetSan FranciscoCaliforniaUSA94118
| | - Johnny Beney
- Institut Central des Hopitaux ValaisansPharmacyGrand Champsec 86CP 736SionSwitzerland1951
| | - Christine M Bond
- University of AberdeenDepartment of General Practice and Primary CareForesterhill Health CentreWestburn RoadAberdeenUKAB25 2AY
| | - Lisa Bero
- University of California San FranciscoProfessor of Clinical Pharmacy & Health PolicySuite 420, Box 06133333 California StreetSan FranciscoCaliforniaUSA94143‐0613
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Medves J, Godfrey C, Turner C, Paterson M, Harrison M, MacKenzie L, Durando P. Systematic review of practice guideline dissemination and implementation strategies for healthcare teams and team-based practice. INT J EVID-BASED HEA 2010. [DOI: 10.1111/j.1479-6988.2010.00166.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Robertson J, Walkom E, Pearson S, Hains I, Williamson M, Newby D. The impact of pharmacy computerised clinical decision support on prescribing, clinical and patient outcomes: a systematic review of the literature. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2010. [DOI: 10.1211/ijpp.18.02.0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Jane Robertson
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia
| | - Emily Walkom
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia
| | - Sallie‐Anne Pearson
- UNSW Cancer Research Centre, University of New South Wales and Prince of Wales Clinical School, Sydney
| | - Isla Hains
- UNSW Cancer Research Centre, University of New South Wales and Prince of Wales Clinical School, Sydney
| | | | - David Newby
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia
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Hayward GL, Parnes AJ, Simon SR. Using health information technology to improve drug monitoring: a systematic review. Pharmacoepidemiol Drug Saf 2010; 18:1232-7. [PMID: 19725020 DOI: 10.1002/pds.1831] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE To conduct a systematic review of current evidence regarding the use of health information technology (HIT) interventions to improve drug monitoring in ambulatory care. METHODS We searched PubMed, CINAHL, the Cochrane Library, and other computerized databases from 1 January 1998 to 30 June 2008 using the key words "drug monitoring," "medical records systems, computerized," "ambulatory care," and "outpatients." We manually reviewed reference lists of articles identified through computer searches and asked experts in the field to review our search strategy and results for completeness. RESULTS Seven relevant studies were identified. Four of these studies assessed real-time interventions that used alerts to physicians at the time of medication ordering to ensure adequate monitoring, only one of which showed an improvement in monitoring. Of three studies using HIT outside the physician encounter, two suggested some improvement in monitoring rates. Methodological limitations were apparent in all studies identified. CONCLUSIONS Few studies have assessed the effectiveness of HIT interventions to improve drug monitoring, and among them, there is no clear consensus regarding the most consistently effective approaches to reducing drug monitoring errors. There is a clear need for well designed randomized trials to evaluate possible interventions to reduce drug monitoring errors. Such studies should incorporate health outcomes and detailed cost analyses to further characterize the feasibility of successful interventions.
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Affiliation(s)
- Geoffrey L Hayward
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Damiani G, Pinnarelli L, Colosimo SC, Almiento R, Sicuro L, Galasso R, Sommella L, Ricciardi W. The effectiveness of computerized clinical guidelines in the process of care: a systematic review. BMC Health Serv Res 2010; 10:2. [PMID: 20047686 PMCID: PMC2837004 DOI: 10.1186/1472-6963-10-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Accepted: 01/04/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical practice guidelines have been developed aiming to improve the quality of care. The implementation of the computerized clinical guidelines (CCG) has been supported by the development of computerized clinical decision support systems.This systematic review assesses the impact of CCG on the process of care compared with non-computerized clinical guidelines. METHODS Specific features of CCG were studied through an extensive search of scientific literature, querying electronic databases: Pubmed/Medline, Embase and Cochrane Controlled Trials Register. A multivariable logistic regression was carried out to evaluate the association of CCG's features with positive effect on the process of care. RESULTS Forty-five articles were selected. The logistic model showed that Automatic provision of recommendation in electronic version as part of clinician workflow (Odds Ratio [OR]= 17.5; 95% confidence interval [CI]: 1.6-193.7) and Publication Year (OR = 6.7; 95%CI: 1.3-34.3) were statistically significant predictors. CONCLUSIONS From the research that has been carried out, we can conclude that after implementation of CCG significant improvements in process of care are shown. Our findings also suggest clinicians, managers and other health care decision makers which features of CCG might improve the structure of computerized system.
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Affiliation(s)
- Gianfranco Damiani
- Department of Public Health-Università Cattolica Sacro Cuore-Rome, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Luigi Pinnarelli
- San Filippo Neri-Hospital Trust-Rome, Italy, Piazza di Santa Maria della Pietà 5, 00135, Rome, Italy
| | - Simona C Colosimo
- Department of Public Health-Università Cattolica Sacro Cuore-Rome, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Roberta Almiento
- Department of Public Health-Università Cattolica Sacro Cuore-Rome, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Lorella Sicuro
- Department of Public Health-Università Cattolica Sacro Cuore-Rome, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Rocco Galasso
- Oncological Referral Center of Basilicata (IRCCS CROB), Via Padre Pio 1, 85028, Rionero in Vulture, Potenza, Italy
| | - Lorenzo Sommella
- San Filippo Neri-Hospital Trust-Rome, Italy, Piazza di Santa Maria della Pietà 5, 00135, Rome, Italy
| | - Walter Ricciardi
- Department of Public Health-Università Cattolica Sacro Cuore-Rome, Largo Francesco Vito 1, 00168, Rome, Italy
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Medves J, Godfrey C, Turner C, Paterson M, Harrison M, MacKenzie L, Durando P. Practice Guideline Dissemination and Implementation Strategies for Healthcare Teams and Team-Based Practice: a systematic review. JBI LIBRARY OF SYSTEMATIC REVIEWS 2009; 7:450-491. [PMID: 27819946 DOI: 10.11124/01938924-200907120-00001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES The objective of this systematic review is to describe and identify the effectiveness of different practice guideline implementation strategies on team-based practice and/or patient outcomes. METHODS A systematic review was conducted, using a comprehensive, reproducible search strategy that revealed 88 studies that met the inclusion criteria. RESULTS A descriptive analysis revealed multiple approaches using teams of health care providers with 72.7% of the studies reporting statistically significant results in knowledge, practice and/or outcomes. Of 10 dissemination strategies the most effective were reminders, and audit and feedback. The most popular strategy was education meetings. A secondary analysis revealed different populations with chronic or complex disorders where a team approach was effective in practice guideline dissemination and implementation. CONCLUSIONS Many of the studies provided caveats to explain how or why the strategies did or did not demonstrate improvements. Overall, authors described complex health care requiring increasingly complex approaches to ensure evidence based guidelines were utilised in practice, including using multiple dissemination and implementation strategies. The review has provided evidence that a multi-pronged approach to dissemination and implementation of practice guidelines will assist in gaining significant improvements in change in knowledge, practice and patient outcomes.
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Affiliation(s)
- Jennifer Medves
- Queen's Joanna Briggs Collaboration: a Collaborating Centre of the Joanna Briggs Institute, School of Nursing, Queen's University, Kingston, Ontario, Canada
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Lo HG, Matheny ME, Seger DL, Bates DW, Gandhi TK. Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care. J Am Med Inform Assoc 2008; 16:66-71. [PMID: 18952945 DOI: 10.1197/jamia.m2687] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Interruptive alerts within electronic applications can cause "alert fatigue" if they fire too frequently or are clinically reasonable only some of the time. We assessed the impact of non-interruptive, real-time medication laboratory alerts on provider lab test ordering. DESIGN We enrolled 22 outpatient practices into a prospective, randomized, controlled trial. Clinics either used the existing system or received on-screen recommendations for baseline laboratory tests when prescribing new medications. Since the warnings were non-interruptive, providers did not have to act upon or acknowledge the notification to complete a medication request. MEASUREMENTS Data were collected each time providers performed suggested laboratory testing within 14 days of a new prescription order. Findings were adjusted for patient and provider characteristics as well as patient clustering within clinics. RESULTS Among 12 clinics with 191 providers in the control group and 10 clinics with 175 providers in the intervention group, there were 3673 total events where baseline lab tests would have been advised: 1988 events in the control group and 1685 in the intervention group. In the control group, baseline labs were requested for 771 (39%) of the medications. In the intervention group, baseline labs were ordered by clinicians in 689 (41%) of the cases. Overall, no significant association existed between the intervention and the rate of ordering appropriate baseline laboratory tests. CONCLUSION We found that non-interruptive medication laboratory monitoring alerts were not effective in improving receipt of recommended baseline laboratory test monitoring for medications. Further work is necessary to optimize compliance with non-critical recommendations.
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Affiliation(s)
- Helen G Lo
- Department of Emergency Medicine, Hospital of University of Pennsylvania, Philadelphia, PA, USA
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Matheny ME, Sequist TD, Seger AC, Fiskio JM, Sperling M, Bugbee D, Bates DW, Gandhi TK. A randomized trial of electronic clinical reminders to improve medication laboratory monitoring. J Am Med Inform Assoc 2008; 15:424-9. [PMID: 18436905 PMCID: PMC2442256 DOI: 10.1197/jamia.m2602] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Accepted: 03/11/2008] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Recommendations for routine laboratory monitoring to reduce the risk of adverse medication events are not consistently followed. We evaluated the impact of electronic reminders delivered to primary care physicians on rates of appropriate routine medication laboratory monitoring. DESIGN We enrolled 303 primary care physicians caring for 1,922 patients across 20 ambulatory clinics that had at least one overdue routine laboratory test for a given medication between January and June 2004. Clinics were randomized so that physicians received either usual care or electronic reminders at the time of office visits focused on potassium, creatinine, liver function, thyroid function, and therapeutic drug levels. MEASUREMENTS Primary outcomes were the receipt of recommended laboratory monitoring within 14 days following an outpatient clinic visit. The effect of the intervention was assessed for each reminder after adjusting for clustering within clinics, as well as patient and provider characteristics. RESULTS Medication-laboratory monitoring non-compliance ranged from 1.6% (potassium monitoring with potassium-supplement use) to 6.3% (liver function monitoring with HMG CoA Reductase Inhibitor use). Rates of appropriate laboratory monitoring following an outpatient visit ranged from 14% (therapeutic drug levels) to 64% (potassium monitoring with potassium-sparing diuretic use). Reminders for appropriate laboratory monitoring had no impact on rates of receiving appropriate testing for creatinine, potassium, liver function, renal function, or therapeutic drug level monitoring. CONCLUSION We identified high rates of appropriate laboratory monitoring, and electronic reminders did not significantly improve these monitoring rates. Future studies should focus on settings with lower baseline adherence rates and alternate drug-laboratory combinations.
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Affiliation(s)
- Michael E. Matheny
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Decision Systems Group, Department of Radiology, Brigham & Women's Hospital, Boston, MA
| | - Thomas D. Sequist
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Andrew C. Seger
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Massachusetts College of Pharmacy and Health Sciences, Cambridge, MA
| | - Julie M. Fiskio
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Partners HealthCare System, Boston, MA
| | | | | | - David W. Bates
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Tejal K. Gandhi
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Lu CY, Ross-Degnan D, Soumerai SB, Pearson SA. Interventions designed to improve the quality and efficiency of medication use in managed care: a critical review of the literature - 2001-2007. BMC Health Serv Res 2008; 8:75. [PMID: 18394200 PMCID: PMC2323373 DOI: 10.1186/1472-6963-8-75] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Accepted: 04/07/2008] [Indexed: 12/05/2022] Open
Abstract
Background Managed care organizations use a variety of strategies to reduce the cost and improve the quality of medication use. The effectiveness of such policies is not well understood. The objective of this research was to update a previous systematic review of interventions, published between 1966 and 2001, to improve the quality and efficiency of medication use in the US managed care setting. Methods We searched MEDLINE and EMBASE for publications from July 2001 to January 2007 describing interventions targeting drug use conducted in the US managed care setting. We categorized studies by intervention type and adequacy of research design using commonly accepted criteria. We summarized the outcomes of well-controlled strategies and documented the significance and magnitude of effects for key study outcomes. Results We identified 164 papers published during the six-year period. Predominant strategies were: educational interventions (n = 20, including dissemination of educational materials, and group or one-to-one educational outreach); monitoring and feedback (n = 22, including audit/feedback and computerized monitoring); formulary interventions (n = 66, including tiered formulary and patient copayment); collaborative care involving pharmacists (n = 15); and disease management with pharmacotherapy as a primary focus (n = 41, including care for depression, asthma, and peptic ulcer disease). Overall, 51 studies met minimum criteria for methodological adequacy. Effective interventions included one-to-one academic detailing, computerized alerts and reminders, pharmacist-led collaborative care, and multifaceted disease management. Further, changes in formulary tier-design and related increases in copayments were associated with reductions in medication use and increased out-of-pocket spending by patients. The dissemination of educational materials alone had little or no impact, while the impact of group education was inconclusive. Conclusion There is good evidence for the effectiveness of several strategies in changing drug use in the managed care environment. However, little is known about the cost-effectiveness of these interventions. Computerized alerts showed promise in improving short-term outcomes but little is known about longer-term outcomes. Few well-designed, published studies have assessed the potential negative clinical effects of formulary-related interventions despite their widespread use. However, some evidence suggests increases in cost sharing reduce access to essential medicines for chronic illness.
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Affiliation(s)
- Christine Y Lu
- Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA, USA.
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Rommers MK, Teepe-Twiss IM, Guchelaar HJ. Preventing adverse drug events in hospital practice: an overview. Pharmacoepidemiol Drug Saf 2007; 16:1129-35. [PMID: 17610221 DOI: 10.1002/pds.1440] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Adverse drug events (ADEs) are a considerable cause of morbidity and mortality in hospital practice. The precise frequency is unknown, but studies give an incidence number ranging from 2 until 52 ADEs per 100 patients. There are many different methods for definition, causality assessment, severity classification and detection which make it difficult to compare the different studies. A substantial part (in some studies up to 70%) of ADEs can be prevented and it is important to, besides their detection, focus on the prevention of these ADEs. In this literature review we give an overview of methods for preventing ADEs. There are many different tools with different impact on a particular part of the distribution system which has the potential to prevent ADEs. A multifaceted approach is needed. Two interesting strategies of prevention, pharmacist participation on ward rounds and computerised physician order entry with clinical decision support systems (CDSS), are highlighted. Moreover, two promising CDSS are discussed in more detail, namely computer-based monitoring systems and information systems which link laboratory and pharmacy data.
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Affiliation(s)
- Mirjam K Rommers
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, The Netherlands.
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Elston Lafata J, Simpkins J, Kaatz S, Horn JR, Raebel MA, Schultz L, Smith DH, Yood MU. What Do Medical Records Tell Us About Potentially Harmful Co-Prescribing? Jt Comm J Qual Patient Saf 2007; 33:395-400. [PMID: 17711141 DOI: 10.1016/s1553-7250(07)33045-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Previous efforts document drug-drug interactions in ambulatory care. Yet little is known about medical record documentation or clinical management when interacting medications are received. METHODS The study population was identified from the HMO Research Network's Centers for Education and Research on Therapeutics (n = 2,020,037). A random subsample of patients > or = 18 years of age with drug coverage in 2000 initiating a co-dispensing for (1) warfarin with a nonsteroidal anti-inflammatory drug (n = 97), (2) digoxin with verapamil or diltiazem (n = 100), or (3) lovastatin/simvastatin with diltiazem or verapamil (n = 89) was identified. RESULTS The majority (63%-74%) of patients had documentation indicating receipt of both drugs during a single office visit. Documentation of risks and patient education was less common (< or = 14%, with all corresponding upper bounds of the 95% CIs < 23%). Clinical management changes were more frequently documented, ranging from 64% (95% CI: 47-81%) for lovastatin/simvastatin patients to 79% (95% CI: 60-99%) for warfarin patients. CONCLUSIONS The findings, although indicating that clinicians are likely aware of concomitant receipt of interacting medications, call into question the adequacy of medical record documentation as well as clinical management when interacting drugs are co-prescribed in the ambulatory setting.
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Raebel MA, Carroll NM, Kelleher JA, Chester EA, Berga S, Magid DJ. Randomized trial to improve prescribing safety during pregnancy. J Am Med Inform Assoc 2007; 14:440-50. [PMID: 17460126 PMCID: PMC2244894 DOI: 10.1197/jamia.m2412] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE This study sought to determine whether a computerized tool that alerted pharmacists when pregnant patients were prescribed U.S. Food and Drug Administration pregnancy risk category D or X medications was effective in decreasing dispensings of these medications. DESIGN Randomized trial. Pharmacy, diagnostic, and laboratory data were linked to identify pregnant patients prescribed targeted medications. Women (n = 11,100) were randomized to intervention or usual care. Physicians and pharmacists collaborated on the intervention. MEASUREMENTS The primary outcome was the proportion of pregnant women dispensed a category D or X medication. The secondary outcome was the total number of first dispensings of targeted medications. RESULTS A total of 2.9% of intervention (n = 177) and 5.5% of usual care (n = 276) patients were dispensed targeted medications (p < 0.001): 1.8% of intervention (n = 108) and 3.9% of usual care (n = 198) patients were dispensed only category D medication(s); 0.9% of intervention (n = 54) and 1.2% of usual care (n = 58) patients were dispensed only category X medication(s); 0.2% of intervention (n = 15) and 0.4% of usual care (n = 20) patients were dispensed both category D and X medications (p = 0.05). This resulted in intervention patients receiving 238 dispensings of unique targeted medications and usual care patients receiving 361 dispensings of unique targeted medications (p = 0.03). The study was stopped primarily due to 2 false-positive alert types: Misidentification of medications as contraindicated in pregnancy by the pharmacy information system and misidentification of pregnancy related to delayed transfer of diagnosis information. CONCLUSION Coupling data from information systems with knowledge and skills of physicians and pharmacists resulted in improved prescribing safety. Systems limitations contributed to project discontinuation. Linking ambulatory clinical, laboratory, and pharmacy information to provide safety alerts is not sufficient to ensure project success and sustainability.
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Affiliation(s)
- Marsha A Raebel
- Kaiser Permanente Colorado Clinical Research Unit, PO Box 378066, Denver, CO 80237-8066, USA.
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ten Berg MJ, Huisman A, van den Bemt PMLA, Schobben AFAM, Egberts ACG, van Solinge WW. Linking laboratory and medication data: new opportunities for pharmacoepidemiological research. Clin Chem Lab Med 2007; 45:13-9. [PMID: 17243908 DOI: 10.1515/cclm.2007.009] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Transfer of automated laboratory data collected during routine clinical care from the laboratory information system into a database format that enables linkage to other administrative (e.g., patient characteristics) or clinical (e.g., medication, diagnoses, procedures) data provides a valuable tool for clinical epidemiological research. It allows the investigation of biochemical characteristics of diseases, therapeutic effects and diagnostic and/or prognostic markers for disease with easy access and at relatively low cost. To this end, the Utrecht Patient Oriented Database (UPOD), an infrastructure of relational databases comprising data on patient characteristics, laboratory test results, medication orders, hospital discharge diagnoses and medical procedures for all patients treated at the University Medical Centre Utrecht since January 2004, was established. Current research within UPOD is focused on the innovative linkage of laboratory and medication data, which, for example, makes it possible to assess the quality of pharmacotherapy in clinical practice, to investigate interference between laboratory tests and drugs, to study the risk of adverse drug reactions, and to develop diagnostic and prognostic markers or algorithms for adverse drug reactions. Although recently established, we believe that UPOD broadens the opportunities for clinical pharmacoepidemiological research and can contribute to patient care from a laboratory perspective.
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Affiliation(s)
- Maarten J ten Berg
- Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
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Raebel MA, Chester EA, Newsom EE, Lyons EE, Kelleher JA, Long C, Miller C, Magid DJ. Randomized trial to improve laboratory safety monitoring of ongoing drug therapy in ambulatory patients. Pharmacotherapy 2006; 26:619-26. [PMID: 16637791 DOI: 10.1592/phco.26.5.619] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To determine whether an electronic tool effectively increases the percentage of patients receiving laboratory monitoring during ongoing drug therapy. DESIGN Randomized trial. SETTING Outpatient medical offices of a group model health maintenance organization. PATIENTS A total of 9,139 patients prescribed ongoing therapy with any of 14 drugs, resulting in 4,871 patient-drug combinations in the intervention group and 4,780 in the usual-care (control) group. INTERVENTION Physicians and pharmacists jointly developed monitoring guidelines based on published recommendations. Pharmacists were electronically alerted to missing laboratory results and then ordered tests, reminded patients to undergo tests, and reviewed and managed abnormal results. MEASUREMENTS AND MAIN RESULTS In the intervention group, 64% of patientdrug combinations were monitored, whereas in the usual-care group 58% were monitored (p < 0.001). Differences in monitoring were observed in the intervention versus usual-care groups for amiodarone (71% vs 55%, p<0.01), theophylline (54% vs 28%, p<0.001), carbamazepine (49% vs 32%, p<0.001), lithium (42% vs 28%, p<0.01), phenytoin (44% vs 33%, p<0.001), and metformin (72% vs 67%, p<0.001). Of 1981 laboratory tests ordered, 1,472 (74%) were completed. The tests revealed 181 serum drug concentrations outside the therapeutic range and 126 abnormal serum creatinine, alanine aminotransferase, aspartate aminotransferase, and thyroid-stimulating hormone levels, and complete blood counts. CONCLUSION A computerized tool plus collaboration of health care professionals effectively increased the number of patients who received laboratory safety monitoring of drug therapy.
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Affiliation(s)
- Marsha A Raebel
- Kaiser Permannente Colorado Clinical Research Unit, Denver, 80237-8066, USA.
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Abstract
PURPOSE OF REVIEW To summarize the pertinent case reports, case series and clinical studies that described clinical, histological, epidemiological and mechanistic features of drug-induced liver disease in 2005. RECENT FINDINGS Acetaminophen, highly active antiretroviral therapy and drugs for tuberculosis retained their preeminent position as the most commonly reported agents causing drug-induced liver disease, with acetaminophen continuing to be the leading cause of acute liver failure in the USA. While the frequency of drug-induced liver disease remains low, a large case-series of acute drug-induced liver disease from Spain and Sweden supported the observation that acute hepatocellular jaundice from a drug is associated with death or the need for transplant in at least 10% (known as Hy's Law). With respect to using potentially hepatotoxic medications in patients with underlying liver disease, statins and second-generation thiazolidinediones were shown to be safe when used in patients with elevated baseline alanine aminotransferase or aspartate aminotransferase levels. SUMMARY Drug-induced liver disease remains an important cause of acute liver failure, and research efforts by the National Institutes of Health and others are underway to better determine the risk factors and other host susceptibilities that will allow for the safer use of drugs in the future.
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Affiliation(s)
- James H Lewis
- Division of Gastroenterology, Georgetown University Medical Center, Washington DC 20007, USA.
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