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Hassanzadeh TE, Hohmann C, Culmsee C. Impact of a DSS-supported medication review on the safety of drug therapy and quality of life in patients with antithrombotic therapy. Front Pharmacol 2024; 15:1194201. [PMID: 38846096 PMCID: PMC11153675 DOI: 10.3389/fphar.2024.1194201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 04/17/2024] [Indexed: 06/09/2024] Open
Abstract
Polypharmacy is common among patients with antithrombotic medication, giving rise to concerns about Drug-Related Problems (DRPs). Therefore, these patients would benefit from a Medication Review (MR) along with pharmacist counselling to reduce the risks accompanying polymedication. This prospective study presents a concept for MRs that are applicable in German community pharmacies and can efficiently support pharmacist counselling and improve the safety of drug therapy. As this is a major challenge in everyday pharmacy practice, we used a Decision Support System (DSS) to evaluate its ability to support the process of pharmacist-led MRs. The primary endpoint was the impact of a community pharmacist on the reduction of DRPs. We investigated the impact of the interventions resulting from MRs on patients taking at least one antithrombotic drug as part of their polymedication regimen. Secondary endpoints were the reduction in the number of patients with bleeding risks and the improvement of patients' Quality of Life (QoL) and therapy adherence. Furthermore, the DSS used in the study was controlled for correct data assessment and plausibility of data. We selected adult patients who were taking no less than three different medications for long-term treatment, at least one of which had to be an antithrombotic drug, and who were customers in one of eight selected pharmacies over a period of 6 months. Data from 87 patients were analyzed with DSS-support. A total of 234 DRPs were identified by the pharmacist (2.7 DRPs per patient). MR reduced DRPs by 43.2% which, resulting to a reduction of 1.2 DRPs per patient. The intervention also led to a significant improvement in the patients' QoL (assessed via EQ-5D-5L questionnaire; p < 0.001) and enhanced therapy adherence (assessed via A14 questionnaire; p < 0.001). The control of correct data assessment (with 93.8% concordance) and plausibility of data (with 91.7% concordance) of the DSS software were conducted by an external auditor. No significant effect was found for overall bleeding risk. The results of this study indicate that DSS-supported and structured MR conducted by pharmacists can contribute to a reduction in DRPs and significantly improve patient's QoL and adherence to treatment.
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Affiliation(s)
- Tanja Elnaz Hassanzadeh
- Pharma4u GmbH, Munich, Germany
- Institute for Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, University of Marburg, Marburg, Germany
| | - Carina Hohmann
- Department of Pharmacy, Klinikum Fulda gAG, Fulda, Germany
| | - Carsten Culmsee
- Institute for Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, University of Marburg, Marburg, Germany
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2
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Potier A, Ade M, Demoré B, Divoux E, Dony A, Dufay E. Enhancing pharmaceutical decision support system: evaluating antithrombotic-focused algorithms for addressing drug-related problems. Eur J Hosp Pharm 2024:ejhpharm-2023-003944. [PMID: 38233119 DOI: 10.1136/ejhpharm-2023-003944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/26/2023] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVES To evaluate the efficacy of integrating antithrombotic-focused pharmaceutical algorithms (PAs) into a pharmaceutical decision support system (PDSS) for detecting drug-related problems (DRPs) and facilitating pharmaceutical interventions. METHODS A set of 26 PAs (12.4%) out of a total of 210 were created to model patient situations involving antithrombotics, and their contributions were compared with the entire PDSS system.The observational prospective study was conducted between November 2019 and June 2023 in two health facilities with 1700 beds. Pharmacists, who followed a DRP resolution strategy to support human supervision, analysed alerts generated by these encoded PAs. They registered their interventions and the acceptance by physicians. RESULTS From 3290 alerts analysed targeting antithrombotics, the pharmacists issued 1170 interventions of which 676 (57.8%) were accepted by physicians. With the 184 other PAs, from 9484 alerts the pharmacists issued 3341 interventions of which 1785 were accepted (53.4%).Results indicate that the detection of DRPs related to antithrombotics usage represents a high proportion of those detected by the PDSS, highlighting the importance of incorporating tailored PA elements at the modelling stage. CONCLUSIONS The system evolves alongside the physiological changes associated to the patient situations, adapts the alerts and complements the current care. Therefore, we recommend that all PDSS should integrate specific algorithms targeting DRPs associated with antithrombotics to enhance pharmaceutical interventions and improve patient safety.
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Affiliation(s)
- Arnaud Potier
- Pharmacy, Centre Hospitalier de Lunéville, Lunéville, France
| | - Mathias Ade
- Pharmacy, Centre Psychothérapique de Nancy, Laxou, France
| | - Béatrice Demoré
- Pharmacy, Centre Hospitalier Universitaire de Nancy, Vandoeuvre-lès-Nancy, France
- APEMAC, Université de Lorraine, Nancy, France
| | | | - Alexandre Dony
- Service de Pharmacie, Centre Hospitalier de Lunéville, Lunéville, France
| | - Edith Dufay
- Pharmacy, Centre Hospitalier de Lunéville, Lunéville, France
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3
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Austin JA, Barras M, Woods LS, Sullivan C. AIDH Summit 2022 - The effect of digitisation on the safe management of anticoagulants. Appl Clin Inform 2022; 13:845-856. [PMID: 35896507 PMCID: PMC9474267 DOI: 10.1055/a-1910-4339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Anticoagulants are high-risk medications and are a common cause of adverse events of hospitalised inpatients. The incidence of adverse events involving anticoagulants has remained relatively unchanged over the past two decades, suggesting novel approaches are required to address this persistent issue. Electronic medication management systems (eMMS) offer strategies to help reduce medication incidents and adverse drug events, yet poor system design can introduce new error types. OBJECTIVE To evaluate the effect of the introduction of an electronic medical record (EMR) on the quality and safety of therapeutic anticoagulation management. METHODS A retrospective, observational pre/post study was conducted, analysing real-world data across five hospital sites in a single health service. Four metrics were compared one year pre- and one year post-EMR implementation. They included clinician-reported medication incidents, toxic pathology results, hospital-acquired bleeding complications (HACs) and rate of heparin-induced thrombocytopenia. Further sub-analyses of patients experiencing HACs in the post-EMR period, identified key opportunities for intervention to maximise safety and quality of anticoagulation within an eMMS. RESULTS A significant reduction in HACs was observed in the post-EMR implementation period (mean (SD) =12.1 (4.4)/month, vs. mean (SD) =7.8 (3.5)/month; p=0.01). The categorisation of potential EMR design enhancements found that new automated clinical decision support or improved pathology result integration would be suitable to mitigate future HACs in an eMMS. There was no significant difference in the mean monthly clinician-reported incident rates for anticoagulants or the rate of toxic pathology results in the pre- versus post-EMR implementation period. A 62.5% reduction in the cases of heparin-induced thrombocytopenia were observed in the post-EMR implementation period. CONCLUSION The implementation of an EMR improves clinical care outcomes for patients receiving anticoagulation. System design plays a significant role in mitigating the risks associated with anticoagulants and consideration must be given to optimising eMMS.
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Affiliation(s)
- Jodie Ann Austin
- Centre for Health Services Research, The University of Queensland Faculty of Medicine, Herston, Australia
| | - Michael Barras
- School of Pharmacy, The University of Queensland Faculty of Health and Behavioural Sciences, Woolloongabba, Australia.,Department of Pharmacy, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Leanna Sarah Woods
- Centre for Health Services Research, The University of Queensland, Herston, Australia.,Digital Health Cooperative Research Centre, Sydney, Australia
| | - Clair Sullivan
- Centre for Health Services Research, The University of Queensland Faculty of Medicine, Herston, Australia.,Digital Metro North, Royal Brisbane and Women's Hospital, Herston, Australia
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4
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Moghaddasi H, Rahimi R, Kazemi A, Arjmandi Rafsanjani K, Bahoush G, Rahimi F. A Clinical Decision Support System for Increasing Compliance with Protocols in Chemotherapy of Children with Acute Lymphoblastic Leukemia. Cancer Inform 2022; 21:11769351221084812. [PMID: 35342287 PMCID: PMC8943570 DOI: 10.1177/11769351221084812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 02/11/2022] [Indexed: 11/27/2022] Open
Abstract
Objective: In this survey, a protocol-based Chemotherapy Prescription Decision Support
System (CPDSS) was designed and evaluated to reduce medication errors in the
chemotherapy process of children with ALL. Methods: The CPDSS algorithm was extracted by the software development team based on
the protocol used by doctors to treat children with ALL. The ASP.Net MVC
and SQL Server 2016 programming languages were used to develop the system. A
3-step evaluation (technical, retrospective, and user satisfaction) was
performed on CPDSS designed at 2 children’s hospitals in Tehran. The data
were analyzed using descriptive statistics. At the technical evaluation
step, users provided recommendations included in the system. Results: In the retrospective CPDSS evaluation step, 1281 prescribed doses of the
drugs related to 30 patients were entered into the system. CPDSS detected
735 cases of protocol deviations and 57 (95%, CI = 1.25-2.55) errors in
prescribed chemotherapy for children with ALL. In the user satisfaction
evaluation, the users approved two dimensions of the user interface and
functionality of the system. Conclusions: With the provision of alerts, the CPDSS can help increase compliance with
chemotherapy protocols and decrease the chemotherapy prescribing errors that
can improve patient safety.
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Affiliation(s)
- Hamid Moghaddasi
- Department of Health Information Management and Technology, School of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rezvan Rahimi
- Department of Medical Informatics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Alireza Kazemi
- Department of Health Information Management and Technology, School of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Khadijeh Arjmandi Rafsanjani
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Ali-Asghar Children Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Gholamreza Bahoush
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Ali-Asghar Children Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Forough Rahimi
- School of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Bai Y, Yao H, Jiang X, Bian S, Zhou J, Sun X, Hu G, Sun L, Xie G, He K. Construction of a Non-Mutually Exclusive Decision Tree for Medication Recommendation of Chronic Heart Failure. Front Pharmacol 2022; 12:758573. [PMID: 35280259 PMCID: PMC8904717 DOI: 10.3389/fphar.2021.758573] [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: 08/16/2021] [Accepted: 12/31/2021] [Indexed: 11/24/2022] Open
Abstract
Objective: Although guidelines have recommended standardized drug treatment for heart failure (HF), there are still many challenges in making the correct clinical decisions due to the complicated clinical situations of HF patients. Each patient would satisfy several recommendations, meaning the decision tree of HF treatment should be nonmutually exclusive, and the same patient would be allocated to several leaf nodes in the decision tree. In the current study, we aim to propose a way to ensemble a nonmutually exclusive decision tree for recommendation system for complicated diseases, such as HF. Methods: The nonmutually exclusive decision tree was constructed via knowledge rules summarized from the HF clinical guidelines. Then similar patients were defined as those who followed the same pattern of leaf node allocation according to the decision tree. The frequent medication patterns for each similar patient were mined using the Apriori algorithms, and we also carried out the outcome prognosis analyses to show the capability for the evidence-based medication recommendations of our nonmutually exclusive decision tree. Results: Based on a large database that included 29,689 patients with 84,705 admissions, we tested the framework for HF treatment recommendation. In the constructed decision tree, the HF treatment recommendations were grouped into two independent parts. The first part was recommendations for new cases, and the second part was recommendations when patients had different historical medication. There are 14 leaf nodes in our decision tree, and most of the leaf nodes had a guideline adherence of around 90%. We reported the top 10 popular similar patients, which accounted for 32.84% of the whole population. In addition, the multiple outcome prognosis analyses were carried out to assess the medications for one of the subgroups of similar patients. Our results showed even for the subgroup of the same similar patients that no one medication pattern would benefit all outcomes. Conclusion: In the present study, the methodology to construct a nonmutually exclusive decision tree for medication recommendations for HF and its application in CDSS was proposed. Our framework is universal for most diseases and could be generally applied in developing the CDSS for treatment.
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Affiliation(s)
- Yongyi Bai
- Department of Cardiology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China.,Beijing Key Laboratory of Precision Medicine for Chronic Heart Failure, Chinese PLA General Hospital, Beijing, China
| | | | | | - Suyan Bian
- Department of Cardiology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China.,Beijing Key Laboratory of Precision Medicine for Chronic Heart Failure, Chinese PLA General Hospital, Beijing, China
| | | | | | - Gang Hu
- Ping An Health Technology, Beijing, China
| | - Lan Sun
- Institute of Materia Medica, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | | | - Kunlun He
- Beijing Key Laboratory of Precision Medicine for Chronic Heart Failure, Chinese PLA General Hospital, Beijing, China.,Research Center of Medical Big Data, The Medical Innovation Research Division, Chinese PLA General Hospital, Beijing, China
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6
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Barnes GD, Sippola E, Ranusch A, Takamine L, Lanham M, Dorsch M, Sales A, Sussman J. Implementing an electronic health record dashboard for safe anticoagulant management: learning from qualitative interviews with existing and potential users to develop an implementation process. Implement Sci Commun 2022; 3:10. [PMID: 35109916 PMCID: PMC8812192 DOI: 10.1186/s43058-022-00262-w] [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: 08/26/2021] [Accepted: 01/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Facilitating appropriate care delivery using electronic health record (digital health) tools is increasing. However, frequently used determinants frameworks seldom address key barriers for technology-associated implementation. METHODS Semi-structured interviews were conducted in two contexts: the national Veterans Health Affairs (VA) following implementation of an electronic dashboard, a population health tool, and the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) prior to implementation of a similar electronic dashboard. The dashboard is designed for pharmacist or nurse use to monitor safe outpatient anticoagulant prescribing by physicians and other clinicians We performed rapid qualitative inquiry analysis and selected implementation strategies. Through a stakeholder focus group session, we selected implementation strategies to address determinants and facilitate implementation in the MAQI2 sites. RESULTS Among 45 interviewees (32 in VA, 13 in MAQI2), we identified five key determinants of implementation success: (1) clinician authority and autonomy, (2) clinician self-identity and job satisfaction, (3) documentation and administrative needs, (4) staffing and work schedule, and (5) integration with existing information systems. Key differences between the two contexts included concerns about information technology support and prioritization within MAQI2 (prior to implementation) but not VA (after implementation) and concerns about authority and autonomy that differed between the VA (higher baseline levels, more concerns) and MAQI2 (lower baseline levels, less concern). CONCLUSIONS The successful implementation of electronic health record tools requires unique considerations that differ from other types of implementation, must account for the status of implementation, and should address the effects of the tool deployment on clinical staff authority and autonomy. Interviewing both post-implementation and pre-implementation users can provide a robust understanding of implementation determinants.
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Affiliation(s)
- Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, 2800 Plymouth Rd, B14 G214, Ann Arbor, MI, 48109-2800, USA. .,Center for Behavioral and Social Sciences in Medicine, University of Michigan, Ann Arbor, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA.
| | - Emily Sippola
- Center for Behavioral and Social Sciences in Medicine, University of Michigan, Ann Arbor, USA
| | - Allison Ranusch
- Center for Clinical Management Research, Ann Arbor Veterans Health Affairs, Ann Arbor, USA
| | - Linda Takamine
- Center for Clinical Management Research, Ann Arbor Veterans Health Affairs, Ann Arbor, USA
| | - Michael Lanham
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, USA
| | - Michael Dorsch
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA.,College of Pharmacy, University of Michigan, Ann Arbor, USA
| | - Anne Sales
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA.,Center for Clinical Management Research, Ann Arbor Veterans Health Affairs, Ann Arbor, USA.,Department of Learning Health Sciences, University of Michigan, Ann Arbor, USA
| | - Jeremy Sussman
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA.,Center for Clinical Management Research, Ann Arbor Veterans Health Affairs, Ann Arbor, USA.,Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, USA
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7
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Ibrahim MS, Mohamed Yusoff H, Abu Bakar YI, Thwe Aung MM, Abas MI, Ramli RA. Digital health for quality healthcare: A systematic mapping of review studies. Digit Health 2022; 8:20552076221085810. [PMID: 35340904 PMCID: PMC8943311 DOI: 10.1177/20552076221085810] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 02/20/2021] [Indexed: 01/05/2023] Open
Abstract
Objective To systematically catalogue review studies on digital health to establish extent of evidence on quality healthcare and illuminate gaps for new understanding, perspectives and insights for evidence-informed policies and practices. Methods We systematically searched PubMed database using sensitive search strings. Two reviewers independently conducted two-phase selection via title and abstract, followed by full-text appraisal. Consensuses were derived for any discrepancies. A standardized data extraction tool was used for reliable data mining. Results A total of 54 reviews from year 2014 to 2021 were included with notable increase in trend of publications. Systematic reviews constituted the majority (61.1%, (37.0% with meta-analyses)) followed by scoping reviews (38.9%). Domains of quality being reviewed include effectiveness (75.9%), accessibility (33.3%), patient safety (31.5%), efficiency (25.9%), patient-centred care (20.4%) and equity (16.7%). Mobile apps and computer-based were the commonest (79.6%) modalities. Strategies for effective intervention via digital health included engineering improved health behaviour (50.0%), better clinical assessment (35.1%), treatment compliance (33.3%) and enhanced coordination of care (24.1%). Psychiatry was the discipline with the most topics being reviewed for digital health (20.3%). Conclusion Digital health reviews reported findings that were skewed towards improving the effectiveness of intervention via mHealth applications, and predominantly related to mental health and behavioural therapies. There were considerable gaps on review of evidence on digital health for cost efficiency, equitable healthcare and patient-centred care. Future empirical and review studies may investigate the association between fields of practice and tendency to adopt and research the use of digital health to improve care.
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Affiliation(s)
| | | | | | - Myat Moe Thwe Aung
- Faculty of Medicine, Universiti Sultan Zainal Abidin, Terengganu, Malaysia
| | | | - Ras Azira Ramli
- Faculty of Medicine, Universiti Sultan Zainal Abidin, Terengganu, Malaysia
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8
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Quintens C, Verhamme P, Vanassche T, Vandenbriele C, Van den Bosch B, Peetermans WE, Van der Linden L, Spriet I. Improving appropriate use of anticoagulants in hospitalised patients: a pharmacist-led Check of Medication Appropriateness intervention. Br J Clin Pharmacol 2021; 88:2959-2968. [PMID: 34913184 DOI: 10.1111/bcp.15184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/13/2021] [Accepted: 12/05/2021] [Indexed: 11/29/2022] Open
Abstract
AIM Inappropriate anticoagulant use increases the risk of bleeding and thrombotic events. We implemented clinical decision rules to promote judicious medication use, as part of the 'Check of Medication Appropriateness' (CMA). The CMA concerns a pharmacist-led review service, targeting potentially inappropriate prescriptions (PIPs). In this analysis, we aimed to evaluate the impact of the CMA on anticoagulant prescribing. METHODS The number of anticoagulant-related PIPs was evaluated before and after implementation of the intervention in a quasi-experimental interrupted time series analysis. The pre-implementation cohort received usual care. The anticoagulant-focused CMA, comprising 13 clinical rules pertaining to anticoagulation therapies, was implemented in the post-implementation cohort. Segmented regression analysis was used to assess the impact of the intervention on the number of residual PIPs. A residual PIP was defined as a PIP which persisted up to 48h after the CMA intervention. Total number of recommendations and acceptance rate were documented for the 2-year post-implementation period. RESULTS Pre-implementation, we observed 501 PIPs in 466 inpatients on 36 days, with a median proportion of 78.5% (range: 46.2%-100%) residual PIPs per day. Post-implementation, 538 PIPs were detected in 485 patients over the same number of days. The CMA intervention reduced the median proportion to 18.2% (range: 0-100%) per day. The effect coincided with an immediate relative reduction of 70% (95%CI 0.19-0.46) in anticoagulant-related residual PIPs. Post-implementation, 2778 recommendations were provided and 75.1% were accepted. CONCLUSION Our CMA approach significantly reduced anticoagulant-related PIPs. Implementing a pharmacist-led intervention, based on clinical rules, may support safer prescribing of anticoagulants.
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Affiliation(s)
- Charlotte Quintens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Bart Van den Bosch
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Department of Information Technology, University Hospitals Leuven, Leuven, Belgium
| | - Willy E Peetermans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Lorenz Van der Linden
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
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9
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Kleymenova EB, Otdelenov VA, Nigmatkulova MD, Payushchik SA, Chernov AA, Konova OD, Yashina LP, Cherkashov AM, Sychev DA. Changes in anticoagulant prescription in a general hospital in 2008-2018. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-08-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aim. To study the structure of anticoagulant prescription in a general hospital to identify trends and contributing factors.Materials and methods. The study was conducted in an urban general hospital. According to retrospective retrieval from electronic health records, total 17,129 patients received anticoagulants from 2008 to 2018. Formal appropriateness of oral anticoagulants (OАС) prescriptions for 6,638 patients with atrial fibrillation (AF) was analyzed with CHA2-DS2-VASc score.Results. Appearance of recommendations for the direct oral anticoagulants (DOAC) prescription in clinical guidelines for venous thromboembolism (VTE) and AF management contributed to steady increase in the DOAC taking and decrease in the proportion of warfarin prescription. From 2011 to 2018, the proportion of patients with DOACs prescription increased from 1.7% to 81.5%. The most common indications for anticoagulant were ischemic stroke prevention in AF and VTE with mean rate 75.3% and 23.2%, respectively for the 2011-2018 period. Steady increase in low-molecular-weight heparin (LMWH) prophylactic prescriptions was also shown (Chi-square for linear trend=1340, df=1, p<0.0001). Since 2014, the prescription of LMWH in prophylactic doses increased dramatically, probably related to implementation of computerized decision support system (CDSS) for VTE prevention in the hospital.Conclusion. The study showed that in a general hospital anticoagulants were prescribed in 19% of hospitalized patient. Not only the new clinical recommendations based on the results of the recent studies on anticoagulants efficacy and safety (external factors), but also implementation standard operating protocols and CDSS, providing physicians current information about the relevant clinical recommendations (internal changes), could influence the appropriateness of anticoagulants prescription.
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Affiliation(s)
- E. B. Kleymenova
- General Medical Center of the Bank of Russia;
Russian Medical Academy of Continuing Professional Education;
Federal Research Center “Computer Science and Control” of the Russian Academy of Sciences
| | - V. A. Otdelenov
- General Medical Center of the Bank of Russia;
Russian Medical Academy of Continuing Professional Education
| | | | | | | | - O. D. Konova
- General Medical Center of the Bank of Russia;
Russian Medical Academy of Continuing Professional Education
| | - L. P. Yashina
- General Medical Center of the Bank of Russia;
Federal Research Center “Computer Science and Control” of the Russian Academy of Sciences
| | - A. M. Cherkashov
- General Medical Center of the Bank of Russia;
Russian Medical Academy of Continuing Professional Education
| | - D. A. Sychev
- Russian Medical Academy of Continuing Professional Education
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10
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Siddique SM, Tipton K, Leas B, Greysen SR, Mull NK, Lane-Fall M, McShea K, Tsou AY. Interventions to Reduce Hospital Length of Stay in High-risk Populations: A Systematic Review. JAMA Netw Open 2021; 4:e2125846. [PMID: 34542615 PMCID: PMC8453321 DOI: 10.1001/jamanetworkopen.2021.25846] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Many strategies to reduce hospital length of stay (LOS) have been implemented, but few studies have evaluated hospital-led interventions focused on high-risk populations. The Agency for Healthcare Research and Quality (AHRQ) Learning Health System panel commissioned this study to further evaluate system-level interventions for LOS reduction. OBJECTIVE To identify and synthesize evidence regarding potential systems-level strategies to reduce LOS for patients at high risk for prolonged LOS. EVIDENCE REVIEW Multiple databases, including MEDLINE and Embase, were searched for English-language systematic reviews from January 1, 2010, through September 30, 2020, with updated searches through January 19, 2021. The scope of the protocol was determined with input from AHRQ Key Informants. Systematic reviews were included if they reported on hospital-led interventions intended to decrease LOS for high-risk populations, defined as those with high-risk medical conditions or socioeconomically vulnerable populations (eg, patients with high levels of socioeconomic risk, who are medically uninsured or underinsured, with limited English proficiency, or who are hospitalized at a safety-net, tertiary, or quaternary care institution). Exclusion criteria included interventions that were conducted outside of the hospital setting, including community health programs. Data extraction was conducted independently, with extraction of strength of evidence (SOE) ratings provided by systematic reviews; if unavailable, SOE was assessed using the AHRQ Evidence-Based Practice Center methods guide. FINDINGS Our searches yielded 4432 potential studies. We included 19 systematic reviews reported in 20 articles. The reviews described 8 strategies for reducing LOS in high-risk populations: discharge planning, geriatric assessment, medication management, clinical pathways, interdisciplinary or multidisciplinary care, case management, hospitalist services, and telehealth. Interventions were most frequently designed for older patients, often those who were frail (9 studies), or patients with heart failure. There were notable evidence gaps, as there were no systematic reviews studying interventions for patients with socioeconomic risk. For patients with medically complex conditions, discharge planning, medication management, and interdisciplinary care teams were associated with inconsistent outcomes (LOS, readmissions, mortality) across populations. For patients with heart failure, clinical pathways and case management were associated with reduced length of stay (clinical pathways: mean difference reduction, 1.89 [95% CI, 1.33 to 2.44] days; case management: mean difference reduction, 1.28 [95% CI, 0.52 to 2.04] days). CONCLUSIONS AND RELEVANCE This systematic review found inconsistent results across all high-risk populations on the effectiveness associated with interventions, such as discharge planning, that are often widely used by health systems. This systematic review highlights important evidence gaps, such as the lack of existing systematic reviews focused on patients with socioeconomic risk factors, and the need for further research.
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Affiliation(s)
- Shazia Mehmood Siddique
- Division of Gastroenterology, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia
| | - Kelley Tipton
- ECRI Evidence-based Practice Center, Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania
| | - Brian Leas
- Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia
| | - S. Ryan Greysen
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia
| | - Nikhil K. Mull
- Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia
| | - Meghan Lane-Fall
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia
| | - Kristina McShea
- ECRI Evidence-based Practice Center, Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania
| | - Amy Y. Tsou
- ECRI Evidence-based Practice Center, Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania
- Division of Neurology, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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11
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Navarro Cárdenas JD, Alarcón Nieto MC, Bernal Vargas MP, Estrada-Orozco K, Gaitán Duarte H. Effectiveness, safety and implementation results of the strategies aimed at the safe prescription of medications in university hospitals in adult patients. Systematic review. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.5554/22562087.e997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: A broad range of practices aimed at improving the effectives and safety of this process have been documented over the past few years.
Objective: to establish the effectiveness, safety and results of the implementation of these strategies in adult patients in university hospitals.
Methodology: A review of systematic reviews was conducted, in addition to a database search in the Cochrane Library of Systematic Reviews, Embase, Epistemonikos, LILACS and gray literature. Any strategy aimed at reducing prescription-associated risks was included as intervention. This review followed the protocol registered in the International Prospective Registry of Systematic Reviews (PROSPERO): CRD42020165143.
Results: 7,637 studies were identified, upon deleting duplicate references. After excluding records based on titles and abstracts, 111 full texts were assessed for eligibility. Fifteen studies were included in the review. Several interventions grouped into 5 strategies addressed to the prescription process were identified; the use of computerized medical order entry systems (CPOE), whether integrated or not with computerized decision support systems (CDSS), was the most effective approach.
Conclusions: The beneficial effects of the interventions intended to the prescription process in terms of efficacy were identified; however, safety and implementation results were not thoroughly assessed. The heterogeneity of the studies and the low quality of the reviews, preclude a meta-analysis.
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12
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Spyropoulos AC, Giannis D, Cohen J, John S, Myrka A, Inlall D, Qiu M, Akgul S, Hyman RJ, Wang JJ. Implementation of the Management of Anticoagulation in the Periprocedural Period App Into an Electronic Health Record: A Prospective Cohort Study. Clin Appl Thromb Hemost 2021; 26:1076029620925910. [PMID: 32633538 PMCID: PMC7495935 DOI: 10.1177/1076029620925910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Appropriate perioperative management of patients on chronic oral anticoagulation (OAC)—including warfarin and the direct oral anticoagulants—is a poorly defined yet important clinical issue with potentially severe consequences in the postoperative period. We sought to prospectively evaluate the effect of the Management of Anticoagulation in the Periprocedural Period (MAPPP) mobile app as a clinical decision tool in the management of patients on chronic OAC undergoing elective procedures or surgeries. Between January 1, 2018, and January 31, 2019, 642 patients treated in our health system were included. Eligible patients met the following criteria: age >18 years old, creatinine clearance ≥15 mL/min, and on chronic OAC with adequate information regarding baseline characteristics. Our study outcome was patient’s emergency department (ED) visits within 30 days postprocedure. The MAPPP app was integrated into the electronic health record (EHR), and the end user was free to accept or decline recommended evidence-based perioperative anticoagulation management guidance. Analysis revealed that acceptance was more common in younger patients (P = .0137), patients on oral anticoagulants other than warfarin (P < .0001), and patients undergoing increased bleeding risk procedures (P = .0068). Acceptance of the MAPPP app recommendation was significantly associated with fewer ED visits (acceptance group: 4.0% vs rejection group: 8.3%, P = .0205). Logistic regression showed that intervention acceptance and female gender were significantly associated with fewer—while age ≥80 with more—30-day ED visits. Our findings indicate that newer technologies, such as the MAPPP app, integrated into clinical EHR workflow, can significantly augment evidence-based perioperative anticoagulation management and potentially result in a reduction of adverse outcomes.
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Affiliation(s)
- Alex C Spyropoulos
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY, USA.,The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Dimitrios Giannis
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Jessica Cohen
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Northwell Health at North Shore University Hospital, Manhasset, NY, USA
| | - Suja John
- Northwell Health at North Shore University Hospital, Manhasset, NY, USA
| | | | - Damian Inlall
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Michael Qiu
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Saydi Akgul
- Decker College of Health Sciences, Binghamton University, Binghamton, NY, USA
| | - Roger J Hyman
- SC Johnson College of Business, Cornell University, Ithaca, NY, USA
| | - Jason J Wang
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY, USA.,The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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