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Berger V, Sommer C, Boje P, Hollmann J, Hummelt J, König C, Lezius S, van der Linde A, Marhenke C, Melzer S, Michalowski N, Baehr M, Langebrake C. The impact of pharmacists' interventions within the Closed Loop Medication Management process on medication safety: An analysis in a German university hospital. Front Pharmacol 2022; 13:1030406. [PMID: 36452222 PMCID: PMC9704051 DOI: 10.3389/fphar.2022.1030406] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/17/2022] [Indexed: 07/21/2023] Open
Abstract
Background: Single elements of the Closed Loop Medication Management process (CLMM), including electronic prescribing, involvement of clinical pharmacists (CPs), patient individual logistics and digital administration/documentation, have shown to improve medication safety and patient health outcomes. The impact of the complete CLMM on patient safety, as reflected in pharmacists' interventions (PIs), is largely unknown. Aim: To evaluate the extent and characterization of routine PIs performed by hospital-wide CPs at a university hospital with an implemented CLMM. Methods: This single-center study included all interventions documented by CPs on five self-chosen working days within 1 month using the validated online-database DokuPIK (Documentation of Pharmacists' Interventions in the Hospital). Based on different workflows, two groups of CPs were compared. One group operated as a part of the CLMM, the "Closed Loop Clinical Pharmacists" (CL-CPs), while the other group worked less dependent of the CLMM, the "Process Detached Clinical Pharmacists" (PD-CPs). The professional experience and the number of medication reviews were entered in an online survey. Combined pseudonymized datasets were analyzed descriptively after anonymization. Results: A total of 1,329 PIs were documented by nine CPs. Overall CPs intervened in every fifth medication review. The acceptance rate of PIs was 91.9%. The most common reasons were the categories "drugs" (e.g., indication, choice of formulation/drug and documentation/transcription) with 42.7%, followed by "dose" with 29.6%. One-quarter of PIs referred to the therapeutic subgroup "J01 antibacterials for systemic use." Of the 1,329 underlying PIs, 1,295 were classified as medication errors (MEs) and their vast majority (81.5%) was rated as "error, no harm" (NCC MERP categories B-D). Among PIs performed by CL-CPs (n = 1,125), the highest proportion of errors was categorized as B (56.5%), while in the group of PIs from PD-CPs (n = 170) errors categorized as C (68.2%) dominated (p < 0.001). Conclusion: Our study shows that a structured CLMM enables CPs to perform a high number of medication reviews while detecting and solving MEs at an early stage before they can cause harm to the patient. Based on key quality indicators for medication safety, the complete CLMM provides a suitable framework for the efficient medication management of inpatients.
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Affiliation(s)
- Vivien Berger
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Sommer
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peggy Boje
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Josef Hollmann
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Hummelt
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christina König
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Lezius
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Annika van der Linde
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Corinna Marhenke
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simone Melzer
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nina Michalowski
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Baehr
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claudia Langebrake
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Pharmacotherapy Problems in Best Possible Medication History of Hospital Admission in the Elderly. PHARMACY 2022; 10:pharmacy10050136. [PMID: 36287456 PMCID: PMC9610174 DOI: 10.3390/pharmacy10050136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 11/16/2022] Open
Abstract
Transfer of care is a sensitive process, especially for the elderly. Polypharmacy, potentially inappropriate medications (PIMs), drug-drug interactions (DDIs), and renal risk drugs (RRDs) are important issues in the elderly. The aim of the study was to expand the use of the Best Possible Medication History (BPMH) and to evaluate polypharmacy, PIMs, DDIs, and inappropriately prescribed RRDs on hospital admission, as well as to determine their mutual relationship and association with patients’ characteristics. An observational prospective study was conducted at the Internal Medicine Clinic of Clinical Hospital Dubrava. The study included 383 elderly patients. Overall, 49.9% of patients used 5−9 prescription medications and 31.8% used 10 or more medications. EU(7)-PIMs occurred in 80.7% (n = 309) of the participants. In total, 90.6% of participants had ≥1 potential DDI. In total, 43.6% of patients were found to have estimated glomerular filtration rate < 60 mL/min/1.73 m2, of which 64.7% of patients had one or more inappropriately prescribed RRDs. The clinical pharmacist detected a high incidence of polypharmacy, PIMs, DDIs, and inappropriately prescribed RRDs on hospital admission. This study highlights the importance of early detection of pharmacotherapy problems by using the BPMH in order to prevent their circulation during a hospital stay. The positive correlations between polypharmacy, PIMs, DDIs, and inappropriately prescribed RRDs indicate that they are not independent, but rather occur simultaneously.
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Daignault C, Sauer HE, Lindsay H, Alonzo A, Foster J. Investigating Potential Drug-Drug Interactions in Pediatric and Adolescent Patients Receiving Chemotherapy. J Oncol Pharm Pract 2022; 28:904-909. [PMID: 35179058 DOI: 10.1177/10781552221079786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Pediatric and adolescent oncology patients admitted to receive chemotherapy are at risk for drug-drug interactions (DDI). While adult literature has quoted this risk to be as high as 95% of encounters, the literature in pediatrics is limited. This is a single-center, retrospective chart review of DDI in hospitalized pediatric oncology patients. METHODS All patients admitted to Texas Children's Hospital for chemotherapy were included. Medications ordered during the hospitalization were evaluated by Lexicomp® Drug Interactions Tool. Interactions classified as D or X or interactions rated a C including a chemotherapeutic agent were independently reviewed by three clinicians for clinical relevance. Medications associated with central nervous system (CNS) depression or QTc prolongation were counted separately. RESULTS Of 100 admissions evaluated, 100% had a flagged interaction. There were a total of 12 X-rated interactions, 8 D-rated interactions, and 12 C-rated interactions with a chemotherapeutic agent found to be clinically relevant. Thirty-three percent of admissions had 4 or more QTc prolonging medications ordered. Twenty-four percent of admissions had 3 or more prescribed CNS depressants. In total 49% of admissions were found to have at least 1 clinically-significant DDI. CONCLUSIONS This study exemplifies the risk of drug-drug interactions in children and young adults admitted to the hospital for chemotherapy. We demonstrated a high rate of flagged interactions with about half of admissions found to have a potentially clinically-significant DDI. Concomitant use of multiple QTc prolonging and CNS depressant medications was also prevalent, indicating a need to evaluate monitoring practices.
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Affiliation(s)
- Chelsea Daignault
- 506057Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Hannah E Sauer
- Department of Pharmacy, 3984Texas Children's Hospital, Houston, TX, United States
| | - Holly Lindsay
- 506057Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Amy Alonzo
- Department of Pharmacy, 3984Texas Children's Hospital, Houston, TX, United States
| | - Jennifer Foster
- 506057Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
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Lau L, Bagri H, Legal M, Dahri K. Comparison of Clinical Importance of Drug Interactions Identified by Hospital Pharmacists and a Local Clinical Decision Support System. Can J Hosp Pharm 2021; 74:203-210. [PMID: 34248160 DOI: 10.4212/cjhp.v74i3.3147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Background Drug-drug interactions (DDIs) may cause adverse drug events, potentially leading to hospital admission. Clinical decision support systems (CDSSs) can improve decision-making by clinicians as well as drug safety. However, previous research has suggested that pharmacists are concerned about discrepancies between CDSSs and common clinical practice in terms of severity ratings and recommended actions for DDIs. Objectives The primary objective was to characterize the level of agreement in terms of DDI severity ranking and actions recommended between the local CDSS and pharmacists. The secondary objectives were to determine the level of agreement among pharmacists concerning DDI severity, to determine the influence of the CDSS on clinicians' decision-making, and to review the literature supporting the severity rankings of DDIs identified in the study institution's database. Methods This 2-part survey study involved pharmacists and pharmacy residents working at 1 of 4 health organizations within the Lower Mainland Pharmacy Services, British Columbia, who were invited to participate by email. Participants were first asked to rank the severity of 15 drug pairs (representing potential DDIs) on a 5-point Likert scale and to select an action to manage each interaction. Participants were then given the CDSS severity classification for the same 15 pairs and again asked to select an appropriate management action. Results Of the estimated 500 eligible pharmacists, a total of 73 pharmacists participated, for a response rate of about 15%. For DDIs of moderate severity, most participants chose to monitor. For severe and contraindicated interactions, the severity ranking and action proposed by participants varied, despite the same severity classification by the CDSS. There was poor agreement among respondents about the severity of the various DDIs. Moreover, knowledge of the CDSS severity ranking did not seem to change the actions proposed by most respondents. Conclusion This study identified a gap between the local CDSS and clinical practice. There were discrepancies in terms of severity rankings and actions proposed to manage DDIs, particularly for severe and contraindicated DDIs. The current CDSS did not appear to have a large impact on clinical decision-making, which suggests that it may not be functioning to its full potential.
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Affiliation(s)
- Louise Lau
- , BSc, BSc Pharm, ACPR, is a Clinical Pharmacist with Vancouver General Hospital, Vancouver, British Columbia
| | - Harkaryn Bagri
- , BSc, BScPharm, ACPR, is a Clinical Pharmacist with Surrey Memorial Hospital, Surrey, British Columbia
| | - Michael Legal
- , BScPharm, PharmD, ACPR, FCSHP, is a Clinical Manager with Lower Mainland Pharmacy Services, Vancouver, British Columbia
| | - Karen Dahri
- , BSc, BScPharm, PharmD, ACPR, FCSHP, is a Clinical Pharmacotherapeutic Specialist (Internal Medicine) with Vancouver General Hospital and an Assistant Professor (Partner) with the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
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Moreau F, Simon N, Walther J, Dambrine M, Kosmalski G, Genay S, Perez M, Lecoutre D, Belaiche S, Rousselière C, Tod M, Décaudin B, Odou P. Does DDI-Predictor Help Pharmacists to Detect Drug-Drug Interactions and Resolve Medication Issues More Effectively? Metabolites 2021; 11:metabo11030173. [PMID: 33802983 PMCID: PMC8002594 DOI: 10.3390/metabo11030173] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 12/01/2022] Open
Abstract
The characterization of drug-drug interactions (DDIs) may require the use of several different tools, such as the thesaurus issued by our national health agency (i.e., ANSM), the metabolic pathways table from the Geneva University Hospital (GUH), and DDI-Predictor (DDI-P). We sought to (i) compare the three tools’ respective abilities to detect DDIs in routine clinical practice and (ii) measure the pharmacist intervention rate (PIR) and physician acceptance rate (PAR) associated with the use of DDI-P. The three tools’ respective DDI detection rates (in %) were measured. The PIRs and PARs were compared by using the area under the curve ratio given by DDI-P (RAUC) and applying a chi-squared test. The DDI detection rates differed significantly: 40.0%, 76.5%, and 85.2% for ANSM (The National Agency for the Safety of Medicines and Health Products), GUH and DDI-P, respectively (p < 0.0001). The PIR differed significantly according to the DDI-P’s RAUC: 90.0%, 44.2% and 75.0% for RAUC ≤ 0.5; RAUC 0.5–2 and RAUC > 2, respectively (p < 0.001). The overall PAR was 85.1% and did not appear to depend on the RAUC category (p = 0.729). Our results showed that more pharmacist interventions were issued when details of the strength of the DDI were available. The three tools can be used in a complementary manner, with a view to refining medication adjustments.
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Affiliation(s)
- Fanny Moreau
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France; (F.M.); (J.W.); (M.D.); (G.K.); (S.G.); (M.P.); (D.L.); (S.B.); (C.R.); (B.D.); (P.O.)
| | - Nicolas Simon
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France; (F.M.); (J.W.); (M.D.); (G.K.); (S.G.); (M.P.); (D.L.); (S.B.); (C.R.); (B.D.); (P.O.)
- ULR 7365–GRITA–Groupe de Recherche sur les formes Injectables et les Technologies Associées, University of Lille, F-59000 Lille, France
- Correspondence: ; Tel.: +33-320-964-029
| | - Julia Walther
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France; (F.M.); (J.W.); (M.D.); (G.K.); (S.G.); (M.P.); (D.L.); (S.B.); (C.R.); (B.D.); (P.O.)
| | - Mathilde Dambrine
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France; (F.M.); (J.W.); (M.D.); (G.K.); (S.G.); (M.P.); (D.L.); (S.B.); (C.R.); (B.D.); (P.O.)
| | - Gaetan Kosmalski
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France; (F.M.); (J.W.); (M.D.); (G.K.); (S.G.); (M.P.); (D.L.); (S.B.); (C.R.); (B.D.); (P.O.)
| | - Stéphanie Genay
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France; (F.M.); (J.W.); (M.D.); (G.K.); (S.G.); (M.P.); (D.L.); (S.B.); (C.R.); (B.D.); (P.O.)
- ULR 7365–GRITA–Groupe de Recherche sur les formes Injectables et les Technologies Associées, University of Lille, F-59000 Lille, France
| | - Maxime Perez
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France; (F.M.); (J.W.); (M.D.); (G.K.); (S.G.); (M.P.); (D.L.); (S.B.); (C.R.); (B.D.); (P.O.)
| | - Dominique Lecoutre
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France; (F.M.); (J.W.); (M.D.); (G.K.); (S.G.); (M.P.); (D.L.); (S.B.); (C.R.); (B.D.); (P.O.)
| | - Stéphanie Belaiche
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France; (F.M.); (J.W.); (M.D.); (G.K.); (S.G.); (M.P.); (D.L.); (S.B.); (C.R.); (B.D.); (P.O.)
| | - Chloé Rousselière
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France; (F.M.); (J.W.); (M.D.); (G.K.); (S.G.); (M.P.); (D.L.); (S.B.); (C.R.); (B.D.); (P.O.)
| | - Michel Tod
- EMR: 3738, Faculté de Médecin Lyon-Sud-Charles Mérieux, Université Lyon 1, F-69921 Oullins, France;
- Pharmacie, Groupement Hospitalier Nord, Hospices Civils de Lyon, F-69005 Lyon, France
| | - Bertrand Décaudin
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France; (F.M.); (J.W.); (M.D.); (G.K.); (S.G.); (M.P.); (D.L.); (S.B.); (C.R.); (B.D.); (P.O.)
- ULR 7365–GRITA–Groupe de Recherche sur les formes Injectables et les Technologies Associées, University of Lille, F-59000 Lille, France
| | - Pascal Odou
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France; (F.M.); (J.W.); (M.D.); (G.K.); (S.G.); (M.P.); (D.L.); (S.B.); (C.R.); (B.D.); (P.O.)
- ULR 7365–GRITA–Groupe de Recherche sur les formes Injectables et les Technologies Associées, University of Lille, F-59000 Lille, France
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Yan L, Reese T, Nelson SD. A Narrative Review of Clinical Decision Support for Inpatient Clinical Pharmacists. Appl Clin Inform 2021; 12:199-207. [PMID: 33730757 DOI: 10.1055/s-0041-1722916] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Increasingly, pharmacists provide team-based care that impacts patient care; however, the extent of recent clinical decision support (CDS), targeted to support the evolving roles of pharmacists, is unknown. Our objective was to evaluate the literature to understand the impact of clinical pharmacists using CDS. METHODS We searched MEDLINE, EMBASE, and Cochrane Central for randomized controlled trials, nonrandomized trials, and quasi-experimental studies which evaluated CDS tools that were developed for inpatient pharmacists as a target user. The primary outcome of our analysis was the impact of CDS on patient safety, quality use of medication, and quality of care. Outcomes were scored as positive, negative, or neutral. The secondary outcome was the proportion of CDS developed for tasks other than medication order verification. Study quality was assessed using the Newcastle-Ottawa Scale. RESULTS Of 4,365 potentially relevant articles, 15 were included. Five studies were randomized controlled trials. All included studies were rated as good quality. Of the studies evaluating inpatient pharmacists using a CDS tool, four showed significantly improved quality use of medications, four showed significantly improved patient safety, and three showed significantly improved quality of care. Six studies (40%) supported expanded roles of clinical pharmacists. CONCLUSION These results suggest that CDS can support clinical inpatient pharmacists in preventing medication errors and optimizing pharmacotherapy. Moreover, an increasing number of CDS tools have been developed for pharmacists' roles outside of order verification, whereby further supporting and establishing pharmacists as leaders in safe and effective pharmacotherapy.
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Affiliation(s)
- Liang Yan
- University of Utah College of Pharmacy, University of Utah Health, Salt Lake City, Utah, United States
| | - Thomas Reese
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Scott D Nelson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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Muylle KM, Gentens K, Dupont AG, Cornu P. Evaluation of an optimized context-aware clinical decision support system for drug-drug interaction screening. Int J Med Inform 2021; 148:104393. [PMID: 33486355 DOI: 10.1016/j.ijmedinf.2021.104393] [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: 07/29/2020] [Revised: 11/06/2020] [Accepted: 01/08/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Evaluation of the effect of six optimization strategies in a clinical decision support system (CDSS) for drug-drug interaction (DDI) screening on alert burden and alert acceptance and description of clinical pharmacist intervention acceptance. METHODS Optimizations in the new CDSS were the customization of the knowledge base (with addition of 67 extra DDIs and changes in severity classification), a new alert design, required override reasons for the most serious alerts, the creation of DDI-specific screening intervals, patient-specific alerting, and a real-time follow-up system of all alerts by clinical pharmacists with interventions by telephone was introduced. The alert acceptance was evaluated both at the prescription level (i.e. prescription acceptance, was the DDI prescribed?) and at the administration level (i.e. administration acceptance, did the DDI actually take place?). Finally, the new follow-up system was evaluated by assessing the acceptance of clinical pharmacist's interventions. RESULTS In the pre-intervention period, 1087 alerts (92.0 % level 1 alerts) were triggered, accounting for 19 different DDIs. In the post-intervention period, 2630 alerts (38.4 % level 1 alerts) were triggered, representing 86 different DDIs. The relative risk forprescription acceptance in the post-intervention period compared to the pre-intervention period was 4.02 (95 % confidence interval (CI) 3.17-5.10; 25.5 % versus 6.3 %). The relative risk for administration acceptance was 1.16 (95 % CI 1.08-1.25; 54.4 % versus 46.7 %). Finally, 86.9 % of the clinical pharmacist interventions were accepted. CONCLUSION Six concurrently implemented CDSS optimization strategies resulted in a high alert acceptance and clinical pharmacist intervention acceptance. Administration acceptance was remarkably higher than prescription acceptance.
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Affiliation(s)
- Katoo M Muylle
- Research Group Clinical Pharmacology & Clinical Pharmacy (KFAR), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Laarbeeklaan 103, 1090 Brussels, Belgium.
| | - Kristof Gentens
- Department of Medical Informatics, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Alain G Dupont
- Research Group Clinical Pharmacology & Clinical Pharmacy (KFAR), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Laarbeeklaan 103, 1090 Brussels, Belgium.
| | - Pieter Cornu
- Research Group Clinical Pharmacology & Clinical Pharmacy (KFAR), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Laarbeeklaan 103, 1090 Brussels, Belgium; Department of Medical Informatics, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.
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Targeting continuity of care and polypharmacy to reduce drug-drug interaction. Sci Rep 2020; 10:21279. [PMID: 33277524 PMCID: PMC7718252 DOI: 10.1038/s41598-020-78236-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/19/2020] [Indexed: 11/27/2022] Open
Abstract
Drug–drug interaction (DDI) is common among the elderly, and it can have detrimental effects on patients. However, how DDI can be targeted has been under-researched. This study investigates whether DDI can be reduced by targeting continuity of care (COC) through reducing polypharmacy. Population claims data of Taiwan National Health Insurance were used to conduct a 7-year-long longitudinal study on patients aged ≥ 65 years (n = 2,318,766). Mediation analysis with counterfactual method and a 4-way decomposition of the effect of COC on DDI was conducted. Mediation effect through excessive polypharmacy differed from that through lower-level polypharmacy. Compared with the low COC group, the high COC group demonstrated reduced excess relative risk of DDI by 26% (excess relative risk = − 0.263; 95% Confidence Interval (CI) = − 0.263 to − 0.259) to 30% (excess relative risk = − 0.297; 95% CI = − 0.300 to − 0.295) with excessive polypharmacy as the mediator. The risk only reduced by 8% (excess relative risk = − 0.079; 95% CI, − 0.08 to − 0.078) to 10% (excess relative risk = − 0.096; 95% CI, − 0.097 to − 0.095) when the mediator was changed to lower-level polypharmacy. The effect of COC on DDI was mediated by polypharmacy, and the mediation effect was higher with excessive polypharmacy. Therefore, to reduce DDI in the elderly population, different policy interventions should be designed by considering polypharmacy levels to maximize the positive effect of COC on DDI.
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Muylle KM, Gentens K, Dupont AG, Cornu P. Evaluation of context-specific alerts for potassium-increasing drug-drug interactions: A pre-post study. Int J Med Inform 2019; 133:104013. [PMID: 31698230 DOI: 10.1016/j.ijmedinf.2019.104013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/04/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To investigate whether context-specific alerts for potassium-increasing drug-drug interactions (DDIs) in a clinical decision support system reduced the alert burden, increased alert acceptance, and had an effect on the occurrence of hyperkalemia. MATERIALS AND METHODS In the pre-intervention period all alerts for potassium-increasing DDIs were level 1 alerts advising absolute contraindication, while in the post-intervention period the same drug combinations could trigger a level 1 (absolute contraindication), a level 2 (monitor potassium values), or a level 3 alert (informative, not shown to physicians) based on the patient's recent laboratory value of potassium. Alert acceptance was defined as non-prescription or non-administration of the interacting drug combination for level 1 alerts and as monitoring of the potassium levels for level 2 alerts. RESULTS The alert burden decreased by 92.8%. The relative risk (RR) for alert acceptance based on prescription rates for level 1 alerts and monitoring rates for level 2 alerts was 15.048 (86.5% vs 5.7%; 95% CI 12.037-18.811; P < 0.001). With alert acceptance for level 1 alerts based on actual administration and for level 2 alerts on monitoring rates, the RR was 3.597 (87.6% vs 24.4%; 95% CI 3.192-4.053; P < 0.001). In the generalized linear mixed model the effect of the intervention on the occurrence of hyperkalemia was not significant (OR 1.091, 95% CI 0.172-6.919). CONCLUSION The proposed strategy seems effective to get a grip on the delicate balance between over- and under alerting.
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Affiliation(s)
- Katoo M Muylle
- Research Group Clinical Pharmacology & Clinical Pharmacy (KFAR), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Laarbeeklaan 103, 1090, Brussels, Belgium.
| | - Kristof Gentens
- Department of Medical Informatics, UZ Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Alain G Dupont
- Research Group Clinical Pharmacology & Clinical Pharmacy (KFAR), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Laarbeeklaan 103, 1090, Brussels, Belgium.
| | - Pieter Cornu
- Research Group Clinical Pharmacology & Clinical Pharmacy (KFAR), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Laarbeeklaan 103, 1090, Brussels, Belgium; Department of Medical Informatics, UZ Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
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Bagri H, Dahri K, Legal M. Hospital Pharmacists' Perceptions and Decision-Making Related to Drug-Drug Interactions. Can J Hosp Pharm 2019; 72:288-294. [PMID: 31452540 PMCID: PMC6699872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Pharmacists often overlook drug interaction alerts because of limitations in clinical decision support (CDS) software systems intended to detect evidence-based, clinically significant drug-drug interactions (DDIs). Alert fatigue, which occurs when pharmacists become desensitized to an overload of DDIs, may also contribute. OBJECTIVES To gain a better understanding of how pharmacists assess common DDIs and the extent to which computerized drug alerts affect their decision-making, as background for initiatives to overcome alert fatigue and improve detection of DDIs. METHODS This qualitative study used focus group methodology. A structured focus group was planned at each of 3 large tertiary hospitals. Pharmacists were invited to participate if their jobs included patient care and/or dispensary responsibilities. The focus group discussions were audio-recorded and subsequently transcribed, analyzed, and coded into themes using NVivo software. Four main categories of themes were identified: perceived challenges, pharmacists' assessment of DDIs, barriers to responding to alerts, and proposed solutions. RESULTS The participants (n = 24) described a large discrepancy among CDS software systems in terms of the severity of specific DDIs, which made it difficult to view these systems as reliable sources. The participants agreed that alert fatigue is present and contributes to DDIs being overlooked. However, lack of patient information to make an initial assessment, as well as the constant need for multitasking, prevents pharmacists from focusing on the evaluation of DDIs. CONCLUSIONS Although alert fatigue was reported to be a common factor responsible for pharmacists missing DDIs, other barriers also exist. Participants suggested ways to limit DDI alerts to those that are clinically relevant. Having a collaborative team of pharmacists periodically review the DDIs embedded in the CDS system, incorporating a colour-code system, and removing duplicate entries were discussed as ways to improve system efficiency.
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Affiliation(s)
- Harkaryn Bagri
- , BSc, BScPharm, ACPR, is a Clinical Pharmacist with Surrey Memorial Hospital, Surrey, British Columbia
| | - Karen Dahri
- , BSc, BScPharm, PharmD, ACPR, BCPS, is a Clinical Pharmacotherapeutic Specialist (Internal Medicine) with Vancouver General Hospital and a Clinical Instructor with the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Michael Legal
- , BScPharm, PharmD, ACPR, is a Clinical Pharmacy Specialist, Internal Medicine with St Paul's Hospital, and a Clinical Associate Professor with the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
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Cena C, Traina S, Parola B, Bo M, Fagiano R, Siviero C. Prescription of proton pump inhibitors in older adults with complex polytherapy. Eur J Hosp Pharm 2019; 27:341-345. [PMID: 33097617 DOI: 10.1136/ejhpharm-2018-001697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 01/28/2019] [Accepted: 02/12/2019] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Prescription of proton pump inhibitors (PPIs) may be a source of potentially clinically relevant drug-drug interactions (DDIs) and related complications for elderly patients with complex polytherapy at discharge from hospital. The aim of the study was to identify, through the analysis of hospital discharge records, the co-administrations (PPIs + one or more drugs potentially generating DDIs) hypothetically leading to severe consequences according to the literature and online databases. Subsequently, alternatives to PPIs were evaluated for the treatment of gastric acidity and ulcers. METHODS The medical records of 1288 patients, discharged from a geriatric ward at the Città della Salute e della Scienza Hospital in Turin from January 2012 to December 2013, were collected in an Excel database for analysis of DDIs using the literature and online sources such as Micromedex. RESULTS : Six hundred and sixty-three of the 1288 clinical folders had a PPI prescription. A list of 18 drugs considered potentially hazardous and able to trigger a DDI when co-administrated with PPIs was drafted; the frequencies of the co-prescriptions of each PPI with one of the listed drugs were esomeprazole 65.38%, lansoprazole 52.87%, omeprazole 48.19% and pantoprazole 37.11%. An analysis of these co-prescriptions, according to Micromedex classification, gave a percentage of major interactions of 11.01% over 663 clinical folders including a PPI. CONCLUSIONS This study provides a collection of potentially hazardous drug associations and helpful suggestions to improve the quality of prescriptions for elderly patients and strengthens the case for synergic work between doctors and pharmacists in the wards.
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Affiliation(s)
- Clara Cena
- Dipartimento di Scienza e Tecnologia del Farmaco, Universita degli Studi di Torino, Torino, Italy
| | - Sara Traina
- Dipartimento di Scienza e Tecnologia del Farmaco, Universita degli Studi di Torino, Torino, Italy
| | - Beatrice Parola
- Dipartimento di Scienza e Tecnologia del Farmaco, Universita degli Studi di Torino, Torino, Italy
| | - Mario Bo
- Azienda Ospedaliero Universitaria Citta della Salute e della Scienza di Torino, Torino, Italy
| | - Riccardo Fagiano
- Azienda Ospedaliero Universitaria Citta della Salute e della Scienza di Torino, Torino, Italy
| | - Carlotta Siviero
- Dipartimento di Scienza e Tecnologia del Farmaco, Universita degli Studi di Torino, Torino, Italy
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12
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Impact of a clinical decision support system for drug dosage in patients with renal failure. Int J Clin Pharm 2018; 40:1225-1233. [PMID: 29785684 DOI: 10.1007/s11096-018-0612-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/02/2018] [Indexed: 01/27/2023]
Abstract
Background A clinical decision support system (CDSS) linked to the computerized physician order entry may help improve prescription appropriateness in inpatients with renal insufficiency. Objective To evaluate the impact on prescription appropriateness of a CDSS prescriber alert for 85 drugs in renal failure patients. Setting Before-after study in a 975-bed academic hospital. Method Prescriptions of patients with renal failure were reviewed during two comparable periods of 6 days each, before and after the implementation of the CDSS (September 2009 and 2010). Main outcome measure The proportion of inappropriate dosages of 85 drugs included in the CDSS was compared in the pre- and post-implementation group. Results Six hundred and fifteen patients were included in the study (301 in pre- and 314 in post-implementation periods). In the pre- and post-implementation period, respectively 2882 and 3485 prescriptions were evaluated, of which 14.9 and 16.6% triggered an alert. Among these, the dosage was inappropriate in respectively 25.4 and 24.6% of prescriptions in the pre- and post-implementation periods (OR 0.97; 95% CI 0.72-1.29). The most frequently involved drugs were paracetamol, perindopril, tramadol and allopurinol. Conclusion The implementation of a CDSS did not significantly reduce the proportion of inappropriate drug dosages in patients with renal failure. Further research is required to investigate the reasons why prescribers override alerts. Collaboration with clinical pharmacists might improve compliance with the CDSS recommendations.
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Cornu P, Phansalkar S, Seger DL, Cho I, Pontefract S, Robertson A, Bates DW, Slight SP. High-priority and low-priority drug-drug interactions in different international electronic health record systems: A comparative study. Int J Med Inform 2018; 111:165-171. [PMID: 29425628 DOI: 10.1016/j.ijmedinf.2017.12.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 11/28/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To investigate whether alert warnings for high-priority and low-priority drug-drug interactions (DDIs) were present in five international electronic health record (EHR) systems, to compare and contrast the severity level assigned to them, and to establish the proportion of alerts that were overridden. METHODS We conducted a comparative, retrospective, multinational study using a convenience sample of 5 EHRs from the U.S., U.K., Republic of Korea and Belgium. RESULTS Of the 15 previously defined, high-priority, class-based DDIs, alert warnings were found to exist for 11 in both the Korean and UK systems, 9 in the Belgian system, and all 15 in the two US systems. The specific combinations that were included in these class-based DDIs varied considerably in number, type and level of severity amongst systems. Alerts were only active for 8.4% (52/619) and 52.4% (111/212) of the specific drug-drug combinations contained in the Belgian and UK systems, respectively. Hard stops (not possible to override) existed in the US and UK systems only. The override rates for high-priority alerts requiring provider action ranged from 56.7% to 83.3%. Of the 33 previously defined low-priority DDIs, active alerts existed only in the US systems, for three class-based DDIs. The majority were non-interruptive. CONCLUSIONS Alert warnings existed for most of the high-priority DDIs in the different EHRs but overriding them was easy in most of the systems. In addition to validating the high- and low-priority DDIs, this study reported a lack of standardization in DDI levels across different international knowledge bases.
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Affiliation(s)
- Pieter Cornu
- Research group, Clinical Pharmacology & Clinical Pharmacy (KFAR), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Shobha Phansalkar
- The Centre for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Partners Healthcare, Boston, MA, USA; Harvard Medical School, 250 Longwood Ave, Boston, MA, USA
| | - Diane L Seger
- The Centre for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Partners Healthcare, Boston, MA, USA; Partners Healthcare, Wellesley, MA, USA
| | - Insook Cho
- Department of Nursing, Inha University, Incheon, Republic of Korea
| | - Sarah Pontefract
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | | | - David W Bates
- The Centre for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Partners Healthcare, Boston, MA, USA; Harvard Medical School, 250 Longwood Ave, Boston, MA, USA; Harvard School of Public Health, 677 Huntington Avenue, Boston, MA, USA
| | - Sarah P Slight
- The Centre for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Partners Healthcare, Boston, MA, USA; School of Pharmacy, Newcastle University, King George VI Building, Newcastle Upon Tyne, Queen Victoria Road, UK; Newcastle upon Tyne Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle, UK.
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Clinical reasoning in the context of active decision support during medication prescribing. Int J Med Inform 2017; 97:1-11. [DOI: 10.1016/j.ijmedinf.2016.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 08/20/2016] [Accepted: 09/07/2016] [Indexed: 11/21/2022]
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Giraldo NA, Amariles P, Monsalve M, Faus MJ. Free software to analyse the clinical relevance of drug interactions with antiretroviral agents (SIMARV ®) in patients with HIV/AIDS. Res Social Adm Pharm 2016; 13:831-839. [PMID: 27751754 DOI: 10.1016/j.sapharm.2016.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 09/17/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Highly active antiretroviral therapy has extended the expected lifespan of patients with HIV/AIDS. However, the therapeutic benefits of some drugs used simultaneously with highly active antiretroviral therapy may be adversely affected by drug interactions. OBJECTIVE The goal was to design and develop a free software to facilitate analysis, assessment, and clinical decision making according to the clinical relevance of drug interactions in patients with HIV/AIDS. METHODS A comprehensive Medline/PubMed database search of drug interactions was performed. Articles that recognized any drug interactions in HIV disease were selected. The publications accessed were limited to human studies in English or Spanish, with full texts retrieved. Drug interactions were analyzed, assessed, and grouped into four levels of clinical relevance according to gravity and probability. Software to systematize the information regarding drug interactions and their clinical relevance was designed and developed. RESULTS Overall, 952 different references were retrieved and 446 selected; in addition, 67 articles were selected from the citation lists of identified articles. A total of 2119 pairs of drug interactions were identified; of this group, 2006 (94.7%) were drug-drug interactions, 1982 (93.5%) had an identified pharmacokinetic mechanism, and 1409 (66.5%) were mediated by enzyme inhibition. In terms of clinical relevance, 1285 (60.6%) drug interactions were clinically significant in patients with HIV (levels 1 and 2). With this information, a software program that facilitates identification and assessment of the clinical relevance of antiretroviral drug interactions (SIMARV®) was developed. CONCLUSIONS A free software package with information on 2119 pairs of antiretroviral drug interactions was designed and developed that could facilitate analysis, assessment, and clinical decision making according to the clinical relevance of drug interactions in patients with HIV/AIDS.
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Affiliation(s)
- N A Giraldo
- Research Group on Pharmaceutical Prevention and Promotion, University of Antioquia, Medellin, Colombia; Pharmaceutical Care Program, Humax Pharmaceutical, Medellin, Colombia
| | - P Amariles
- Research Group on Pharmaceutical Prevention and Promotion, University of Antioquia, Medellin, Colombia; Department of Pharmacy, University of Antioquia, Medellin, Colombia; Research Group on Pharmaceutical Care, University of Granada, Granada, Spain.
| | - M Monsalve
- Research Group on Pharmaceutical Prevention and Promotion, University of Antioquia, Medellin, Colombia; Pharmaceutical Care Program, Humax Pharmaceutical, Medellin, Colombia
| | - M J Faus
- Research Group on Pharmaceutical Care, University of Granada, Granada, Spain; Department of Biochemistry and Molecular Biology, University of Granada, Spain
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Joos E, Mehuys E, Remon JP, Van Winckel M, Boussery K. Analysis of drug use in institutionalized individuals with intellectual disability and tube feeding. Acta Clin Belg 2016; 71:76-80. [PMID: 27075803 DOI: 10.1080/17843286.2015.1122332] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Little is known about the medication used by people with intellectual disabilities (ID) and enteral feeding tube (EFT). However, in light of the complexity associated with drug administration through EFT, data on medication use in this population may be helpful in the development of practical guidelines and staff training initiatives. METHODS A cross-sectional, observational study was conducted in six Belgian residential care facilities (RCFs) for individuals with ID. Anonymized medication records of all residents receiving chronic medication through EFT were collected (n = 156). All chronic drugs were categorized according to the ATC classification, and medication records were checked for potential major drug-drug interactions (DDI). RESULTS The 156 residents used a total of 1029 chronic drugs via EFT, with a median of six drugs per resident (range 1-14). A total of 148 different drug molecules were identified, belonging to 38 main ATC therapeutic groups (ATC level 2). Antiepileptics, drugs for constipation and drugs for acid-related disorders were the most frequently used groups. Seventy-four of the 156 screened medication records (47%) contained at least one potential DDI; in total, 116 potential interactions were identified, which represent 38 different interacting drug pairs. CONCLUSION This study describes medication use through EFT among people with ID in Belgian RCFs, with antiepileptics being the most frequently used group. Our study also demonstrated that a high number of drugs is administered through EFT, and that the number of potential DDIs is high. These observations warrant an increased attention for drug administration through the EFT in individuals with ID.
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Cornu P, Steurbaut S, Gentens K, Van de Velde R, Dupont AG. Pilot evaluation of an optimized context-specific drug–drug interaction alerting system: A controlled pre-post study. Int J Med Inform 2015; 84:617-29. [DOI: 10.1016/j.ijmedinf.2015.05.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 12/08/2014] [Accepted: 05/13/2015] [Indexed: 01/08/2023]
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