Anaesthesia equipment safety in Canada: the role of government regulation

Medical device problems as detected by the Health Protection Branch (HPB) of Health and Welfare Canada were studied in order to examine the frequency and safety priority of problems in the subgroup of anaesthesia devices. Data pertaining to the time period from April 1, 1987 to November 30, 1992 were gathered from the Medical Devices Notification Database and the DAFFY Reporting System. The Medical Devices Notification Database contains all notifications for newly marketed medical devices in Canada and the DAFFY Reporting System keeps record of all submitted problem reports and manufacturer recalls along with their designated safety priority status. When an important safety hazard is associated with a medical device as determined from information submitted to HPB, an Alert-Medical Devices may be issued to inform hospitals and health care professionals of the problem. During the studied time period, the percentages of problem reports and recalls as well as Alerts were compared with the percentage of newly marketed anaesthesia devices. It was found that although only 2.3% of the newly marketed medical devices were classified as anaesthesia devices, 8.6% of all problem reports/recalls and 37.5% of all Alerts originated from the field of anaesthesia devices. Comparison of the percentages of problem reports/recalls (8.6%) and Alerts (37.5%) with the percentage of marketed devices for anaesthesia (2.3%) showed differences (P < 0.05). As well, the percentage of class I priority (the highest safety priority) problem reports/recalls for anaesthesia devices was 10.2% compared with 4.9% for non-anaesthesia devices (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Prescriber profile and post-marketing surveillance

The response rate to requests to general practitioners (GPs) to supply post-marketing data on new drugs has been falling within the prescription-event monitoring (PEM) system organised by the Drug Safety Research Unit in Southampton, UK. To find out why, we looked at the characteristics of prescribers and the pattern of their prescribing for twenty seven PEM drugs and 543,788 treatments dispensed in England between September, 1984, and June, 1991. 28,402 GPs identified during PEM studies were divided into six groups according to the largest number of prescriptions for one or more of the drugs, ranging from group 1 (none of the drugs prescribed) to group 6 (one or more drugs for over 60 patients). From group 1 to group 6 the proportion of the GPs who were women decreased from 46% to 9%, and the proportion of overseas-qualified doctors increased from 13% to 47%. 10% of doctors who had prescribed most heavily accounted for 42% of total prescribing. 19 doctors had each prescribed a drug for more than 120 patients during the early post-marketing period. There was a consistent inverse relation between the number of prescriptions and the response to requests for post-marketing information. The overall response was 53% but the heaviest 10% of prescribers returned only 44% and the heaviest 1% returned only 34% of questionnaires. No differences in medical need can account for such variations in prescribing practice. Heavy prescribing by a minority of doctors during the period immediately following licensing for marketing may be placing patients at unnecessary risk. These doctors also affect the success of attempts to monitor the safety of new drugs.

A follow-up safety study of ciprofloxacin users

We followed 37,233 outpatients for 45 days after receiving a prescription for ciprofloxacin to identify any newly diagnosed, important illnesses that might have been caused by the drug. For 29 users the role of ciprofloxacin in the etiology of the illness could not be confidently ruled out (7.79/10,000 persons; 95% CI 5.42-11.18). In only seven was a causal relation to ciprofloxacin considered likely: three skin reactions and one case each of thrombocytopenia, "headache, nausea, and shakes," hallucinations, and palpitations. No fatal illnesses occurred, and all patients recovered after discontinuing the drug. In addition, few cases of photosensitivity were associated with the agent. We conclude that important adverse reactions attributable to ciprofloxacin are uncommon.

[Evaluation of ten years of pharmacovigilance of antihypertensive drugs in the Toulouse University Regional Hospital Center (1981-1990)]

The eighties were characterized by the introduction of angiotensin converting enzyme inhibitors (ACEI) and calcium channel blockers (CCB) in the treatment of arterial hypertension. The present study investigates the side effects of antihypertensive drugs in the Toulouse University Hospital (France) between 1981 and 1990. Most of the side effects involved ACEI (45%), CCB (22%) and diuretics (18%). Central antihypertensive agents and beta-blocking drugs were involved in 8 and 9% of side effects respectively. During these 10 years, 197 side effects were reported in our hospital (3300 beds). Some of them were found more frequently: renal insufficiency (15%) or cough (9%) with ACEI, constipation (3%), gingivitis (1%) or lower limb oedema (4.5%) with CCB, hemolytic or autoimmune anemia (2.5%) and confusional state (1.5%) with central antihypertensive agents, nightmares (1.5%) with propranolol. The most frequently side effects were dermatological (20%), hydroelectrolytic (10%) and neuropsychiatric (9.6%) disturbances. In spite of the methodological problems of this kind of study (retrospective evaluation, under-notification of the side effects and different scores of imputability), these data indicate the most frequently observed side effects of antihypertensive agents during the eighties. It allows to estimate an approximate frequency of these side effects: among the antihypertensive drugs, CCB and diuretics seems the less frequently involved in the occurrence of reported side effects.

[Quality of event data in detection of unwanted drug side-effects in general practice of established physicians]

Since 1986, the Federal Health Office (BGA) has supported the model project "Monitoring Adverse Drug Reactions (ADRs) in the Surgeries of Office-Based Physicians". The project itself is being carried out by the Institute for Health Systems Research in Kiel. The aim of the project is to develop a method for the systematic monitoring of the risks involved with selected new drugs. This should also facilitate the determining of the incidence rate of ADRs as well as reveal as yet unknown ADRs. Several conclusions can be drawn when examining the quality of event data when monitoring ADRs through office-based physicians. The documentation quality of the transferred data fluctuates from surgery to surgery. In order to obtain valid outcomes, the data should be thoroughly examined and checked by consulting the participating surgery. When quantifying known events with a suspected ADR, the Sentinel approach leads to reliable results. When monitoring drug therapies through office-based physicians, risk situations can be monitored and assessed more easily under everyday conditions. When assessing the quality of event data with regard to disclosing hitherto unknown, potential ADRs, the character of the individual surgery is of utmost importance. The object of the research project is to examine cause-effect associations which have nothing whatsoever to do with the participating physicians themselves but which reflect interactions between drugs and patients.

[Hemorrhages of the upper gastrointestinal tract and nonsteroidal anti-inflammatory drugs: the results of a case-controlled surveillance]

A postmarketing surveillance case-control study was set up and applied in an Italian Hospital network to quantify the risk of upper gastrointestinal bleeding (UGB) and exposure to non steroidal anti-inflammatory drugs (NSAIDs). During the period of study 441 cases of UGB and 1323 controls were recruited. The odds ratios (OR) associated with NSAIDs use were estimated for intake occurring over two different periods of time prior to hospital admission (i.e. during the preceding week and month). A strong association emerged for aspirin intake, both in the week (ORMLR = 11.2; 95% CI 7.8-16.9) and in the month (ORMLR = 6.9; 95% CI 4.6-10.2) preceding hospital admission. [MLR = Multiple logistic regression; CI = Confidence interval]. A significant increase in the risk of UGB and use of diclofenac, phenylpropionic acid derivatives, and indomethacin was also found in the two exposure periods considered, while for piroxicam a significant association was only apparent in the analysis of 1-month exposure. As expected, paracetamol and pyrazolone derivatives were not associated with UGB. This pilot experience has shown the feasibility of setting up a multicenter post-marketing surveillance programme and of establishing a network for drug monitoring within the Italian National Health Service, capable of providing a thorough evaluation of the benefit/risk profile of drugs.

Monitoring of drug utilization in public health surveillance activities: a conceptual framework

The surveillance of individual and aggregate patterns of prescribed medication can potentially provide some very useful information to those involved in public health. At present however, this activity has attracted relatively little attention in Canada. This article will introduce a conceptual framework with which to examine the possibilities of prescription drug monitoring as a tool for public health surveillance. The sources of data available to undertake this activity as well as their limitations, will be presented along with some recent concrete applications.

A primer of drug safety surveillance: an industry perspective. Part III: Managing adverse-event data

OBJECTIVE

To place the fundamentals of clinical drug safety surveillance in a conceptual framework that will facilitate understanding and application of adverse drug event data to protect the health of the public and support a market for pharmaceutical manufacturers' products. Part III of this series describes management of adverse-event data. This process involves an interplay of regulations, labeling, and product knowledge. Types of databases are defined and the scope of paper files and computerized files is discussed. Database management is discussed in terms of four processes: receipt, retention, retrieval, and review of adverse-event reports. A summary of the application of the fundamentals to the incident described in the scenario shows that knowledge of the fundamentals may be sufficient to make a substantial contribution to the health of patients and the commercial well-being of manufacturers.

DATA SOURCES

This review uses primary sources from the federal laws (regulations), commentaries, and summaries. Very complex topics are briefly summarized in the text and additional readings are listed in the appendix. Secondary sources, ranging from newspaper articles to judicial summaries, illustrate the interpretation of adverse drug events and opportunities for drug safety surveillance intervention.

STUDY SELECTION

The reference materials used were articles theoretically or practically applicable in the day-to-day practice of drug safety surveillance.

DATA SYNTHESIS

The role of clinical drug safety surveillance in product monitoring and drug development is described. The process of drug safety surveillance is defined by the Food and Drug Administration regulations, product labeling, product knowledge, and database management. Emphasis is placed on the dynamic interaction of the components of the process. Suggestions are offered to facilitate communication of a review of adverse-event data for various audiences.

CONCLUSIONS

Careful drug safety surveillance is beneficial to the health of the public and the commercial well-being of manufacturers. Attention to the basic principles is essential and, as illustrated, may be sufficient to resolve some problems.

Cutaneous adverse reactions following the administration of nonsteroidal antiinflammatory drugs and antibiotics: an Italian survey

The Italian Group for Epidemiological Research in Dermatology (GISED) collected a series of cutaneous adverse reactions following NSAID and/or antibiotics administered by topical and/or systemic route. Dermatologists from North and Central Italy took part in this survey by filling in 1457 case report forms during a four-month observation time in 1988-89. The main purpose of our epidemiological study aimed at evaluating a post-marketing surveillance program by examining spontaneous reports of cutaneous adverse reactions. This result seems to be noteworthy, considering the difficulties encountered in Italy to develop such a program.

Postmarketing surveillance of adverse drug reactions: patient self-monitoring

BACKGROUND

This report summarizes our experience with a new approach to postmarketing drug surveillance using a pharmacy-based patient self-monitoring strategy, developed in collaboration with Eckerd Drug Company, the American Association of Retired Persons Pharmacy Service, and other pharmacies nationwide.

METHODS

Patients presenting prescriptions to collaborating pharmacies for a targeted drug or a standard drug used as a control received an entry form asking them to register and then call a toll-free telephone number to report possible drug reactions. When contacted by patients, study staff conducted a standardized, computer-driven interview. Two brief mail questionnaires were also employed.

RESULTS

Original validation data gathered from 1984 through 1986 indicated that the most commonly expected adverse drug reactions caused by antibiotic and tricyclic antidepressants reported by 162 self-monitoring patients closely matched those elicited from a comparable control sample of 1109 patients who were independently interviewed by our staff. Results from subsequent studies are also described.

CONCLUSIONS

We believe this method has great promise for providing not only a cost-effective, complementary, early alerting mechanism for detecting adverse drug reactions, but also the additional possibility for discovering unsuspected therapeutic benefits of newly marketed drugs.

National adverse drug reaction reporting. 1984-1989

Surveillance of adverse reactions due to pharmaceuticals is important because the drug approval process cannot totally assure safety and because new knowledge is bound to accrue after drugs enter usual medical practice. Reporting of reactions to the Food and Drug Administration increased markedly between 1985 and 1989 and totaled 261,515 reports for this period. A large part of this increase was due to new legal requirements, which ensure that manufacturers report reactions to the Food and Drug Administration. Most reaction reports originated with practicing physicians who contacted drug manufacturers. High proportions of the reports involved new drugs and serious reactions. Reaction surveillance leads to 50 to 100 important safety investigations annually and to numerous changes in product information. Health care providers must continue to report suspect adverse reactions to the Food and Drug Administration and manufacturers if pharmaceutical use and safety are to improve.

Consumption of analgesics and anti-inflammatory drugs in the nordic countries between 1978-1988

Comparative wholesale statistics from the five Nordic countries show an increase of 15-42% in the total consumption of analgesics and anti-inflammatory drugs (including antirheumatics) in the period 1978-1988. Denmark had the highest total consumption (112 DDD/1000 inhab/day in 1988) and Norway had the lowest (61 DDD/1000 inhab/day). Iceland and Finland, with the highest increases in total consumption (45% and 35%), overtook Norway in the early to mid 1980's. Division of total consumption into subgroups showed that Denmark had the highest consumption of analgesics (90 DDDs) and that Finland and Iceland had the lowest figure. The latter countries, however, had the highest consumption of nonsteroidal anti-inflammatory drugs (NSAID), 35 and 30 DDDs, respectively, in 1988. The increase in NSAID consumption was 57% in Finland and 54% in Iceland, while Denmark had only an 18% increase. The new NSAIDs introduced in the 1970's appear to have increased the overall consumption of pain relievers in the Nordic countries, especially in Finland and Iceland.

Spontaneous Adverse Drug Reaction Reporting Vs Event Monitoring: A Comparison

Spontaneous adverse drug reaction (ADR) reporting is the mainstay of national and international drug safety evaluation in the post-approval phase. A major criticism of the method has been a high, but essentially unquantifiable, level of under-reporting by doctors. A direct comparison has been made between spontaneous ADR reporting and an observational event monitoring system for a group of more than 44 000 patients receiving one or other of a group of seven new drugs. The data suggests that under-reporting by the spontaneous system may be as high as 98% for several clinical events believed to be associated with drug treatment.

Assessing risk in postmarketing surveillance

We need to find some way to assess the probability of risk for individuals taking medications for a prolonged period of time either singly or, as is usually more likely, in combinations. It is not possible to perform detailed, controlled studies for all combinations of drugs, not even those most commonly administered. Therefore, we must rely primarily on data from various case studies of attending physicians. Since this data is not collected in a controlled setting, we require a statistical technique that can do the following: be modified to handle data sequentially as information continues to accumulate, be very robust for dependent data, make minimal assumptions concerning the underlying distribution of the data, and be used for multivariate data. A statistical technique--nonparametric density estimation--is available that will satisfy all of the above requirements. We will demonstrate its use in postmarketing surveillance.

Adverse drug reaction monitoring in Mississippi home health care agencies

A statewide survey of home health care agency directors in Mississippi was conducted to determine the extent of Adverse Drug Reaction (ADR) monitoring and reporting by health care professionals. A 24-item questionnaire was sent to agency directors eliciting responses on agency characteristics, rate of occurrence of ADRs, and attitudes toward responsibility for monitoring ADRs. A total of 77 questionnaires were returned yielding a response rate of 48%. The average program enrolled 104 patients with 3.5 ADRs reported by health care professionals per year (range 0-65). Agency directors reported that physicians, nurses, pharmacists, and members of the pharmacy and therapeutics committee should monitor ADRs. Results indicated a need for all health-care professional involved in home health care to increase their ADR monitoring and reporting activities.

Defibrillator failures. Causes of problems and recommendations for improvement. Defibrillator Working Group

The Defibrillator Working Group of the Food and Drug Administration reviewed data from the Medical Device Reporting System and a recent five-state survey, as well as information presented at two Food and Drug Administration-sponsored conferences. These data include 156 reports of defibrillator problems to the Emergency Care Research Institute Problem Reporting Network, 495 reports of device problems to the Medical Device Reporting System, 676 reports of "defibrillator failure" in the five-state survey, 594 inspections of in-service defibrillators, and site visits to 212 emergency care facilities. The Defibrillator Working Group concluded that the frequency of defibrillator failures during clinical use may be unacceptably high. While some failures are attributable to component malfunctions, evidence suggests that errors in operator use and errors in defibrillator care and maintenance account for a high proportion of defibrillator failures. Inadequate initial training and cursory continuing education increases the chances of operator errors at the moment when correct operation is needed most. Failure of operators to perform daily equipment checks leads to poor familiarity with the equipment and failure to identify component failures or damaged devices. Many defibrillators and batteries are kept in service beyond an expected useful life, given their level of clinical use. In smaller hospitals and emergency medical services systems periodic maintenance responsibilities are not always appropriately delegated between qualified engineering personnel and defibrillator operators, and some systems completely lack services from clinical engineers. The objectives of the Defibrillator Working Group are to make personnel who use defibrillators more aware of the potential for errors in operator performance and in periodic maintenance and to recommend improvements in training, maintenance, and defibrillator design. This article presents the initial observations and recommendations of the working group.

Physician reporting of adverse drug reactions. Results of the Rhode Island Adverse Drug Reaction Reporting Project

The Food and Drug Administration, Rockville, Md, contracted with the Rhode Island Department of Health, Providence, to conduct a project to increase reporting of suspected adverse drug reactions through physician education. Voluntary reporting, an important part of postmarketing surveillance that signals potential problems with marketed drugs, historically has been underused by physicians. After 2 years, there was a more than 17-fold increase in reports submitted directly from Rhode Island compared with the yearly average before initiation of the project. Increases in the total numbers of reports were paralleled by significant increases in the numbers of reports of severe reactions. Similar increases were not experienced nationally. Physicians in Rhode Island were surveyed before and 2 years after interventions began to determine changes in knowledge and attitudes about reporting of adverse drug reactions. Significant gains in knowledge and positive attitudes toward the reporting system occurred. We conclude that physicians can be stimulated to increase their reporting of suspected reactions, thereby improving the viability of the federal reporting system.

[A 30-month study of the calls to the Regional Drug Monitoring Center in Lorraine (Nancy)]

For over a period of 30 months, all the questions to the French "Centre de Pharmacovigilance" of Nancy Lorraine have been analysed. The University Hospital of Nancy is by for the main caller (65%) and the suspicion of adverse drug reaction represents 61% of all the questions. Gastrointestinal and hepatic disorders, cardiovascular drugs arouse the greatest number of questions. Comparison with results previously published by some French Pharmacovigilance Centres points out some regional particularities.

Epidemiological screening for potentially carcinogenic drugs

This paper describes a unique program for the systematic screening of commonly used prescription drugs for possible carcinogenic effects, by following up a large cohort of patients with computer-stored pharmacy data for incidence of cancer. Among the most interesting findings in recent analyses are an association of several antibiotics with subsequent lung cancer, and negative associations of prescribed vitamin E and diazepam with certain cancers. Analyses of additional data do not clearly indicate that these represent causal relationships to the drugs themselves. Also of interest is our continuing negative evidence regarding reserpine and metronidazole. The planned computerization of all pharmacies in our medical care program now serving over 2.2 million subscribers, should greatly increase our drug surveillance capabilities.