Evaluating the prescribing and monitoring of medications associated with QTc-prolongation in the ambulatory care setting

RATIONALE

Little is known about the prescribing of medications with potential to cause QTc-prolongation in the ambulatory care settings. Understanding real-world prescribing of QTc-prolonging medications and actions taken to mitigate this risk will help guide strategies to optimize safety and appropriate prescribing among ambulatory patients.

OBJECTIVE

To evaluate the frequency of clinician action taken to monitor and mitigate modifiable risk factors for QTc-prolongation when indicated.

METHODS

This retrospective, cross-sectional study evaluated clinician action at the time of prescribing prespecified medications with potential to prolong QTc in adult patients in primary care. The index date was defined as the date the medication was ordered. Electronic health record (EHR) data were evaluated to assess patient, clinician and visit characteristics. Clinician action was determined if baseline or follow-up monitoring was ordered or if action was taken to mitigate modifiable risk factors (laboratory abnormalities or electrocardiogram [ECG] monitoring) within 48 h of prescribing a medication with QTc-prolonging risk. Descriptive statistics were used to describe current practice.

RESULTS

A total of 399 prescriptions were prescribed to 386 patients, with a mean age of 51 ± 18 years, during March 2021 from a single-centre, multisite health system. Of these, 17 (4%) patients had a known history of QTc-prolongation, 170 (44%) did not have a documented history of QTc-prolongation and 199 (52%) had an unknown history (no ECG documented). Thirty-nine patients (10%) had at least one laboratory-related risk factor at the time of prescribing, specifically hypokalemia (16 patients), hypomagnesemia (8 patients) or hypocalcemia (19 patients). Of these 39 patients with laboratory risk factors, only 6 patients (15%) had their risk acknowledged or addressed by a clinician. Additionally, eight patients' most recent QTc was ≥500 ms and none had an ECG checked at the time the prescription was ordered.

CONCLUSION

Despite national recommendations, medication monitoring and risk mitigation is infrequent when prescribing QTc-prolonging medications in the ambulatory care setting. These findings call for additional research to better understand this gap, including reasons for the gap and consequences on patient outcomes.

Leveraging artificial intelligence to advance implementation science: potential opportunities and cautions

BACKGROUND

The field of implementation science was developed to address the significant time delay between establishing an evidence-based practice and its widespread use. Although implementation science has contributed much toward bridging this gap, the evidence-to-practice chasm remains a challenge. There are some key aspects of implementation science in which advances are needed, including speed and assessing causality and mechanisms. The increasing availability of artificial intelligence applications offers opportunities to help address specific issues faced by the field of implementation science and expand its methods.

MAIN TEXT

This paper discusses the many ways artificial intelligence can address key challenges in applying implementation science methods while also considering potential pitfalls to the use of artificial intelligence. We answer the questions of "why" the field of implementation science should consider artificial intelligence, for "what" (the purpose and methods), and the "what" (consequences and challenges). We describe specific ways artificial intelligence can address implementation science challenges related to (1) speed, (2) sustainability, (3) equity, (4) generalizability, (5) assessing context and context-outcome relationships, and (6) assessing causality and mechanisms. Examples are provided from global health systems, public health, and precision health that illustrate both potential advantages and hazards of integrating artificial intelligence applications into implementation science methods. We conclude by providing recommendations and resources for implementation researchers and practitioners to leverage artificial intelligence in their work responsibly.

CONCLUSIONS

Artificial intelligence holds promise to advance implementation science methods ("why") and accelerate its goals of closing the evidence-to-practice gap ("purpose"). However, evaluation of artificial intelligence's potential unintended consequences must be considered and proactively monitored. Given the technical nature of artificial intelligence applications as well as their potential impact on the field, transdisciplinary collaboration is needed and may suggest the need for a subset of implementation scientists cross-trained in both fields to ensure artificial intelligence is used optimally and ethically.

Implementation of clopidogrel pharmacogenetic clinical decision support for a preemptive return of results program

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

To describe our experiences implementing and iterating CYP2C19 genotype-guided clopidogrel pharmacogenetic clinical decision support (CDS) tools over time in the setting of a large health system-wide, preemptive pharmacogenomics program.

SUMMARY

Clopidogrel-treated patients who are genetically predicted cytochrome P450 isozyme 2C19 intermediate or poor metabolizers have an increased risk of atherothrombotic events, some of which can be life-threatening. The Clinical Pharmacogenetics Implementation Consortium provides guidance for the use of clopidogrel based on CYP2C19 genotype in patients with cardiovascular and cerebrovascular diseases. Our multidisciplinary team implemented an automated, interruptive alert that fires when clopidogrel is ordered or refilled for biobank participants with structured CYP2C19 intermediate or poor metabolizer genomic indicators in the electronic health record. The implementation began with a narrow cardiovascular indication and setting and was then scaled in 4 primary dimensions: (1) clinical indication; (2) availability across health-system locations; (3) care venue (e.g., inpatient vs outpatient); and (4) provider groups (eg, cardiology and neurology). We iterated our approach over time based on evolving clinical evidence and proactive strategies to optimize CDS maintenance and sustainability. A key facilitator of expansion was socialization of the broader pharmacogenomics initiative among our academic medical center community, accompanied by clinician acceptance of pharmacogenetic alerts in practice.

CONCLUSION

A multidisciplinary collaboration is recommended to facilitate the use of CYP2C19 genotype-guided antiplatelet therapy in patients with cardiovascular and cerebrovascular diseases. Evolving clopidogrel pharmacogenetic evidence necessitates thoughtful iteration of implementation efforts and strategies to optimize long-term maintenance and sustainability.

Clinician challenges to evidence-based prescribing for heart failure and reduced ejection fraction: A qualitative evaluation

BACKGROUND

Reasons for suboptimal prescribing for heart failure with reduced ejection fraction (HFrEF) have been identified, but it is unclear if they remain relevant with recent advances in healthcare delivery and technologies. This study aimed to identify and understand current clinician-perceived challenges to prescribing guideline-directed HFrEF medications.

METHODS

We conducted content analysis methodology, including interviews and member-checking focus groups with primary care and cardiology clinicians. Interview guides were informed by the Cabana Framework.

RESULTS

We conducted interviews with 33 clinicians (13 cardiology specialists, 22 physicians) and member checking with 10 of these. We identified four levels of challenges from the clinician perspective. Clinician level challenges included misconceptions about guideline recommendations, clinician assumptions (e.g., drug cost or affordability), and clinical inertia. Patient-clinician level challenges included misalignment of priorities and insufficient communication. Clinician-clinician level challenges were primarily between generalists and specialists, including lack of role clarity, competing priorities of providing focused versus holistic care, and contrasting confidence regarding safety of newer drugs. Policy and system/organisation level challenges included insufficient access to timely/reliable patient data, and unintended care gaps for medications without financially incentivized metrics.

CONCLUSION

This study presents current challenges faced by cardiology and primary care which can be used to strategically design interventions to improve guideline-directed care for HFrEF. The findings support the persistence of many challenges and also sheds light on new challenges. New challenges identified include conflicting perspectives between generalists and specialists, hesitancy to prescribe newer medications due to safety concerns, and unintended consequences related to value-based reimbursement metrics for select medications.

Sustained Effect of Clinical Decision Support for Heart Failure: A Natural Experiment Using Implementation Science

OBJECTIVES

In a randomized controlled trial, we found that applying implementation science (IS) methods and best practices in clinical decision support (CDS) design to create a locally customized, "enhanced" CDS significantly improved evidence-based prescribing of β blockers (BB) for heart failure compared with an unmodified commercially available CDS. At trial conclusion, the enhanced CDS was expanded to all sites. The purpose of this study was to evaluate the real-world sustained effect of the enhanced CDS compared with the commercial CDS.

METHODS

In this natural experiment of 28 primary care clinics, we compared clinics exposed to the commercial CDS (preperiod) to clinics exposed to the enhanced CDS (both periods). The primary effectiveness outcome was the proportion of alerts resulting in a BB prescription. Secondary outcomes included patient reach and clinician adoption (dismissals).

RESULTS

There were 367 alerts for 183 unique patients and 171 unique clinicians (pre: March 2019-August 2019; post: October 2019-March 2020). The enhanced CDS increased prescribing by 26.1% compared with the commercial (95% confidence interval [CI]: 17.0-35.1%), which is consistent with the 24% increase in the previous study. The odds of adopting the enhanced CDS was 81% compared with 29% with the commercial (odds ratio: 4.17, 95% CI: 1.96-8.85). The enhanced CDS adoption and effectiveness rates were 62 and 14% in the preperiod and 92 and 10% in the postperiod.

CONCLUSION

Applying IS methods with CDS best practices was associated with improved and sustained clinician adoption and effectiveness compared with a commercially available CDS tool.

The iPRISM webtool: an interactive tool to pragmatically guide the iterative use of the Practical, Robust Implementation and Sustainability Model in public health and clinical settings

BACKGROUND

To increase uptake of implementation science (IS) methods by researchers and implementers, many have called for ways to make it more accessible and intuitive. The purpose of this paper is to describe the iPRISM webtool (Iterative, Practical, Robust Implementation and Sustainability Model) and how this interactive tool operationalizes PRISM to assess and guide a program's (a) alignment with context, (b) progress on pragmatic outcomes, (c) potential adaptations, and (d) future sustainability across the stages of the implementation lifecycle.

METHODS

We used an iterative human-centered design process to develop the iPRISM webtool.

RESULTS

We conducted user-testing with 28 potential individual and team-based users who were English and Spanish speaking from diverse settings in various stages of implementing different types of programs. Users provided input on all aspects of the webtool including its purpose, content, assessment items, visual feedback displays, navigation, and potential application. Participants generally expressed interest in using the webtool and high likelihood of recommending it to others. The iPRISM webtool guides English and Spanish-speaking users through the process of iteratively applying PRISM across the lifecycle of a program to facilitate systematic assessment and alignment with context. The webtool summarizes assessment responses in graphical and tabular displays and then guides users to develop feasible and impactful adaptations and corresponding action plans. Equity considerations are integrated throughout.

CONCLUSIONS

The iPRISM webtool can intuitively guide individuals and teams from diverse settings through the process of using IS methods to iteratively assess and adapt different types of programs to align with the context across the implementation lifecycle. Future research and application will continue to develop and evaluate this IS resource.

Comparative effectiveness of generic commercial versus locally customized clinical decision support tools to reduce prescription of nonsteroidal anti-inflammatory drugs for patients with heart failure

OBJECTIVE

To compare the effectiveness of 2 clinical decision support (CDS) tools to avoid prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with heart failure (HF): a "commercial" and a locally "customized" alert.

METHODS

We conducted a retrospective cohort study of 2 CDS tools implemented within a large integrated health system. The commercial CDS tool was designed according to third-party drug content and EHR vendor specifications. The customized CDS tool underwent a user-centered design process informed by implementation science principles, with input from a cross disciplinary team. The customized CDS tool replaced the commercial CDS tool. Data were collected from the electronic health record via analytic reports and manual chart review. The primary outcome was effectiveness, defined as whether the clinician changed their behavior and did not prescribe an NSAID.

RESULTS

A random sample of 366 alerts (183 per CDS tool) was evaluated that represented 355 unique patients. The commercial CDS tool was effective for 7 of 172 (4%) patients, while the customized CDS tool was effective for 81 of 183 (44%) patients. After adjusting for age, chronic kidney disease, ejection fraction, NYHA class, concurrent prescription of an opioid or acetaminophen, visit type (inpatient or outpatient), and clinician specialty, the customized alerts were at 24.3 times greater odds of effectiveness compared to the commercial alerts (OR: 24.3 CI: 10.20-58.06).

CONCLUSION

Investing additional resources to customize a CDS tool resulted in a CDS tool that was more effective at reducing the total number of NSAID orders placed for patients with HF compared to a commercially available CDS tool.

A machine learning evaluation of patient characteristics associated with prescribing of guideline-directed medical therapy for heart failure

Introduction/background

Patients with heart failure and reduced ejection fraction (HFrEF) are consistently underprescribed guideline-directed medications. Although many barriers to prescribing are known, identification of these barriers has relied on traditional a priori hypotheses or qualitative methods. Machine learning can overcome many limitations of traditional methods to capture complex relationships in data and lead to a more comprehensive understanding of the underpinnings driving underprescribing. Here, we used machine learning methods and routinely available electronic health record data to identify predictors of prescribing.

Methods

We evaluated the predictive performance of machine learning algorithms to predict prescription of four types of medications for adults with HFrEF: angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACE/ARB), angiotensin receptor-neprilysin inhibitor (ARNI), evidence-based beta blocker (BB), or mineralocorticoid receptor antagonist (MRA). The models with the best predictive performance were used to identify the top 20 characteristics associated with prescribing each medication type. Shapley values were used to provide insight into the importance and direction of the predictor relationships with medication prescribing.

Results

For 3,832 patients meeting the inclusion criteria, 70% were prescribed an ACE/ARB, 8% an ARNI, 75% a BB, and 40% an MRA. The best-predicting model for each medication type was a random forest (area under the curve: 0.788-0.821; Brier score: 0.063-0.185). Across all medications, top predictors of prescribing included prescription of other evidence-based medications and younger age. Unique to prescribing an ARNI, the top predictors included lack of diagnoses of chronic kidney disease, chronic obstructive pulmonary disease, or hypotension, as well as being in a relationship, nontobacco use, and alcohol use.

Discussion/conclusions

We identified multiple predictors of prescribing for HFrEF medications that are being used to strategically design interventions to address barriers to prescribing and to inform further investigations. The machine learning approach used in this study to identify predictors of suboptimal prescribing can also be used by other health systems to identify and address locally relevant gaps and solutions to prescribing.

Ontologizing health systems data at scale: making translational discovery a reality

Common data models solve many challenges of standardizing electronic health record (EHR) data but are unable to semantically integrate all of the resources needed for deep phenotyping. Open Biological and Biomedical Ontology (OBO) Foundry ontologies provide computable representations of biological knowledge and enable the integration of heterogeneous data. However, mapping EHR data to OBO ontologies requires significant manual curation and domain expertise. We introduce OMOP2OBO, an algorithm for mapping Observational Medical Outcomes Partnership (OMOP) vocabularies to OBO ontologies. Using OMOP2OBO, we produced mappings for 92,367 conditions, 8611 drug ingredients, and 10,673 measurement results, which covered 68-99% of concepts used in clinical practice when examined across 24 hospitals. When used to phenotype rare disease patients, the mappings helped systematically identify undiagnosed patients who might benefit from genetic testing. By aligning OMOP vocabularies to OBO ontologies our algorithm presents new opportunities to advance EHR-based deep phenotyping.

Interpretable Machine Learning Prediction of Drug-Induced QT Prolongation: Electronic Health Record Analysis

BACKGROUND

Drug-induced long-QT syndrome (diLQTS) is a major concern among patients who are hospitalized, for whom prediction models capable of identifying individualized risk could be useful to guide monitoring. We have previously demonstrated the feasibility of machine learning to predict the risk of diLQTS, in which deep learning models provided superior accuracy for risk prediction, although these models were limited by a lack of interpretability.

OBJECTIVE

In this investigation, we sought to examine the potential trade-off between interpretability and predictive accuracy with the use of more complex models to identify patients at risk for diLQTS. We planned to compare a deep learning algorithm to predict diLQTS with a more interpretable algorithm based on cluster analysis that would allow medication- and subpopulation-specific evaluation of risk.

METHODS

We examined the risk of diLQTS among 35,639 inpatients treated between 2003 and 2018 with at least 1 of 39 medications associated with risk of diLQTS and who had an electrocardiogram in the system performed within 24 hours of medication administration. Predictors included over 22,000 diagnoses and medications at the time of medication administration, with cases of diLQTS defined as a corrected QT interval over 500 milliseconds after treatment with a culprit medication. The interpretable model was developed using cluster analysis (K=4 clusters), and risk was assessed for specific medications and classes of medications. The deep learning model was created using all predictors within a 6-layer neural network, based on previously identified hyperparameters.

RESULTS

Among the medications, we found that class III antiarrhythmic medications were associated with increased risk across all clusters, and that in patients who are noncritically ill without cardiovascular disease, propofol was associated with increased risk, whereas ondansetron was associated with decreased risk. Compared with deep learning, the interpretable approach was less accurate (area under the receiver operating characteristic curve: 0.65 vs 0.78), with comparable calibration.

CONCLUSIONS

In summary, we found that an interpretable modeling approach was less accurate, but more clinically applicable, than deep learning for the prediction of diLQTS. Future investigations should consider this trade-off in the development of methods for clinical prediction.

How Dissemination and Implementation Science Can Contribute to the Advancement of Learning Health Systems

Many health systems are working to become learning health systems (LHSs), which aim to improve the value of health care by rapidly, continuously generating evidence to apply to practice. However, challenges remain to advance toward the aspirational goal of becoming a fully mature LHS. While some important challenges have been well described (i.e., building system-level supporting infrastructure and the accessibility of inclusive, integrated, and actionable data), other key challenges are underrecognized, including balancing evaluation rapidity with rigor, applying principles of health equity and classic ethics, focusing on external validity and reproducibility (generalizability), and designing for sustainability. Many LHSs focus on continuous learning cycles, but with limited consideration of issues related to the rapidity of these learning cycles, as well as the sustainability or generalizability of solutions. Some types of data have been consistently underrepresented, including patient-reported outcomes and preferences, social determinants, and behavioral and environmental data, the absence of which can exacerbate health disparities. A promising approach to addressing many challenges that LHSs face may be found in dissemination and implementation (D&I) science. With an emphasis on multilevel dynamic contextual factors, representation of implementation partner engagement, pragmatic research, sustainability, and generalizability, D&I science methods can assist in overcoming many of the challenges facing LHSs. In this article, the authors describe the current state of LHSs and challenges to becoming a mature LHS, propose solutions to current challenges, focusing on the contributions of D&I science with other methods, and propose key components and characteristics of a mature LHS model that others can use to plan and develop their LHSs.

Research and Scholarly Methods: Implementation Science Studies

Traditional research focuses on efficacy or effectiveness of interventions but lacks evaluation of strategies needed for equitable uptake, scalable implementation, and sustainable evidence-based practice transformation. The purpose of this introductory review is to describe key implementation science (IS) concepts as they apply to medication management and pharmacy practice, and to provide guidance on literature review with an IS lens. There are five key ingredients of IS, including: (1) evidence-based intervention; (2) implementation strategies; (3) IS theory, model, or framework; (4) IS outcomes and measures; and (5) stakeholder engagement, which is key to a successful implementation. These key ingredients apply across the three stages of IS research: (1) pre-implementation; (2) implementation; and (3) sustainment. A case example using a combination of IS models, PRISM (Practical, Robust Implementation and Sustainability model) and RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance), is included to describe how an IS study is designed and conducted. This case is a cluster randomized trial comparing two clinical decision support tools to improve guideline-concordant prescribing for patients with heart failure and reduced ejection fraction. The review also includes information on the Standards for Reporting Implementation Studies (StaRI), which is used for literature review and reporting of IS studies,as well as IS-related learning resources.

Pragmatic considerations and approaches for measuring staff time as an implementation cost in health systems and clinics: key issues and applied examples

Background

As the field of implementation science wrestles with the need for system decision-makers to anticipate the budget impact of implementing new programs, there has been a push to report implementation costs more transparently. For this purpose, the method of time-driven activity-based costing (TDABC) has been heralded as a pragmatic advance. However, a recent TDABC review found that conventional methods for estimating staff time remain resource-intensive and called for simpler alternatives. Our objective was to conceptually compare conventional and emerging TDABC approaches to measuring staff time.

Methods

Our environmental scan of TDABC methods identified several categories of approaches for staff time estimation; across these categories, staff time was converted to cost as a pro-rated fraction of salary/benefits. Conventional approaches used a process map to identify each step of program delivery and estimated the staff time used at each step in one of 3 ways: (a) uniform estimates of time needed for commonly occurring tasks (self-report), (b) retrospective “time diary” (self-report), or (c) periodic direct observation. In contrast, novel semi-automated electronic health record (EHR) approaches “nudge” staff to self-report time for specific process map step(s)—serving as a contemporaneous time diary. Also, novel EHR-based automated approaches include timestamps to track specific steps in a process map. We compared the utility of these TDABC approach categories according to the 5 R’s model that measures domains of interest to system decision-makers: relevance, rapidity, rigor, resources, and replicability, and include two illustrative case examples.

Results

The 3 conventional TDABC staff time estimation methods are highly relevant to settings but have limited rapidity, variable rigor, are rather resource-intensive, and have varying replicability. In contrast to conventional TDABC methods, the semi-automated and automated EHR-based approaches have high rapidity, similar rigor, similar replicability, and are less resource-intensive, but have varying relevance to settings.

Conclusions

This synthesis and evaluation of conventional and emerging methods for staff time estimation by TDABC provides the field of implementation science with options beyond the current approaches. The field remains pressed to innovatively and pragmatically measure costs of program delivery that rate favorably across all of the 5 R’s domains.

An evaluation of clinical decision support tools for Patient Health Questionnaire-9 administration

Introduction

Many health care institutions are working to improve depression screening and management with the use of the Patient Health Questionnaire 9 (PHQ-9). Clinical decision support (CDS) within the EHR is one strategy, but little is known about effective approaches to design or implement such CDS. The purpose of this study is to compare implementation outcomes of two versions of a CDS tool to improve PHQ-9 administration for patients with depression.

Methods

This was a retrospective, observational study comparing two versions of a CDS. Version 1 interrupted clinician workflow, and version 2 did not interrupt workflow. Outcomes of interest included reach, adoption, and effectiveness. PHQ-9 administration was determined by chart review. Chi-square tests were used to evaluate associations between PHQ-9 administration with versions 1 and 2.

Results

Version 1 resulted in PHQ-9 administration 77 times (15.3% of 504 unique encounters) compared with 49 times (9.8% of 502 unique encounters) with version 2 (P = .011).

Discussion

An interruptive CDS tool may be more effective at increasing PHQ-9 administration, but a noninterruptive CDS tool may be preferred to minimize alert fatigue despite a decrease in effectiveness.

Applying Clinical Decision Support Design Best Practices With the Practical Robust Implementation and Sustainability Model Versus Reliance on Commercially Available Clinical Decision Support Tools: Randomized Controlled Trial

BACKGROUND

Limited consideration of clinical decision support (CDS) design best practices, such as a user-centered design, is often cited as a key barrier to CDS adoption and effectiveness. The application of CDS best practices is resource intensive; thus, institutions often rely on commercially available CDS tools that are created to meet the generalized needs of many institutions and are not user centered. Beyond resource availability, insufficient guidance on how to address key aspects of implementation, such as contextual factors, may also limit the application of CDS best practices. An implementation science (IS) framework could provide needed guidance and increase the reproducibility of CDS implementations.

OBJECTIVE

This study aims to compare the effectiveness of an enhanced CDS tool informed by CDS best practices and an IS framework with a generic, commercially available CDS tool.

METHODS

We conducted an explanatory sequential mixed methods study. An IS-enhanced and commercial CDS alert were compared in a cluster randomized trial across 28 primary care clinics. Both alerts aimed to improve beta-blocker prescribing for heart failure. The enhanced alert was informed by CDS best practices and the Practical, Robust, Implementation, and Sustainability Model (PRISM) IS framework, whereas the commercial alert followed vendor-supplied specifications. Following PRISM, the enhanced alert was informed by iterative, multilevel stakeholder input and the dynamic interactions of the internal and external environment. Outcomes aligned with PRISM's evaluation measures, including patient reach, clinician adoption, and changes in prescribing behavior. Clinicians exposed to each alert were interviewed to identify design features that might influence adoption. The interviews were analyzed using a thematic approach.

RESULTS

Between March 15 and August 23, 2019, the enhanced alert fired for 61 patients (106 alerts, 87 clinicians) and the commercial alert fired for 26 patients (59 alerts, 31 clinicians). The adoption and effectiveness of the enhanced alert were significantly higher than those of the commercial alert (62% vs 29% alerts adopted, P<.001; 14% vs 0% changed prescribing, P=.006). Of the 21 clinicians interviewed, most stated that they preferred the enhanced alert.

CONCLUSIONS

The results of this study suggest that applying CDS best practices with an IS framework to create CDS tools improves implementation success compared with a commercially available tool.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04028557; http://clinicaltrials.gov/ct2/show/NCT04028557.

Assessing Prescriber Behavior with a Clinical Decision Support Tool to Prevent Drug-Induced Long QT Syndrome

OBJECTIVE

Clinical decision support (CDS) alerts built into the electronic health record (EHR) have the potential to reduce the risk of drug-induced long QT syndrome (diLQTS) in susceptible patients. However, the degree to which providers incorporate this information into prescription behavior and the impact on patient outcomes is often unknown.

METHODS

We examined provider response data over a period from October 8, 2016 until November 8, 2018 for a CDS alert deployed within the EHR from a 13-hospital integrated health care system that fires when a patient with a QTc ≥ 500 ms within the past 14 days is prescribed a known QT-prolonging medication. We used multivariate generalized estimating equations to analyze the impact of therapeutic alternatives, relative risk of diLQTS for specific medications, and patient characteristics on provider response to the CDS and overall patient mortality.

RESULTS

The CDS alert fired 15,002 times for 7,510 patients for which the most common response (51.0%) was to override the alert and order the culprit medication. In multivariate models, we found that patient age, relative risk of diLQTS, and presence of alternative agents were significant predictors of adherence to the CDS alerts and that nonadherence itself was a predictor of mortality. Risk of diLQTS and presence of an alternative agent are major factors in provider adherence to a CDS to prevent diLQTS; however, provider nonadherence was associated with a decreased risk of mortality.

CONCLUSION

Surrogate endpoints, such as provider adherence, can be useful measures of CDS value but attention to hard outcomes, such as mortality, is likely needed.

Twice-daily versus once-daily lisinopril and losartan for hypertension: Real-world effectiveness and safety

BACKGROUND

Lisinopril and losartan manufacturer labels recommend twice-daily dosing (BID) if once-daily (QDay) is insufficient to lower blood pressure (BP).

METHODS AND RESULTS

Retrospective cohort study of patients taking QDay lisinopril and losartan who experienced a dose-doubling (index date). A text-processing tool categorized BID and QDay groups at the index date based on administration instructions. We excluded: pregnant/hospice, regimens other than BID/QDay, and without BP measurements -6 months/+12 months of the index date. The most proximal BP measurements -6 months and +2 weeks to 12 months of the index date were used to evaluate BP differences. Propensity scores were generated, and differences in BP and adverse events (angioedema, acute kidney injury, hyperkalemia) between BID/QDay groups were analyzed within dosing cohorts using inverse propensity of treatment-weighted regression models. Of 11,210 and 6,051 patients who met all criteria for lisinopril and losartan, 784 (7.0%) and 453 (7.5%) were taking BID, respectively. BID patients were older and had higher comorbidity and medication burdens. There were no differences in systolic/diastolic BP between BID and QDay, with absolute differences in mean systolic BP ranging from -1.8 to 0.7 mmHg and diastolic BP ranging from -1.1 to 0.1 mmHg (all 95% confidence intervals [CI] cross 0). Lisinopril 10mg BID was associated with an increased odds of angioedema compared to lisinopril 20mg QDay (odds ratio 2.27, 95%CI 1.13-4.58).

CONCLUSIONS

Adjusted models do not support improved effectiveness or safety of BID lisinopril and losartan.

An Electronically Delivered Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure With Reduced Ejection Fraction: The EPIC-HF Trial

BACKGROUND

Major gaps exist in the routine initiation and dose up-titration of guideline-directed medical therapies (GDMT) for patients with heart failure with reduced ejection fraction. Without novel approaches to improve prescribing, the cumulative benefits of heart failure with reduced ejection fraction treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients.

METHODS

The EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction) trial randomized patients with heart failure with reduced ejection fraction from a diverse health system to usual care versus patient activation tools-a 3-minute video and 1-page checklist-delivered electronically 1 week before, 3 days before, and 24 hours before a cardiology clinic visit. The tools encouraged patients to work collaboratively with their clinicians to "make one positive change" in heart failure with reduced ejection fraction prescribing. The primary endpoint was the percentage of patients with GDMT medication initiations and dose intensifications from immediately preceding the cardiology clinic visit to 30 days after, compared with usual care during the same period.

RESULTS

EPIC-HF enrolled 306 patients, 290 of whom attended a clinic visit during the study period: 145 were sent the patient activation tools and 145 were controls. The median age of patients was 65 years; 29% were female, 11% were Black, 7% were Hispanic, and the median ejection fraction was 32%. Preclinic data revealed significant GDMT opportunities, with no patients on target doses of β-blocker, sacubitril/valsartan, and mineralocorticoid receptor antagonists. From immediately preceding the cardiology clinic visit to 30 days after, 49.0% in the intervention and 29.7% in the control experienced an initiation or intensification of their GDMT (P=0.001). The majority of these changes were made at the clinician encounter itself and involved dose uptitrations. There were no deaths and no significant differences in hospitalization or emergency department visits at 30 days between groups.

CONCLUSIONS

A patient activation tool delivered electronically before a cardiology clinic visit improved clinician intensification of GDMT. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03334188.

An Electronically delivered, Patient-activation tool for Intensification of medications for Chronic Heart Failure with reduced ejection fraction: Rationale and design of the EPIC-HF trial

BACKGROUND

Heart failure with reduced ejection fraction (HFrEF) benefits from initiation and intensification of multiple pharmacotherapies. Unfortunately, there are major gaps in the routine use of these drugs. Without novel approaches to improve prescribing, the cumulative benefits of HFrEF treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients.

HYPOTHESIS

Encouraging patients to engage providers in HFrEF prescribing decisions will improve the use of guideline-directed medical therapies.

DESIGN

The Electronically delivered, Patient-activation tool for Intensification of Chronic medications for Heart Failure with reduced ejection fraction (EPIC-HF) trial randomizes patients with HFrEF to usual care versus patient-activation tools-a 3-minute video and 1-page checklist-delivered prior to cardiology clinic visits that encourage patients to work collaboratively with their clinicians to intensify HFrEF prescribing. The study assesses the effectiveness of the EPIC-HF intervention to improve guideline-directed medical therapy in the month after its delivery while using an implementation design to also understand the reach, adoption, implementation, and maintenance of this approach within the context of real-world care delivery. Study enrollment was completed in January 2020, with a total 305 patients. Baseline data revealed significant opportunities, with <1% of patients on optimal HFrEF medical therapy.

SUMMARY

The EPIC-HF trial assesses the implementation, effectiveness, and safety of patient engagement in HFrEF prescribing decisions. If successful, the tool can be easily disseminated and may inform similar interventions for other chronic conditions.

Integrating the Practical Robust Implementation and Sustainability Model With Best Practices in Clinical Decision Support Design: Implementation Science Approach

Background

Clinical decision support (CDS) design best practices are intended to provide a narrative representation of factors that influence the success of CDS tools. However, they provide incomplete direction on evidence-based implementation principles.

Objective

This study aims to describe an integrated approach toward applying an existing implementation science (IS) framework with CDS design best practices to improve the effectiveness, sustainability, and reproducibility of CDS implementations.

Methods

We selected the Practical Robust Implementation and Sustainability Model (PRISM) IS framework. We identified areas where PRISM and CDS design best practices complemented each other and defined methods to address each. Lessons learned from applying these methods were then used to further refine the integrated approach.

Results

Our integrated approach to applying PRISM with CDS design best practices consists of 5 key phases that iteratively interact and inform each other: multilevel stakeholder engagement, designing the CDS, design and usability testing, thoughtful deployment, and performance evaluation and maintenance. The approach is led by a dedicated implementation team that includes clinical informatics and analyst builder expertise.

Conclusions

Integrating PRISM with CDS design best practices extends user-centered design and accounts for the multilevel, interacting, and dynamic factors that influence CDS implementation in health care. Integrating PRISM with CDS design best practices synthesizes the many known contextual factors that can influence the success of CDS tools, thereby enhancing the reproducibility and sustainability of CDS implementations. Others can adapt this approach to their situation to maximize and sustain CDS implementation success.

Lessons and tips for designing a machine learning study using EHR data

Machine learning (ML) provides the ability to examine massive datasets and uncover patterns within data without relying on a priori assumptions such as specific variable associations, linearity in relationships, or prespecified statistical interactions. However, the application of ML to healthcare data has been met with mixed results, especially when using administrative datasets such as the electronic health record. The black box nature of many ML algorithms contributes to an erroneous assumption that these algorithms can overcome major data issues inherent in large administrative healthcare data. As with other research endeavors, good data and analytic design is crucial to ML-based studies. In this paper, we will provide an overview of common misconceptions for ML, the corresponding truths, and suggestions for incorporating these methods into healthcare research while maintaining a sound study design.

Clinicians' Values and Preferences for Medication Adherence and Cost Clinical Decision Support in Primary Care: A Qualitative Study

BACKGROUND

Medication nonadherence and unaffordability are prevalent, burdensome issues in primary care. In response, technology companies are capitalizing on clinical decision support (CDS) to deliver patient-specific information regarding medication adherence and costs to clinicians using electronic health records (EHRs). To maximize adoption and usability, these CDS tools should be designed with consideration of end users' values and preferences.

OBJECTIVE

This article evaluates primary care clinicians' values and preferences for a medication adherence and cost CDS.

METHODS

We conducted semistructured interviews with primary care clinicians with prescribing privileges and EHR access to identify clinicians' perceptions of and approaches to assessing medication adherence and costs, and to determine perceived values and preferences for medication adherence and cost CDS. Interviews were conducted until saturation of responses was reached. ATLAS.ti was used for thematic analysis.

RESULTS

Among 26 clinicians interviewed, themes identified included a high value, but moderate need for a medication adherence CDS and high value and need for cost CDS. Clinicians expressed the cost CDS would provide actionable solutions and greatly impact patient care. Another theme identified was a desire for medication adherence and cost CDS to be separate tools yet integrated into workflow. The majority of clinicians preferred a medication adherence CDS that integrated claims data and actively displayed data using color-coded adherence categories within patients' medication lists in the EHR. For the cost CDS, clinicians preferred medication out-of-pocket costs and a list of cheaper or payor-preferred alternatives to display within the order queue of the EHR.

CONCLUSION

We identified valuable insights regarding clinician values and preferences for medication adherence and cost CDS. Overall, primary care clinicians feel CDS for medication adherence and cost are valuable and prefer them to be separate. These insights should be used to inform the design, implementation, and EHR integration of future medication and cost CDS tools.

Heart Failure Management Innovation Enabled by Electronic Health Records

Patients with congestive heart failure (CHF) require complex medical management across the continuum of care. Electronic health records (EHR) are currently used for traditional tasks of documentation, reviewing and managing test results, computerized order entry, and billing. Unfortunately many clinicians view EHR as merely digitized versions of paper charts, which create additional work and cognitive burden without improving quality or efficiency of care. In fact, EHR are revolutionizing the care of chronic diseases such as CHF. This review describes how appropriate use of technologies offered by EHR can help standardize CHF care, promote adherence to evidence-based guidelines, optimize workflow efficiency, improve performance metrics, and facilitate patient engagement. This review discusses a number of tools including documentation templates, telehealth and telemedicine, health information exchange, order sets, clinical decision support, registries, and analytics. Where available, evidence of their potential utility in management of CHF is presented. Together these EHR tools can also be used to enhance quality improvement, patient management, and clinical research as part of a learning health care system model. This review describes how existing EHR tools can support patients, cardiologists, and care teams to deliver consistent, high-quality, coordinated, patient-centered, and guideline-concordant care of CHF.

Clinical implementation of pharmacogenomics via a health system-wide research biobank: the University of Colorado experience

In recent years, the genomics community has witnessed the growth of large research biobanks, which collect DNA samples for research purposes. Depending on how and where the samples are genotyped, biobanks also offer the potential opportunity to return actionable genomic results to the clinical setting. We developed a preemptive clinical pharmacogenomic implementation initiative via a health system-wide research biobank at the University of Colorado. Here, we describe how preemptive return of clinical pharmacogenomic results via a research biobank is feasible, particularly when coupled with strong institutional support to maximize the impact and efficiency of biobank resources, a multidisciplinary implementation team, automated clinical decision support tools, and proactive strategies to engage stakeholders early in the clinical decision support tool development process.

Patient Treatment Preferences for Heart Failure Medications: A Mixed Methods Study

INTRODUCTION

Consideration of patient preferences for guideline-directed medical therapies (GDMT) for heart failure with reduced ejection fraction (HFrEF) may help improve major gaps in prescribing and adherence. This study aimed to identify the range and relative priority of factors influencing patients' decisions to take HFrEF medications.

MATERIALS AND METHODS

This was a convergent mixed methods study of patients with HFrEF. Focus groups were conducted to identify a list of factors followed by individuals rating and ranking the influence of each factor on their decision to take a medication. Using thematic analysis, we summarized preferences into categories.

RESULTS

Two focus groups with 13 participants reported 22 factors. Of the factors, "keeping you alive" was most commonly ranked in the top three (seven participants), followed by "communication and understanding" (six participants). Factors were summarized into six categories (listed in order of patient-reported influence): 1) demonstrated improvements in quality of life and longevity, 2) decreased risk of hospitalization, 3) opportunity for shared decision-making and trust in provider, 4) absence of adverse events, 5) affordability, and 6) convenience of taking and absence of interference with daily life.

CONCLUSION

Patients prioritize treatment benefits and being informed more than risks, cost and inconvenience of taking HFrEF medications.

Clinician preferences for computerised clinical decision support for medications in primary care: a focus group study

BACKGROUND

To improve user-centred design efforts and efficiency; there is a need to disseminate information on modern day clinician preferences for technologies such as computerised clinical decision support (CDS).

OBJECTIVE

To describe clinician perceptions regarding beneficial features of CDS for chronic medications in primary care.

METHODS

This study included focus groups and clinicians individually describing their ideal CDS. Three focus groups were conducted including prescribing clinicians from a variety of disciplines. Outcome measures included identification of favourable features and unintended consequences of CDS for chronic medication management in primary care. We transcribed recordings, performed thematic qualitative analysis and generated counts when possible.

RESULTS

There were 21 participants who identified four categories of beneficial CDS features during the group discussion: non-interruptive alerts, clinically relevant and customisable support, presentation of pertinent clinical information and optimises workflow. Non-interruptive alerts were broadly defined as passive alerts that a user chooses to review, whereas interruptive were active or disruptive alerts that interrupted workflow and one is forced to review before completing a task. The CDS features identified in the individual descriptions were consistent with the focus group discussion, with the exception of non-interruptive alerts. In the individual descriptions, 12 clinicians preferred interruptive CDS compared with seven clinicians describing non-interruptive CDS.

CONCLUSION

Clinicians identified CDS for chronic medications beneficial when they are clinically relevant and customisable, present pertinent clinical information (eg, labs, vitals) and improve their workflow. Although clinicians preferred passive, non-interruptive alerts, most acknowledged that these may not be widely seen and may be less effective. These features align with literature describing best practices in CDS design and emphasise those features clinicians prioritise, which should be considered when designing CDS for medication management in primary care. These findings highlight the disparity between the current state of CDS design and clinician-stated design features associated with beneficial CDS.

Association of Total Medication Burden With Intensive and Standard Blood Pressure Control and Clinical Outcomes: A Secondary Analysis of SPRINT

Total medication burden (antihypertensive and nonantihypertensive medications) may be associated with poor systolic blood pressure (SBP) control. We investigated the association of baseline medication burden and clinical outcomes and whether the effect of the SBP intervention varied according to baseline medication burden in SPRINT (Systolic Blood Pressure Intervention Trial). Participants were randomized to intensive or standard SBP goal (below 120 or 140 mm Hg, respectively); n=3769 participants with high baseline medication burden (≥5 medications) and n=5592 with low burden (<5 medications).

PRIMARY OUTCOME

differences in SBP.

SECONDARY OUTCOMES

8-item Morisky Medication Adherence Scale and modified Treatment Satisfaction Questionnaire for Medications measured at baseline and 12 months and incident cardiovascular disease events and serious adverse events throughout the trial. Participants in the intensive group with high versus low medication burden were less likely to achieve their SBP goal at 12 months (risk ratio, 0.91; 95% CI, 0.85-0.97) but not in the standard group (risk ratio, 0.98; 95% CI, 0.93-1.03; P_interaction<0.001). High medication burden was associated with increased cardiovascular disease events (hazard ratio, 1.39; 95% CI, 1.14-1.70) and serious adverse events (hazard ratio, 1.34; 95% CI, 1.24-1.45), but the effect of intensive versus standard treatment did not vary between medication burden groups (P_interaction>0.5). Medication burden had minimal association with adherence or satisfaction. High baseline medication burden was associated with worse intensive SBP control and higher rates of cardiovascular disease events and serious adverse events. The relative benefits and risks of intensive SBP goals were similar regardless of medication burden.

CLINICAL TRIAL REGISTRATION- URL

http://www.

CLINICALTRIALS

gov. Unique identifier: NCT01206062.

Patient Outreaches for Clinical Pharmacy Services: A Population Health Management Program Assessment

BACKGROUND

Pharmacists in ambulatory care can utilize population health approaches to identify patients needing disease management and improve outcomes. However, population health is only effective when identified patients are successfully outreached and show to appointments.

OBJECTIVE

Describe a population health approach utilized by pharmacists in primary care, report outcomes of outreach attempts and scheduled appointments, and determine whether patient and referral characteristics predict no-show appointments.

METHODS

Retrospective cohort study of patients referred for pharmacist management of hypertension or chronic pain through population health between 2013-2016. Outreach attempt and appointments outcomes were collected. Patient and referral characteristics were analyzed to determine whether predictive of no-show appointments using logistic regression.

RESULTS

Of 450 outreach attempts, 250 (56%) patients were not reached, 164 (36%) scheduled appointments, and 36 (8%) were reached but declined an appointment. Of 164 patients with appointments, 71 (43%) no-showed. Patients with higher systolic blood pressure were more likely to no-show (OR: 1.02, 95% CI: 1.00-1.04). Other characteristics were not predictive of no-show appointments.

CONCLUSION

Successful outreach and showed appointments are essential components of successful population health programs. Using multiple outreach modalities and further identifying factors predictive of no-show appointments to refine the current approach may lead to increased efficiency.

Factors influencing the acceptance of referrals for clinical pharmacist managed disease states in primary care

OBJECTIVE

Clinical pharmacists use population health methods to generate chronic disease management referrals for patients with uncontrolled chronic conditions. The purpose of this study was to compare primary care providers' (PCPs) referral responses for 4 pharmacist-managed indications and to identify provider and patient characteristics that are predictive of PCP response.

DESIGN

Retrospective cohort study.

SETTING

This study occurred in an academic internal medicine clinic.

PARTICIPANTS

Clinical pharmacy referrals generated through a population health approach between 2012 and 2016 for hypertension, chronic pain, depression, and benzodiazepine management were included.

MAIN OUTCOME MEASURES

Proportion of referrals accepted, left pending, or rejected and influencing provider and patient characteristics.

RESULTS

Of 1769 referrals generated, PCPs accepted 869 (49%), left pending 300 (17%), and rejected 600 (34%). Compared with referrals for hypertension, benzodiazepine management, and depression, chronic pain referrals had the lowest likelihood of rejection (odds ratio [OR] 0.31; 95% CI 0.19-0.49). Depression referrals had an equal likelihood of being accepted or rejected (OR 1.04; 95% CI 0.66-1.64). Provider characteristics were not significantly associated with referral response, but residents were more likely to accept referrals. Patient characteristics associated with lower referral rejection included black race (OR 0.39; 95% CI 0.18-0.87), higher systolic blood pressure (OR 0.98; 95% CI 0.97-0.99), and missed visits (OR 0.24; 95% CI 0.07-0.81).

CONCLUSION

The majority of referrals for clinical pharmacists in primary care settings were responded to, varying mostly between acceptance and rejection. There was variability in referral acceptance across indications, and some patient characteristics were associated with increased referral acceptance.

Assessing the incidence of acidosis in patients receiving metformin with and without risk factors for lactic acidosis

BACKGROUND

Despite strong recommendations to use metformin as first-line therapy for type 2 diabetes (T2DM), its use has been suboptimal, likely due to concerns of lactic acidosis. This study compared the association of acidosis in patients with T2DM prescribed metformin with those prescribed other antihyperglycemic medications or no medications.

METHODS

This was a retrospective cohort study of patients with newly diagnosed T2DM utilizing an administrative database, which includes medical and prescription claims. Eligible patients had a diagnosis of T2DM, had continuous health plan enrollment 3 months prior to study enrollment and during the study period, and were at least 18 years of age. Mutually exclusive exposure groups were metformin only, other antihyperglycemic medications, and no medication. Acidosis cases were stratified by exposure group and risk factors for lactic acidosis (chronic obstructive pulmonary disease, hepatic dysfunction, alcohol abuse, heart failure, renal insufficiency, age of 80 years or older, and a history of acidosis). Degree of renal insufficiency was not available. Associations between exposure and acidosis were estimated, and risk factors evaluated.

RESULTS

A total of 132,780 patients met inclusion criteria: 24,936 (20%) metformin only group, 15,059 (11%) other antihyperglycemic medication group, and 92,785 (70%) no medication group. Acidosis was observed in 1.45 per 10,000 patient months (0.78 metformin, 1.59 other antihyperglycemic medication, 1.51 no medication). The unadjusted relative risk of acidosis was 0.5 for patients prescribed metformin only compared with the other exposure groups (95% confidence interval = 0.2-1.2). There was no significant difference in risk of acidosis between exposure groups, irrespective of risk factors for lactic acidosis.

CONCLUSIONS

Risk of acidosis was similar with metformin only compared with those prescribed other antihyperglycemic medications or no medication. These results support expanded use of metformin for T2DM. Additional studies are needed to understand the impact of risk factor severity on risk of lactic acidosis.

Abstract P208: Association of Baseline Medication Burden With Blood Pressure Control, Patient-Reported Outcomes, and Serious Adverse Events: Findings from the SPRINT Trial

Background: Achieving intensive systolic blood pressure (SBP) control (<120 mmHg) requires more antihypertensive medications than standard control (<140 mmHg). It is unclear how total medication burden impacts hypertension outcomes.

Objective: To evaluate the association of total medication burden at baseline and SBP control, serious adverse events (SAEs), medication adherence, and treatment satisfaction in the Systolic Blood Pressure Intervention Trial (SPRINT).

Methods: Baseline medication data were obtained by pill bottle review at randomization and categorized as high (≥ 5 prescription medications) vs low (< 5 medications) medication burden. SBP control per randomization goal, eight item Morisky Medication Adherence Scale (MMAS 8), and Treatment Satisfaction Questionnaire were evaluated at 1-year. SAEs were collected over the trial. We calculated adjusted risk ratios (RR) and hazard ratios (HR) for each outcome associated with medication burden using multivariable regression models stratified by randomized group.

Results: Among 8454 participants with available data at 1-year follow up, 4797 (57%) and 3657 (43%) had high and low medication burden, respectively (mean medications ± SD; 8 ± 3 vs 3 ± 1). High medication burden was associated with reduced SBP control in the intensive arm (RR, 95%CI; intensive 0.92, 0.87-0.98; standard 0.98, 0.94-1.03; interaction p 0.01) and increased SAEs in both arms (HR, 95%CI; intensive 1.57, 1.40-1.77; standard 1.59, 1.41-1.78; interaction p 0.54). High medication burden was associated with worse medication adherence in the intensive arm and improved adherence in the standard arm (RR for MMAS 8 ≥6, 95%CI; intensive 0.97, 0.94-1.00; standard 1.05, 1.02-1.09; interaction p <0.01). High medication burden was not associated with hypertension treatment satisfaction (RR for satisfied/very satisfied, 95%CI; intensive 0.99, 0.98-1.00; standard 0.98, 0.97-1.00; interaction p 0.50).

Conclusion: In SPRINT, high medication burden at baseline was associated with higher risk of SAEs. The association of high medication burden on the likelihood of achieving SBP goal and medication adherence at 1 year was different by treatment arm; medication burden was not associated with hypertension treatment satisfaction.

Design and Implementation of a Depression Registry for Primary Care

Registries are fundamental to the success of population health initiatives to improve care and outcomes for patients, including those with depression. The purpose of this article is to describe the design and clinical implementation of a depression registry as part of a collaborative care for depression intervention at 2 large academic outpatient internal medicine practices. The primary objective of the registry was to identify and track patients with depression and monitor antidepressant therapy. Secondary objectives of the registry were to assist in addressing pay-for-performance and value-based reimbursement metrics for depression screening and remission. The registry design and variables for inclusion in the registry were defined with input from clinicians, institutional leadership, and data analysts. For implementation, specific clinical workflows were established and responsible team roles were designated.

Efficacy and Safety of Atypical Antipsychotics for Behavioral and Psychological Symptoms of Dementia Among Community Dwelling Adults

Introduction:

Options for the treatment of the behavioral and psychological symptoms of dementia (BPSD) are limited. Atypical antipsychotics are often used but have questionable efficacy and are generally considered high risk. Therefore, the objective of this study is to evaluate the efficacy and safety of using any atypical antipsychotic for the treatment of BPSD among outpatients.

Methods:

Retrospective observational study of an academic outpatient memory disorders clinic. Participants included any community-dwelling patient with a diagnosis of dementia, not trauma induced, with documented BPSD treated with an atypical antipsychotic for at least 2 weeks. Medical records were reviewed from January 1, 1990 to March 23, 2010. Safety outcomes were documented from the time of antipsychotic initiation, and behavioral/psychological efficacy outcomes were documented beginning 2 weeks after antipsychotic therapy was initiated, until the last documentation available.

Results:

A total of 87 distinct antipsychotic treatment periods for 81 unique patients were included. Antipsychotic treatment was continued for more than a year in 33% of patients and only 17% of patients discontinued antipsychotic treatment over the entire period. The behavioral/psychological outcomes improved for 24 (28%) treatments, remained stable for 17 (20%) treatments, and worsened for 46 (53%) treatments. Adverse events were reported by 53% of patients, with the most common adverse events being metabolic, fall related, type, and vascular. Few adverse events were severe. The odds ratio of adverse events per every 90-day increase in duration of treatment was 1.20 ( P = 0.02).

Conclusion:

Antipsychotic treatment improved behavioral/psychological symptoms for less than one-third of patients and increased the potential risk of adverse events for more than half of patients.

Evaluation of a Clinical Pharmacist-Led Multidisciplinary Antidepressant Telemonitoring Service in the Primary Care Setting

Guidelines recommend patient follow-up within 2 weeks of antidepressant initiation or uptitration to minimize treatment discontinuation and suicidal ideation risks; however, time constraints and lack of systematic processes remain barriers in primary care. A pharmacist-led multidisciplinary telemonitoring service aimed to address these barriers. This was a retrospective, observational study of adults with depression initiated or uptitrated on an antidepressant between May and October 2016. Outcomes included the proportion of eligible patients successfully contacted, adherence, adverse effects, suicidal ideations, and pharmacist interventions. Clinical pharmacists successfully reached 258 of 380 (68%) patients and provided follow-up in 298 calls. Patients endorsed antidepressant nonadherence during 56 (19%) calls, adverse effects in 81 (27%) calls, and suicidal ideations in 13 (4%) calls. Pharmacists provided 109 total interventions for 102 patients. The clinical pharmacist-led multidisciplinary antidepressant telemonitoring service is an alternative resource to monitor patients after antidepressant initiation or titration in primary care settings.

Efficacy and safety of atypical antipsychotics for behavioral symptoms of dementia among patients residing in long-term care

Background There are limited options for the treatment of behavioral and psychological symptoms of dementia (BPSD). Objective Evaluate the efficacy and safety of using atypical antipsychotics for BPSD among patients residing in long-term care. Setting Long term care community facility in the United States. Methods Retrospective observational study of patients residing in a long-term care facility with a diagnosis of dementia not trauma-induced with documented BPSD treated with an atypical antipsychotic for at least 2 weeks. Paper medical records were reviewed from January 1, 1990 until March 23, 2010. Main outcome measure Behavioral/psychological efficacy outcomes were documented beginning 2 weeks after atypical antipsychotic therapy was initiated and safety outcomes were documented from the time of atypical antipsychotic initiation, until the last documentation available. Efficacy and safety outcomes were documented as part of routine clinical practice based on the responsible clinician. Results A total of 85 distinct atypical antipsychotic treatment periods for 73 unique patients were included. Nearly 50% of patients continued atypical antipsychotic treatment for at least 1 year and 5.6% of treatments were discontinued due to an adverse event. Patients' behavioral/psychological outcomes improved for 52 (61%) treatments, remained stable for 17 (20%) treatments, and worsened for 16 (19%) treatments. Adverse events were reported by 57% of patients, with the most common adverse events being metabolic, fall related, and extrapyramidal symptoms. The odds ratio for an adverse event was 1.08 (p = 0.03) for every 90 day increase in duration of treatment. Conclusion In patients who reside in a long-term care setting, atypical antipsychotic treatment improved BPSD, but also increased the potential risk of adverse events.

Integration of Community Pharmacists in Transition of Care (TOC) Services: Current Trends and Pharmacist Perceptions

BACKGROUND:

Barriers exist for patients transitioning from one health-care setting to another, or to home, and health-care systems are falling short of meeting patient needs during this time. Community pharmacist incorporation poses a solution to the current communication breakdown and high rates of medication errors during transitions of care (TOC). The purpose of this study was to determine community pharmacists' involvement in and perceptions of TOC services.

METHODS:

Cross-sectional study using electronic surveys nationwide to pharmacists employed by a community pharmacy chain.

RESULTS:

Of 7236 pharmacists surveyed, 546 (7.5%) responded. Only 33 (6%) pharmacists reported their pharmacy participates in TOC services. Most pharmacists (81.5%) reported receiving discharge medication lists. The most common reported barrier to TOC participation is lack of electronic integration with surrounding hospitals (51.1%). Most pharmacists agreed that (1) it is valuable to receive discharge medication lists (83.3%), (2) receiving discharge medication lists is beneficial for patients' health (89.1%), (3) discharge medication list receipt improves medication safety (88.8%).

CONCLUSIONS:

Most pharmacists reported receiving discharge medication lists and reported discharge medication lists are beneficial, but less than half purposefully used medication lists. To close TOC gaps, health-care providers must collaborate to overcome barriers for successful TOC services.

Efficacy and safety of twice- vs once-daily dosing of lisinopril for hypertension

This retrospective cohort study compared administration of lisinopril twice daily and once daily for hypertension. Data were collected from an ambulatory electronic health record between 2011 and 2014. Patients previously receiving lisinopril 20 mg were placed into the once-daily cohort if changed to 40 mg once daily or into the twice-daily cohort if changed to 20 mg twice daily. Efficacy outcome measures were change in systolic blood pressure and diastolic blood pressure and achievement of blood pressure control (<140/90 mm Hg). Of 90 patients included (45 per cohort), the mean age was 61.8 years and 17.8% were black. Once- and twice-daily administrations were associated with blood pressure reductions of 6.2/1.5 mm Hg and 16.5/5.9 mm Hg, with a 10.2/4.3 mm Hg greater reduction with twice-daily administration (systolic blood pressure, P=.016; diastolic blood pressure, P=.068). Twice-daily lisinopril dosing was associated with greater systolic blood pressure reductions compared with the same total daily dose administered once daily.

Clinical pharmacists in primary care: Provider satisfaction and perceived impact on quality of care provided

PURPOSE

The purpose of this study is to evaluate primary care provider satisfaction and perceived impact of clinical pharmacy services on the disease state management in primary care.

METHODS

A cross-sectional survey with 24 items and 4 domains was distributed anonymously to pharmacy residency program directors across the United States who were requested to forward the survey to their primary care provider colleagues. Primary care providers were asked to complete the survey.

RESULTS

A total of 144 primary care providers responded to the survey, with 130 reporting a clinical pharmacist within their primary care practice and 114 completing the entire survey. Primary care providers report pharmacists positively impact quality of care (mean = 5.5 on Likert scale of 1-6; standard deviation = 0.72), high satisfaction with pharmacy services provided (5.5; standard deviation = 0.79), and no increase in workload as a result of clinical pharmacists (5.5; standard deviation = 0.77). Primary care providers would recommend clinical pharmacists to other primary care practices (5.7; standard deviation = 0.59). Primary care providers perceived specific types of pharmacy services to have the greatest impact on patient care: medication therapy management (38.6%), disease-focused management (29.82%), and medication reconciliation (11.4%). Primary care providers indicated the most valuable disease-focused pharmacy services as diabetes (58.78%), hypertension (9.65%), and pain (11.4%).

CONCLUSION

Primary care providers report high satisfaction with and perceived benefit of clinical pharmacy services in primary care and viewed medication therapy management and disease-focused management of diabetes, hypertension, and pain as the most valuable clinical pharmacy services. These results can be used to inform development or expansion of clinical pharmacy services in primary care.

Identification and Characterization of Adverse Drug Events in Primary Care

The purpose of this study was to identify and characterize adverse drug events (ADEs) in a primary care setting using an electronic health record (EHR). This prospective, observational study enrolled patients with any medication change who were seen at an outpatient internal medicine clinic. Patients were evaluated for ADEs by EHR review and telephone interview. ADEs were independently assessed for causality, severity, preventability, and ameliorability by a physician and a pharmacist using a grading instrument. There were 1368 unique medication changes for 701 individuals who completed the study (1.95 changes per person). Of the 226 suspected ADEs, 68 (58%) were deemed to be "definite" or "probable" following causality assessment; 21% were preventable and 40% ameliorable. Only 2 ADEs were serious or life-threatening. Compared with prior reports, ADEs in primary care have decreased in frequency and severity, yet the occurrence of preventable and ameliorable ADEs has increased.

Prescribing Patterns for Outpatient Treatment of Constipation, Irritable Bowel Syndrome-Related Constipation, and Opioid-Induced Constipation: A Retrospective Cross-Sectional Study

BACKGROUND

Despite national recommendations for treatment of constipation, prescribing patterns for treatment are inconsistent, and health care utilization has increased.

OBJECTIVE

To identify patterns in pharmacologic and nonpharmacologic treatment of constipation and associations between treatment and other variables across age groups.

METHODS

This was a retrospective cross-sectional study that used the National Ambulatory Medical Care Survey (NAMCS) to compare prescribing from 2000 to 2004 and from 2005 to 2009. Treatment patterns for constipation, irritable bowel syndrome-related constipation (IBS-C), and opioid-induced constipation were considered.

RESULTS

From 2000 to 2009, there were 89.6 million office visits related to constipation: 63.4 million for constipation alone, 28.2 million for IBS-C alone, and 3.7 million for opioid-induced constipation. For constipation, there was an overall decrease in the prescription of combination therapy (17% vs. 11%, P  less than  0.05); an increase in the prescription of medication monotherapy (21% vs. 29%, P  less than  0.05); decreases in the use of lubricants (9% vs. 2%, P  less than  0.05) and saline (7% vs. 1%, P  less than   0.001) among patients aged less than  18 years; a decrease in combination therapy (31% vs. 17%, P  less than  0.05); and age group differences in the prescription of specific medications. For IBS-C and opioid-induced constipation, there were no changes in major treatment category or specific medication. Age, gender, race, ethnicity, payer source, physician specialty, and region were all found to be associated with treatment choice.

CONCLUSIONS

Health care utilization for constipation increased, and prescribing patterns shifted significantly from 2000 to 2009 for constipation and IBS-C. Patterns in treatment were significantly influenced by many factors, including age, gender, and race. Changes in treatment categories over time included a decrease in combination therapy for patients aged less than  18 years and an increase in medication monotherapy for all ages, which are in contrast to national recommendations.

Prescribing attitudes, behaviors and opinions regarding metformin for patients with diabetes: a focus group study

BACKGROUND

The purpose of this study was to identify the reasons why metformin prescribing is suboptimal.

METHODS

Two semi-structured focus groups with attitudinal questionnaires and a brief educational presentation were held in two US cities. Participants included providers (physicians, pharmacists, midlevel practitioners) caring for patients with type 2 diabetes mellitus (T2DM) in an ambulatory setting. Outcome measures included provider attitudes, behaviors and opinions regarding the use of metformin.

RESULTS

Participants identified three main themes influencing the use of metformin, including the appropriate timing of metformin initiation, known risks associated with metformin, and procedures to manage safety concerns and mitigate adverse effects associated with metformin. Participant prescribing behaviors of metformin were not consistent with the best available evidence in the settings of renal insufficiency, heart failure, hepatic dysfunction, alcohol use, and lactic acidosis. With minimal education, provider prescribing behaviors appeared to change by the end of the focus group to align more closely with the best available evidence.

CONCLUSIONS

Provider attitudes, behaviors and opinions regarding the use of metformin for T2DM reveals the need for further education to improve appropriate use of metformin. Educational interventions should target prescribing behaviors and opinions identified to be inconsistent with the evidence.

A Pharmacist-Physician Collaboration to Optimize Benzodiazepine Use for Anxiety and Sleep Symptom Control in Primary Care

INTRODUCTION

Benzodiazepines are prescribed inappropriately in up to 40% of outpatients. The purpose of this study is to describe a collaborative team-based care model in which clinical pharmacists work with primary care providers (PCPs) to improve the safe use of benzodiazepines for anxiety and sleep disorders and to assess the preliminary results of the impact of the clinical service on patient outcomes.

METHODS

Adult patients were eligible if they received care from the academic primary care clinic, were prescribed a benzodiazepine chronically, and were not pregnant or managed by psychiatry. Outcomes included baseline PCP confidence and knowledge of appropriate benzodiazepine use, patient symptom severity, and medication changes.

RESULTS

Twenty-five of 57 PCPs responded to the survey. PCPs reported greater confidence in diagnosing and treating generalized anxiety and panic disorders than sleep disorder and had variable knowledge of appropriate benzodiazepine prescribing. Twenty-nine patients had at least 1 visit. Over 44 total patient visits, 59% resulted in the addition or optimization of a nonbenzodiazepine medication and 46% resulted in the discontinuation or optimization of a benzodiazepine. Generalized anxiety symptom severity scores significantly improved (-2.0; 95% confidence interval (CI): -3.57 to -0.43).

CONCLUSION

Collaborative team-based models that include clinical pharmacists in primary care can assist in optimizing high-risk benzodiazepine use. Although these findings suggest improvements in safe medication use and symptoms, additional studies are needed to confirm these preliminary results.

Perceived Benefit of Teaching Patient Safety to Pharmacy Students by Integrating Classroom Teaching With Introductory (IPPE) Visits

INTRODUCTION

Ensuring a culture that prioritizes and implements patient safety requires educating all future health care professionals to prepare them for their active role in reducing medical errors. There is limited literature describing integration of patient safety education into the curriculum of health care professionals, including pharmacists. The purpose of this study was to evaluate the perceived benefit of integrating patient safety education into a pharmacy curriculum.

METHODS

Second-year pharmacy students (P2s) completed a patient safety self-study, followed by in-class and experiential application of a root cause analysis (RCA). An electronic, anonymous postsurvey was administered to P2s and third-year pharmacy students (P3s) who had not had formal patient safety education.

RESULTS

Of the 310 students, 53% responded to the survey. Significantly more P2s reported more confidence to describe patient safety and its purpose ( P = .0092), describe factors that influence patient safety ( P = .0055), and conduct an RCA ( P < .001). P2s also reported significantly better ability to conduct a RCA compared to P3s (88.9% positive vs 58.7%, respectively; P ≤ .001).

CONCLUSIONS

Both classes perceived patient safety education to be valuable; however, formal education resulted in some significant improvements in perceived confidence and understanding, including ability to conduct an RCA.

Physician Acceptance of a Physician-Pharmacist Collaborative Treatment Model for Hypertension Management in Primary Care

Physician-pharmacist collaborative care (PPCC) is effective in improving blood pressure (BP) control, but primary care provider (PCP) engagement in such models has not been well-studied. The authors analyzed data from PPCC referrals to 108 PCPs, for patients with uncontrolled hypertension, assessing the proportion of referral requests approved, disapproved, and not responded to, and reasons for disapproval. Of 2232 persons with uncontrolled hypertension, PPCC referral requests were sent for 1516 (67.9%): 950 (62.7%) were approved, 406 (26.8%) were disapproved, and 160 (10.6%) received no response. Approval rates differed widely by PCP with a median approval rate of 75% (interquartile range, 41%-100%). The most common reasons for disapproval were: PCP prefers to manage hypertension (19%), and BP controlled per PCP (18%); 8% of cases were considered too complex for PPCC. Provider acceptance of a PPCC hypertension clinic was generally high and sustained but varied widely among PCPs. No single reason for disapproval predominated.

Automating and estimating glomerular filtration rate for dosing medications and staging chronic kidney disease

Objective

The purpose of this paper is to serve as a review for primary care providers on the bedside methods for estimating glomerular filtration rate (GFR) for dosing and chronic kidney disease (CKD) staging and to discuss how automated health information technologies (HIT) can enhance clinical documentation of staging and reduce medication errors in patients with CKD.

Methods

A nonsystematic search of PubMed (through March 2013) was conducted to determine the optimal approach to estimate GFR for dosing and CKD staging and to identify examples of how automated HITs can improve health outcomes in patients with CKD. Papers known to the authors were included, as were scientific statements. Articles were chosen based on the judgment of the authors.

Results

Drug-dosing decisions should be based on the method used in the published studies and package labeling that have been determined to be safe, which is most often the Cockcroft–Gault formula unadjusted for body weight. Although Modification of Diet in Renal Disease is more commonly used in practice for staging, the CKD–Epidemiology Collaboration (CKD–EPI) equation is the most accurate formula for estimating the CKD staging, especially at higher GFR values. Automated HITs offer a solution to the complexity of determining which equation to use for a given clinical scenario. HITs can educate providers on which formula to use and how to apply the formula in a given clinical situation, ultimately improving appropriate medication and medical management in CKD patients.

Conclusion

Appropriate estimation of GFR is key to optimal health outcomes. HITs assist clinicians in both choosing the most appropriate GFR estimation formula and in applying the results of the GFR estimation in practice. Key limitations of the recommendations in this paper are the available evidence. Further studies are needed to better understand the best method for estimating GFR.

Medication management of irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a complex syndrome that is difficult to manage. Here we present the evidence supporting medication treatments for specific IBS symptoms, discuss evidence-based management of IBS with medications including dose regimens and adverse effects and review progress on research for new IBS treatments.

SUMMARY

Currently, there is evidence to support improvements in specific IBS symptoms following treatment with loperamide, psyllium, bran, lubiprostone, linaclotide, amitriptyline, trimipramine, desipramine, citalopram, fluoxetine, paroxetine, dicyclomine, peppermint oil, rifaximin, ketotifen, pregabalin, gabapentin and octreotide and there are many new medications being investigated for the treatment of IBS. Key Message: Of the medications with demonstrated improvements for IBS symptoms, rifaximin, lubiprostone, linaclotide, fiber supplementation and peppermint oil have the most reliable evidence supporting their use for the treatment of IBS. Onset of efficacy for the various medications has been noted to be as early as 6 days after initiation; however, the efficacy of most medications was not assessed prospectively at predefined periods. Additional studies of currently available and new medications are ongoing and are needed to better define their place in therapy and expand therapeutic options for the treatment of IBS. The most promising new medications for IBS include a variety of novel pharmacologic approaches, most notably the dual μ-opioid receptor agonist and δ-opioid antagonist, JNJ-27018966.

QT interval prolongation and the risk of torsades de pointes: essentials for clinicians

OBJECTIVE

QT interval prolongation signifies an increased risk of the life-threatening arrhythmia torsades de pointes (TdP). The purpose of this paper is to review the diverse methods for assessing and monitoring the risk of TdP, discuss risk factors for TdP, and recommend interventions that may mitigate the risk of TdP.

METHODS

A non-systematic search of PubMed (through March 2013) was conducted to determine the optimal approach to assessing and monitoring QT interval, prevention of TdP, and to identify risks factors for TdP. Papers known to the authors were included, as were scientific statements. Articles were chosen based on the judgment of the authors.

RESULTS

Risk factors for drug-induced TdP include hypokalemia, female sex, drug-drug interactions, advancing age, genetic predisposition, hypomagnesemia, heart failure, bradycardia, and corrected QT (QTc) interval prolongation. Many risk factors, including hypokalemia, use of QT-interval-prolonging drugs, and drug interactions are potentially modifiable and should be corrected in persons at risk for QT interval prolongation. Given the variable onset of TdP following initiation of QT-interval-prolonging drugs, careful and regular monitoring of electrocardiography (EKG) and electrolytes are necessary. Patients at risk for QT interval prolongation should be educated to go directly to the emergency room if they experience palpitations, lightheadedness, dizziness or syncope. When the QTc interval is 470-500 ms for males, or 480-500 ms for females, or the QTc interval increases 60 ms or more from pretreatment values, dose reduction or discontinuation of the offending drug should be considered where possible, and electrolytes corrected as needed. Furthermore, if the QTc interval is ≥500 ms, the offending drug should be discontinued, and continuous EKG telemetry monitoring should be performed, or the 12-lead EKG should be repeated every 2-4 hours, until the QT interval has normalized.

CONCLUSIONS

Close monitoring for QTc prolongation is necessary to prevent TdP. The recommendations in this paper are limited by the available evidence and additional studies are needed to better define the approach to monitoring.

Phentermine/topiramate for the treatment of obesity

OBJECTIVE

To review the pharmacology, efficacy, and safety of phentermine/topiramate (PHEN/TPM) in the management of obese patients.

DATA SOURCES

MEDLINE (1966-July 2012) was searched using the terms weight loss, obesity, phentermine and topiramate, phentermine, topiramate, Qnexa, Qsymia, and VI-0521. Additionally, the new drug application and prescribing information for PHEN/TPM were retrieved.

STUDY SELECTION/DATA EXTRACTION

All studies considering the pharmacology, efficacy, and safety of PHEN/TPM were reviewed with a focus on efficacy and safety data from Phase 3 trials.

DATA SYNTHESIS

In 3 Phase 3 trials (EQUIP, CONQUER, and SEQUEL), treatment with PHEN/TPM consistently demonstrated statistically significant weight loss compared with placebo. After 56 weeks of treatment, percent weight loss achieved with PHEN/TPM was 10.6%, 8.4%, and 5.1% with 15/92 mg, 7.5/46 mg, and 3.75/23 mg, respectively (p < 0.0001). The 52-week extension study (SEQUEL) showed maintained weight loss over 2 years with 9.3% and 10.5% weight loss from baseline for 7.5/46 mg and 15/92 mg PHEN/TPM (p < 0.0001). A significantly higher proportion of patients achieved greater than 5%, 10%, or 15% weight loss with PHEN/TPM compared with placebo. Significant reductions in waist circumference, fasting triglycerides, and fasting glucoses were also attributable to PHEN/TPM. The drug was generally well tolerated in clinical trials. Adverse reactions occurring in 5% or more of study subjects included paresthesia, dizziness, dysgeusia, insomnia, constipation, and dry mouth.

CONCLUSIONS

PHEN/TPM is a new, once-daily, controlled-release, combination weight-loss product approved as an adjunct to diet and exercise for chronic weight management of obese or overweight patients with weight-related comorbidities. PHEN/TPM is modestly effective and a viable option for patients interested in losing weight, although long-term safety data are lacking.