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Khalil K, Lyons J, Teuteberg JJ, Henricksen EJ. The Impact of the COVID-19 Pandemic on the Transplant Pharmacist Workforce. J Pharm Pract 2024; 37:296-300. [PMID: 36206374 PMCID: PMC9548482 DOI: 10.1177/08971900221131906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background: The COVID-19 pandemic has placed an unprecedented strain on the US healthcare system, greatly impacting transplant centers. Objective: The purpose of this survey was to evaluate the impact of the COVID-19 pandemic on the transplant pharmacist workforce. Methods: A survey was disseminated electronically to assess the impact of the COVID-19 pandemic on the transplant pharmacist workforce. Respondents were asked to give background regarding transplant center, patient, population, and departmental staffing. Results: There were 67 total respondents from 56 transplant centers. In response to the COVID-19 pandemic, 55% of centers reported stopping non-life saving transplants, and a majority (89%) stopped living donor transplants altogether. The banning of caregivers on-site during education, reduction of bedside education teaching, and cancelling of group teaching classes occurred at 46%, 40%, and 22% of centers, respectively. Consequently, 42% of pharmacists surveyed felt that their confidence in patient and caregiver's understanding of medications had decreased since these changes have been implemented. Conclusions: Pharmacist perception of patient and caregiver understanding of transplant medications has decreased since before the COVID-19 pandemic. As health systems strategize resource allocation throughout the pandemic, the importance of patient education must be prioritized to sustain and improve transplant outcomes.
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Affiliation(s)
- Karen Khalil
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
| | - John Lyons
- Department of Pharmacy, Loyola University Medical
Center, Maywood, IL, USA
| | - Jeffrey J. Teuteberg
- Department of Medicine and Section
of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, Stanford University, CA, USA
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2
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Taber DJ, Ward RC, Buchanan CH, Axon RN, Milfred-LaForest S, Rife K, Felkner R, Cooney D, Super N, McClelland S, McKenna D, Santa E, Gebregziabher M. Results of a multicenter cluster-randomized controlled clinical trial testing the effectiveness of a bioinformatics-enabled pharmacist intervention in transplant recipients. Am J Transplant 2023; 23:1939-1948. [PMID: 37562577 DOI: 10.1016/j.ajt.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/05/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023]
Abstract
An ambulatory medication safety dashboard was developed to identify missing labs, concerning labs, drug interactions, nonadherence, and transitions in care. This system was tested in a 2-year, prospective, cluster-randomized, controlled multicenter study. Pharmacists at 5 intervention sites used the dashboard to address medication safety issues, compared with usual care provided at 5 control sites. A total of 2196 transplant events were included (1300 intervention vs 896 control). During the 2-year study, the intervention arm had a 11.3% (95% confidence interval, 7.1%-15.5%) absolute risk reduction of having ≥1 emergency department (ED) visit (44.2% vs 55.5%, respectively; P < .001, respectively) and a 12.3% (95% confidence interval, 8.2%-16.4%) absolute risk reduction of having ≥1 hospitalization (30.1% vs 42.4%, respectively; P < .001). In those with ≥1 event, the median ED visit rate (2 [interquartile range (IQR) 1, 5] vs 2 [IQR 1, 4]; P = .510) and hospitalization rate (2 [IQR 1, 3] vs 2 [IQR 1, 3]; P = .380) were similar. Treatment effect varied by comorbidity burden, previous ED visits or hospitalizations, and heart or lung recipients. A bioinformatics dashboard-enabled, pharmacist-led intervention reduced the risk of having at least one ED visit or hospitalization, predominantly demonstrated in lower risk patients.
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Affiliation(s)
- David J Taber
- Department of Pharmacy Services, Ralph H Johnson Veterans Affairs Medical Center, Health Equity and Rural Outreach Innovation Center, Charleston, South Carolina, USA; Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
| | - Ralph C Ward
- Department of Pharmacy Services, Ralph H Johnson Veterans Affairs Medical Center, Health Equity and Rural Outreach Innovation Center, Charleston, South Carolina, USA; Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Casey H Buchanan
- Department of Pharmacy Services, Ralph H Johnson Veterans Affairs Medical Center, Health Equity and Rural Outreach Innovation Center, Charleston, South Carolina, USA
| | - Robert Neal Axon
- Department of Pharmacy Services, Ralph H Johnson Veterans Affairs Medical Center, Health Equity and Rural Outreach Innovation Center, Charleston, South Carolina, USA
| | - Sherry Milfred-LaForest
- Department of Pharmacy Service, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Kelsey Rife
- Department of Pharmacy Service, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Rebecca Felkner
- Department of Pharmacy Services, William S. Middleton Veterans Affairs Medical Center, Madison, Wisconsin, USA
| | - Danielle Cooney
- Department of Pharmacy Service, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Nicholas Super
- Department of Pharmacy Services, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois, USA
| | - Samantha McClelland
- Department of Pharmacy Services, Veterans Affairs Great Lakes Health Care System (VISN 12), Westchester, Illinois, USA
| | - Domenica McKenna
- Department of Pharmacy Services, Portland Veterans Affairs Health Care System, Portland, Oregon, USA
| | - Elizabeth Santa
- Department of Pharmacy Services, Atlanta Veterans Affairs Health Care System, Atlanta, Georgia, USA
| | - Mulugeta Gebregziabher
- Department of Pharmacy Services, Ralph H Johnson Veterans Affairs Medical Center, Health Equity and Rural Outreach Innovation Center, Charleston, South Carolina, USA; Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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3
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Shawaqfeh MS, Alangari D, Aldamegh G, Almotairi J, Bin Orayer L, Albekairy NA, Abdel-Razaq W, Mardawi G, Almuqbil F, Aldebasi TM, Albekairy AM. Unveiling medication errors in liver transplant patients towards enhancing the imperative patient safety. Saudi Pharm J 2023; 31:101789. [PMID: 37799574 PMCID: PMC10550402 DOI: 10.1016/j.jsps.2023.101789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023] Open
Abstract
Background Medication errors (MEs) are a significant healthcare problem that can harm patients and increase healthcare expenses. Being immunocompromised, liver-transplant patients are at high risk for complications if MEs inflict harmful or damaging effects. The present study reviewed and analyzed all MEs reported in Liver Transplant Patients. Methods All MEs in the Liver Transplant Patients admitted between January 2016 to August 2022 were retrieved through the computerized physician order entry system, which two expert pharmacists classified according to the type and severity risk index. Results A total of 314 records containing 407 MEs were committed by at least 71 physicians. Most of these errors involved drugs unrelated to managing liver-transplant-related issues. Antibiotic prescriptions had the highest mistake rate (17.0%), whereas immunosuppressants, routinely used in liver transplant patients, rank second with fewer than 14% of the identified MEs. The most often reported MEs (43.2%) are type-C errors, which, despite reaching patients, did not cause patient harm. Subgroup analysis revealed several factors associated with a statistically significant great incidence of MEs among physicians treating liver transplant patients. Conclusion Although a substantial number of MEs occurred with liver transplant patients, the majority are not related to liver-transplant medications, which mainly belonged to type-C errors. This could be attributed to polypharmacy of transplant patients or the heavy workload on health care practitioners. Improving patient safety requires adopting regulations and strategies to promptly identify MEs and address potential errors.
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Affiliation(s)
- Mohammad S. Shawaqfeh
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh 14611, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh 11481, Saudi Arabia
| | - Dalal Alangari
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh 14611, Saudi Arabia
| | - Ghaliah Aldamegh
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh 14611, Saudi Arabia
| | - Jumana Almotairi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh 14611, Saudi Arabia
| | - Luluh Bin Orayer
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh 14611, Saudi Arabia
| | - Nataleen A. Albekairy
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh 14611, Saudi Arabia
| | - Wesam Abdel-Razaq
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh 14611, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh 11481, Saudi Arabia
| | - Ghada Mardawi
- King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
| | - Faisal Almuqbil
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh 14611, Saudi Arabia
| | - Tariq M. Aldebasi
- King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh 14611, Saudi Arabia
| | - Abdulkareem M. Albekairy
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh 14611, Saudi Arabia
- King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh 11481, Saudi Arabia
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4
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Gholamzadeh M, Safdari R, Amini S, Abtahi H. Feasibility study and determination of prerequisites of telecare programme to enhance patient management in lung transplantation: a qualitative study from the perspective of Iranian healthcare providers. BMJ Open 2023; 13:e073370. [PMID: 37349094 PMCID: PMC10314650 DOI: 10.1136/bmjopen-2023-073370] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/02/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Non-adherence to treatment plans, follow-up visits and healthcare advice is a common obstacle in the management of lung transplant patients. This study aims to investigate experts' views on the needs and main aspects of telecare programmes for lung transplantation. DESIGN A qualitative study incorporating an inductive thematic analysis. SETTING Lung transplant clinic and thoracic research centre. PARTICIPANTS Clinicians: four pulmonologists, two cardiothoracic surgeons, two general physicians, two pharmacotherapists, one cardiologist, one nurse and one medical informatician. METHOD This study adopted a focus group discussion technique to gather experts' opinions on the prerequisites and features of a telecare programme in lung transplantation. All interviews were coded and combined into main categories and themes. Thematic analysis was performed to extract the key concepts using ATLAS.Ti. Ultimately, all extracted themes were integrated to devise a conceptual model. RESULTS Ten focus groups with 13 participants were conducted. Forty-six themes and subthemes were extracted through the thematic analysis. The main features of the final programme were extracted from expert opinions through thematic analysis, such as continuous monitoring of symptoms, drug management, providing a specific care plan for each patient, educating patients module, creating an electronic medical record to collect patient information, equipping the system with decision support tools, smart electronic prescription and the ability to send messages to the care team. The prerequisites of the system were summarised in self-care activities, clinician's tasks and required technologies. In addition, the barriers and benefits of using a telecare system to enhance the quality of care were determined. CONCLUSION Our investigation recognised the main factors that must be considered to design a telecare programme to provide ideal continuous care for lung transplant patients. Users should further explore the proposed model to support the development of telecare interventions at the point of care.
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Affiliation(s)
- Marsa Gholamzadeh
- Health Information Management and Medical Informatics Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Safdari
- Health Information Management and Medical Informatics Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahideh Amini
- Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Abtahi
- Pulmonary and Critical Care Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
- Thoracic Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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5
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Wu CW, Huang YJ, Chen YW, Chen CH, Tsao CI, Wu CC, Hsu RB, Chen YS, Huang CF. Cost-Benefit Analysis of Involving Pharmacist for Medication Therapy Management in a Heart Transplant Clinic. Transplant Proc 2023; 55:426-431. [PMID: 36822883 DOI: 10.1016/j.transproceed.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/13/2022] [Accepted: 01/24/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Drug-related problems (DRPs) are common in recipients of solid organ transplants. Pharmacist-led medication therapy management (MTM) has cost benefits in kidney and liver transplants; however, whether MTM is also beneficial in heart transplants remains unclear. This study explored the cost benefits of involving pharmacists in the heart transplant clinic. METHODS This retrospective study evaluated DRPs for 1 year after implementation of pharmacist-led MTM in a heart transplant clinic. The DRPs were compared between patients receiving transplantation for <1 and >1 year. The risk matrix method was used to assess each DRP in terms of the estimated probability and severity of consequent adverse drug events (ADEs). For cost analysis, both estimated cost savings and avoidance were calculated. RESULTS During the 1-year MTM, 372 DRPs were identified by the pharmacist, among which 169 (45%) and 203 (55%) were from patients at <1-year and ≥1-year post-transplant periods, respectively. The 2 post-transplant periods (<1 year and ≥1 year) exhibited significant differences in the distribution of the dosage or frequency problems (30% vs 18%, P = .005) and the suggestion of more appropriate medication (4% vs 10%, P = .024). In all, 92 (29%) DRPs had an ADE probability of >10%; and 63 (17%) DRPs were estimated to cause ADEs with moderate severity or higher. The estimated cost savings and cost avoidance were US $4902 and US $4519, which equaled a cost-benefit ratio of 2.39. CONCLUSION Integration of pharmacists into heart transplant clinics could help address DRPs and may have cost benefits.
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Affiliation(s)
- Chia-Wei Wu
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Jen Huang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Wen Chen
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Hao Chen
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chuan-I Tsao
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Chih Wu
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Ron-Bin Hsu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Fen Huang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
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6
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Mulder MB, Doga B, Borgsteede SD, van den Burg AM, Metselaar HJ, den Hoed CM, Hunfeld NGM. Evaluation of medication-related problems in liver transplant recipients with and without an outpatient medication consultation by a clinical pharmacist: a cohort study. Int J Clin Pharm 2022; 44:1114-1122. [PMID: 36100818 PMCID: PMC9618499 DOI: 10.1007/s11096-022-01423-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/26/2022]
Abstract
Background Transplant recipients undergo significant changes in their medication regimen during follow-up and are at an increased risk for medication-related problems (MRPs). Aim This study aimed to compare the prevalence and types of MRPs and interventions in liver transplant recipients with and without an outpatient medication consultation by a clinical pharmacist as well as the satisfaction with information about medicines and medication adherence. Method We performed a single-center, observational cohort study. A retro- and prospective cohort were used and subdivided in a group that did and did not receive a medication consultation. The prevalence and types of MRPs and interventions were identified and categorized. The satisfaction parameters were evaluated using validated questionnaires. Results Included were 291 patients. In total, 368 MRPs were identified in 197 patients in the non-medication consultation cohort (median 1; range 1–3 per patient) and 248 MRPs in 94 patients in the medication consultation cohort (median 2; range 1–4 per patient). In the medication consultation cohort, significantly fewer MRPs as unnecessary drugs (17.3% versus 58.7%, p < 0.001), suboptimal therapy (2.4% versus 9.5%, p < 0.001), untreated indication (2.8% versus 6.8%, p = 0.040) and underdosed drugs (0.4% versus 6.3%, p < 0.001) were identified. In the non-medication consultation cohort significantly more patients used unnecessary drugs (72.1% versus 39.4%, p < 0.001) compared to the medication consultation cohort. Patients in both cohorts are satisfied with the information about medicines and reported a high medication adherence. Conclusion Patients in the medication consultation cohort had significantly fewer MRPs and used significantly less unnecessary drugs. Including a clinical pharmacist to the post-transplant care has an added value. Supplementary information The online version contains supplementary material available at 10.1007/s11096-022-01423-6.
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Affiliation(s)
- Midas B Mulder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.
- Department of Pharmacy, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3015 GD, Rotterdam, The Netherlands.
| | - B Doga
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S D Borgsteede
- Department of Clinical Decision Support, Health Base Foundation, Houten, The Netherlands
| | - A M van den Burg
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - H J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - C M den Hoed
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - N G M Hunfeld
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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7
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Gonzales HM, Li J, Orara J, Patel N, Bartlett F, Parks SE, Pilch NA. The impact of a student
pharmacist‐led
inpatient medication counseling initiative on medication safety in kidney transplant recipients. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Haley M. Gonzales
- Department of Surgery Medical University of South Carolina Charleston South Carolina USA
| | - Jiaying Li
- College of Pharmacy, Medical University of South Carolina Charleston South Carolina USA
| | - Joshua Orara
- College of Pharmacy, Medical University of South Carolina Charleston South Carolina USA
| | - Neha Patel
- Department of Pharmacy Medical University of South Carolina Charleston South Carolina USA
| | - Felicia Bartlett
- Department of Pharmacy Medical University of South Carolina Charleston South Carolina USA
| | - Sarah E. Parks
- Department of Nursing Medical University of South Carolina Charleston South Carolina USA
| | - Nicole A. Pilch
- Department of Pharmacy Medical University of South Carolina Charleston South Carolina USA
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8
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Taber DJ, Fleming JN, Su Z, Mauldin P, McGillicuddy JW, Posadas A, Gebregziabher M. Significant hospitalization cost savings to the payer with a pharmacist-led mobile health intervention to improve medication safety in kidney transplant recipients. Am J Transplant 2021; 21:3428-3435. [PMID: 34197699 DOI: 10.1111/ajt.16737] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/10/2021] [Accepted: 06/27/2021] [Indexed: 01/25/2023]
Abstract
This was an economic analysis of a 12-month, parallel arm, randomized controlled trial in adult kidney recipients 6 to 36 months posttransplant (NCT03247322). All participants received usual posttransplant care, while the intervention arm received supplemental clinical pharmacist-led medication therapy monitoring and management, via a smartphone-enabled mHealth app, integrated with risk-based televisits. Hospitalization charges were captured from the study institution accounts payable and non-study institution hospitalization charges were estimated using multiple imputation. Multivariable modeling was used to assess the impact of the intervention on charges. The intervention significantly reduced rates of hospitalization (1.08 per patient-year in the control arm vs 0.65 per patient-year in the intervention arm, p = .007). The control arm had estimated hospitalization costs of $870,468 vs $390,489 in the intervention arm. Modeling demonstrated a 49% lower hospitalization charge risk in the intervention arm (RR 0.51, 95% CI 0.28-0.91; p = .022). From a payer or societal perspective, the net estimated cost savings, after accounting for intervention delivery costs, was $368,839, with a return on investment (ROI) of $4.30 for every $1 spent. These results demonstrate that a mHealth-enabled, pharmacist-led intervention significantly reduced hospitalization costs for payers over a 12-month period and has a positive ROI.
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Affiliation(s)
- David J Taber
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - James N Fleming
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Zemin Su
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Patrick Mauldin
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John W McGillicuddy
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aurora Posadas
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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Abstract
PURPOSE OF REVIEW To provide a summary of complications of antimicrobials and opportunities for antimicrobial stewardship (AS) in solid organ transplant (SOT) patient care. RECENT FINDINGS Personalized, precision antimicrobial prescribing in SOT aiming to avoid negative consequences of antimicrobials is essential to improving patient outcomes. The positive impact AS efforts in transplant care has been recognized and bespoke activities tailored to special interests of transplant patients and providers are evolving. Strategies to optimize stewardship interventions targeting antibacterial, antiviral, and antifungal drug selection and dosing in the transplant population have been recently published though clinical integration using a 'handshake' stewardship model is an optimal starting point in transplant care. Other recent studies involving transplant recipients have identified opportunities to shorten duration or avoid antimicrobials for certain commonly encountered clinical syndromes. This literature, informing recent consensus clinical practice guidelines, may help support institutional practice guidelines and protocols. Proposals to track and report stewardship process and outcome measures as a routine facet of programmatic transplant quality reporting have been published. However, developing novel metrics accounting for nuances of transplant patients and programs is critical. Important studies are needed to evaluate organizational transplant prescribing cultures and optimal behavioral science-based interventions relevant to antimicrobial use in this population. SUMMARY Consequences of antimicrobial use, such as drug toxicities, and Clostridiodes difficile (CDI) and multidrug-resistant organisms colonization and infection disproportionately affect SOT recipients and are associated with poor allograft and patient outcomes. Stewardship programs encompassing transplant patients aim to personalize antimicrobial prescribing and optimize outcomes. Further studies are needed to better understand optimal intervention strategies in SOT.
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Affiliation(s)
- Jonathan M Hand
- Department of Infectious Diseases, Ochsner Health, The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana, USA
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10
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Gonzales HM, Fleming JN, Gebregziabher M, Posadas-Salas MA, Su Z, McGillicuddy JW, Taber DJ. Pharmacist-Led Mobile Health Intervention and Transplant Medication Safety: A Randomized Controlled Clinical Trial. Clin J Am Soc Nephrol 2021; 16:776-784. [PMID: 33931415 PMCID: PMC8259471 DOI: 10.2215/cjn.15911020] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/24/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Medication safety events are predominant contributors to suboptimal graft outcomes in kidney transplant recipients. The goal of this study was to examine the efficacy of improving medication safety through a pharmacist-led, mobile health-based intervention. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was a 12-month, single-center, prospective, parallel, two-arm, single-blind, randomized controlled trial. Adult kidney recipients 6-36 months post-transplant were eligible. Participants randomized to intervention received supplemental clinical pharmacist-led medication therapy monitoring and management via a mobile health-based application, integrated with risk-guided televisits and home-based BP and glucose monitoring. The application provided an accurate medication regimen, timely reminders, and side effect surveys. Both the control and intervention arms received usual care, including serial laboratory monitoring and regular clinic visits. The coprimary outcomes were to assess the incidence and severity of medication errors and adverse events. RESULTS In total, 136 kidney transplant recipients were included, 68 in each arm. The mean age was 51 years, 57% were male, and 64% were Black individuals. Participants receiving the intervention experienced a significant reduction in medication errors (61% reduction in the risk rate; incident risk ratio, 0.39; 95% confidence interval, 0.28 to 0.55; P<0.001) and a significantly lower incidence risk of Grade 3 or higher adverse events (incident risk ratio, 0.55, 95% confidence interval, 0.30 to 0.99; P=0.05). For the secondary outcome of hospitalizations, the intervention arm demonstrated significantly lower rates of hospitalizations (incident risk ratio, 0.46; 95% confidence interval, 0.27 to 0.77; P=0.005). CONCLUSIONS We demonstrated a significant reduction in medication errors, adverse events, and hospitalizations using a pharmacist-led, mobile health-based intervention.
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Affiliation(s)
- Haley M. Gonzales
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - James N. Fleming
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | | | - Zemin Su
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - John W. McGillicuddy
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - David J. Taber
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
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11
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Mulder MB, Borgsteede SD, Darwish Murad S, Landman CS, Metselaar HJ, Hunfeld NGM. Medication-Related Problems in Liver Transplant Recipients in the Outpatient Setting: A Dutch Cohort Study. Front Pharmacol 2021; 12:637090. [PMID: 33986672 PMCID: PMC8111087 DOI: 10.3389/fphar.2021.637090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/08/2021] [Indexed: 12/05/2022] Open
Abstract
Background: After liver transplantation (LTx), adherence to immunosuppressive medication and avoidance of contra-indicated drugs is essential for long-term survival. This study aimed to investigate the prevalence, types and severity of medication-related problems (MRPs) and interventions initiated by a clinical pharmacist (CP) in a cohort of LTx recipients in the outpatient setting. Method: This study was a retrospective, observational study in LTx recipients that visited the outpatient clinic for an annual check-up. A 20-minutes consultation with a CP consisted of medication reconciliation and consultation about medication, adherence, and adverse drug reactions (ADRs). Discrepancies between actual and intended drug use, and MRPs were identified and the severity of MRPs was assessed. Potential interventions were discussed with the patient and the treating physician and evaluated after one year. Results: The CP counseled 64 LTx recipients and found 96 discrepancies in 37 patients. Most discrepancies (60.4%, n = 58) concerned missing medications. In total, 98 MRPs were identified in 53 patients (median 2; range 1-5 per patient), with a total of 113 interventions. Most frequent MRPs were: ADRs (22.4%, n = 22), nonadherence (19.3%, n = 19), unnecessary drugs (16.3%, n = 16) and undertreatment (12.2%, n = 12). Interventions most frequently proposed included optimization of dosage regimen (21.2%, n = 24), individualized recommendation regarding compliance (16.8%, n = 19) and drug discontinuation (12.4%, n = 14). After one year, 15 of the 19 patients (79%) experienced no longer compliance issues and 27 of the 29 patients (93%) used no drugs with indication issues anymore. Conclusion: The CP in an outpatient monitoring program for LTx recipients can signal relevant discrepancies and MRPs. This leads to interventions that are accepted by both the patients and the physicians, with a positive effect after one year.
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Affiliation(s)
- Midas B Mulder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,The Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sander D Borgsteede
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Clinical Decision Support, Health Base Foundation, Houten, Netherlands
| | - Sarwa Darwish Murad
- The Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Hepatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Catelijne S Landman
- The Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Hepatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Herold J Metselaar
- The Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Hepatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Nicole G M Hunfeld
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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12
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Nobakht E, Jagadeesan M, Paul R, Bromberg J, Dadgar S. Precision Medicine in Kidney Transplantation: Just Hype or a Realistic Hope? Transplant Direct 2021; 7:e650. [PMID: 33437865 PMCID: PMC7793397 DOI: 10.1097/txd.0000000000001102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 12/17/2022] Open
Abstract
Desirable outcomes including rejection- and infection-free kidney transplantation are not guaranteed despite current strategies for immunosuppression and using prophylactic antimicrobial medications. Graft survival depends on factors beyond human leukocyte antigen matching such as the level of immunosuppression, infections, and management of other comorbidities. Risk stratification of transplant patients based on predisposing genetic modifiers and applying precision pharmacotherapy may help improving the transplant outcomes. Unlike certain fields such as oncology in which consistent attempts are being carried out to move away from the "error and trial approach," transplant medicine is lagging behind in implementing personalized immunosuppressive therapy. The need for maintaining a precarious balance between underimmunosuppression and overimmunosuppression coupled with adverse effects of medications calls for a gene-based guidance for precision pharmacotherapy in transplantation. Technologic advances in molecular genetics have led to increased accessibility of genetic tests at a reduced cost and have set the stage for widespread use of gene-based therapies in clinical care. Evidence-based guidelines available for precision pharmacotherapy have been proposed, including guidelines from Clinical Pharmacogenetics Implementation Consortium, the Pharmacogenomics Knowledge Base National Institute of General Medical Sciences of the National Institutes of Health, and the US Food and Drug Administration. In this review, we discuss the implications of pharmacogenetics and potential role for genetic variants-based risk stratification in kidney transplantation. A single score that provides overall genetic risk, a polygenic risk score, can be achieved by combining of allograft rejection/loss-associated variants carried by an individual and integrated into practice after clinical validation.
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Affiliation(s)
- Ehsan Nobakht
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University School of Medicine, Washington, DC
| | - Muralidharan Jagadeesan
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University School of Medicine, Washington, DC
| | - Rohan Paul
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University School of Medicine, Washington, DC
| | - Jonathan Bromberg
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Sherry Dadgar
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University School of Medicine, Washington, DC
- Personalized Medicine Care Diagnostics Laboratory (PMCDx), Inc., Germantown, MD
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13
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Cohen EA, McKimmy D, Cerilli A, Kulkarni S. A Pharmacist-Driven Intervention Designed to Improve Medication Accuracy in the Outpatient Kidney Transplant Setting. DRUG HEALTHCARE AND PATIENT SAFETY 2020; 12:229-235. [PMID: 33269008 PMCID: PMC7701366 DOI: 10.2147/dhps.s264022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/31/2020] [Indexed: 11/23/2022]
Abstract
Background Medication errors are one of the leading causes of complications and readmissions in healthcare and stem directly from inadequate medication lists. In transplantation, medication discrepancies can lead to fluctuating levels of immunosuppression, resulting in rejection, infection, or drug toxicity. Methods We implemented a pharmacist-driven intervention designed to improve the accuracy of outpatient kidney transplant patients’ medication lists in the electronic medical record (EMR). Baseline medication error rates (Phase 1) were collected, and the intervention was a dedicated pharmacist (Phase 2) who performed medication reconciliation with patients. The primary outcome was the percent of patients with inadequate medication reconciliation determined by any one error in medication reconciliation (Phase 1 vs Phase 2). Secondary outcomes included the number of medication errors, of all medications and high-risk medications, identified per patient sample using statistical process control phase analysis. Results Pharmacist-driven medication reconciliation significantly reduced medication list discrepancies from 95% to 28% (P<0.05). There were a total of 398 errors in the control group and 49 errors in the intervention group. In addition, there were 73 high-risk medication discrepancies in the control group and three in the intervention group. The total number of medication errors decreased post-intervention with a marked reduction in the variation of control limits (LCL, UCL: phase 1, −34.3, 113.9; phase 2, −7.1, 15.3) and average number of medication errors per sample (phase 1, 39.8; phase 2, 14.1). For high-risk medications, phase analysis demonstrated a marked reduction in control limit variation between phases (LCL, UCL: phase 1, −10.4, 25.0; phase 2, −0.5, 0.7) and average number of medication errors per sample (phase 1, 7.3; phase 2, 0.1). Discussion A dedicated pharmacist improved medication list accuracy over conventional practice that utilizes transplant nurses and physicians. Further studies into the cost-effectiveness of this strategy should further justify this approach.
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Affiliation(s)
- Elizabeth A Cohen
- Yale New Haven Transplant Center, Yale New Haven Hospital, New Haven, CT, USA
| | - Danielle McKimmy
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainsville, FL, USA
| | - Anna Cerilli
- Heart and Vascular Center, Yale-New Haven Hospital, New Haven, CT, USA
| | - Sanjay Kulkarni
- Section of Organ Transplantation, Yale University School of Medicine, New Haven, CT, USA
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14
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Neuberger J. Follow-up of liver transplant recipients. Best Pract Res Clin Gastroenterol 2020; 46-47:101682. [PMID: 33158465 PMCID: PMC7485448 DOI: 10.1016/j.bpg.2020.101682] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/31/2020] [Accepted: 09/03/2020] [Indexed: 01/31/2023]
Abstract
The number of surviving liver allograft recipients is increasing almost exponentially. The quality and length of life is increasing but most recipients have reduced survival and quality of life compared with healthy matched individuals. Causes of premature death include cardio and cerebrovascular disease, renal failure, graft failure, de novo malignancy and recurrent disease. Follow-up is needed lifelong to ensure graft and patient health and ensure that complications are recognised and treated early. Immunosuppression is kept to the appropriate minimum and prophylactic interventions are given early, such as use of statins and tight control of blood pressure and blood sugar. Recipients will require life-long follow-up, and this is placing an increasing burden on transplant units. Follow-up is best done by close collaboration between the Liver Transplant Unit, the local hospital and primary care team. Involvement of other health care practitioners, such as recipient coordinators, pharmacists, dermatologists and addiction specialists may improve outcomes. Key to successful follow-up are agreed protocols and good communication between the recipients and all relevant health care providers. Use of IT allows for better communication and will support use of video and telephone consultations in selected instances. The most appropriate follow-up will depend on many factors, including logistic and geographic issues, local experience. The provision of well-funded and supported registries at local, national and international levels will allow for improvements in management.
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15
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Hall CL, Fominaya CE, Gebregziabher M, Milfred-LaForest SK, Rife KM, Taber DJ. Improving Transplant Medication Safety Through a Technology and Pharmacist Intervention (ISTEP): Protocol for a Cluster Randomized Controlled Trial. JMIR Res Protoc 2019; 8:e13821. [PMID: 31573933 PMCID: PMC6774238 DOI: 10.2196/13821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/31/2019] [Accepted: 05/31/2019] [Indexed: 12/31/2022] Open
Abstract
Background Medication errors, adverse drug events, and nonadherence lead to increased health care utilization and increased risk of adverse clinical outcomes, including graft loss, in solid organ transplant recipients. Veterans living with organ transplants represent a population that is at substantial risk for medication safety events and fragmented care coordination issues. To improve medication safety and long-term clinical outcomes in veteran transplant patients, interventions should address interorganizational system failures and provider-level and patient-level factors. Objective This study aims to measure the clinical and economic effectiveness of a pharmacist-led, technology-enabled intervention, compared with usual care, in veteran organ transplant recipients. Methods This is a 24-month prospective, parallel-arm, cluster-randomized, controlled multicenter study. The pharmacist-led intervention uses an innovative dashboard system to improve medication safety and health outcomes, compared with usual posttransplant care. Pharmacists at 10 study sites will be consented into this study before undergoing randomization, and 5 sites will then be randomized to each study arm. Approximately, 1600 veteran transplant patients will be included in the assessment of the primary outcome across the 10 sites. Results This study is ongoing. Institutional review board approval was received in October 2018 and the study opened in March 2019. To date there are no findings from this study, as the delivery of the intervention is scheduled to occur over a 24-month period. The first results are expected to be submitted for publication in August 2021. Conclusions With this report, we describe the study design, methods, and outcome measures that will be used in this ongoing clinical trial. Successful completion of the Improving Transplant Medication Safety through a Technology and Pharmacist Intervention study will provide empirical evidence of the effectiveness of a feasible and scalable technology-enabled intervention on improving medication safety and costs. Clinical Trial ClinicalTrials.gov NCT03860818; https://clinicaltrials.gov/ct2/show/NCT03860818 International Registered Report Identifier (IRRID) PRR1-10.2196/13821
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Affiliation(s)
- Casey L Hall
- Health Equity & Rural Outreach Innovation Center, Ralph H Johnson Veterans Affairs Medical Center, Charleston, SC, United States
| | - Cory E Fominaya
- Department of Pharmacy, Ralph H Johnson Veterans Affairs Medical Center, Charleston, SC, United States
| | - Mulugeta Gebregziabher
- Health Equity & Rural Outreach Innovation Center, Ralph H Johnson Veterans Affairs Medical Center, Charleston, SC, United States.,Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | | | - Kelsey M Rife
- Department of Pharmacy, VA Northeast Ohio Healthcare System, Cleveland, OH, United States
| | - David J Taber
- Health Equity & Rural Outreach Innovation Center, Ralph H Johnson Veterans Affairs Medical Center, Charleston, SC, United States.,Department of Pharmacy, Ralph H Johnson Veterans Affairs Medical Center, Charleston, SC, United States.,Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, United States
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16
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Taber DJ, Pilch NA, McGillicuddy JW, Mardis C, Treiber F, Fleming JN. Using informatics and mobile health to improve medication safety monitoring in kidney transplant recipients. Am J Health Syst Pharm 2019; 76:1143-1149. [DOI: 10.1093/ajhp/zxz115] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Abstract
Purpose
The development, testing, and preliminary validation of a technology-enabled, pharmacist-led intervention aimed at improving medication safety and outcomes in kidney transplant recipients are described.
Summary
Medication safety issues, encompassing medication errors (MEs), medication nonadherence, and adverse drug events (ADEs), are a predominant cause of poor outcomes after kidney transplantation. However, a limited number of clinical trials assessing the effectiveness of technology in improving medication safety and outcomes in transplant recipients have been conducted. Through an iterative, evidence-based approach, a technology-enabled intervention aimed at improving posttransplant medication safety outcomes was developed, tested, and preliminarily validated. Early acceptability and feasibility results from a prospective, randomized controlled trial assessing the effectiveness of this system are reported here. Of the 120 patients enrolled into the trial at the time of writing, 60 were randomly assigned to receive the intervention. At a mean ± S.D. follow-up of 5.8 ± 4.0 months, there were 2 patient dropouts in the intervention group, resulting in a retention rate of 98%, which was higher than the expected 90% retention rate.
Conclusion
The development and deployment of a comprehensive medication safety monitoring dashboard for kidney transplant recipients is feasible and acceptable to patients in the current healthcare environment. An ongoing randomized controlled clinical trial is assessing whether such a system reduces MEs and ADRs, leading to improved patient outcomes.
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Affiliation(s)
- David J Taber
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina
- Department of Pharmacy Services, Ralph H. Johnson VAMC, Charleston, SC
| | - Nicole A Pilch
- Transplant Center, Medical University of South Carolina, and College of Pharmacy, Medical University of South Carolina, Charleston, SC
| | - John W McGillicuddy
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Caitlin Mardis
- College of Pharmacy, University of South Carolina, Columbia, SC
| | - Frank Treiber
- College of Nursing, Medical University of South Carolina, Charleston, SC
| | - James N Fleming
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, and College of Pharmacy, Medical University of South Carolina, Charleston, SC
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17
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Taber DJ, Gebregziabher M, Posadas A, Schaffner C, Egede LE, Baliga PK. Pharmacist-Led, Technology-Assisted Study to Improve Medication Safety, Cardiovascular Risk Factor Control, and Racial Disparities in Kidney Transplant Recipients. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019; 1:81-88. [PMID: 30714026 DOI: 10.1002/jac5.1024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Introduction Health disparities in African-American (AA) kidney transplant recipients compared with non-AA recipients are well established. Cardiovascular disease (CVD) risk control is a significant mediator of this disparity. Objective To assess the efficacy of improved medication safety, CVD risk control, and racial disparities in kidney transplant recipients. Methods Prospective, pharmacist-led, technology-aided, 6-month interventional clinical trial. A total of 60 kidney recipients with diabetes and hypertension were enrolled. Patients had to be at least one-year post transplant with stable graft function. Primary outcome measured included hypertension, diabetes, and lipid control using intent-to-treat analyses, with differences assessed between AA and non-AA recipients. Results The participants mean age was 59 years, with 42% being female and 68% being AA. Overall, patients demonstrated improvements in blood pressure <140/90 mmHg (baseline 50% vs. end of study 68%, p=0.054) and hemoglobin A1c <7% (baseline 33% vs. end of study 47%, p=0.061). AAs demonstrated a significant reduction from baseline in systolic blood pressure (-0.86 mmHg per month, p=0.026), which was not evident in non-AAs (-0.13 mmHg per month, p=0.865). Mean HgbA1c decreased from baseline in the overall group (-0.12% per month, p=0.003), which was similar within AAs (-0.11% per month, p=0.004) and non-AAs (-0.14% per month, p=0.029). There were no changes in low-density lipoproteins, triglycerides, or high-density lipoproteins over the course of the study. Medication errors were significantly reduced and self-reported medication adherence significantly improved over the course of the study. Conclusion These results demonstrate the potential efficacy of a pharmacist-led, technology-aided, educational intervention in improving medication safety, diabetes, and hypertension and reducing racial disparities in AA kidney transplant recipients. (ClinicalTrials.gov NCT02763943).
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Affiliation(s)
- David J Taber
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC.,Department of Pharmacy Services, Ralph H Johnson VAMC, Charleston, SC
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Aurora Posadas
- Division of Transplant Nephrology, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Caitlin Schaffner
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Leonard E Egede
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Prabhakar K Baliga
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC
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18
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El Raichani L, Du Q, Mathieu A, Almassy S, Lalonde L, Berbiche D, Gélinas‐Lemay E, Boudreau N, Cardinal H. Development and validation of PART (Pharmacotherapy Assessment in Renal Transplant Patients) criteria to assess drug-related problems in an outpatient renal transplant population: A cross-sectional study. Pharmacol Res Perspect 2019; 7:e00453. [PMID: 30675363 PMCID: PMC6333916 DOI: 10.1002/prp2.453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 12/03/2018] [Indexed: 11/09/2022] Open
Abstract
Kidney transplant recipients are at risk of pharmacological interactions and adverse drug reactions. Community pharmacists are uniquely poised to detect and intervene in cases of drug-related problems. The aims of this study were to develop and validate a list of explicit criteria to be used by community pharmacists to assess drug-related problems in kidney transplant patients, and to assess their frequency and their determinants. First, we used a modified RAND method where a panel of experts established the PART (Pharmacotherapy Assessment in Renal Transplant Patient) criteria. Then, we performed a cross-sectional study in which we applied the PART criteria to 97 prevalent kidney transplant recipients followed at a single university-affiliated center. The final list of PART criteria included 70 drug-related problems and was reliable (kappa: 0.88). An average of 1.2 drug-related problems per patient was detected when the PART criteria were applied, with 68% of patients having at least 1 problem. This figure was 1.4 per patient using the expert judgment of renal transplant pharmacists who had no access to the PART list. The total number of medications taken was the only factor associated with the number of drug-related problems (β: 0.27 for an increase of five medications, 95% CI 0.005, 0.547). The PART criteria provide a novel tool for community pharmacists to systematically detect drug-related problems in kidney transplant recipients.
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Affiliation(s)
- Layal El Raichani
- Department of PharmacyCentre intégré de santé et de services sociaux CISSS de la Montérégie CentreLongueuilQuebecCanada
- Faculty of PharmacyUniversity of MontrealMontrealQuebecCanada
| | - Qian Du
- Faculty of PharmacyUniversity of MontrealMontrealQuebecCanada
- Department of PharmacyCentre intégré universitaire de santé et de services sociaux du Centre‐Sud‐de‐l’île‐MontréalMontrealQuebecCanada
| | - Alexandre Mathieu
- Faculty of PharmacyUniversity of MontrealMontrealQuebecCanada
- Department of PharmacyCentre Hospitalier de l'Université de MontréalMontrealQuebecCanada
| | - Sabrina Almassy
- Faculty of PharmacyUniversity of MontrealMontrealQuebecCanada
- Department of PharmacyCentre intégré universitaire de santé et de services sociaux de l'EstrieSherbrookeQuebecCanada
| | - Lyne Lalonde
- Faculty of PharmacyUniversity of MontrealMontrealQuebecCanada
| | - Djamal Berbiche
- Faculty of Medicine and Health SciencesUniversité de SherbrookeSherbrookeQuebecCanada
| | - Elisabeth Gélinas‐Lemay
- Faculty of PharmacyUniversity of MontrealMontrealQuebecCanada
- Department of PharmacyCentre Hospitalier de l'Université de MontréalMontrealQuebecCanada
| | - Nathalie Boudreau
- Faculty of PharmacyUniversity of MontrealMontrealQuebecCanada
- Department of PharmacyCentre Hospitalier de l'Université de MontréalMontrealQuebecCanada
- Research centerCentre Hospitalier de l'Université de MontréalMontrealQuebecCanada
| | - Héloïse Cardinal
- Research centerCentre Hospitalier de l'Université de MontréalMontrealQuebecCanada
- Nephrology DivisionCentre Hospitalier de l'Université de MontréalMontrealQuebecCanada
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19
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Fleming JN, Treiber F, McGillicuddy J, Gebregziabher M, Taber DJ. Improving Transplant Medication Safety Through a Pharmacist-Empowered, Patient-Centered, mHealth-Based Intervention: TRANSAFE Rx Study Protocol. JMIR Res Protoc 2018; 7:e59. [PMID: 29500161 PMCID: PMC5856926 DOI: 10.2196/resprot.9078] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/19/2018] [Accepted: 01/21/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Medication errors, adverse drug events, and nonadherence are the predominant causes of graft loss in kidney transplant recipients and lead to increased healthcare utilization. Research has demonstrated that clinical pharmacists have the unique education and training to identify these events early and develop strategies to mitigate or prevent downstream sequelae. In addition, studies utilizing mHealth interventions have demonstrated success in improving the control of chronic conditions that lead to kidney transplant deterioration. OBJECTIVE The goal of the prospective, randomized TRANSAFE Rx study is to measure the clinical and economic effectiveness of a pharmacist-led, mHealth-based intervention, as compared to usual care, in kidney transplant recipients. METHODS TRANSAFE Rx is a 12-month, parallel, two-arm, 1:1 randomized controlled clinical trial involving 136 participants (68 in each arm) and measuring the clinical and economic effectiveness of a pharmacist-led intervention which utilizes an innovative mobile health application to improve medication safety and health outcomes, as compared to usual posttransplant care. RESULTS The primary outcome measure of this study will be the incidence and severity of MEs and ADRs, which will be identified, categorized, and compared between the intervention and control cohorts. The exploratory outcome measures of this study are to compare the incidence and severity of acute rejections, infections, graft function, graft loss, and death between research cohorts and measure the association between medication safety issues and these events. Additional data that will be gathered includes sociodemographics, health literacy, depression, and support. CONCLUSIONS With this report we describe the study design, methods, and outcome measures that will be utilized in the ongoing TRANSAFE Rx clinical trial. TRIAL REGISTRATION ClinicalTrials.gov NCT03247322: https://clinicaltrials.gov/ct2/show/NCT03247322 (Archived by WebCite at http://www.webcitation.org/6xcSUnuzW).
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Affiliation(s)
- James N Fleming
- Department of Pharmacy, Medical University of South Carolina, Charleston, SC, United States
| | - Frank Treiber
- Technology Center to Advance Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - John McGillicuddy
- Department of Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - David J Taber
- Department of Surgery, Medical University of South Carolina, Charleston, SC, United States.,Department of Pharmacy, Ralph H Johnson Veterans Affairs Medical Center, Charleston, SC, United States
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20
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Taber DJ, Hamedi M, Rodrigue JR, Gebregziabher MG, Srinivas TR, Baliga PK, Egede LE. Quantifying the Race Stratified Impact of Socioeconomics on Graft Outcomes in Kidney Transplant Recipients. Transplantation 2017; 100:1550-7. [PMID: 26425875 DOI: 10.1097/tp.0000000000000931] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Socioeconomic status (SES) is a significant determinant of health outcomes and may be an important component of the causal chain surrounding racial disparities in kidney transplantation. The social adaptability index (SAI) is a validated and quantifiable measure of SES, with a lack of studies analyzing this measure longitudinally or between races. METHODS Longitudinal cohort study in adult kidney transplantation transplanted at a single-center between 2005 and 2012. The SAI score includes 5 domains (employment, education, marital status, substance abuse and income), each with a minimum of 0 and maximum of 3 for an aggregate of 0 to 15 (higher score → better SES). RESULTS One thousand one hundred seventy-one patients were included; 624 (53%) were African American (AA) and 547 were non-AA. African Americans had significantly lower mean baseline SAI scores (AAs 6.5 vs non-AAs 7.8; P < 0.001). Cox regression analysis demonstrated that there was no association between baseline SAI and acute rejection in non-AAs (hazard ratio [HR], 0.92; 95% confidence interval [95% CI], 0.81-1.05), whereas it was a significant predictor of acute rejection in AAs (HR, 0.89; 95% CI, 0.80-0.99). Similarly, a 2-stage approach to joint modelling of time to graft loss and longitudinal SAI did not predict graft loss in non-AAs (HR, 1.01; 95% CI, 0.28-3.62), whereas it was a significant predictor of graft loss in AAs (HR, 0.23; 95% CI, 0.06-0.93). CONCLUSIONS After controlling for confounders, SAI scores were associated with a lower risk of acute rejection and graft loss in AA kidney transplant recipients, whereas neither baseline nor follow-up SAI predicted outcomes in non-AA kidney transplant recipients.
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Affiliation(s)
- David J Taber
- 1 Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC. 2 Department of Pharmacy, Ralph H Johnson VAMC, Charleston, SC. 3 College of Medicine, Medical University of South Carolina, Charleston, SC. 4 Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. 5 Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC. 6 Division of Transplant Nephrology, College of Medicine, Medical University of South Carolina, Charleston, SC. 7 Veterans Affairs HSR&D Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H Johnson VAMC, Charleston, SC
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21
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Covert KL, Mardis CR, Fleming JN, Pilch NA, Meadows HB, Mardis BA, Mohan P, Posadas-Salas M, Srinivas T, Taber DJ. Development of a Predictive Model for Drug-Related Problems in Kidney Transplant Recipients. Pharmacotherapy 2017; 37:159-169. [DOI: 10.1002/phar.1886] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Kelly L. Covert
- Department of Pharmacy Practice, Bill Gatton College of Pharmacy; East Tennessee State University; Johnson City Tennessee
| | - Caitlin R. Mardis
- Transplant Service Line; Medical University of South Carolina; Charleston South Carolina
| | - James N. Fleming
- Department of Pharmacy Services; Medical University of South Carolina; Charleston South Carolina
| | - Nicole A. Pilch
- Department of Pharmacy Services; Medical University of South Carolina; Charleston South Carolina
| | - Holly B. Meadows
- Department of Pharmacy Services; Medical University of South Carolina; Charleston South Carolina
| | - Benjamin A. Mardis
- Department of Pharmacy Services; Medical University of South Carolina; Charleston South Carolina
| | - Prince Mohan
- Department of Transplant Nephrology; Medical University of South Carolina; Charleston South Carolina
| | - Maria Posadas-Salas
- Department of Transplant Nephrology; Medical University of South Carolina; Charleston South Carolina
| | - Titte Srinivas
- Department of Transplant Nephrology; Medical University of South Carolina; Charleston South Carolina
| | - David J. Taber
- Department of Surgery; Medical University of South Carolina; Charleston South Carolina
- Department of Pharmacy; Ralph H. Johnson VAMC; Charleston South Carolina
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22
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Value of solid organ transplant-trained pharmacists in transplant infectious diseases. Curr Infect Dis Rep 2015; 17:475. [PMID: 25870143 DOI: 10.1007/s11908-015-0475-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Advances in organ transplantation have led to improved graft and patient survival. Transplant pharmacist's education and training uniquely position them to contribute knowledge and skills to the management of these highly complex patients. In 2004, the United Network for Organ Sharing bylaws added requirements that all transplant programs identify one or more pharmacists with experience in transplant pharmacotherapy to be responsible for providing pharmaceutical care to solid organ transplant recipients. These bylaws also delineated the transplant pharmacist's roles and responsibilities. To further support these efforts, in 2007 the Centers for Medicare and Medicaid Services accreditation standards for transplant centers also mandated that a center have a designated, qualified expert in transplant pharmacology as a multidisciplinary team member. The transplant pharmacist is a consistent member of the transplant team that can add value to the multidisciplinary approach of prevention and treatment of transplant infectious diseases through all phases of transplant care.
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23
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Baehr A, Peña JC, Hu DJ. Racial and Ethnic Disparities in Adverse Drug Events: A Systematic Review of the Literature. J Racial Ethn Health Disparities 2015; 2:527-36. [PMID: 26863559 DOI: 10.1007/s40615-015-0101-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/19/2015] [Accepted: 02/27/2015] [Indexed: 10/23/2022]
Abstract
The 2014 National Action Plan for Adverse Drug Event Prevention has recognized adverse drug events (ADEs) as a national priority in order to facilitate a nationwide reduction in patient harms from these events. Throughout this effort, it will be integral to identify populations that may be at particular risk in order to improve care for these patients. We have undertaken a systematic review to evaluate the evidence regarding racial or ethnic disparities in ADEs with particular emphasis on anticoagulants, diabetes agents, and opioids due to the clinical significance and preventability of ADEs associated with these medication classes. From an initial search yielding 3302 studies, we identified 40 eligible studies. Twenty-seven of these included studies demonstrated the presence of a racial or ethnic disparity. There was no consistent evidence for racial or ethnic disparities in the eight studies of ADEs in general. Asians were most frequently determined to be at higher risk of anticoagulant-related ADEs, and black patients were most frequently determined to be at higher risk for diabetes agents-related ADEs. Whites were most frequently identified as at increased risk for opioid-related ADEs. However, few of these studies were specifically designed to evaluate racial or ethnic disparities, lacking a standardized approach to racial/ethnic categorization as well as control for potential confounders. We suggest the need for targeted interventions to reduce ADEs in populations that may be at increased risk, and we suggest strategies for future research.
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Affiliation(s)
- Avi Baehr
- Division of Health Care Quality, Office of Disease Prevention and Health Promotion, US Department of Health and Human Services, 1101 Wootton Parkway, Suite 200, Rockville, MD, 20852, USA. .,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Juliet C Peña
- Division of Health Care Quality, Office of Disease Prevention and Health Promotion, US Department of Health and Human Services, 1101 Wootton Parkway, Suite 200, Rockville, MD, 20852, USA
| | - Dale J Hu
- Division of Health Care Quality, Office of Disease Prevention and Health Promotion, US Department of Health and Human Services, 1101 Wootton Parkway, Suite 200, Rockville, MD, 20852, USA
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24
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Taber DJ, Spivey JR, Tsurutis VM, Pilch NA, Meadows HB, Fleming JN, McGillicuddy JW, Bratton CF, Treiber FA, Baliga PK, Chavin KD. Clinical and economic outcomes associated with medication errors in kidney transplantation. Clin J Am Soc Nephrol 2014; 9:960-6. [PMID: 24763866 DOI: 10.2215/cjn.09300913] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Modern immunosuppressant regimens have significantly decreased acute rejection rates, but may have increased the risk of graft loss driven by adverse drug reactions (ADRs) and medication errors (MEs). The objectives of this study were to determine the incidence and risk factors for MEs and ADRs and determine the association between transplant outcomes and these events. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was a post hoc analysis of a prospective, randomized trial that included patients aged>18 years that received a solitary renal transplant at an academic medical center recruited between March 2009 and July 2011. Patients were divided into groups based on developing a clinical significant ME (CSME), defined as a significant ME that contributed to a hospital admission. RESULTS The mean study follow-up was 2.5 ± 0.7 years. There were a total of 233 MEs and 327 ADRs in the 200 patients included in the analysis, with 64% of the cohort experiencing at least one ME and 87% experiencing an ADR; 23 patients (12%) experienced a CSME. Patients that experienced CSMEs had a trend toward more post-transplant readmissions (median 1 [interquartile range (IQR), 0-5] versus 0 [0-2]; P=0.06), higher costs for readmissions (median $18,091 [IQR, $3023-$56,268] versus $0 [$0-$15,991]; P<0.01), and overall length of stay (median 5.0 days [IQR, 2.0-14.0] versus 0.0 days [IQR, 0.0-5.5]; P<0.01) after the CSME event. CSME patients were also more likely to experience graft failure (22% versus 10%; P=0.05). CONCLUSIONS Significant MEs commonly occur in renal transplant recipients and are associated with an increased risk of deleterious clinical outcomes, including subsequent hospital days, costs, and graft loss.
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Affiliation(s)
- David J Taber
- Division of Transplant Surgery,, †Department of Pharmacy Services, and, ‡College of Nursing, Medical University of South Carolina, Charleston, South Carolina
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