Rule-based standardised switching of drugs at the interface between primary and tertiary care

A newly developed algorithm for switching outpatient medications to medications listed in the hospital formulary: a prospective real-word evaluation in patients admitted electively to hospital

PURPOSE

In many countries, outpatient and inpatient care are separated. During hospitalization, therefore, switching the outpatient medication to medication of the hospital formulary is required.

METHODS

We newly designed a switching algorithm in six switching steps (S0-S5) and conducted a study at Bundeswehr Hospital Hamburg (300 beds, 80% civilians). We performed (i) a medication reconciliation to obtain information on outpatient medications and (ii) a medication review to solve drug-related-problems, e.g., drug-drug interactions. We applied (iii) the algorithm to switch medications to the hospital formulary.

RESULTS

(i) We identified 475 outpatient medications (median per patient: 4; Q25/Q75 2/7) in 100 patients consecutively admitted to hospital (median age: 71; Q25/Q75: 64/80 years). Of 475 medications, the switching algorithm could not be used since product names were missing in 23.9% and strength in 1.7%. In 3.2%, switching was not required since medication was not prescribed during the hospital stay. (ii) Drug-drug interactions were identified in 31 of 79 patients with more than one medication. (iii) Of 475 medications, 18.5% were on the hospital formulary and therefore did not need to be  switched (S0), 0.2% were on a substitution-exclusion list not allowing switching (S1), 42.0% were switched to a generic medication of the hospital formulary (S2), 1.7% to a therapeutically equivalent medication (S3), 0.4% were patient-individually switched (S4), and for 8.2% a standardized/patient-individual switching was not possible (S5).

CONCLUSIONS

Despite comprehensive medication reconciliation, patient- and medication-related information for switching medications to the hospital formulary was often missing. Once all the necessary information was available, standardized switching could be easily carried out according to a newly developed switching algorithm.

Workflow, Time Requirement, and Quality of Medication Documentation with or without a Computerized Physician Order Entry System-A Simulation-Based Lab Study

BACKGROUND

 The introduction of a computerized physician order entry (CPOE) system is changing workflows and redistributing tasks among health care professionals.

OBJECTIVES

 The aim of this study is to describe exemplary changes in workflow, to objectify the time required for medication documentation, and to evaluate documentation quality with and without a CPOE system (Cerner® i.s.h.med).

METHODS

 Workflows were assessed either through direct observation and in-person interviews or through semistructured online interviews with clinical staff involved in medication documentation. Two case scenarios were developed consisting of exemplary medications (case 1 = 6 drugs and case 2 = 11 drugs). Physicians and nurses/documentation assistants were observed documenting the case scenarios according to workflows established prior to CPOE implementation and those newly established with CPOE implementation, measuring the time spent on each step in the documentation process. Subsequently, the documentation quality of the documented medication was assessed according to a previously established and published methodology.

RESULTS

 CPOE implementation simplified medication documentation. The overall time needed for medication documentation increased from a median of 12:12 min (range: 07:29-21:10 min) without to 14:40 min (09:18-25:18) with the CPOE system (p = 0.002). With CPOE, less time was spent documenting peroral prescriptions and more time documenting intravenous/subcutaneous prescriptions. For physicians, documentation time approximately doubled, while nurses achieved time savings. Overall, the documentation quality increased from a median fulfillment score of 66.7% without to 100.0% with the CPOE system (p < 0.001).

CONCLUSION

 This study revealed that CPOE implementation simplified the medication documentation process but increased the time spent on medication documentation by 20% in two fictitious cases. This increased time resulted in higher documentation quality, occurred at the expense of physicians, and was primarily due to intravenous/subcutaneous prescriptions. Therefore, measures to support physicians with complex prescriptions in the CPOE system should be established.

Effects of clinical decision support and pharmacist prescribing authority on a therapeutic interchange program

PURPOSE

Results of an evaluation of therapeutic interchange (TI) program outcomes with use of prescriber alerts alone or in combination with pharmacist prescribing are reported.

METHODS

A retrospective single-center study was conducted to compare TI outcomes before incorporation of prescriber alerts encouraging formulary agent use into the electronic medical record (period 1), after alert implementation (period 2), and after implementation and expansion of TI protocols including pharmacist prescribing authority (period 3). The evaluation focused on TI orders for 3 drug classes: angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), and 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (HMG-CoA RIs). The primary outcome was formulary medication utilization.

RESULTS

In total, 2,881, 2,700, and 3,088 prescriptions for medications in the ACEI, ARB, or HMG-CoA RI class were ordered during periods 1, 2, and 3, respectively. Overall formulary adherence improved from 78.3% in period 1 to 97.6% in period 2 and 99.2% in period 3 (p < 0.001 for both comparisons with period 1). The percentages of inappropriate dosing conversions were 51.6%, 37.2%, and 2.4% in periods 1, 2, and 3, respectively; the corresponding percentages of inappropriate discharge medications were 64.5%, 16.3%, and 2.4%.

CONCLUSION

Percentages of formulary medications in 3 medication classes, considered separately and together, increased with the implementation of TI alerts for prescribers and the addition of TI-related pharmacist prescribing authority. Over the same study periods, percentages of inappropriate dosing conversions and inappropriate discharge medications decreased.

Systematic literature review of the methodology for developing pharmacotherapeutic interchange guidelines and their implementation in hospitals and ambulatory care settings

PURPOSE

To summarize literature specific to therapeutic interchange (TI) focusing on methodological approaches in order to develop a list of steps that healthcare facilities can consult when developing pharmacotherapeutic interchange guidelines (PTIGs) in hospitals and primary care centers.

METHODS

A search was conducted in PreMEDLINE, Medline, EMBASE, PsycINFO, and the Cochrane Library up to and including December 2015. PRISMA guidelines were used. The inclusion criteria were articles published on TI: methodology, implementation, guidelines, and position statements of scientific societies. Two authors independently reviewed all articles for eligibility and extracted the data.

RESULTS

A total of 102 articles were selected for full-text review; we included three guidelines on how to effect TI, nine position papers of various scientific societies with regard to TI, two articles dealt exclusively about methodology, three articles consisted of recommendations and perspectives on TI, three articles dealt with legal aspects, four articles examined general implementation procedures, two articles were a post-discharge follow-up of patients who had TI, six were surveys referring to TI, and three were articles on the use of TI in ambulatory care The remaining 67 articles focused on therapeutic groups. Study quality was generally low.

CONCLUSIONS

This review identified articles on TI as published guidelines, recommendations, and studies on TI carried out in hospital settings. As a result, eight fundamental steps were established for obtaining adequate results in the development of TI programs.

Medication and Treatment Adherence Following Hospital Discharge

BACKGROUND

Patients' drug regimens often need to be changed when they pass from one care sector to another, but these changes sometimes pose a safety risk. To avoid such risks, a new inter-sector transition concept was developed incorporating discharge medication plans and counseling modules for the patients themselves and the doctors receiving them into their care.

METHODS

A prospective interventional trial was carried out in two internal medicine wards of a general hospital. After data acquisition from the control group, the transition concept was developed and evaluated in an independent intervention group. The discharge medication plan and the first post-discharge prescription were compared to identify patients who had at least one medication change that increased the post-discharge risk of either failure to achieve the therapeutic goal (category A, first endpoint) or of patient's lack of treatment adherence (category B). Gaps in care after discharge were also analyzed.

RESULTS

200 consecutive patients were enrolled in the trial. In the intention-to-treat analysis, the percentage of patients with potentially jeopardizing medication changes in category A declined from 54% (54/100) in the control group to 15% (15/100) in the intervention group. (p<0.001). For medication changes in category B, there was a corresponding decline from 53% (53/100) to 7% (7/100) (p < 0.001). Gaps in care were seen in 28% (28/100) of control patients and 18% (18/100) of patients in the intervention group (p = 0.031).

CONCLUSION

The likelihood of a potentially jeopardizing medication change upon hospital discharge can be markedly reduced with the aid of a modular transition concept. Gaps in care can be closed in this way as well.

Development and evaluation of an algorithm to facilitate drug prescription for inpatients with feeding tubes

PURPOSE

We aimed to develop and evaluate an algorithm to facilitate drug switching between primary and tertiary care for patients with feeding tubes.

METHODS

An expert consortium developed an algorithm and applied it manually to 267 preadmission drugs of 46 patients admitted to a surgical ward of a tertiary care university hospital between June 12 and December 2, 2013, and requiring a feeding tube during their inpatient stay.

RESULTS

The new algorithm considered the following principles: Drugs should be ideally listed on the hospital drug formulary (HDF). Additionally, drugs should include the same ingredient instead of a therapeutic equivalent. Preferred dosage forms were appropriate liquids, followed by solid drugs with liquid administration form, and solid drugs that could be crushed and/or suspended. Of all evaluated drugs, 83.5% could be switched to suitable drugs listed on the HDF and another 6.0% to drugs available on the German drug market. Additionally, for 4.1% of the drugs, the integration of individual switching rules allowed the switch from enteric-coated to immediate-release drugs. Consequently, 6.4% of the drugs could not be automatically switched and required case-to-case decision by a clinical professional (e.g., from sustained-release to immediate-release).

CONCLUSIONS

The predefined principles were successfully integrated in the new algorithm. Thus, the algorithm switched more than 90% of the evaluated preadmission drugs to suitable drugs for inpatients with feeding tubes. This finding suggests that the algorithm can readily be transferred to an electronic format and integrated into a clinical decision support system.

Drug and therapeutics committees in Danish hospitals: a survey of organization, activities and drug selection procedures

To implement rational pharmacotherapy in hospitals, it is important to develop, implement and evaluate hospital drug formularies (HDFs). A report from Denmark recommended standardizing activities of the drug and therapeutics committees (DTCs) in Denmark, but little is known about their current organization. The aim of the study was to describe the organization of DTCs in Denmark, how HDFs are developed and implemented, and to what extent policies that support the use of HDFs exist. A questionnaire was developed based on previous research and guidelines and contained 20 questions, which were divided into the following subjects: structure, activities, drug selection and implementation. The questionnaire was sent to the chairmen of the nine DTCs in Denmark. The response rate was 100% (9/9). The DTCs varied in structure and activities; meetings were held between 2 and 6 times annually, and the duration of the meetings lasted between 1 and 2.5 hr. Eight (89%) DTCs developed HDFs, policies and guidelines (P&Gs) that supported the use of HDFs. Eight (89%) had established criteria for inclusion of drugs on the HDFs, and seven had developed criteria for generic substitution and therapeutic interchange. The number of trade names on the HDFs varied between 116 and 1195. The nine DTCs in Denmark varied considerably regarding structure and activity. The main activity was to develop formularies, and most of the committees developed policies that supported medication use.

Development and evaluation of a computerised clinical decision support system for switching drugs at the interface between primary and tertiary care

Background

Upon admission to a hospital patients’ medications are frequently switched to alternative drugs compiled in so called hospital drug formularies. This substitution process is a laborious and error-prone task which should be supported by sophisticated electronic tools. We developed a computerised decision support system and evaluated benefit and potential harm associated with its use.

Methods

Based on a multi-step algorithm we identified drug classes suitable for exchange, defined conversion factors for therapeutic interchange, built a web-based decision support system, and implemented it into the computerised physician order entry of a large university hospital. For evaluation we compared medications manually switched by clinical pharmacists with the results of automated switching by the newly developed computer system and optimised the system in an iterative process. Thereafter the final system was tested in an independent set of prescriptions.

Results

After iterative optimisation of the logical framework the tool was able to switch drugs to pharmaceutical equivalents and alternatives; in addition, it contained 21 different drug classes for therapeutic substitution. In this final version it switched 91.6% of 202 documented medication consultations (containing 1,333 drugs) automatically, leaving 8.4% for manual processing by clinical professionals. No incorrect drug switches were found.

Conclusion

A large majority (>90%) of drug switches performed at the interface between primary and tertiary care can be handled automatically using electronic decision support systems, indicating that medication errors and workload of healthcare professionals can be considerably reduced.

Design and evaluation of an ontology-based drug application database

OBJECTIVES

Several recently published cases of preventable adverse drug reactions were associated with flaws in drug application. However, current clinical decision support (CDS) systems do not properly consider drug application issues and thus do not support effective prevention of such medication errors. With the aim to improve CDS in this respect, we developed a comprehensive model precisely describing all aspects of drug application.

METHODS

The model consists of 1) a schema comprising all relevant attributes of drug application and 2) an ontology providing a hierarchically structured vocabulary of terms that describe the possible values of the schema's attributes. Finally, medical products were annotated by a semi-automatic term assignment process. For evaluation, we developed an algorithm that uses our model to compute a meaningful similarity between medicinal products with respect to their drug application characteristics.

RESULTS

Our schema consists of 22 attributes. The ontology contains 248 terms, textual descriptions, and synonym lists. More than 58,700 medicinal products were automatically annotated with >386,600 terms. 2,450 drugs were manually reviewed by experts, adding >4500 terms. The annotation and similarity measure allow for (similarity) searches, clustering, and proper discrimination of drugs with different drug application characteristics. We demonstrated the value of our approach by means of a set of case studies.

CONCLUSION

Our model enables a detailed description of drug application, allowing for semantically meaningful comparisons of drugs. This is an important prerequisite for improving the ability of CDS systems to prevent prescription errors.

[Patient safety based on computer-assisted drug therapy. Electronic check-up of the patient]

Patients in internal medicine frequently experience adverse drug events. Many of those events, however, are avoidable because they are caused by medication errors, which are particularly frequent in drug prescribing. Therefore, practical concepts are needed to make the rapidly growing knowledge on drugs available already during prescription. But also when deviations from standards are intended access to up-to-date information is required. Computer-based systems can offer support for prescribing clinicians to meet these claims and thus improve the quality of pharmacotherapy. To reach this goal, such systems have to be interlinked among each other and with systems of primary, secondary, and tertiary care. They must be based on scientific published evidence and should consider as many factors as possible for individualization of drug therapy. Individualization and focusing on relevant information are prerequisites to prevent inappropriate alerts (over-alerting) and thus to increase acceptance in practical use.