Preventable and non-preventable adverse drug events in hospitalized patients: a prospective chart review in the Netherlands

International Trends in Adverse Drug Event-Related Mortality from 2001 to 2019: An Analysis of the World Health Organization Mortality Database from 54 Countries

BACKGROUND AND OBJECTIVE

Adverse drug events (ADEs) are becoming a significant public health issue. However, reports on ADE-related mortality are limited to national-level evaluations. Therefore, we aimed to reveal overall trends in ADE-related mortality across the 21st century on an international level.

METHODS

This observational study analysed long-term trends in ADE-related mortality rates from 2001 to 2019 using the World Health Organization Mortality Database. The rates were analysed according to sex, age and region. North America, Latin America and the Caribbean, Western Europe, Eastern Europe and Western Pacific regions were assessed. Fifty-four countries were included with four-character International Statistical Classification of Disease and Related Health Problems, Tenth Revision codes in the database, population data in the World Population Prospects 2019 report, mortality data in more than half of the study period, and high-quality or medium-quality death registration data. A locally weighted regression curve was used to show international trends in age-standardised rates.

RESULTS

The global ADE-related mortality rate per 100,000 population increased from 2.05 (95% confidence interval 0.92-3.18) in 2001 to 6.86 (95% confidence interval 5.76-7.95) in 2019. Mortality rates were higher among men than among women, especially in those aged 20-50 years. The population aged ≥ 75 years had higher ADE-related mortality rates than the younger population. North America had the highest mortality rate among the five regions. The global ADE-related mortality rate increased by approximately 3.3-fold from 2001 to 2019.

CONCLUSIONS

The burden of ADEs has increased internationally with rising mortality rates. Establishing pharmacovigilance systems can facilitate efforts to reduce ADE-related mortality rates globally.

Prescriptive Appropriateness: Inhospital Adherence to Proton Pump Inhibitors Deprescription Flow Chart

The prescriptive appropriateness of Proton Pump Inhibitors (PPIs) in polypharmacy is controversial. PPIs are often overprescribed and the risk of prescribing errors and adverse drug reactions increases for each additional drug added to therapy. Hence, guided deprescription should be considered and easily implementable in ward practice. This observational prospective study evaluated the implementation of a validated PPIs deprescription flow chart to real-life internal ward activity through the presence of a clinical pharmacologist as an enhancing additional factor by assessment of inhospital prescriber's adherence to the proposed flow chart. Patients' demographics and prescribing trends of PPIs prescriptions were analyzed by descriptive statistics. The final analysis of data included ninety-eight patients (forty-nine male and forty-nine female), aging 75.6 ± 10.6 years; 55.1% of patients had home-PPIs prescriptions, while 44.9% received inhospital-PPIs prescriptions. Evaluation of prescriber's adherence to the flow chart revealed that the percentage of patients with a prescriptive/deprescriptive pathway conforming to that of the flow chart was 70.4%, with low symptomatologic recurrences. The clinical pharmacologists' presence and influence in ward activity may have contributed to this finding, since continuous training of the prescribing physicians is deemed a success-related factor in the deprescribing strategy. Multidisciplinary management of PPIs deprescription protocols shows high adherence by prescribers in real-life hospital settings and low recurrence events.

Impact of suspected adverse drug reactions on mortality and length of hospital stay in the hospitalised patients: a meta-analysis

PURPOSE

To estimate the risk of mortality and length of stay in hospitalised patients who have experienced suspected adverse drug reactions (ADRs) as compared to patients who did not experience suspected ADRs.

METHODS

A systematic literature search was conducted on databases for observational and randomised controlled studies conducted in any inpatient setting that reported deaths and/or length of hospital stay in patients who had suspected ADRs and did not have suspected ADRs during hospitalisation. PRISMA guidelines were strictly followed during the review. The methodological quality of included studies was assessed using a tool designed by Smyth et al. for the studies of adverse drug reactions. The meta-analytic summary of all-cause mortality was estimated using odds ratio-OR (95% CI) and length of stay using mean difference-MD (95% CI). Both outcomes were pooled using a random effect model (DerSimonian and Laird method). Subgroup and meta-regression were performed based on study variables: study design, age group, study ward, study region, types of suspected ADRs (ADR_Ad-suspected ADRs that lead to hospitalisation and ADR_In-suspected ADRs that occur following hospitalisation), study duration, sample size and study period. The statistical analysis was conducted through the 'Review manager software version 5.4.1 and JASP (Version 0.14.1)'.

RESULTS

After screening 475 relevant articles, 55 studies were included in this meta-analysis. Patients having suspected ADRs had reported significantly higher odds of all-cause mortality [OR: 1.50 (95% CI: 1.21-1.86; I² = 100%) than those patients who did not have suspected ADRs during hospitalisation. Study wards, types of suspected ADRs and sample size were observed as significant predictors of all-cause mortality (p < 0.05). Patients having suspected ADRs had reported significantly higher mean difference in hospital stay [MD: 3.98 (95% CI: 2.91, 5.05; I² = 99%) than those patients who did not have suspected ADRs during hospitalisation. Types of suspected ADRs and study periods were observed as significant predictors of length of stay (p < 0.05).

CONCLUSION

Suspected ADRs significantly increase the risk of mortality and length of stay in hospitalised patients.

SYSTEMATIC REVIEW REGISTRATION

CRD42020176320.

Drug‐related problems among hospitalized hypertensive and heart failure patients and physician acceptance of pharmacists' interventions at a teaching hospital in Ghana

Background

Hypertensive and heart failure patients frequently require multiple drug therapy which may be associated with drug‐related problems (DRPs).

Aim

To determine the frequency, types, and predictors of DRPs, and acceptance of pharmacists' interventions among hospitalized hypertensive and heart failure patients.

Method

It was a prospective cross‐sectional study at the internal medicine department wards of Korle Bu Teaching Hospital (KBTH) between January and June 2019 using a validated form (the pharmaceutical care form used by clinical pharmacists at the medical department). DRPs were classified based on the Pharmaceutical Care Network Europe (PCNE) Classification scheme for DRPs V8.02. Descriptive and inferential statistics were used for data analysis.

Results

A total of 247 DRPs were identified in 134 patients. The mean number of DRPs was 1.84 (SD: 1.039) per patient. Most DRPs occurred during the prescribing process (40.5%; n(DRPs) = 100), and the highest prescribing problem was untreated indication (11.7%; n = 29). Other frequent DRPs were medication counseling need (25.1%; n = 62), administration errors 10.1%(n = 25), drug interaction (10.5%; n = 26), and “no” or inappropriate monitoring (10.5%; n = 26). The number of drugs received significantly predicted the number of DRPs (adjusted odds ratio [AOR]: 9.85; 95% CI: 2.04–47.50; p < 0.001). Clinical variables were significant predictors of number of DRPs (diabetic status: AOR: 0.41, 95% CI: 0.18–0.98, p < 0.05; statin use: AOR: 0.34, 95% CI: 0.14–0.81, p < 0.05; antiplatelet use: AOR: 5.95, 95% CI: 2.03–17.48, p < 0.01). Average acceptance of interventions by physicians was 71.6% (SD: 11.7). Most (70.6%; n = 48) accepted interventions were implemented by physicians (resolved).

Conclusion

DRPs frequently occur, with most problems identified in the prescribing process. Medication counseling was frequently needed. Patients' number of drugs and clinical factors predicted the occurrence of DRPs. Physicians accepted and implemented most interventions. Our findings suggest that clinical pharmacists have an important role in cardiovascular patient care, but this study should be replicated in other hospitals in Ghana to corroborate these findings.

Systematic Review of Risk Factors Assessed in Predictive Scoring Tools for Drug-Related Problems in Inpatients

Drug-related problems (DRP, defined as adverse drug events/reactions and medication errors) are a common threat for patient safety. With the aim to aid improved allocation of specialist resources and to improve detection and prevention of DRP, numerous predictive scoring tools have been proposed. The external validation and evidence for the transferability of these tools still faces limitations. However, the proposed scoring tools include partly overlapping sets of similar factors, which may allow a new approach to estimate the external usability and validity of individual risk factors. Therefore, we conducted this systematic review and analysis. We identified 14 key studies that assessed 844 candidate risk factors for inclusion into predictive scoring tools. After consolidation to account for overlapping terminology and variable definitions, we assessed each risk factor in the number of studies it was assessed, and, if it was found to be a significant predictor of DRP, whether it was included in a final scoring tool. The latter included intake of ≥ 8 drugs, drugs of the Anatomical Therapeutic Chemical (ATC) class N, ≥1 comorbidity, an estimated glomerular filtration rate (eGFR) <30 mL/min and age ≥60 years. The methodological approach and the individual risk factors presented in this review may provide a new starting point for improved risk assessment.

Adverse drug reactions and correlations with drug–drug interactions: A retrospective study of reports from 2011 to 2020

Introduction: Adverse drug reactions (ADRs) represent a public health problem worldwide that deserves attention due to the impact on mortality, morbidity, and healthcare costs. Drug–drug interactions (DDIs) are an important contributor to ADRs. Most of the studies focused only on potential DDIs (pDDIs), while the detailed data are limited regarding the ADRs associated with actual DDIs.

Methods: This retrospective study evaluated ADRs reported between 2011 and 2020 in a tertiary hospital. The causality and severity of ADRs were evaluated through the Naranjo Algorithm and Hartwig’s scale, respectively. Preventability classification was based on the modified Schoumock and Thornton scale. For ADRs with at least two suspected drugs, pDDIs were identified according to the Lexi-Interact. We further checked whether the ADR description in the reports corresponded to the clinical consequences of the pDDIs.

Results: A total of 1,803 ADRs were reported, of which 36.77% ADRs were classified as mild, 43.26% as moderate, and 19.97% as severe. The assessment of causality showed that the distributions of definite, probable, and possible categories were 0.33%, 58.68%, and 40.99%, respectively. A total of 53.97% of ADRs were identified as preventable ADRs, while 46.03% were recognized as unpreventable. The severity of ADRs was significantly correlated with age, the number of suspected drugs and preventability. Antimicrobial agents were the most common implicated pharmacological group, and the most frequently affected system was the gastrointestinal system. Considering individual drugs, aspirin was the most frequently reported drug. Among 573 ADRs with at least two suspected drugs, 105 ADRs were caused by actual DDIs, of which only 59 and 6 ADRs were caused by actual DDIs in category D and X, respectively. The most frequent drugs involved in actual DDIs of category D were aspirin and heparin, with the majority of ADRs being gastrointestinal bleeding.

Conclusion: This study analyzed the pattern of ADRs in detail and obtained clinical evidence about ADRs associated with actual DDIs. These findings may be useful to compare patterns between different centers and to design preventive strategies for ADRs. Continuous education and training should be provided for physicians regarding the knowledge and recognition of ADRs associated with DDIs.

The Sex-Specific Impact of the FORTA (Fit-fOR-The-Aged) List on Medication Quality and Clinical Endpoints in Older Hospitalized Patients: Secondary Analysis of a Randomized Controlled Trial

Background

Little is known about the sex-specific impact of drug optimization tools such as the Fit fOR The Aged (FORTA) list on drug use and relevant clinical endpoints in older people.

Objective

We aimed to detect gender differences of interventional effects on medication quality and related clinical effects in the VALFORTA trial.

Patients and methods

A sex-specific analysis of data from 409 patients (147 men and 262 women, mean age 79.4 and 82.7 years, respectively) in acute geriatric care comparing the control and FORTA intervention groups was performed. Changes of the FORTA score (sum of over- and undertreatment errors per patient), the incidence of adverse drug events (ADEs) during hospitalization, and several clinically relevant endpoints [e.g., the Barthel index (BI)] were tested for equivalence at a 20% margin. “Success” or “failure” for the development of these clinical endpoints was defined and their frequencies compared by a risk reduction analysis.

Results

Sex differences were insignificant for the reduction of the FORTA score, the improvement of BI, or over- and undertreatment errors (p > 0.05). In women only, the FORTA intervention significantly increased the number of patients without an ADE (p = 0.010). Statistical sex equivalence was found for the improvement of the FORTA scores, BI, and the number of prevented events (e.g., falls, confusion, or renal failure) (p < 0.05), but not for the improvement of specific mistreatments or over- and undertreatment scores under altered inclusion criteria (p > 0.05).

Conclusions

Both sexes benefit equally from the FORTA intervention regarding the amelioration of the quality of drug treatment as well as several clinically relevant outcomes. In addition, the positive impact of the FORTA intervention on the number of adverse drug events appears to be greater in women.

Trial Registration Number

DRKS00000531.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40801-022-00292-9.

Development and Implementation of an e-Trigger Tool for Adverse Drug Events in a Swiss University Hospital

PURPOSE

The purpose of the study was to develop and implement an institution-specific trigger tool based on the Institute for Healthcare Improvement medication module trigger tool (IHI MMTT) in order to detect and monitor ADEs.

METHODS

We performed an investigator-driven, single-center study using retrospective and prospective patient data to develop ("development phase") and implement ("implementation phase") an efficient, institution-specific trigger tool based on the IHI MMTT. Complete medical data from 1008 patients hospitalized in 2018 were used in the development phase. ADEs were identified by chart review. The performance of two versions of the tool was assessed by comparing their sensitivities and specificities. Tool A employed only digitally extracted triggers ("e-trigger-tool") while Tool B employed an additional manually extracted trigger. The superior tool - taking efficiency into account - was applied prospectively to 19-22 randomly chosen charts per month for 26 months during the implementation phase.

RESULTS

In the development phase, 189 (19%) patients had ≥1 ADE (total 277 ADEs). The time needed to identify these ADEs was 15 minutes/chart. A total of 203 patients had ≥1 trigger (total 273 triggers - Tool B). The sensitivities and specificities of Tools A and B were 0.41 and 0.86, and 0.43 and 0.86, respectively. Tool A was more time-efficient than Tool B (4 vs 9 minutes/chart) and was therefore used in the implementation phase. During the 26-month implementation phase, 22 patients experienced trigger-identified ADEs and 529 did not. The median number of ADEs per 1000 patient days was 6 (range 0-13). Patients with at least one ADE had a mean hospital stay of 22.3 ± 19.7 days, compared to 8.0 ± 7.6 days for those without an ADE (p = 2.7×10-14).

CONCLUSION

We developed and implemented an e-trigger tool that was specific and moderately sensitive, gave consistent results and required minimal resources.

Medication-related adverse events in health care-what have we learned? A narrative overview of the current knowledge

Purpose

Although medication-related adverse events (MRAEs) in health care are vastly studied, high heterogeneity in study results complicates the interpretations of the current situation. The main objective of this study was to form an up-to-date overview of the current knowledge of the prevalence, risk factors, and surveillance of MRAEs in health care.

Methods

Electronic databases (PubMed, MEDLINE, Web of Science, and Scopus) were searched with applicable search terms to collect information on medication-related adverse events. In order to obtain an up-to-date view of MRAEs, only studies published after 2000 were accepted.

Results

The prevalence rates of different MRAEs vary greatly between individual studies and meta-analyses. Study setting, patient population, and detection methods play an important role in determining detection rates, which should be regarded while interpreting the results. Medication-related adverse events are more common in elderly patients and patients with lowered liver or kidney function, polypharmacy, and a large number of additional comorbidities. However, the risk of MRAEs is also significantly increased by the use of high-risk medicines but also in certain care situations. Preventing MRAEs is important as it will decrease patient mortality and morbidity but also reduce costs and functional challenges related to them.

Conclusions

Medication-related adverse events are highly common and have both immediate and long-term effects to patients and healthcare systems worldwide. Conclusive solutions for prevention of all medication-related harm are impossible to create. In the future, however, the development of efficient real-time detection methods can provide significant improvements for event prevention and forecasting.

Clinical factors associated with increased length of stay and readmission in patients with medication-related hospital admissions: a retrospective study

BACKGROUND

Adverse drug events (ADEs) remain a key contributor to hospitalisations, resulting in long hospital stays and readmissions. Information pertaining to the specific medications and clinical factors associated with these outcomes is limited. Hence, a better understanding of these factors and their relationship to ADEs is required.

OBJECTIVES

To investigate medications involved, clinical manifestations of ADE-related hospitalisations, and their association with length of stay and readmission.

METHODS

A retrospective medical record review of patients admitted to a major, tertiary referral hospital in NSW, Australia, from January 2019 to August 2020 was conducted. ADEs were identified using Australian Refined Diagnosis Related Group (AR-DRG) codes: X40, X61, X62 and X64. Medications were classified per the Anatomical Therapeutic Chemical (ATC) classification system and clinical symptoms were classified per the International Classification of Disease (ICD) 9-CM. Logistic regression was performed to assess the relationship between medication and presentation classes with length of stay (≥2 days vs <2 days) and readmission.

RESULTS

There were 125 patients who met inclusion criteria (median age = 64 [interquartile range, 45-75] years; 53.6% male). Anti-thrombotic agents, opioids, antidepressants, antipsychotics, insulins and NSAIDs were the most implicated pharmacological classes. Neurological medications and falls were associated with a length of stay ≥2 days (adjusted odds ratio [aOR] 3.92, 95% confidence interval [CI] 1.48-10.33 and aOR 3.24, 95% CI 1.05-10.06, respectively). Neurological medications and neurological and cognitive disorders were associated with an increased likelihood of 90-day readmission (aOR 2.63, 95% CI 1.05-6.57 and aOR 3.20, 95% CI 1.17-8.75, respectively).

CONCLUSION

This study identified neurological medications as high-risk for increased length of stay and readmission in those hospitalised due to ADEs. This highlights the need for judicious prescribing and monitoring of these medications.

Life-Threatening and Fatal Adverse Drug Events in a Danish University Hospital

OBJECTIVES

Detection of adverse drug events (ADEs) in Danish hospitals relies on health care professionals' incident reporting to a national database for adverse events, but the method is incomplete; thus, fatal and life-threatening ADEs may remain unrecognized.The objectives of this study were to examine the occurrence of life-threatening and fatal ADEs in population of hospitalized patients with suspected adverse outcome and to compare these findings with the actual number of reported ADEs in the study period of 3 months.

METHODS

Study was designed as a cross-sectional study of adult population, hospitalized for more than 24 hours, having an unplanned transfer to an intensive care unit (ICU), or having unexpected death. Medical records were retrospectively screened by the Global Trigger Tool. All positive triggers were assessed for ADEs by a clinical pharmacologist.

RESULTS

Of the 26,176 patients admitted in the study period, 105 had an unplanned transfer to the ICU and 36 died unexpectedly. In total, 15 positive triggers were identified in 10 patients. Life-threatening ADEs accounted for 7.6% (8/105) of patients transferred to the ICU, and fatal ADEs constituted 5.5% (2/36) of the deceased patients. Life-threatening and fatal ADEs corresponded to an overall prevalence of 0.04% (10/26,176). Most ADEs were related to hemorrhages and respiratory problems. No serious or fatal ADEs were reported in the incident reporting system in the study period.

CONCLUSIONS

Ten life-threatening and fatal ADEs were uncovered as not reported in the incident reporting system. Further steps are needed for recognition and prevention of this patient safety challenge.

A patient-centred approach to deprescribing antiretroviral therapy in people living with HIV

Only a few studies have explored the benefit of deprescribing in people living with HIV (PLWH), focusing on the discontinuation of non-antiretrovirals (non-ARVs) used for HIV-associated comorbidities (co-medications), or the management of drug-drug interactions (DDIs) between ARVs or between ARVs and co-medications. The availability of modern single-tablet regimens, two-drug regimens and long-acting therapy opens a discussion regarding ARV deprescribing strategies. The objective of this article is to discuss ARV deprescribing strategies in the context of medication-related burden and patients' lived experience with medicine (PLEM) and to suggest indications for whom, when, how and why to consider these ARV options in PLWH. A PLEM construct helps to better interpret these strategies and provides a patient-centred precision-medicine approach. There are several safe and virologically effective ARV deprescribing strategies, but the ultimate benefits of these interventions still need to be further explored in terms of the overall health and quality of life of patients.

Beliefs and attitudes about deprescription in older HIV-infected patients: ICARD Project

OBJECTIVE

HIV population is aging at an earlier age than those uninfected, requiring more non-HIV medications to treat noncommunicable diseases. In the context of chronic HIV infection, the next therapeutic change would be the polymedication control. This paper has the purpose of explore the attitudes of older people living with HIV toward deprescribing.

METHODS

This was an observational, prospective and multicenter study conducted from March-April, 2018. People living with HIV (PLWH) on highly active antiretroviral therapy and older than 65 years were included. In addition to demographic and pharmacotherapeutic data, attitudes regarding deprescribing were collected through the "Revised Patients' Attitudes Towards Deprescribing Questionnaire".

RESULTS

A total of 42 patients were included in this study. Regarding their attitudes in relation to deprescription, there were three statements with the most consensuses. The first ("I have a good understanding of the reasons I was prescribed each of my medicines") had 91.9% consensus. The second and third questions showed 89.2% consensus in both cases; "Overall, I am satisfied with my current medicines" and "I like to be involved in making decisions about my medicines with my doctors".

CONCLUSIONS

This study is the first to explore the beliefs and attitudes of older PLWH in relation to deprescription process. There are positive attitudes regarding medication knowledge but there also is a percentage of patients who had a negative opinion regarding deprescription. We must study and go deeper in our knowledge of techniques that could help us to better understand their preferences, in order to establish effective and successful deprescription strategies.

Multimorbidity, polypharmacy, and drug-drug-gene interactions following a non-ST elevation acute coronary syndrome: analysis of a multicentre observational study

BACKGROUND

The number of patients living with co-existing diseases is growing. This study aimed to assess the extent of multimorbidity, medication use, and drug- and gene-based interactions in patients following a non-ST elevation acute coronary syndrome (NSTE-ACS).

METHODS

In 1456 patients discharged from hospital for a NSTE-ACS, comorbidities and multimorbidity (≥ 2 chronic conditions) were assessed. Of these, 698 had complete drug use recorded at discharge, and 652 (the 'interaction' cohort) had drug use and actionable genotypes available for CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP3A5, DPYD, F5, SLCO1B1, TPMT, UGT1A1, and VKORC1. The following drug interactions were investigated: pharmacokinetic drug-drug (DDIs) involving CYPs (CYPs above, plus CYP1A2, CYP2C8, CYP3A4), SLCO1B1, and P-glycoprotein; drug-gene (DGIs); drug-drug-gene (DDGIs); and drug-gene-gene (DGGIs). Interactions predicted to be 'substantial' were defined as follows: DDIs due to strong inhibitors/inducers, DGIs due to variant homozygous/compound heterozygous genotypes, and DDGIs/DGGIs where the constituent DDI/DGI(s) both influenced the victim drug in the same direction.

RESULTS

In the whole cohort, 727 (49.9%) patients had multimorbidity. Non-linear relationships between age and increasing comorbidities and decreasing coronary intervention were observed. There were 98.1% and 39.8% patients on ≥ 5 and ≥ 10 drugs, respectively (from n = 698); women received more non-cardiovascular drugs than men (median (IQR) 3 (1-5) vs 2 (1-4), p = 0.014). Overall, 98.7% patients had at least one actionable genotype. Within the interaction cohort, 882 interactions were identified in 503 patients (77.1%), of which 346 in 252 patients (38.7%) were substantial: 59.2%, 11.6%, 26.3%, and 2.9% substantial interactions were DDIs, DGIs, DDGIs, and DGGIs, respectively. CYP2C19 (49.5% of all interactions) and SLCO1B1 (18.4%) were involved in the largest number of interactions. Multimorbidity (p = 0.019) and number of drugs (p = 9.8 × 10-10) were both associated with patients having ≥ 1 substantial interaction. Multimorbidity (HR 1.76, 95% CI 1.10-2.82, p = 0.019), number of drugs (HR 1.10, 95% CI 1.04-1.16, p = 1.2 × 10-3), and age (HR 1.05, 95% CI 1.03-1.07, p = 8.9 × 10-7), but not drug interactions, were associated with increased subsequent major adverse cardiovascular events.

CONCLUSIONS

Multimorbidity, polypharmacy, and drug interactions are common after a NSTE-ACS. Replication of results is required; however, the high prevalence of DDGIs suggests integrating co-medications with genetic data will improve medicines optimisation.

Effect of medication reconciliation on patient reported potential adverse events after hospital discharge

BACKGROUND

Although medication reconciliation (MedRec) is effective in decreasing medication discrepancies, the effectiveness on Adverse Events (AEs) is very scarce. The objective of this study was to assess the effect of MedRec by a pharmacy team on patient-reported, potential AEs post-discharge.

METHODS

This was a multicenter prospective intervention study with before-after design at two Dutch hospitals. Participants were patients aged ≥18 years admitted for more than 48 h using three or more prescription medications upon discharge. Patients in the control group received usual care. In the intervention period, a trained team of pharmacy staff executed medication reconciliation consisting of patient education upon admission and discharge, review of prescribed medication to identify errors, and information transfer to primary care. To address the primary outcome, the difference in proportion of patients with one or more potential AEs was measured by a structured telephone interview, two weeks after discharge between usual care and intervention group. To address the second outcome, the difference in median number of potential AEs per patient was calculated. Other outcomes assessed included the association between the intervention and patient characteristics.

RESULTS

In total, 221 (138 usual care and 83 intervention) patients were included. The proportion of control and intervention patients with AEs was 88.4% and 86.7% respectively (p > 0.05). The median number of potential AEs per patient was lower in the intervention group compared with usual care (1.1 vs. 2.1, p < 0.0001). Being in the intervention arm was associated with less potential AEs (RR 0.5, 95% CI [0.4-0.6]), whereas being previously admitted was associated with a higher number of potential AEs (RR 1.3, 95% CI [1.1-1.5]). The effect of the intervention on the number of potential AE was stronger among women compared with men (p = 0.04).

CONCLUSION

Although the intervention did not decrease the proportion of patients with AEs, a significant reduction in the median number of potential AEs after hospital discharge between the intervention and usual care group was observed.

What do older adults with multimorbidity and polypharmacy think about deprescribing? The LESS study - a primary care-based survey

Background

Multimorbidity and polypharmacy are very common in older adults in primary care. Ideally, general practitioners (GPs), should regularly review medication lists to identify inappropriate medication(s) and, where appropriate, deprescribe. However, it remains challenging to deprescribe given time constraints and few recommendations from guidelines. Further, patient related barriers and enablers to deprescribing have to be accounted for. The aim of this study was to identify barriers and enablers to deprescribing as reported by older adults with polypharmacy and multimorbidity.

Methods

We conducted a survey among participants aged ≥70 years, with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 chronic medications). We invited Swiss GPs, to recruit eligible patients who then completed a paper-based survey on demographics, medications and chronic conditions. We used the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire and added twelve additional Likert scale questions and two open-ended questions to assess barriers and enablers towards deprescribing, which we coded and categorized into meaningful themes.

Result

Sixty four Swiss GPs consented to recruit 5–6 patients each and returned 300 participant responses. Participants were 79.1 years (SD 5.7), 47% female, 34% lived alone, and 86% managed their medications themselves. Sixty-seven percent of participants took 5–9 regular medicines and 24% took ≥10 medicines. The majority of participants (77%) were willing to deprescribe one or more of their medicines if their doctor said it was possible. There was no association with sex, age or the number of medicines and willingness to deprescribe. After adjustment for baseline characteristics, there was a strong positive association between willingness to deprescribe and saying that because they have a good relationship with their GP, they would feel that deprescribing was safe OR 11.3 (95% CI: 4.64–27.3) and agreeing that they would be willing to deprescribe if new studies showed an avoidable risk OR 8.0 (95% CI 3.79–16.9). From the open questions, the most mentioned barriers towards deprescribing were patients feeling well on their current medicines and being convinced that they need all their medicines.

Conclusions

Most older adults with polypharmacy are willing to deprescribe. GPs may be able to increase deprescribing by building trust with their patients and communicating evidence about the risks of medication use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01843-x.

Risk Factors for Electronic Prescription Errors in Pediatric Intensive Care Patients

OBJECTIVES

To assess risk factors for electronic prescription errors in a PICU.

DESIGN

A database of electronic prescriptions issued by a computerized physician order entry with clinical decision support system was analyzed to identify risk factors for prescription errors.

MEASUREMENTS AND MAIN RESULTS

Of 6,250 prescriptions, 101 were associated with errors (1.6%). The error rate was twice as high in patients older than 12 years than in patients children 6-12 and 0-6 years old (2.4% vs 1.3% and 1.2%, respectively, p < 0.05). Compared with patients without errors, patients with errors had a significantly higher score on the Pediatric Index of Mortality 2 (-3.7 vs -4.5; p = 0.05), longer PICU stay (6 vs 3.1 d; p < 0.0001), and higher number of prescriptions per patient (40.8 vs. 15.7; p < 0.0001). In addition, patients with errors were more likely to have a neurologic main admission diagnosis (p = 0.008) and less likely to have a cardiologic diagnosis (p = 0.03) than patients without errors.

CONCLUSIONS

Our findings suggest that older patient age and greater disease severity are risk factors for electronic prescription errors.

Impact of emergency hospital admissions on patterns of primary care prescribing: a retrospective cohort analysis of electronic records in England

Background

Little is known about the impact of hospitalisation on prescribing in UK clinical practice.

Aim

To investigate whether an emergency hospital admission drives increases in polypharmacy and potentially inappropriate prescriptions (PIPs).

Design and setting

A retrospective cohort analysis set in primary and secondary care in England.

Method

Changes in number of prescriptions and PIPs following an emergency hospital admission in 2014 (at admission and 4 weeks post-discharge), and 6 months post-discharge were calculated among 37 761 adult patients. Regression models were used to investigate changes in prescribing following an admission.

Results

Emergency attendees surviving 6 months (N = 32 657) had a mean of 4.4 (standard deviation [SD] = 4.6) prescriptions before admission, and a mean of 4.7 (SD = 4.7; P<0.001) 4 weeks after discharge. Small increases (<0.5) in the number of prescriptions at 4 weeks were observed across most hospital specialties, except for surgery (−0.02; SD = 0.65) and cardiology (2.1; SD = 2.6). The amount of PIPs increased after hospitalisation; 4.0% of patients had ≥1 PIP immediately before pre-admission, increasing to 8.0% 4 weeks post-discharge. Across hospital specialties, increases in the proportion of patients with a PIP ranged from 2.1% in obstetrics and gynaecology to 8.0% in cardiology. Patients were, on average, prescribed fewer medicines at 6 months compared with 4 weeks post-discharge (mean = 4.1; SD = 4.6; P<0.001). PIPs decreased to 5.4% (n = 1751) of patients.

Conclusion

Perceptions that hospitalisation is a consistent factor driving rises in polypharmacy are unfounded. Increases in prescribing post-hospitalisation reflect appropriate clinical response to acute illness, whereas decreases are more likely in patients who are multimorbid, reflecting a focus on deprescribing and medicines optimisation in these individuals. Increases in PIPs remain a concern.

Development of a structured clinical pharmacology review for specialist support for management of complex polypharmacy in primary care

AIMS

Polypharmacy is widespread and associated with medication-related harms, including adverse drug reactions, medication errors and poor treatment adherence. General practitioners and pharmacists cite limited time and training to perform effective medication reviews for patients with complex polypharmacy, yet no specialist referral mechanism exists. To develop a structured framework for specialist review of primary care patients with complex polypharmacy.

METHODS

We developed the clinical pharmacology structured review (CPSR) and stopping by indication tool (SBIT). We tested these in an age-sex stratified sample of 100 people with polypharmacy aged 65-84 years from the Clinical Practice Research Datalink, an anonymised primary care database. Simulated medication reviews based on electronic records using the CPSR and SBIT were performed. We recommended medication changes or review to optimise treatment benefits, reduce risk of harm or reduce treatment burden.

RESULTS

Recommendations were made for all patients, for almost half (4.8 ± 2.4) of existing medicines (9.8 ± 3.1), most commonly stopping a drug (1.7 ± 1.3/patient) or reviewing with the patient (1.4 ± 1.2/patient). At least 1 new medicine (0.7 ± 0.9) was recommended for 51% patients. Recommendations predominantly aimed to reduce harm (44%). There was no relationship between number of recommendations made and time since last primary care medication review. We identified a core set of clinical information and investigations (polypharmacy workup) that could inform a standard screen prior to specialist review.

CONCLUSION

The CPSR, SBIT and polypharmacy workup could form the basis of a specialist review for patients with complex polypharmacy. Further research is needed to test this approach in patients in general practice.

Assessment of correlates of hand hygiene compliance among final year medical students: a cross-sectional study in the Netherlands

OBJECTIVES

To identify the factors that influence the hand hygiene compliance of final year medical students, using a theoretical behavioural framework.

DESIGN

Cross-sectional survey assessing self-reported compliance and its behavioural correlates.

SETTING

Internships of medical students in the Netherlands.

PARTICIPANTS

322 medical students of the Erasmus Medical Center were recruited over a period of 12 months during the Public Health internship, which is the final compulsory internship after an 18-month rotation schedule in all major specialities.

PRIMARY AND SECONDARY OUTCOME MEASURES

Behavioural factors influencing compliance to hand hygiene guidelines were measured by means of a questionnaire based on the Theory of Planned Behaviour and Social Ecological Models. Multiple linear regression analysis was used to identify the effect of including attitudes, social norms, self-efficacy, knowledge, risk perception and habit on hand hygiene compliance.

RESULTS

We included 313 students in the analysis (response rate 97%). The behavioural model explained 40% of the variance in self-reported compliance (adjusted R²=0.40). Hand hygiene compliance was strongly influenced by attitudes (perceived outcomes of preventive actions), self-efficacy (perception of the ability to perform hand hygiene at the clinical ward) and habit, but was not associated with knowledge and risk perception.

CONCLUSIONS

Targeting medical students' behaviour should focus on the empowerment of these juniors and provide them with evidence on the health benefits of prevention, rather than increasing their factual knowledge of procedures. Clinical teaching environments could help them form good patient safety habits during this vital phase of their career.

Preventable adverse drug events: Descriptive epidemiology

AIM

Our objective was to identify preventable adverse drug events and factors contributing to their development.

METHODS

We performed a retrospective chart review combining data from three prospective multicentre observational studies that assessed emergency department patients for adverse drug events. A clinical pharmacist and physician independently reviewed the charts, extracted data and rated the preventability of each adverse drug event. A third reviewer adjudicated all discordant or uncertain cases. We calculated the proportion of adverse drug events that were deemed preventable, performed multivariable logistic regression to explore the characteristics of patients with preventable events, and identified contributing factors.

RESULTS

We reviewed the records of 1 356 adverse drug events in 1 234 patients. Raters considered 869 (64.1%) of adverse drug events probably or definitely preventable. Patients with mental health diagnoses (OR 1.8; 95% CI 1.3-2.5) and diabetes (OR 1.7; 95% CI 1.2-2.4) were more likely to present with preventable events. The medications most commonly implicated in preventable events were warfarin (9.4%), hydrochlorothiazide (4.5%), furosemide (4.0%), insulin (3.9%) and acetylsalicylic acid (2.7%). Common contributing factors included inadequate patient instructions, monitoring and follow-up, and reassessments after medication changes had been made.

CONCLUSIONS

Our study suggests that patients with mental health conditions and diabetes require close monitoring. Efforts to address the identified contributing factors are needed.

Deprescribing of non-antiretroviral therapy in HIV-infected patients

PURPOSE

In recent decades, the life expectancy of HIV-infected patients has increased considerably, to the extent that the disease can now be considered chronic. In this context of progressive aging, HIV-infected persons have a greater prevalence of comorbid conditions. Consequently, they usually take more non-antiretroviral drugs, and their drug therapy are more complex. This supposes a greater risk of drug interactions, of hospitalization, falls, and death. In the last years, deprescribing has gained attention as a means to rationalize medication use.

METHODS

Review of the different therapeutic approach that includes optimization of polypharmacy and control and reduction of potentially inappropriate prescription.

RESULTS

There are several protocols for systematizing the deprescribing process. The most widely used tool is the Medication Regimen Complexity Index, an index validated in HIV-infected persons. Anticholinergic medications are the agents that have been most associated with major adverse effects so, various scales have been employed to measure it. Other tools should be employed to detect and prevent the use of potentially inappropriate drugs. Prioritization of candidates should be based, among others, on drugs that should always be avoided and drugs with no justified indication.

CONCLUSIONS

The deprescribing process shared by professionals and patients definitively would improve management of treatment in this population. Because polypharmacy in HIV-infected patients show that a considerable percentage of patients could be candidates for deprescribing, we must understand the importance of deprescribing and that HIV-infected persons should be a priority group. This process would be highly feasible and effective in HIV-infected persons.

Preventability analysis of adverse drug reactions in a Jordanian hospital: a prospective observational study

Background Adverse drug reactions remain to be an issue that compromise patient's safety in Jordan and worldwide. In Jordan, an assessment of factors involved in preventability of adverse drug reactions has not been conducted previously. Objectives To describe the proportion of preventable adverse drug reactions, and the causes of hospital-related preventable adverse reactions in one Jordanian hospital. Methods A prospective observational study of 4 months duration conducted by clinical pharmacists in the hospital. Setting Surgical and medical wards in one Jordanian private hospital. Main outcome measure Proportions of admissions related to adverse drug reactions, proportions of preventable reactions and analysis of the factors involved in the preventable adverse drug reactions. Results Out of 350 admissions recorded during the study period, a total of 38 (10.8%) adverse reactions were detected. Among those, 29 (8.3%) were detected in the hospital and 9 (2.6%) were the cause of the hospital admission. Many (44.7%) of the adverse drug reactions were preventable (31.6% were probably preventable and 13.1% were definitely preventable). About half (55.3%) were unpreventable. Insufficient monitoring was involved in 29.4% of the preventable adverse reactions and inappropriate dosing and drug-drug interactions were independently responsible for 17.6% of the preventable adverse reactions. Conclusion A high proportion of the identified adverse drug reactions were found to be preventable. Insufficient monitoring and inappropriate dosing were the most important factors associated with preventable adverse drug reactions. Nationally, more focused efforts need to be stimulated to prevent preventable adverse drug reactions in hospitals.

Improving drug safety in hospitals: a retrospective study on the potential of adverse drug events coded in routine data

BACKGROUND

Adverse drug events (ADEs) that occur during hospitalization are an ongoing medical concern. Systematic strategies for ADE identification are lacking. The aim of this study was to evaluate the potential to identify adverse drug events caused by medication errors (preventable ADEs, pADEs), and previously unknown adverse drug reactions (ADRs or non-preventable ADEs, npADEs) in inpatients by combining diagnosis codes in routine data with a chart review.

METHODS

Diagnoses of inpatients are routinely coded using the International Classification of Diseases, 10th Revision (ICD-10). A total of 2326 cases were sampled from routine data of four hospitals using a set of ICD-10 German Modification ADE codes. Following a chart review, cases were evaluated in a standardized process with regard to drug relation and preventability of events.

RESULTS

By chart review, 1302 cases were classified as hospital-acquired and included in the evaluation. This yielded 1285 cases indicating an ADE. 96.8% of ADEs (1244 ADEs) were classified as known npADEs, only three cases as suspected previously unknown npADEs, one case as event after drug abuse. A total of 37 ADEs were classified as preventable (2.9% of all ADEs) by identifying a medication error as probable cause. The prevalence of pADEs varied considerably between included ADE codes, with hemorrhagic diathesis due to coumarins and localized skin eruptions showing the highest rates (8.7 and 9.1%, respectively). Most frequent medication errors were non-compliance to a known allergy, and improper dose.

CONCLUSIONS

When focusing on specific ADE codes, routine data can be used as markers for npADEs and medication errors, thus providing a meaningful complement to existing drug surveillance systems. However, the prevalence of medication errors is lower than in former studies on the frequency of pADEs.

Efficiency versus thoroughness in medication review: a qualitative interview study in UK primary care

BACKGROUND

Medication reviews may improve the safety of prescribing and the National Institute for Health and Care Excellence (NICE) highlights the importance of involving patients in this process.

AIM

To explore GP and pharmacist perspectives on how medication reviews were conducted in general practice in the UK.

DESIGN AND SETTING

Analysis of semi-structured interviews with GPs and pharmacists working in the South West of England, Northern England, and Scotland, sampled for heterogeneity. Interviews took place between January and October 2017.

METHOD

Interviews focused on experience of medication review. Data saturation was achieved when no new insights arose from later interviews. Interviews were analysed thematically.

RESULTS

In total, 13 GPs and 10 pharmacists were interviewed. GPs and pharmacists perceived medication review as an opportunity to improve prescribing safety. Although interviewees thought patients should be involved in decisions about their medicines, high workload pressures meant that most medication reviews were conducted with limited or no patient input. For some GPs, a medication review was done 'in the quickest way possible to say that it was done'. Pharmacists were perceived by both professions as being more thorough but less time efficient than GPs, and few pharmacists were routinely involved in medication reviews even in practices employing a pharmacist. Interviewees argued that it was easier to continue medicines than it was to stop them, particularly because stopping medicines required involving the patient and this generated extra work.

CONCLUSION

Practices tended to prioritise being efficient (getting the work done) rather than being thorough (doing it well), so that most medication reviews were carried out with little or no patient involvement, and medicines were rarely stopped or reduced. Time and resource constraints are an important barrier to implementing NICE guidance.

How general practitioners would deprescribe in frail oldest-old with polypharmacy - the LESS study

BACKGROUND

Many oldest-old (> 80-years) with multimorbidity and polypharmacy are at high risk of inappropriate use of medication, but we know little about whether and how GPs would deprescribe, especially in the frail oldest-old. We aimed to determine whether, how, and why Swiss GPs deprescribe for this population.

METHODS

GPs took an online survey that presented case-vignettes of a frail oldest-old patient with and without history of cardiovascular disease (CVD) and asked if they would deprescribe any of seven medications. We calculated percentages of GPs willing to deprescribe at least one medication in the case with CVD and compared these with the case without CVD using paired t-tests. We also included open-ended questions to capture reasons for deprescribing and asked which factors could influence their decision to deprescribe by asking for their agreement on a 5-point-Likert-scale.

RESULTS

Of the 282 GPs we invited, 157 (56%) responded: 73% were men; mean age was 56. In the case-vignette without CVD, 98% of GPs deprescribed at least one medication (usually cardiovascular preventive medications) stating it had no indication nor benefit. They would lower the dose or prescribe pain medication as needed to reduce side effects. Their response was much the same when the patient had a history of CVD. GPs reported they were influenced by 'risk' and 'benefit' of medications, 'quality of life', and 'life expectancy', and prioritized the patient's wishes and priorities when deprescribing.

CONCLUSION

Swiss GPs were willing to deprescribe cardiovascular preventive medication when it lacked indication but tended to retain pain medication. Developing tools for GPs to assist them in balancing the risks and benefits of medication in the context of patient values may improve deprescribing activities in practice.

Prospective Cohort Study of the Tolerability of Prosthetic Joint Infection Empirical Antimicrobial Therapy

The empirical use of vancomycin in combination with a broad-spectrum beta-lactam is currently recommended after the initial surgery of prosthetic joint infection (PJI). However, the tolerability of such high-dose intravenous regimens is poorly known. Adult patients receiving an empirical antimicrobial therapy (EAT) for a PJI were enrolled in a prospective cohort study (2011 to 2016). EAT-related adverse events (AE) were described according to the common terminology criteria for AE (CTCAE), and their determinants were assessed by logistic regression and Kaplan-Meier curve analysis. The EAT of the 333 included patients (median age, 69.8 years; interquartile range [IQR], 59.3 to 79.1 years) mostly relies on vancomycin (n = 229, 68.8%), piperacillin-tazobactam (n = 131, 39.3%), and/or third-generation cephalosporins (n = 50, 15%). Forty-two patients (12.6%) experienced an EAT-related AE. Ten (20.4%) AE were severe (CTCAE grade ≥ 3). The use of vancomycin (odds ratio [OR], 6.9; 95% confidence interval [95%CI], 2.1 to 22.9), piperacillin-tazobactam (OR, 3.7; 95%CI, 1.8 to 7.2), or the combination of both (OR, 4.1; 95%CI, 2.1 to 8.2) were the only AE predictors. Acute kidney injury (AKI) was the most common AE (n = 25; 51.0% of AE) and was also associated with the use of the vancomycin and piperacillin-tazobactam combination (OR, 6.7; 95%CI, 2.6 to 17.3). A vancomycin plasma overexposure was noted in nine (37.5%) of the vancomycin-related AKIs only. Other vancomycin-based therapies were significantly less at risk for AE and AKI. The EAT of PJI is associated with an important rate of AE, linked with the use of the vancomycin and the piperacillin-tazobactam combination. These results corroborate recent findings suggesting a synergic toxicity of these drugs in comparison to vancomycin-cefepime, which remains to be evaluated in PJI. (This study has been registered at ClinicalTrials.gov under identifier NCT03010293.).

Prediction of clinically relevant adverse drug events in surgical patients

BACKGROUND

Risk stratification of hospital patients for adverse drug events would enable targeting patients who may benefit from interventions aimed at reducing drug-related morbidity. It would support clinicians and hospital pharmacists in selecting patients to deliver a more efficient health care service. This study aimed to develop a prediction model that helps to identify patients on the day of hospital admission who are at increased risk of developing a clinically relevant, preventable adverse drug event during their stay on a surgical ward.

METHODS

Data of the pre-intervention measurement period of the P-REVIEW study were used. This study was designed to assess the impact of a multifaceted educational intervention on clinically relevant, preventable adverse drug events in surgical patients. Thirty-nine variables were evaluated in a univariate and multivariate logistic regression analysis, respectively. Model performance was expressed in the Area Under the Receiver Operating Characteristics. Bootstrapping was used for model validation.

RESULTS

6780 admissions of patients at surgical wards were included during the pre-intervention period of the PREVIEW trial. 102 patients experienced a clinically relevant, adverse drug event during their hospital stay. The prediction model comprised five variables: age, number of biochemical tests ordered, heparin/LMWH in therapeutic dose, use of opioids, and use of cardiovascular drugs. The AUROC was 0.86 (95% CI 0.83-0.88). The model had a sensitivity of 80.4% and a specificity of 73.4%. The positive and negative predictive values were 4.5% and 99.6%, respectively. Bootstrapping generated parameters in the same boundaries.

CONCLUSIONS

The combined use of a limited set of easily ascertainable patient characteristics can help physicians and pharmacists to identify, at the time of admission, surgical patients who are at increased risk of developing ADEs during their hospital stay. This may serve as a basis for taking extra precautions to ensure medication safety in those patients.

Knowledge and willingness of physicians about deprescribing among older patients: a qualitative study

Purpose

This study aimed to explore the physician’s knowledge and identify the perceived barriers that prevent family medicine physicians from engaging in deprescribing among older patients.

Methods

This qualitative study was designed and conducted using an interpretive theoretical approach. Purposive sampling was undertaken, whereby family medicine physicians of King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia, were invited to participate in the study. The topic guidelines were designed to give the physicians the freedom to express their views on exploring their knowledge about deprescribing and to identify the perceived barriers and enablers that prevent them from engaging in the practice in older patients. The focus group discussions were conducted in English, audio-taped with permission, and transcribed verbatim. Each transcript was independently reviewed and coded separately to explore the themes and sub-themes.

Results

A total of 15 physicians participated in three focus group discussions. Their thematic content analysis identified 24 factors that facilitated or hindered deprescribing. The facilitators included cost-effectiveness and time effectiveness, side effects avoidance, clinical pharmacist’s role, need for system(s) to help in applying deprescribing, and patient counseling/education. Similarly, barriers included lack of knowing the deprescribing term and process, patient comorbidities, risk/fear of conflict between physicians and clinical pharmacists, lack of documentation and communication, lack of time or crowded clinics, and patient resistance/acceptance.

Conclusion

The study identified several factors affecting family medicine physician’s deprescribing behavior. The use of theoretical underpinning design helped to provide a comprehensive range of factors that can be directed when defining targets for intervention(s).

Developing a measure of polypharmacy appropriateness in primary care: systematic review and expert consensus study

BACKGROUND

Polypharmacy is an increasing challenge for primary care. Although sometimes clinically justified, polypharmacy can be inappropriate, leading to undesirable outcomes. Optimising care for polypharmacy necessitates effective targeting and monitoring of interventions. This requires a valid, reliable measure of polypharmacy, relevant for all patients, that considers clinical appropriateness and generic prescribing issues applicable across all medications. Whilst there are several existing measures of potentially inappropriate prescribing, these are not specifically designed with polypharmacy in mind, can require extensive clinical input to complete, and often cover a limited number of drugs. The aim of this study was to identify what experts consider to be the key elements of a measure of prescribing appropriateness in the context of polypharmacy.

METHODS

Firstly, we conducted a systematic review to identify generic (not drug specific) prescribing indicators relevant to polypharmacy appropriateness. Indicators were subject to content analysis to enable categorisation. Secondly, we convened a panel of 10 clinical experts to review the identified indicators and assess their relative clinical importance. For each indicator category, a brief evidence summary was developed, based on relevant clinical and indicator literature, clinical guidance, and opinions obtained from a separate patient discussion panel. A two-stage RAND/UCLA Appropriateness Method was used to reach consensus amongst the panel on a core set of indicators of polypharmacy appropriateness.

RESULTS

We identified 20,879 papers for title/abstract screening, obtaining 273 full papers. We extracted 189 generic indicators, and presented 160 to the panel grouped into 18 classifications (e.g. adherence, dosage, clinical efficacy). After two stages, during which the panel introduced 18 additional indicators, there was consensus that 134 indicators were of clinical importance. Following the application of decision rules and further panel consultation, 12 indicators were placed into the final selection. Panel members particularly valued indicators concerned with adverse drug reactions, contraindications, drug-drug interactions, and the conduct of medication reviews.

CONCLUSIONS

We have identified a set of 12 indicators of clinical importance considered relevant to polypharmacy appropriateness. Use of these indicators in clinical practice and informatics systems is dependent on their operationalisation and their utility (e.g. risk stratification, targeting and monitoring polypharmacy interventions) requires subsequent evaluation.

TRIAL REGISTRATION

Registration number: PROSPERO ( CRD42016049176 ).

Adverse Drug Reactions in Hospitalized Patients: Results of the FORWARD (Facilitation of Reporting in Hospital Ward) Study

Background: Adverse drug reactions (ADRs) are an important public health problem, representing a major cause of morbidity and mortality. However, several countries have no recent studies available. Since 2014, a prospective active pharmacovigilance project, aimed to improve ADRs monitoring in hospital wards (FORWARD) was performed in Sicily. This study, as part of FORWARD project, was aimed to describe ADRs occurred during the hospital stay in Internal Medicine wards. ADRs related to hospital admission, characteristics and preventability of ADRs were also evaluated.

Methods: Demographic, clinical, and pharmacological data on patients admitted to six wards of Internal Medicine, from 2014 to 2015, were collected by trained, qualified monitors, who screened all medical records. The rate of ADRs occurred during hospital stay and those leading to hospitalization were analyzed. A descriptive analysis of the reactions, suspected drugs, and associated factors was performed according to the setting analyzed.

Results: During the study period, 4,802 admissions were recorded; in 3.2% of them ADRs occurred during hospital stay while in 6.2%, admission was due to ADRs. The duration of hospital stay was longer in patients who experienced ADRs during hospitalization, compared to patients without ADRs [median days 12 (Q1–Q3: 8–17) vs. 9 (6–13)]; p < 0.001). Females [OR1.39 (95% CI 1.03–1.93)] and patients taking ≥ 4 drugs [OR1.46 (95% CI 1.06–2.03)] were more likely to experience ADRs during hospital stay, as well as to be admitted because of ADRs [female: OR1.75 (95% CI 1.37–2.24); ≥ 4 drugs: OR2.14 (95% CI 1.67–2.74)]. The most frequent ADRs occurred during hospital stay were cutaneous (26.8%), general (13.4%), vascular (13.4%), and cardiac (11.5%) disorders and the drug classes mainly involved were anti-bacterials (38.2%) and antithrombotic agents (21.7%). ADRs were serious in 44.6% and probably preventable in 69.4%. Gastrointestinal (27.7%), hematological (26.5%), metabolic (18.1%), and nervous (16.1%) disorders were the main ADRs cause of hospitalization, primarily due to antithrombotic agents (39.0%) RAS-inhibitors (13.9%), NSAIDs (11.9%), and diuretics (9.0%). Only 12.9% of them was not preventable.

Conclusion: Adverse drug reactions occurred during hospitalization or contributing to admission to Internal Medicine wards were considerable and most of them were preventable. Females and patients taking many medications were more likely to present ADRs both during hospital stay or as cause of admission.

Validation of a score to identify inpatients at risk of a drug-related problem during a 4-year period

Objective

Drug-related problems (DRP) produce high morbidity and mortality. It is therefore essential to identify patients at higher risk of these events. This study aimed to validate a DRP risk score in a large number of inpatients.

Material and methods

Validation of a previously designed score to identify inpatients at risk of experiencing at least one DRP in a tertiary university hospital from 2010 to 2013. DRP were detected by a pharmacy warning system integrated in the electronic medical record. The score included the following variables associated with a higher risk of DRP: prescription of a higher number of drugs, greater comorbidity, advanced age, specific ATC groups and certain major diagnostic categories.

Results

The study included a total of 52,987 admissions; of these, at least one DRP occurred in 14.9%. After validation of the score (period range, 2010–2013: 0.746–0.764), the area under the curve (AUC) was 0.751 (95% CI: 0.745–0.756).

Conclusions

This value is higher than those reported in other studies describing validation of risk scores. The score showed good capacity to identify those patients at higher risk of DRP in a much larger sample of inpatients than previously described in the literature. This tool allows optimization of drug therapy monitoring in admitted patients.

Measurement of selected preventable adverse drug events in electronic health records: Toward developing a complexity score

PURPOSE

The defining of a select number of high-priority preventable adverse drug events (pADEs) for measurement in the electronic health record (EHR) and the estimation of pADE incidences in two tertiary care facilities are described.

METHODS

This study was part of a larger effort aimed at developing an automated electronic health record (EHR)-based complexity-score (C-score) that ranks hospitalized patients according to their risk for pADEs for clinical intervention. We developed measures for 16 high-priority pADEs often deemed preventable using discrete clinical and administrative EHR data. For each pADE we specified inclusion and exclusion criteria that were used to define risk populations for each specific pADE. The incidence of each type of pADE was then measured during a designated follow-up period considering all adult admissions to 2 large academic tertiary care hospitals, who were eligible for the pADE-specific risk populations during any of their first 5 hospital days.

RESULTS

Utilizing the data from 83,787 admissions who were at risk for at least one pADE during at least one of their first five hospital days, we found that 27,193 admissions (32.5%) developed at least one pADE. Uncontrolled postsurgical pain, uncontrolled pneumonia, and drug-associated hypotension had the highest incidences with the following number of days with pADE per number of patients at risk: 13,484 of 19,640; 527 of 1,530; and 13,394 of 43,630, while drug-associated falls (446 of 75,036), drug-associated acute mental status changes (262 of 66,875) and venous thromboembolism (214 of 74,283) had the lowest incidence rates.

CONCLUSION

EHR-based definitions of clinically important pADEs were developed, and the incidence of the pADEs was estimated. These definitions will be advanced for the creation of prediction models to develop a C-score for identifying patients at risk for pADEs to prioritize pharmacist intervention.

The prevalence and preventability of potentially relevant drug-drug interactions in patients admitted for cardiovascular diseases: A cross-sectional study

AIM

The aim was to describe the type and prevalence of potentially relevant drug-drug interactions (pDDIs) in a population of patients admitted for cardiovascular diseases (CVD), and management strategies for reducing the occurrence of pDDIs.

METHODS

A retrospective cross-sectional study was performed on Cardiology ward of University Clinical Hospital Center in Belgrade, Serbia. A total of 527 patients, with more than one prescription during hospital stay, were enrolled in this study. Data were obtained from medical records. LexiInteract was used as the screening tool.

RESULTS

At least one potentially relevant pDDI was identified in 83.9% of patients. Occurrence was significantly more prevalent in patients with higher number of drugs, multimorbidity, longer length of stay, arrhythmia, heart failure, infectious and respiratory disease. About 13% of pDDIs exposures were accompanied with concurrent renal or liver disease, as an additional risk for DDI manifestation. Among CVD, patients with a history of myocardial infarction possessed the highest additional risk. The most common potential clinical outcome was the effect on cardiovascular system 48.5%, renal function and/or potassium 22.3%, bleeding 9.5%, impaired glucose control 6.8% and digoxin toxicity 4.6%. Main management strategies to avoid X or D class included using paracetamol instead of NSAID or alternative NSAID (38%), alternative antibiotic or antifungal (20.4%), H₂ receptor antagonist instead of PPI (8.3%), avoiding therapeutic duplication (7.3%), and alternative HMG-CoA reductase inhibitor (7%). Heart rate, blood pressure, electrolytes/potassium and blood glucose could have been employed in monitoring for potential consequence of 72.2% C class pDDIs.

CONCLUSIONS

Use of drug interaction screening tools can be beneficial risk mitigation strategy for potentially relevant pDDIs in CVD patients. DDI screening software could be linked to the patient's laboratory results or clinical data regarding renal or liver function, as an approach to reinforce DDIs alert quality.

The prevalence of medication-related adverse events in inpatients-a systematic review and meta-analysis

PURPOSE

Adverse drug events (ADEs) have been internationally recognized as a major threat to patient safety. The purpose of this study was to conduct a meta-analysis focusing on inpatient ADEs in the Western World to provide better estimate of the current state of medication safety in these countries.

METHODS

The studies for meta-analysis were identified through electronic search in Cochrane, Scopus, Medline, and Web of science databases. Included articles focused on adult inpatient ADEs, had commonly accepted definition for ADE, and were conducted between 2000 and 2016. Disease or ADE-specific studies were excluded. Meta-analysis was conducted on the prevalence of inpatient ADEs and fatal adverse drug reactions (FADRs).

RESULTS

The pooled estimate of the prevalence of inpatient ADEs was formed by 46,626 patient records included in 9 articles. Inpatient ADE prevalence was 19 and 32.3% of these ADEs were assessed preventable (MD 28.6%, SD 22.6%). Three articles including 3385 patients focused on inpatient FADRs, but the pooled estimate of this was disregarded due to low number and high heterogeneity of the included studies.

CONCLUSIONS

ADEs are estimated to affect 19% of inpatients during hospitalization. Most of the ADEs are moderate in severity causing no permanent harm to the patient. Only a small amount of ADEs cause inpatient deaths, but in this meta-analysis, however, we were unable to give direct estimate of the prevalence.

Deprescribing: a primary care perspective

Polypharmacy is an increasing and global issue affecting primary care. Although sometimes appropriate, polypharmacy can also be problematic, leading to a range of adverse consequences. Deprescribing is the process of supervised withdrawal of an inappropriate medication and has the potential to reduce some of the problems associated with polypharmacy. It is a complex and sensitive process. We examine the issue of deprescribing from the perspective of primary care. Key steps in the deprescribing process are a review of medications and corresponding indications, consideration of harms, assessment of eligibility for discontinuation, prioritisation of medications and implementation of a stopping plan with appropriate monitoring. Patient involvement is a key feature of this process. Deprescribing should be considered in the context of end-of-life care and medication safety, but approaches are also required to identify other situations where deprescribing is appropriate. General practitioners are well positioned to facilitate deprescribing, usually through formal medication review, with decisions informed by a range of other healthcare professionals. Guidelines are available that help guide these processes. A range of studies have explored attitudes towards deprescribing; patients are generally supportive of the concept, although clinician views are varied. The successful implementation of deprescribing strategies still requires important patient and clinician barriers to be overcome, and clinical trial evidence of effectiveness and safety is essential.

Direct and indirect costs for adverse drug events identified in medical records across care levels, and their distribution among payers

BACKGROUND

Adverse drug events (ADEs) cause considerable costs in hospitals. However, little is known about costs caused by ADEs outside hospitals, effects on productivity, and how the costs are distributed among payers.

OBJECTIVE

To describe the direct and indirect costs caused by ADEs, and their distribution among payers. Furthermore, to describe the distribution of patient out-of-pocket costs and lost productivity caused by ADEs according to socio-economic characteristics.

METHOD

In a random sample of 5025 adults in a Swedish county, prevalence-based costs for ADEs were calculated. Two different methods were used: 1) based on resource use judged to be caused by ADEs, and 2) as costs attributable to ADEs by comparing costs among individuals with ADEs to costs among matched controls. Payers of costs caused by ADEs were identified in medical records among those with ADEs (n = 596), and costs caused to individual patients were described by socio-economic characteristics.

RESULTS

Costs for resource use caused by ADEs were €505 per patient with ADEs (95% confidence interval €345-665), of which 38% were indirect costs. Compared to matched controls, the costs attributable to ADEs were €1631, of which €410 were indirect costs. The local health authorities paid 58% of the costs caused by ADEs. Women had higher productivity loss than men (€426 vs. €109, p = 0.018). Out-of-pocket costs displaced a larger proportion of the disposable income among low-income earners than higher income earners (0.7% vs. 0.2%-0.3%).

CONCLUSION

We used two methods to identify costs for ADEs, both identifying indirect costs as an important component of the overall costs for ADEs. Although the largest payers of costs caused by ADEs were the local health authorities responsible for direct costs, employers and patients costs for lost productivity contributed substantially. Our results indicate inequalities in costs caused by ADEs, by sex and income.

Risk Factors Associated with the Requirement for Pharmaceutical Intervention in the Hospital Setting: A Systematic Review of the Literature

Background

A number of methods exist for the risk assessment of hospital inpatients to determine the likelihood of patients experiencing drug-related problems (DRPs), including manual review of a patient’s medication (medication reviews) and more complex electronic assessment using decision support alerts in electronic prescribing systems. A systematic review was conducted to determine the evidence base for potential risks associated with adult hospital inpatients that could not only lead to medication-related issues but might also be directly associated with pharmacist intervention.

Objectives

The aims were to perform a systematic review of the literature in order to (1) identify all measurable risk factors associated with adult hospital inpatients that potentially lead to a pharmaceutical intervention; (2) critically evaluate the quality of the identified research; and (3) further subcategorise potential risk factors, so that pharmaceutical services may be targeted to patients “at risk” by identifying potential risk factors in a patient’s electronic hospital record.

Methods

A systematic review, conducted in June 2013, searched ten medical literature databases for all papers identifying risks leading to pharmacist interventions or DRPs, adverse drug events (ADEs), adverse drug reactions, drug errors (where not included in the definition of an ADE), and medication-related problems. The search identified 7720 titles, from which 120 papers were sourced. A hand search of a further 11 journals was also performed. No date restrictions were imposed. All primary research and literature reviews were included. Summary articles were excluded with the exception of literature reviews. The inclusion of search outputs was validated by a third party pharmacy research graduate.

Results

From the 7720 titles, 38 publications met the inclusion criteria for the review. The ten most frequently reported risk factors associated with medication-related issues that may potentially lead to a hospital pharmaceutical intervention are as follows (ranked in descending order of frequency): prescription of certain drugs or classes of drugs, polypharmacy, elderly patients (defined as over 65 years), female gender, poor renal function, the presence of multiple comorbidities, length of patient stay, history of drug allergy or sensitivity, patient compliance issues, and poor liver function. The ten classes of drugs most frequently reported to be associated with medication-related issues leading to a hospital pharmaceutical intervention are as follows (ranked in descending order of frequency): intravenous antimicrobials, thrombolytics/anticoagulants, cardiovascular agents, central nervous system agents, corticosteroids, diuretics, chemotherapy, insulin/hypoglycaemics, opiates, and anti-epileptics.

Conclusion

Review of the literature identified 38 papers, from which the ten most frequently reported risk factors linked with factors that are potentially associated with hospital pharmaceutical interventions (all definitions included) were identified. No papers were identified that demonstrated a direct causal relationship between a potential risk factor and hospital pharmaceutical interventions. All of the potential risk factors associated with problems with the use of medicines can be identified from patient records on admission to hospital. These risk factors may be used to identify patients at risk, with a view to targeting pharmaceutical intervention in order to minimise risks of problems with medicines and improve efficiency of clinical pharmacy services.

Epidemiology of adverse drug reactions in Europe: a review of recent observational studies

Adverse drug reactions (ADRs) cause considerable mortality and morbidity but no recent reviews are currently available for the European region. Therefore, we performed a review of all epidemiological studies quantifying ADRs in a European setting that were published between 1 January 2000 and 3 September 2014. Included studies assessed the number of patients who were admitted to hospital due to an ADR, studies that assessed the number of patients who developed an ADR during hospitalization, and studies that measured ADRs in the outpatient setting. In total, 47 articles were included in the final review. The median percentage of hospital admissions due to an ADR was 3.5 %, based on 22 studies, and the median percentage of patients who experienced an ADR during hospitalization was 10.1 %, based on 13 studies. Only five studies were found that assessed ADRs occurring in the outpatient setting. These results indicate that the occurrence of ADRs in the European hospital setting—both ADRs that result in hospitalization and ADRs that occur during the hospital stay—is significant. Furthermore, the limited number of studies that were performed in the outpatient setting identify a lack of information regarding the epidemiology of ADRs in this setting.

The Effect of Contact Precautions on Frequency of Hospital Adverse Events

OBJECTIVE

To determine whether use of contact precautions on hospital ward patients is associated with patient adverse events

DESIGN

Individually matched prospective cohort study

SETTING

The University of Maryland Medical Center, a tertiary care hospital in Baltimore, Maryland

METHODS

A total of 296 medical or surgical inpatients admitted to non-intensive care unit hospital wards were enrolled at admission from January to November 2010. Patients on contact precautions were individually matched by hospital unit after an initial 3-day length of stay to patients not on contact precautions. Adverse events were detected by physician chart review and categorized as noninfectious, preventable and severe noninfectious, and infectious adverse events during the patient's stay using the standardized Institute for Healthcare Improvement's Global Trigger Tool.

RESULTS

The cohort of 148 patients on contact precautions at admission was matched with a cohort of 148 patients not on contact precautions. Of the total 296 subjects, 104 (35.1%) experienced at least 1 adverse event during their hospital stay. Contact precautions were associated with fewer noninfectious adverse events (rate ratio [RtR], 0.70; 95% confidence interval [CI], 0.51-0.95; P=.02) and although not statistically significant, with fewer severe adverse events (RtR, 0.69; 95% CI, 0.46-1.03; P=.07). Preventable adverse events did not significantly differ between patients on contact precautions and patients not on contact precautions (RtR, 0.85; 95% CI, 0.59-1.24; P=.41).

CONCLUSIONS

Hospital ward patients on contact precautions were less likely to experience noninfectious adverse events during their hospital stay than patients not on contact precautions.

Medicines management audit cycle, St. Brigid’s Hospital Ballinasloe

Objectives

This audit cycle aimed to identify deficiencies in medicines management in an adult psychiatric hospital. The original audit in 2009 highlighted that a number of improvements were needed to enhance prescribing standards. Following implementation of these recommendations, two reaudits were performed to assess both the improvements in medicines management along with evaluating the newly introduced drug prescription chart.

Methods

Local, national and international guidelines on medicines management were reviewed in 2009, following which an audit tool was designed. Recommendations from the original audit were taken on board with the introduction of a new medication chart. This chart incorporated many of the recommendations from the original audit into it. Two reaudits were then performed, each over 1 day by four assessors and included all inpatient wards.

Results

The initial audit in 2009 outlined a number of recommendations, namely the introduction of an appropriate ‘fit for purpose’ medication chart, the need for regular postgraduate prescribing education and training and the consideration of a prescribing formulary and/or Drugs & Therapeutics Committee. Results from the reaudits revealed that considerable improvement was made in areas such as patient demographics, pharmacist involvement, generic prescribing, BLOCK capitals, inclusion of Medical Council Registration Number, PRN prescribing and discontinuation procedures.

Conclusion

Although significant improvement was noted, further improvement is required with regards to the need for a review date for PRN medication; the need for improved documentation of allergies, height and weight; and the importance of a working group to assess community medicines management and the need for further reaudits to assess continued improvement in all deficient areas.

Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care

AIMS

Prescribing multiple medications is associated with various adverse outcomes, and polypharmacy is commonly considered suggestive of poor prescribing. Polypharmacy might thus be associated with unplanned hospitalization. We sought to test this assumption.

METHODS

Scottish primary care data for 180 815 adults with long-term clinical conditions and numbers of regular medications were linked to national hospital admissions data for the following year. Using logistic regression (age, gender and deprivation adjusted), we modelled the association of prescribing with unplanned admission for patients with different numbers of long-term conditions.

RESULTS

Admissions were more common in patients on multiple medications, but admission risk varied with the number of conditions. For patients with one condition, the odds ratio for unplanned admission for four to six medications was 1.25 (95% confidence interval 1.11-1.42) vs. one to three medications, and 3.42 (95% confidence interval 2.72-4.28) for ≥10 medications vs. one to three medications. However, this effect was greatly reduced for patients with multiple conditions; amongst patients with six or more conditions, those on four to six medications were no more likely to have unplanned admissions than those taking one to three medications (odds ratio 1.00; 95% confidence interval 0.88-1.14), and those taking ≥10 medications had a modestly increased risk of admission (odds ratio 1.50; 95% confidence interval 1.31-1.71).

CONCLUSIONS

Unplanned hospitalization is strongly associated with the number of regular medications. However, the effect is reduced in patients with multiple conditions, in whom only the most extreme levels of polypharmacy are associated with increased admissions. Assumptions that polypharmacy is always hazardous and represents poor care should be tempered by clinical assessment of the conditions for which those drugs are being prescribed.

Evidence of and recommendations for non-pharmacological interventions for common geriatric conditions: the SENATOR-ONTOP systematic review protocol

INTRODUCTION

Non-pharmacological therapies for common chronic medical conditions in older patients are underused in clinical practice. We propose a protocol for the assessment of the evidence of non-pharmacological interventions to prevent or treat relevant outcomes in several prevalent geriatric conditions in order to provide recommendations.

METHODS AND ANALYSIS

The conditions of interest for which the evidence about efficacy of non-pharmacological interventions will be searched include delirium, falls, pressure sores, urinary incontinence, dementia, heart failure, orthostatic hypotension, sarcopaenia and stroke. For each condition, the following steps will be undertaken: (A) prioritising clinical questions; (B) retrieving the evidence (MEDLINE, the Cochrane Library, CINAHL and PsychINFO will be searched to identify systematic reviews); (C) assessing the methodological quality of the evidence (risk of bias according to the Cochrane method will be applied to the primary studies retrieved from the systematic reviews); (D) developing recommendations based on the evidence (Grading of Recommendations Assessment, Development and Evaluation (GRADE) items-risk of bias, imprecision, inconsistency, indirectness and publication bias-will be used to rate the overall evidence and develop recommendations).

DISSEMINATION

For each target condition, at least one systematic overview concerning the evidence of non-pharmacological interventions will be produced and published in peer-reviewed journals.