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Tukukino C, Eriksson AL, Hamdan W, Wallin Hybelius F, Wallerstedt SM. Interaction alerts: A comparison of classifications and recommendations for clinical management between Janusmed and three other knowledge resources. Basic Clin Pharmacol Toxicol 2023; 132:403-415. [PMID: 36764328 DOI: 10.1111/bcpt.13843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/27/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023]
Abstract
Classifications of drug interaction alerts differ between knowledge resources, but agreement regarding recommendations for clinical management is less explored. Starting from the medication lists of 274 older patients with ≥2 drugs, all unique drug pairs that triggered a clinically significant interaction alert in Janusmed were included: 100 Category C (manageable by, e.g. dose adjustment) and nine Category D interactions (should be avoided). Out of 109 C/D alerts in Janusmed, 89 (82%), 75 (69%) and 45 (41%) drug pairs triggered an alert of similar clinical significance in Lexicomp, Micromedex® and Stockley's Drug Interactions/Checker (Stockley), respectively. Eight (7%), 20 (18%) and 10 (9%) drug pairs did not trigger any alert in these resources. For 81 (74%), 81 (74%) and 94 (86%) drug pairs, Lexicomp, Micromedex and Stockley provided at least one recommendation for clinical management similar to those provided by Janusmed. For 16 (15%), 9 (8%) and 21 (19%) drug pairs, these resources provided recommendation(s) entirely in agreement with Janusmed. Although many drug pairs elicit alerts of similar significance, and partly concordant recommendations, a non-negligible proportion do not. The findings encourage medical/pharmaceutical reflection by prescribing clinicians and dispensing pharmacists; recommendations provided by knowledge resources vary considerably and cannot be considered definite.
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Affiliation(s)
- Carina Tukukino
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna L Eriksson
- Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Internal Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Walaa Hamdan
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Frida Wallin Hybelius
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,HTA-centrum, Sahlgrenska University Hospital, Gothenburg, Sweden
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Birarra MK, Baye E, Tesfa W, Kifle ZD. Knowledge of cardiovascular disease risk factors, practice, and barriers of community pharmacists on cardiovascular disease prevention in North West Ethiopia. Metabol Open 2022; 16:100219. [DOI: 10.1016/j.metop.2022.100219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/01/2022] [Accepted: 11/19/2022] [Indexed: 11/23/2022] Open
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Park H, Chae MK, Jeong W, Yu J, Jung W, Chang H, Cha WC. Appropriateness of Alerts and Physicians’ Responses with a Medication-related Clinical Decision Support System (Preprint). JMIR Med Inform 2022; 10:e40511. [PMID: 36194461 PMCID: PMC9579928 DOI: 10.2196/40511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/13/2022] [Accepted: 09/18/2022] [Indexed: 12/02/2022] Open
Abstract
Background Alert fatigue is unavoidable when many irrelevant alerts are generated in response to a small number of useful alerts. It is necessary to increase the effectiveness of the clinical decision support system (CDSS) by understanding physicians’ responses. Objective This study aimed to understand the CDSS and physicians’ behavior by evaluating the clinical appropriateness of alerts and the corresponding physicians’ responses in a medication-related passive alert system. Methods Data on medication-related orders, alerts, and patients’ electronic medical records were analyzed. The analyzed data were generated between August 2019 and June 2020 while the patient was in the emergency department. We evaluated the appropriateness of alerts and physicians’ responses for a subset of 382 alert cases and classified them. Results Of the 382 alert cases, only 7.3% (n=28) of the alerts were clinically appropriate. Regarding the appropriateness of the physicians’ responses about the alerts, 92.4% (n=353) were deemed appropriate. In the classification of alerts, only 3.4% (n=13) of alerts were successfully triggered, and 2.1% (n=8) were inappropriate in both alert clinical relevance and physician’s response. In this study, the override rate was 92.9% (n=355). Conclusions We evaluated the appropriateness of alerts and physicians’ responses through a detailed medical record review of the medication-related passive alert system. An excessive number of unnecessary alerts are generated, because the algorithm operates as a rule base without reflecting the individual condition of the patient. It is important to maximize the value of the CDSS by comprehending physicians’ responses.
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Affiliation(s)
- Hyunjung Park
- Department of Digital Health, Samsung Advanced Institute of Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
| | - Minjung Kathy Chae
- Department of Digital Health, Samsung Advanced Institute of Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
| | - Woohyeon Jeong
- Department of Digital Health, Samsung Advanced Institute of Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
| | - Jaeyong Yu
- Department of Digital Health, Samsung Advanced Institute of Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
| | - Weon Jung
- Department of Digital Health, Samsung Advanced Institute of Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
| | - Hansol Chang
- Department of Digital Health, Samsung Advanced Institute of Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Chul Cha
- Department of Digital Health, Samsung Advanced Institute of Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Digital Innovation Center, Samsung Medical Center, Seoul, Republic of Korea
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Kadomura S, Imai S, Momo K, Sato Y, Kashiwagi H, Itoh T, Sugawara M, Takekuma Y. Effects of piperacillin/tazobactam or cefepime on folinate dose in patients receiving high-dose methotrexate: A retrospective cohort study using Japanese administrative claims data. J Oncol Pharm Pract 2021; 28:1534-1542. [PMID: 34661469 DOI: 10.1177/10781552211034703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Delayed methotrexate (MTX) clearance with the co-administration of piperacillin/tazobactam (PIPC/TAZ) has been reported. Penicillins have been associated with reduced MTX clearance but the evidence is limited. There are no cases described with cefepime but penicillins are listed as interacting with MTX. We aimed to reveal whether the co-administration of PIPC/TAZ or CFPM affects MTX clearance using data from an administrative database. METHODS We used data from the JMDC database, a large insurance claims database constructed in Japan. We included patients who were prescribed PIPC/TAZ or CFPM between days 1 and 3 in high-dose MTX (HD-MTX). We compared one co-administration episode (with PIPC/TAZ or CFPM) to one control episode (without), as a match-control study of two different episodes in the same patient. The primary outcomes were the duration and cumulative dose of leucovorin (LV) as a surrogate indicator of delayed MTX clearance. RESULTS Three patients who were co-administered PIPC/TAZ and 16 patients who were co-administered CFPM with HD-MTX were included. In the PIPC/TAZ group, the duration and the cumulative doses of LV were similar in co-administration and control episode (median 3.0 vs. 3.0 days and 288.0 vs. 219.0 mg). In the CFPM group, the duration and the cumulative doses of LV were not significantly different in co-administration and control episode (3.0 vs. 4.0 days and 169.5 vs. 258.0 mg). CONCLUSIONS Our findings revealed that PIPC/TAZ did not necessarily cause a delay in MTX clearance during HD-MTX therapy. Moreover, the co-administration of CFPM with HD-MTX did not affect MTX clearance.
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Affiliation(s)
- Shota Kadomura
- Department of Pharmacy, 89455Japan Community Healthcare Organization Sapporo Hokushin Hospital, Sapporo, Japan
- Graduate School of Life Science, 12810Hokkaido University, Sapporo, Japan
| | - Shungo Imai
- Faculty of Pharmaceutical Sciences, 12810Hokkaido University, Sapporo, Japan
| | - Kenji Momo
- Department of Hospital Pharmaceutics, School of Pharmacy, 13059Showa University, Tokyo, Japan
| | - Yuki Sato
- Faculty of Pharmaceutical Sciences, 12810Hokkaido University, Sapporo, Japan
| | - Hitoshi Kashiwagi
- Faculty of Pharmaceutical Sciences, 12810Hokkaido University, Sapporo, Japan
| | - Tatsuya Itoh
- Department of Pharmacy, 89455Japan Community Healthcare Organization Sapporo Hokushin Hospital, Sapporo, Japan
| | - Mitsuru Sugawara
- Faculty of Pharmaceutical Sciences, 12810Hokkaido University, Sapporo, Japan
- Department of Pharmacy, 163693Hokkaido University Hospital, Sapporo, Japan
- Global Station for Biosurfaces and Drug Discovery, 163693Hokkaido University, Sapporo, Japan
| | - Yoh Takekuma
- Department of Pharmacy, 163693Hokkaido University Hospital, Sapporo, Japan
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Olakotan OO, Yusof MM. Evaluating the appropriateness of clinical decision support alerts: A case study. J Eval Clin Pract 2021; 27:868-876. [PMID: 33009698 DOI: 10.1111/jep.13488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/28/2020] [Accepted: 09/07/2020] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Clinical decision support (CDS) generates excessive alerts that disrupt the workflow of clinicians. Therefore, inefficient clinical processes that contribute to the misfit between CDS alert and workflow must be evaluated. This study evaluates the appropriateness of CDS alerts in supporting clinical workflow from a socio-technical perspective. METHOD A qualitative case study evaluation was conducted at a 620-bed public teaching hospital in Malaysia using interview, observation, and document analysis to investigate the features and functions of alert appropriateness and workflow-related issues in cardiological and dermatological settings. The current state map for medication prescribing process was also modelled to identify problems pertinent to CDS alert appropriateness. RESULTS The main findings showed that CDS was not well designed to fit into a clinician's workflow due to influencing factors such as technology (usability, alert content, and alert timing), human (training, perception, knowledge, and skills), organizational (rules and regulations, privacy, and security), and processes (documenting patient information, overriding default option, waste, and delay) impeding the use of CDS with its alert function. We illustrated how alert affect workflow in clinical processes using a Lean tool known as value stream mapping. This study also proposes how CDS alerts should be integrated into clinical workflows to optimize their potential to enhance patient safety. CONCLUSION The design and implementation of CDS alerts should be aligned with and incorporate socio-technical factors. Process improvement methods such as Lean can be used to enhance the appropriateness of CDS alerts by identifying inefficient clinical processes that impede the fit of these alerts into clinical workflow.
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Affiliation(s)
- Olufisayo O Olakotan
- Faculty of Information Science and Technology, Universiti Kebangsaan Malaysia, Bangi, Malaysia
| | - Maryati M Yusof
- Faculty of Information Science and Technology, Universiti Kebangsaan Malaysia, Bangi, Malaysia
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Hassanzad M, Tashayoie Nejad S, Mahboobipour AA, Salem F, Baniasadi S. Potential drug-drug interactions in hospitalized pediatric patients with respiratory disorders: a retrospective review of clinically important interactions. Drug Metab Pers Ther 2020; 35:/j/dmdi.ahead-of-print/dmpt-2019-0012/dmpt-2019-0012.xml. [PMID: 32004144 DOI: 10.1515/dmpt-2019-0012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 12/16/2019] [Indexed: 11/15/2022]
Abstract
Background Hospitalized pediatric patients are at an increased risk of experiencing potential drug-drug interactions (pDDIs) due to polypharmacy and the unlicensed and off-label administration of drugs. The aim of this study is to characterize clinically significant pDDIs in pediatric patients hospitalized in a tertiary respiratory center. Methods A retrospective analysis of medications prescribed to pediatric patients admitted to the pediatric ward (PW) and pediatric intensive care unit (PICU) of a respiratory referral center was carried out over a six-month period. The pDDIs were identified using the Lexi-Interact database and considered as clinically relevant according to the severity rating as defined in the database. Frequency, drug classes, mechanisms, clinical managements, and risk factors were recorded for these potential interactions. Results Eight hundred and forty-five pDDIs were identified from the analysis of 176 prescriptions. Of the total pDDIs, 10.2% in PW and 14.6% in PICU were classified as clinically significant. Anti-infective agents and central nervous system drugs were the main drug classes involved in clinically significant pDDIs as object and/or precipitant drugs. A higher number of medications [odds ratio (OR): 4.8; 95% confidence interval (CI): 2.0-11.4; p < 0.001] and the existence of a nonrespiratory disease, which led to a respiratory disorder (OR: 3.8; 95% CI: 1.40-10.4; p < 0.05), were the main risk factors associated with an increased incidence of pDDIs. Conclusions A high and similar risk of pDDIs exists in pediatric patients with respiratory disorders hospitalized in PW and PICU. The patients prescribed a higher number of medications and presenting respiratory symptoms induced by a nonrespiratory disease require extra care and monitoring. Pediatricians should be educated about clinically significant DDIs for highly prescribed medications in their settings in order to take preventive measures and safeguard patient safety.
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Affiliation(s)
- Maryam Hassanzad
- Pediatric Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sabereh Tashayoie Nejad
- Pediatric Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Farzaneh Salem
- Certara UK Limited, Simcyp Division, Sheffield, United Kingdom
| | - Shadi Baniasadi
- Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Drug-drug interactions in patients undergoing chemoradiotherapy and the impact of an expert team intervention. Int J Clin Pharm 2019; 42:132-140. [PMID: 31865596 DOI: 10.1007/s11096-019-00949-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/03/2019] [Indexed: 02/07/2023]
Abstract
Background Several studies have examined the drug-drug interaction patterns in different patient populations and treatment settings; however, there is a need, particularly in the field of oncology and radiotherapy, for evaluating methods targeted towards preventing potential drug-drug interactions. One of the measures proposed is identifying potential interactions using computer programs and their evaluation by pharmacologists or clinical pharmacists, thereby providing clinically relevant information to the treating physician regarding the required prescription changes. Objective To determine the prevalence of potential drug-drug interactions in patients receiving chemoradiotherapy and assess the usefulness of expert team recommendations in minimizing interactions. Setting Patients admitted to the radiotherapy and oncology ward of a tertiary care teaching hospital in Karnataka, India. Method We conducted a prospective, cross-sectional study of prescriptions written for patients receiving chemoradiotherapy. Prescriptions containing two or more drugs, at least one of the drugs being an anticancer drug, were analyzed. They were screened for potential drug-drug interactions using the Lexicomp® drug interaction software. The interactions were classified as X, drug combination to be avoided; D, modification of therapy to be considered; and C, therapy to be monitored, as per the Lexicomp criteria. Main outcome measure The number of drug-drug interactions detected that were accepted by the treating radio-oncologist as requiring prescription change before and after the prescription review by an expert team. Results Two hundred twenty-three prescriptions were screened for the presence of drug-drug interactions; 106 prescriptions (47.53%) containing 620 drugs and 211 drug-drug interactions were identified. Of the 211 interactions identified, 6.64% (14/211), 18.48% (39/211), and 74.88% (158/211) drug-drug interactions belonged to category X, D, and C, respectively. Twenty-seven (50.94%) of the 53 category X and D interactions identified were accepted the oncologist as requiring a change in the prescription; an additional 13 (24.53%) interactions were identified as significant by the expert team, and 11 (84.62%) of these were accepted by the oncologist. Conclusion A system of alerting the treating physician to a potential drug-drug interaction leads to avoidance of prescription of the interacting drug combination, and the assistance by an expert team adds significantly to avoidance of clinically relevant drug interactions.
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Das S, Behera SK, Xavier AS, Dharanipragada S, Selvarajan S. Are drug-drug interactions a real clinical concern? Perspect Clin Res 2019; 10:62-66. [PMID: 31008071 PMCID: PMC6463504 DOI: 10.4103/picr.picr_55_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Although drug-drug interactions (DDIs) cause major adverse drug reactions (ADRs) in patients under polypharmacy, the risk of some specific DDIs may be overrated in literature and different software. This study was conducted to determine the frequency and type of potential and clinically significant DDIs among inpatients admitted in a tertiary care hospital in South India. Materials and Methods: This longitudinal study was conducted for 30 days. Preformatted forms were used to collect data on the second day of admission. “Medscape Drug Interaction Checker” was used to evaluate and grade the DDIs. All the potential serious DDIs were intimated to the treating physicians and their responses in the prescriptions were noted. The same patients were followed up to evaluate the occurrence of any clinically significant DDIs. Results: A total of 763 drugs with 125 discrete types were prescribed in 155 patients with an average of 4.9 drugs per patient. One hundred and eight minor, 169 significant, and 24 serious potential DDIs were identified. Patient's age did not correlate, but number of drugs prescribed strongly correlated (P < 0.001) with the incidence of different types of DDIs. The prescription was modified in only 6 (25%) cases where potential serious DDIs were reported. Interestingly, no ADRs or impaired efficacy was observed due to the potential serious DDIs. Conclusion: There was a disparity between the potential and clinically relevant DDIs. Hence, clinical prudency is required before changing prescription due to potential DDIs reported by different software.
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Affiliation(s)
- Saibal Das
- Department of Clinical Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sapan Kumar Behera
- Department of Clinical Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Alphienes Stanley Xavier
- Department of Clinical Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Subrahmanyam Dharanipragada
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sandhiya Selvarajan
- Department of Clinical Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Qu C, Meng L, Wang N, Chen Y, Yang X, Wang J, Sun S, Qiu F. Identify and categorize drug-related problems in hospitalized surgical patients in China. Int J Clin Pharm 2019; 41:13-17. [PMID: 30610549 DOI: 10.1007/s11096-018-0777-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 12/19/2018] [Indexed: 11/28/2022]
Abstract
Background Data is lacking on types and severities of drug-related problems (DRPs) in hospitalized surgical patients in China. Objective To identify and categorize types and causes of DRPs, and to assess severities of these DRPs. Setting An academic teaching hospital in Chongqing, China. Method We retrospectively reviewed all medication orders for patients in six surgical departments during a six-month period. DRPs were classified using the Pharmaceutical Care Network Europe (PCNE) classification, and the severity ratings of these DRPs were based on the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) classification. Main outcome measure The number, types, causes and severities of the DRPs. Results A total of 291,944 medication orders in 10,643 patients were reviewed, and 3548 DRPs were identified. The average DRP number per patient was 0.3. The most common problem was treatment effectiveness (39.9%) and the major cause of the problems was dose selection (47.0%). Total 80.1% of the DRPs were rated at severity categories B to D (causing no or potential harm), whereas 19.9% were rated as categories E to H (causing actual harm). Conclusion DRPs are common in surgical patients, and prospective pharmacist medication order review services are needed to improve patients' pharmaceutical care.
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Affiliation(s)
- Can Qu
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, China
| | - Long Meng
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, China
| | - Ning Wang
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, China
| | - Yong Chen
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, China
| | - Xiao Yang
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, China
| | - Jun Wang
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, China
| | - Shusen Sun
- Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Western New England University, 1215 Wilbraham Road, Springfield, MA, 01119, USA. .,Department of Pharmacy, Xiangya Hospital Central South University, Changsha, 410008, Hunan Province, China. .,Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.
| | - Feng Qiu
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, China.
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Tolley CL, Slight SP, Husband AK, Watson N, Bates DW. Improving medication-related clinical decision support. Am J Health Syst Pharm 2018; 75:239-246. [PMID: 29436470 DOI: 10.2146/ajhp160830] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Current uses of medication-related clinical decision support (CDS) and recommendations for improving these systems are reviewed. SUMMARY Using a systematic approach, articles published from 2007 through 2014 were identified in MEDLINE and EMBASE using MeSH terms and keywords relating to the 5 basic medication-related CDS functionalities. A total of 156 full-text articles and 28 conference abstracts were reviewed across each of the 5 areas: drug-drug interaction (DDI) checks (n = 78), drug allergy checks (n = 20), drug dose support (n = 55), drug duplication checks (n = 11), and drug formulary support (n = 20). The success of medication-related CDS depends on users finding the alerts valuable and acting on the information received. Improving alert specificity and sensitivity is important for all domains. Tiering is important for improving the acceptance of DDI alerts. The ability to perform appropriate cross-sensitivity checks is key to producing appropriate drug allergy checks. Drug dosage alerts should be individualized and deliver practical recommendations. How the system is configured to identify certain drug duplications is important to prevent possible patient toxicity. Accurate knowledge databases are needed to produce relevant drug formulary alerts and encourage formulary adherence. Medication-related CDS is still relatively immature in some organizations and has substantial room for improvement. For example, decision support should consider more patient-specific factors, human factors principles should always be considered, and alert specificity must be improved in order to reduce alert fatigue. CONCLUSION Standardization, integration of patient-specific parameters, and consideration of human factors design principles are central to realizing the potential benefits of medication-related CDS.
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Affiliation(s)
- Clare L Tolley
- Institute of Health and Society, Sir James Spence Institute, Newcastle University, Newcastle upon Tyne, United Kingdom, United Kingdom
| | - Sarah P Slight
- School of Pharmacy, Newcastle Univesity, Newcastle upon Tyne, United Kingdom .,Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Andrew K Husband
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Neil Watson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - David W Bates
- Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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Fahs IM, Hallit S, Rahal MK, Malaeb DN. The Community Pharmacist's Role in Reducing Cardiovascular Risk Factors in Lebanon: A Longitudinal Study. Med Princ Pract 2018; 27:508-514. [PMID: 29898452 PMCID: PMC6422117 DOI: 10.1159/000490853] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 06/13/2018] [Accepted: 06/13/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To assess the role of the pharmacist in modifying risk factors for cardiovascular disease (CVD) among Lebanese adults in urban and rural areas. METHODS In a prospective survey, 865 out of 1,000 participants aged ≥45 years, previously interviewed, agreed to be followed at 1 and 2 years time points. Parameters including blood pressure, lipid profile, blood glucose, average number of risk factors, and atherosclerotic CVD (ASCVD) risk were assessed and evaluated at the beginning of the study, then after 1 and 2 years. RESULTS During both follow-ups, the mean average body mass index and systolic blood pressure decreased significantly and the lipid profile improved significantly. Further significant improvements in ASCVD risk occurred during the second follow-up. Monitoring parameters revealed significant improvements as well. CONCLUSION This study showed that a plan that includes pharmacists, who regularly monitor and follow-up patients, could improve CVD prevention through the reduction of risk factors.
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Affiliation(s)
- Iqbal M Fahs
- School of Pharmacy, Lebanese International University, Mouseitbah, Lebanon
| | - Souheil Hallit
- Faculty of Pharmacy, Saint-Joseph University of Beirut, Beirut,
- Lebanese University, Faculty of Pharmacy, Beirut,
- Holy Spirit University of Kaslik, Faculty of Medicine and Medical Sciences, Kaslik,
- Research Department, Psychiatric Hospital of the Cross, Jal Eddib,
- Occupational Health Environment Research Team, U1219 BPH Bordeaux Population Health Research Center Inserm, Université de Bordeaux, Bordeaux,
- INSPECT-LB: Institut National de Sante Publique, Epidemiologie Clinique et Toxicologie, Faculty of Public Health, Lebanese University, Beirut,
| | - Mohamad K Rahal
- School of Pharmacy, Lebanese International University, Mouseitbah, Lebanon
| | - Diana N Malaeb
- School of Pharmacy, Lebanese International University, Mouseitbah, Lebanon
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12
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Cytochrome P450 interactions are common and consequential in Massachusetts hospital discharges. THE PHARMACOGENOMICS JOURNAL 2017; 18:347-350. [PMID: 28696416 DOI: 10.1038/tpj.2017.30] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 05/01/2017] [Accepted: 05/10/2017] [Indexed: 11/08/2022]
Abstract
Despite the recognition that drug-drug interactions contribute substantially to preventable health-care costs, the prevalence of such interactions related to the cytochrome P450 system in clinical practice remains poorly characterized. This study drew retrospective hospital discharge cohorts from a large health claims data set and a large health system data set. For every hospital discharge, frequency of co-occurrence of substrates and inducers or inhibitors at cytochrome P450 2D6, 2C19, 3A4 and 1A2 were determined. A total of 124 520 individuals in the state of Massachusetts (health claims cohort) and 77 026 individuals in two large academic medical centers (electronic health record (EHR) cohort) were examined. In the claims cohort, 35 157 (28.2%) exhibited at least one CYP450 drug-drug interaction at hospital discharge, whereas in the EHR cohort, 36 750 (47.7%) had at least one interaction. The most commonly affected CYP450 systems were 2C19 and 2D6, with putative interactions observed in at least 10% of individuals at discharge in each cohort. Odds of hospital readmission within 90 days among those discharged with at least one interaction were 10-16% greater, with mean health-care cost $574/month greater over the subsequent year, after adjusting for age, sex, insurance type, total number of medications prescribed, Charlson comorbidity score and presence or absence of a psychiatric diagnosis. These two distinct clinical data types show that CYP450 drug-drug interactions are prevalent and associated with greater probability of early hospital readmission and greater health-care cost, despite the widespread availability and application of drug-drug interaction checking software.
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Roblek T, Deticek A, Leskovar B, Suskovic S, Horvat M, Belic A, Mrhar A, Lainscak M. Clinical-pharmacist intervention reduces clinically relevant drug-drug interactions in patients with heart failure: A randomized, double-blind, controlled trial. Int J Cardiol 2015; 203:647-52. [PMID: 26580349 DOI: 10.1016/j.ijcard.2015.10.206] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 10/25/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Incidence of drug-drug interactions (DDIs) increases with complexity of treatment and comorbidities, as in heart failure (HF). This randomized, double-blind study evaluated the intervention of the pharmacist on prevalence of clinically relevant DDIs (NCT01855165). METHODS Patients admitted with HF were screened for clinically relevant DDIs, and randomized to control or intervention. All attending physicians received standard advice about pharmacological therapy; those in the intervention group also received alerts about clinically relevant DDIs. Primary endpoint was DDI at discharge and secondary were re-hospitalization or death during follow-up. RESULTS Of 213 patients, 51 (mean age, 79 ± 6 years; male, 47%) showed 66 clinically relevant DDIs and were randomized. For intervention (n=26) versus control (n=25), the number of patients with and the number of DDIs were significantly lower at discharge: 8 vs. 18 and 10 vs. 31; p=0.003 and 0.0049, respectively. Over a 6 month follow-up period, 11 control and 9 intervention patients were re-hospitalized or died (p>0.2 for all). No significant differences were seen between control and intervention for patients with eGFR <60 mL/min/1.73 m(2) (78%) for re-hospitalization or death (10 vs. 7; p=0.74). CONCLUSIONS Pharmacist intervention significantly reduces the number of patients with clinically relevant DDIs, but not clinical endpoints 6 months from discharge.
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Affiliation(s)
- Tina Roblek
- Faculty of Pharmacy, University of Ljubljana, Askerceva cesta 7, Ljubljana, Slovenia; Lek d.d., Verovskova 57, Ljubljana, Slovenia
| | - Andreja Deticek
- Faculty of Pharmacy, University of Ljubljana, Askerceva cesta 7, Ljubljana, Slovenia
| | - Bostjan Leskovar
- Department of Internal Medicine, General Hospital Trbovlje, Rudarska 9, Trbovlje, Slovenia
| | | | | | - Ales Belic
- Lek d.d., Verovskova 57, Ljubljana, Slovenia
| | - Ales Mrhar
- Faculty of Pharmacy, University of Ljubljana, Askerceva cesta 7, Ljubljana, Slovenia
| | - Mitja Lainscak
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; Department of Cardiology, Department of Research and Education, General Hospital Celje, Celje, Slovenia.
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Slight SP. Capsule Commentary on Shelton et al., Reducing PSA-Based Prostate Cancer Screening in Men ≥ 75 Years Old with Highly Specific Computerized Clinical Decision Support. J Gen Intern Med 2015; 30:1187. [PMID: 25805504 PMCID: PMC4510239 DOI: 10.1007/s11606-015-3286-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Sarah Patricia Slight
- Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont St. 3rd floor, Boston, MA, 02120, USA,
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Roblek T, Vaupotic T, Mrhar A, Lainscak M. Drug-drug interaction software in clinical practice: a systematic review. Eur J Clin Pharmacol 2014; 71:131-42. [PMID: 25529225 DOI: 10.1007/s00228-014-1786-7] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 11/18/2014] [Indexed: 01/23/2023]
Abstract
PURPOSE Several electronic databases which report the prevalence of drug-drug interactions (DDIs) are used as a tool for evaluation of potentially harmful DDIs. The aim of our review was to evaluate the usability and appropriateness of commercially available electronic databases which assess the prevalence of potential DDIs. METHODS The systematic electronic literature search was conducted with the following search terms: "database" AND "software," and "drug-drug interactions" AND "database," and the inclusion and exclusion criteria were applied in order to identify the publications of interest. RESULTS A total of 3766 papers were identified by systematic search. After applying inclusion and exclusion criteria, 38 publications were included in the analysis. The most commonly used software in the included studies was Micromedex® Drug-Reax, for which some authors argue to be the most reliable due to highest sensitivity. It gives information about clinical consequences of DDIs, classifies underlying mechanism and onset of the adverse outcome (either rapid, or delayed) as well as severity (such as minor, moderate, or major), and provides the level of evidence which supports this information. This data is also provided by Drug Interaction Facts®, Lexi-Interact®, and Pharmavista®. A small number of studies which compared assessment of DDIs with electronic database and the clinician's assessment showed large discrepancy in number and relevance of detected DDIs. The overlap was in some cases as low as 11 %. CONCLUSION The deficiency of clinical relevance of detected DDIs should be addressed in the upcoming research as it would provide more relevant information to the prescribers' in clinical practice.
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Affiliation(s)
- Tina Roblek
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
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Simpao AF, Ahumada LM, Desai BR, Bonafide CP, Gálvez JA, Rehman MA, Jawad AF, Palma KL, Shelov ED. Optimization of drug-drug interaction alert rules in a pediatric hospital's electronic health record system using a visual analytics dashboard. J Am Med Inform Assoc 2014; 22:361-9. [PMID: 25318641 DOI: 10.1136/amiajnl-2013-002538] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To develop and evaluate an electronic dashboard of hospital-wide electronic health record medication alerts for an alert fatigue reduction quality improvement project. METHODS We used visual analytics software to develop the dashboard. We collaborated with the hospital-wide Clinical Decision Support committee to perform three interventions successively deactivating clinically irrelevant drug-drug interaction (DDI) alert rules. We analyzed the impact of the interventions on care providers' and pharmacists' alert and override rates using an interrupted time series framework with piecewise regression. RESULTS We evaluated 2 391 880 medication alerts between January 31, 2011 and January 26, 2014. For pharmacists, the median alert rate prior to the first DDI deactivation was 58.74 alerts/100 orders (IQR 54.98-60.48) and 25.11 alerts/100 orders (IQR 23.45-26.57) following the three interventions (p<0.001). For providers, baseline median alert rate prior to the first round of DDI deactivation was 19.73 alerts/100 orders (IQR 18.66-20.24) and 15.11 alerts/100 orders (IQR 14.44-15.49) following the three interventions (p<0.001). In a subgroup analysis, we observed a decrease in pharmacists' override rates for DDI alerts that were not modified in the system from a median of 93.06 overrides/100 alerts (IQR 91.96-94.33) to 85.68 overrides/100 alerts (IQR 84.29-87.15, p<0.001). The medication serious safety event rate decreased during the study period, and there were no serious safety events reported in association with the deactivated alert rules. CONCLUSIONS An alert dashboard facilitated safe rapid-cycle reductions in alert burden that were temporally associated with lower pharmacist override rates in a subgroup of DDIs not directly affected by the interventions; meanwhile, the pharmacists' frequency of selecting the 'cancel' option increased. We hypothesize that reducing the alert burden enabled pharmacists to devote more attention to clinically relevant alerts.
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Affiliation(s)
- Allan F Simpao
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Luis M Ahumada
- Department of Enterprise Analytics and Reporting, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bimal R Desai
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher P Bonafide
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jorge A Gálvez
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mohamed A Rehman
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Abbas F Jawad
- Department of Biostatistics in Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Krisha L Palma
- Department of Pharmacy Services, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eric D Shelov
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Kulkarni V, Bora SS, Sirisha S, Saji M, Sundaran S. A study on drug-drug interactions through prescription analysis in a South Indian teaching hospital. Ther Adv Drug Saf 2014; 4:141-6. [PMID: 25114777 DOI: 10.1177/2042098613490009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The objective of this study was to assess the drug-drug interactions (DDIs) through prescription analysis among the inpatients of a South Indian teaching hospital. METHODS The study was a prospective observational prescription analysis conducted for a period of 6 months, from October 2010 to March 2011. The prescriptions having two or more drugs and where a DDI was suspected were selected by the physician in charge of the ward. The drugs in the prescription were then entered into the drug interaction checker software. The DDIs were classified based on the mechanism of interactions, severity of interactions, relation to the number of drugs prescribed, and disease conditions were also determined. RESULTS A total of 204 prescriptions were analyzed, of which 186 prescriptions had 856 DDIs. Most of the DDIs were pharmacokinetic drug interactions (42%) followed by unknown mechanisms (34%) and pharmacodynamic mechanisms (24%). The study findings showed that the prescriptions for cardiovascular with respiratory disease conditions had the greatest number of drug interactions on average. A severity assessment showed that majority of the DDIs were moderate (70%) followed by minor (28%). The study results showed that as the number of drugs increases in a prescription, the number of DDIs also increases. The interventions determined showed that dosage adjustment (12%) was to be followed in most of the DDIs. CONCLUSION This study assists in understanding the factors associated with DDIs that can help in safe and effective use of drugs in the future.
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Affiliation(s)
- Vijay Kulkarni
- JSS College of Pharmacy (A Constituent College of JSS University) Post Box No.20, Ooty - 643 001 Tamil Nadu, India
| | | | - Sapineni Sirisha
- JSS College of Pharmacy - Pharmacy Practice, Rocklands, Ooty, Tamil Nadu, India
| | - Mohammed Saji
- JSS College of Pharmacy - Pharmacy Practice, Rocklands, Ooty, Tamil Nadu, India
| | - Siraj Sundaran
- JSS College of Pharmacy - Pharmacy Practice, Rocklands, Ooty, Tamil Nadu, India
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Affiliation(s)
- Victor Serebruany
- From the HeartDrug Research Laboratories, Johns Hopkins University, Towson, Maryland (V.S.); and Department of Cardiology, Division of Medicine, Oslo University Hospital Ulleval and Institute for Clinical Sciences, University of Oslo, Oslo, Norway (D.A.)
| | - Dan Atar
- From the HeartDrug Research Laboratories, Johns Hopkins University, Towson, Maryland (V.S.); and Department of Cardiology, Division of Medicine, Oslo University Hospital Ulleval and Institute for Clinical Sciences, University of Oslo, Oslo, Norway (D.A.)
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