Costs of adverse drug events in German hospitals--a microcosting study

Cost avoidance of pharmacist-led deprescribing using STOPPFrail for older adults in nursing homes

BACKGROUND

The Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy (STOPPFrail) criteria aim to reduce inappropriate/unnecessary medications in frail older adults, which should minimise adverse drug events and additional healthcare expenditure. Little is known about the economic outcomes of applying these criteria as an intervention.

AIM

To evaluate cost avoidance of pharmacist-led application of STOPPFrail to frail older nursing home residents with limited life expectancy.

METHOD

Pharmacist-identified STOPPFrail-defined potentially inappropriate medications that were deprescribed by patients' general practitioners were assigned a rating by a multidisciplinary panel, i.e. the probability of an adverse drug event occurring if the medication was not deprescribed. The intervention's net cost benefit and cost-benefit ratio were then determined by factoring in adverse drug event cost avoidance (calculated from probability of adverse drug event ratings), direct cost savings (deprescribed medication costs/reimbursement fees), and healthcare professionals' salaries.

RESULTS

Of the 176 potentially inappropriate medications deprescribed across 69 patients, 65 (36.9%) were rated as having a medium or high probability of an adverse drug event occurring if not deprescribed. With €27,162 for direct cost savings, €61,336 for adverse drug event cost avoidance, and €2,589 for healthcare professionals' salary costs, there was a net cost benefit of €85,909 overall. The cost-benefit ratio was 33.2 and remained positive in all scenarios in sensitivity analyses.

CONCLUSION

Pharmacist-led application of STOPPFrail to frail older nursing home residents is associated with significant cost avoidance. Wider implementation of pharmacist interventions in frail older nursing home residents should be considered to reduce potentially inappropriate medications and patient harm, alongside substantial cost savings for healthcare systems.

Financial impact of medication reviews by clinical pharmacists to reduce in-hospital adverse drug events: a return-on-investment analysis

BACKGROUND

Adverse drug events contribute to rising health care costs. Clinical pharmacists can reduce their risks by identifying and solving drug-related problems (DRPs) through medication review.

AIM

To develop an economic model to determine whether medication reviews performed by clinical pharmacists could lead to a reduction in health care costs associated with the prevention of potential adverse drug events.

METHOD

Two pharmacists performed medication reviews during ward rounds in an internal medicine setting over one year. Avoided costs were estimated by monetizing five categories of DRPs (improper drug selection, drug interactions, untreated indications, inadequate dosages, and drug use without an indication). An expert panel assessed potential adverse drug events and their probabilities of occurrence for 20 randomly selected DRPs in each category. The costs of adverse drug events were extracted from internal hospital financial data. A partial economic study from a hospital perspective then estimated the annual costs avoided by resolving DRPs identified by 3 part-time clinical pharmacists (0.9 full-time equivalent) from 2019 to 2020. The return on investment (ROI) of medication review was calculated.

RESULTS

The estimated annual avoided costs associated with the potential adverse drug events induced by 676 DRPs detected was € 304,170. The cost of a 0.9 full-time equivalent clinical pharmacist was € 112,408. Extrapolated to 1 full-time equivalent, the annual net savings was € 213,069 or an ROI of 1-1.71. Sensitivity analyses showed that the economic model was robust.

CONCLUSION

This economic model revealed the positive financial impact and favorable return on investment of a medication review intervention performed by clinical pharmacists. These findings should encourage the future deployment of a pharmacist-led adverse drug events prevention program.

[Ward-based clinical pharmacists in intensive care medicine: an economic evaluation]

BACKGROUND

The positive impact of pharmaceutical care in improving medication safety is considered proven. Little is known about the economic benefit of clinical pharmaceutical services in Germany.

OBJECTIVE

In 2020, a pilot project was started at the Ernst von Bergmann Hospital to introduce ward-based clinical pharmacists in intensive care medicine, also in order to determine the economic benefit of the medication management offered.

METHODS

By a team of experienced intensive care physicians and clinical pharmacists on the basis of a consensus principle, each pharmaceutical intervention (PI) was assigned a probability score (Nesbit probability score) with which an adverse drug event (ADE) would have occurred. Assuming that each ADE results in an increased length of stay, the costs of intensive care treatment/day were used as potential savings. The model thereby combines the findings of two international publications to enable an economic analysis of pharmaceutical services.

RESULTS

During the study period, 177 pharmaceutical interventions were evaluated and corresponding probability scores for the occurrence of ADE were determined. From this, annual savings of € 80,000 through avoided costs were calculated.

CONCLUSION

In this project, the economic benefit of pharmaceutical services in intensive care medicine was proven. Ward-based clinical pharmacists are now an integral part of the intensive care treatment team at the Ernst von Bergmann Hospital.

Probable effects of polypharmacy and equivalent doses of psychotropic drugs on prevalence of adverse drug events among psychiatric inpatients in a general hospital in Japan

OBJECTIVE

In psychiatry, polypharmacy or high psychotropic drug doses increase adverse drug event (ADE) prevalence. However, the full relationship between polypharmacy and ADEs is unclear, and few studies have evaluated dose equivalents for psychotropic drugs for ADEs. Thus, we conducted a retrospective analysis to clarify the effects of polypharmacy and chlorpromazine (CP)-, diazepam (DAP)-, and imipramine- equivalent doses on all ADEs in inpatients.

METHODS

Psychiatric inpatients in a Japanese hospital from April 1, 2016 to March 31, 2018, were enrolled. ADE severity and causality were assessed. Multiple logistic regression analyses were performed to evaluate ADE risk factors.

RESULTS

Among 462 patients analyzed, out of 471 patients enrolled, 145 (31.4%) experienced ADEs. The causality assessment determined that "possible" was 96.5%. The most common ADEs were nervous system disorders (35%). Multiple logistic regression analyses indicated an increase in ADE prevalence with the number of drugs used (≥5; p = 0.026); CP-equivalent dose (p = 0.048); and endocrine, nutritional, and metabolic disorders (p = 0.045). DAP-equivalent dose; infectious and parasitic diseases; and injury, poisoning, and consequences of other external causes decreased ADE prevalence (p = 0.047, 0.022, and 0.021, respectively).

CONCLUSIONS

Avoiding polypharmacy in psychiatric inpatients and adjusting drug regimens to safe equivalent doses could reduce ADEs during hospitalization.

Machine learning as a tool to identify inpatients who are not at risk of adverse drug events in a large dataset of a tertiary care hospital in the USA

AIMS

Adverse drug events (ADEs) are a major threat to inpatients in the United States of America (USA). It is unknown how well machine learning (ML) is able to predict whether or not a patient will suffer from an ADE during hospital stay based on data available at hospital admission for emergency department patients of all ages (binary classification task). It is further unknown whether ML is able to outperform logistic regression (LR) in doing so, and which variables are the most important predictors.

METHODS

In this study, 5 ML models- namely a random forest, gradient boosting machine (GBM), ridge regression, least absolute shrinkage and selection operator (LASSO) regression, and elastic net regression-as well as a LR were trained and tested for the prediction of inpatient ADEs identified using ICD-10-CM codes based on comprehensive previous work in a diverse population. In total, 210 181 observations from patients who were admitted to a large tertiary care hospital after emergency department stay between 2011 and 2019 were included. The area under the receiver operating characteristics curve (AUC) and AUC-precision-recall (AUC-PR) were used as primary performance indicators.

RESULTS

Tree-based models performed best with respect to AUC and AUC-PR. The gradient boosting machine (GBM) reached an AUC of 0.747 (95% confidence interval (CI): 0.735 to 0.759) and an AUC-PR of 0.134 (95% CI: 0.131 to 0.137) on unforeseen test data, while the random forest reached an AUC of 0.743 (95% CI: 0.731 to 0.755) and an AUC-PR of 0.139 (95% CI: 0.135 to 0.142), respectively. ML statistically significantly outperformed LR both on AUC and AUC-PR. Nonetheless, overall, models did not differ much with respect to their performance. Most important predictors were admission type, temperature and chief complaint for the best performing model (GBM).

CONCLUSIONS

The study demonstrated a first application of ML to predict inpatient ADEs based on ICD-10-CM codes, and a comparison with LR. Future research should address concerns arising from low precision and related problems.

Creating an evidence-based economic model for prefilled parenteral medication delivery in the hospital setting

OBJECTIVES

Prefilled syringes (PFS) may offer clinical and economic advantages over conventional parenteral medication delivery methods (vials and ampoules). The benefits of converting from vials and ampoules to PFS have been explained in previous drug-specific economic models; however, these models have limited generalisability to different drugs, healthcare settings and other countries. Our study aims to (1) present a comprehensive economic model to assess the impact of switching from vials to PFS delivery; and (2) illustrate through two case studies the model's utility by highlighting important features of shifting from vials to PFS.

METHODS

The economic model estimates the potential benefit of switching to PFS associated with four key outcomes: preventable adverse drug events (pADE), preparation time, unused drugs, and cost of supplies. Model reference values were derived from existing peer-reviewed literature sources. The user inputs specific information related to the department, drug, and dose of interest and can change reference values. Two hypothetical case studies are presented to showcase model utility. The first concerns a cardiac intensive care unit in the United Kingdom administering 30 doses of 1 mg/10 mL atropine/day. The second concerns a coronavirus (COVID-19) intensive care unit in France that administers 30 doses of 10 mg/25 mL ephedrine/day.

RESULTS

Total cost savings per hospital per year, associated with reductions in pADEs, unused drugs, drug cost and cost of supplies were £34 829 for the atropine example and €104 570 for the ephedrine example. Annual preparation time decreased by 371 and 234 hours in the atropine and ephedrine examples, respectively.

CONCLUSIONS

The model provides a generalisable framework with customisable inputs, giving hospitals a comprehensive view of the clinical and economic value of adopting PFS. Despite increased costs per dose with PFS, the hypothetical case studies showed notable reductions in medication preparation time and a net budget savings owing to fewer pADEs and reduced drug wastage.

Cost benefit analysis of clinical pharmacist interventions in medical intensive care unit in Palestine medical complex: Prospective interventional study

Background

Clinical pharmacy services in the critical health care settings have expanded dramatically.Study problem.Clinical pharmacy services have limited implementation in Palestine. Many intensive care units (ICUs) patients do not get the intended beneficial effects of their treatment due to treatment related problems and their consequent cost burden.

Aim

To evaluate the impact of the clinical pharmacist interventions on costs of care and safety of patient by assessing treatment related problems among medical ICUs patients in Palestine.

Methodology

A prospective interventional study was conducted at medical ICU of the major public hospital in Ramallah city over a 4-month period (between September and December 2020). Patients were randomly assigned to either an intervention or a control group (With / without clinical pharmacist involvement). Treatment related problems were identified in both study groups by the clinical pharmacist, but interventions were only provided to the intervention group. The total economic benefit included both cost savings from intervention and cost avoidance from preventable adverse drug events (ADEs) resulted from CP interventions. The primary outcomes with the clinical pharmacist interventions were net benefit and benefit to cost ratio, which were calculated using previously published methodologies and adjusted to the Palestinian settings. The analysis of CP interventions acceptance by physicians was performed.

Results

During the 4-month study period, the 117 patients admitted to the ICU were included into the analysis; 66 patients in the intervention group and 51 in the control group. The interventions made by a clinical pharmacist resulted in direct cost saving of NIS8,990.05 ($2799.63) and cost avoidance of NIS22,087.5 ($ 6878.37). Translated into a net savings of NIS188.35 ($58.65) per intervention and NIS470 ($146.36) per patient. Comparison of benefits (NIS31,077.55) ($9678.00) and costs (NIS19,043.928) ($5930.55) indicate a net economic benefit to the institution of (NIS 12,033.623) ($3747.44) and a benefit cost ratio of 1.63.

Conclusion

Integrating a clinical pharmacist in the ICU team was investment that resulted in benefits in term of cost saving and cost avoidance.

Automatic Detection of Adverse Drug Events in Geriatric Care: Study Proposal

BACKGROUND

One-third of older inpatients experience adverse drug events (ADEs), which increase their mortality, morbidity, and health care use and costs. In particular, antithrombotic drugs are among the most at-risk medications for this population. Reporting systems have been implemented at the national, regional, and provider levels to monitor ADEs and design prevention strategies. Owing to their well-known limitations, automated detection technologies based on electronic medical records (EMRs) are being developed to routinely detect or predict ADEs.

OBJECTIVE

This study aims to develop and validate an automated detection tool for monitoring antithrombotic-related ADEs using EMRs from 4 large Swiss hospitals. We aim to assess cumulative incidences of hemorrhages and thromboses in older inpatients associated with the prescription of antithrombotic drugs, identify triggering factors, and propose improvements for clinical practice.

METHODS

This project is a multicenter, cross-sectional study based on 2015 to 2016 EMR data from 4 large hospitals in Switzerland: Lausanne, Geneva, and Zürich university hospitals, and Baden Cantonal Hospital. We have included inpatients aged ≥65 years who stayed at 1 of the 4 hospitals during 2015 or 2016, received at least one antithrombotic drug during their stay, and signed or were not opposed to a general consent for participation in research. First, clinical experts selected a list of relevant antithrombotic drugs along with their side effects, risks, and confounding factors. Second, administrative, clinical, prescription, and laboratory data available in the form of free text and structured data were extracted from study participants' EMRs. Third, several automated rule-based and machine learning-based algorithms are being developed, allowing for the identification of hemorrhage and thromboembolic events and their triggering factors from the extracted information. Finally, we plan to validate the developed detection tools (one per ADE type) through manual medical record review. Performance metrics for assessing internal validity will comprise the area under the receiver operating characteristic curve, F1-score, sensitivity, specificity, and positive and negative predictive values.

RESULTS

After accounting for the inclusion and exclusion criteria, we will include 34,522 residents aged ≥65 years. The data will be analyzed in 2022, and the research project will run until the end of 2022 to mid-2023.

CONCLUSIONS

This project will allow for the introduction of measures to improve safety in prescribing antithrombotic drugs, which today remain among the drugs most involved in ADEs. The findings will be implemented in clinical practice using indicators of adverse events for risk management and training for health care professionals; the tools and methodologies developed will be disseminated for new research in this field. The increased performance of natural language processing as an important complement to structured data will bring existing tools to another level of efficiency in the detection of ADEs. Currently, such systems are unavailable in Switzerland.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40456.

Prevalence and factors associated with adverse drug reactions among heart failure patients hospitalized at Mbarara Regional Referral Hospital, Uganda

BACKGROUND

Adverse drug reaction (ADR) of medications remains an obstacle to achieving optimal disease outcomes. This study aimed to assess the prevalence and associated factors of ADR among Heart failure (HF) patients hospitalized at Mbarara Regional and Referral Hospital.

METHOD

A prospective observational study was conducted among hospitalized HF patients from November 2021 to January 2022. Univariate and multivariate logistic regression was employed to determine factors associated with the ADR.

RESULT

Overall, 118 HF patients were included in the study with a median age of 43 years. A total of 164 ADRs were identified during the follow-up period of 1011 days. The incidence of new ADRs was 106 ADRs/1000 person-days. The prevalence of ADR was 59.3%. Of the 164 ADRs, 118(71.9%) were probable. The gastrointestinal system was the most frequently (27.5%) affected system. Over half (86, 52.4%) of the ADRs were mild and 96(58.5%) were preventable. Age group 19-59(AOR 0.15[0.03-0.35] at 95%CI, p = 0.013), herbal use (AOR 3.07[1.01-9.32] at 95%CI, p = 0.048), poly-pharmacy (AOR 8.7[2.4-15.77] at 95%CI, p < 0.001) and drug-drug interaction (AOR 6.06[2.79-12.5] at 95%CI, p = 0.004) were significantly associated with ADRs among HF patients.

CONCLUSION

More than half of the hospitalized HF patients experienced at least one ADR during their hospital stay. The use of herbal medicines, poly-pharmacy, and drug-drug interaction were associated with a high risk of ARDs whereas the age group 19-59 years was less likely to experience ADRs.

Shortcomings of Administrative Data to Derive Preventive Strategies for Inhospital Drug-Induced Acute Kidney Failure—Insights from Patient Record Analysis

Structured analyses of hospital administrative data may detect potentially preventable adverse drug events (ADE) and therefore are considered promising sources to prevent future harm and estimate cost savings. Whether results of these analyses indeed correspond to ADE that may be preventable in clinical routines needs to be verified. We exemplarily screened all adult inpatients admitted to a German University Hospital (n = 54,032) for International Classification of Diseases-10th revision (ICD-10) diagnoses coding for drug-induced kidney injury (AKI). In a retrospective chart review, we checked the coded adverse events (AE) for inhospital occurrence, causality to drug exposure, and preventability in all identified cases and calculated positive predictive values (ppv). We identified 69 inpatient cases of whom 41 cases (59.4%) experienced the AE in the hospital (ppv-range 0.43–0.80). Causality assessment revealed a rather likely causal relationship between AE and drug exposure in 11 cases (15.9, 11/69, ppv-range 0.17–0.22) whereby preventability measures could be postulated for seven cases (10.1%, 7/69). Focusing on drug-induced AKI, this study exemplarily underlines that ICD-10-code-based ADE prevention efforts are quite limited due to the small identification rate and its high proportion of primarily outpatient events. Furthermore, causality assessment revealed that cases are often too complex to benefit from generic prevention strategies. Thus, ICD-10-code-based calculations might overestimate patient harm and economic losses.

Prioritisation of Adverse Drug Events Leading to Hospital Admission and Occurring during Hospitalisation: A RAND Survey

(1) Adverse drug events (ADEs) are a common cause of emergency department visits and occur frequently during hospitalisation. Instruments that facilitate the detection of the most relevant ADEs could lead to a more targeted and efficient use of limited resources in research and practice. (2) We conducted two consensus processes based on the RAND/UCLA appropriateness method, in order to prioritise ADEs leading to hospital admission (panel 1) and occurring during hospital stay (panel 2) for inclusion in future ADE measurement instruments. In each panel, the experts were asked to assess the “overall importance” of each ADE on a four-point Likert scale (1 = not important to 4 = very important). ADEs with a median rating of ≥3 without disagreement were defined as “prioritised“. (3) The 13 experts in panel 1 prioritised 38 out of 65 ADEs, while the 12 experts in panel 2 prioritised 34 out of 63 ADEs. The highest rated events were acute kidney injury and hypoglycaemia (both panels), as well as Stevens–Johnson syndrome in panel 1 and rhabdomyolysis in panel 2. (4) The survey led to a set of ADEs for which there was consensus that they were of particular importance as presentations of acute medication-related harm, thereby providing a focus for further medication safety research and clinical practice.

Pharmacist-led medication reconciliation at patient discharge: a tool to reduce healthcare utilization? an observational study in patients 65 years or older

Background

Older patients often experience adverse drug events (ADEs) after discharge that may lead to unplanned readmission. Medication Reconciliation (MR) reduces medication errors that lead to ADEs, but results on healthcare utilization are still controversial. This study aimed to assess the effect of MR at discharge (MRd) provided to patients aged over 65 on their unplanned rehospitalization within 30 days and on both patients’ experience of discharge and their knowledge of their medication.

Methods

An observational multicenter prospective study was conducted in 5 hospitals in Brittany, France.

Results

Patients who received both MR on admission (MRa) and MRd did not have significantly fewer deaths, unplanned rehospitalizations and/or emergency visits related to ADEs (OR = 1.6 [0.7 to 3.6]) or whatever the cause (p = 0.960) 30 days after discharge than patients receiving MRa alone. However, patients receiving both MRa and MRd were more likely to feel that their discharge from the hospital was well organized (p = 0.003) and reported more frequently that their community pharmacist received information about their hospital stay (p = 0.036).

Conclusions

This study found no effect of MRd on healthcare utilization 30 days after discharge in patients over 65, but the process improved patients’ experiences of care continuity. Further studies are needed to better understand this positive impact on their drug care pathway in order to improve patients’ ownership of their drugs, which is still insufficient. Improving both the interview step between pharmacist and patient before discharge and the transmission of information from the hospital to primary care professionals is needed to enhance MR effectiveness.

Trial registration

NCT04018781 July 15, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03192-3.

Cost-effectiveness of check of medication appropriateness: methodological approach

Background Adverse drug events following inappropriate prescribing in the hospital cause a substantial and avoidable medical and economic burden to hospitals, payers and patients alike. A clinical rule-based, pharmacist-led medication-review service, the 'Check of Medication Appropriateness' (CMA) was implemented in the University Hospitals Leuven. The CMA is shown to be effective in reducing potentially inappropriate prescriptions. Aim This study investigated whether this centralised clinical pharmacy service is cost-effective. Method We performed a cost-effectiveness analysis of three clinical rules of the CMA, targeting adverse drug events at three levels of severity: A) persistent opioid-induced constipation, B) ketorolac-induced gastrointestinal bleeding and C) drug-induced Torsade de Pointes. A decision tree was developed for each clinical rule. Both intervention costs as well as total costs associated with the occurrence of an adverse drug event were considered. The outcomes were reported in the form of an incremental cost-effectiveness ratio, expressed as an incremental cost per adverse drug event avoided. Results Applying clinical rules to avoid persistent opioid-induced constipation and ketorolac-induced gastrointestinal bleeding were cost-saving. Implementation of a medication check to avoid drug-induced Torsade de Pointes costed €8,846 per Torsade de Pointes avoided. Conclusion Our study provides strong indications that the CMA is worth its investment for clinical rules targeting (very) common adverse drug events, that can be avoided with limited expenses. Further research is required to assess the full CMA. The proposed model may be useful to perform cost-effectiveness analyses of other centralised clinical pharmacy services targeting inappropriate prescribing, at the level of individual adverse drug events.

A cost-benefit analysis of hospital-wide medication reviews: a period prevalence study

Background For specific medical specialties it has been shown that clinical pharmacists can have a beneficial effect on the reduction of drug-related problems by performing medication reviews. However, little is known on the cost–benefit ratio of hospital-wide implementation of medication reviews. Aim To investigate the effect of conducting hospital-wide medication reviews on the detection and resolution of drug-related problems, and to calculate the cost–benefit ratio of the intervention. Method In this observational prospective period prevalence study, medication reviews were conducted during five consecutive working days in a Dutch university hospital. Patients admitted for more than 24 h were included. The cost–benefit ratio of conducting the medication reviews was calculated by dividing the total costs by the total savings. Results In 622 medication reviews, 709 potential drug-related problems (1.1 per patient) were detected. The most common advice was to stop medication (38.6%). Patients with a potentially drug-related problem were significantly older, had a higher median number of prescriptions, and the median number of days from admission to the time of medication reviews was longer. Conducting medication reviews showed a positive cost–benefit ratio of 9.7. Conclusions Hospital-wide medication reviews by clinical pharmacists have a positive cost–benefit ratio and contribute to the detection and the resolution of drug related problems (DRPs), mainly by reducing overtreatment.

Clinical and economic impact of comprehensive medication management implementation by clinical pharmacists in an intensive care unit: a cost–benefit analysis

Objectives

Critically ill patients are at risk of drug-related problems (DRPs) and healthcare-related cost. Clinical pharmacists are specifically trained in pharmacotherapy evaluation; they can identify and prevent DRPs. We aim to evaluate clinical and economic impact of clinical pharmacist by cost–benefit analysis in intensive care unit.

Methods

This was a prospective, interventional study from healthcare provider perspective which conducted over 6 months in a neurosurgery intensive care unit (ICU) of a university hospital on 162 patients. A clinical pharmacist was dedicated to implement comprehensive medication management. All pharmacotherapy problems were categorized and economic impact of clinical pharmacist’s interventions including cost–benefit ratio and net benefit in the ICU was assessed.

Key findings

A total of 1524 interventions were done. The top five pharmacotherapy-related problems were defined as, drug selection (33.3%), dose adjustment (17.32%), fluid and electrolyte management (12.99%), drug discontinuation (12.07%) and therapeutic drug monitoring (6.75%). The minimum and maximum benefit–cost ratio was 8.4:1 to 12.7:1 and net benefit was $169,205 to $266,633, respectively over the 6-month period.

Conclusions

The participation of a clinical pharmacist in a multidisciplinary ICU team by implementation of comprehensive medication management may reduce healthcare expenditures and improve drug safety.

Methods used to attribute costs avoided from pharmacist interventions in acute care: A scoping review

PURPOSE

Cost-avoidance studies are common in pharmacy practice literature. This scoping review summarizes, critiques, and identifies current limitations of the methods that have been used to determine cost avoidance associated with pharmacists' interventions in acute care settings.

METHODS

An Embase and MEDLINE search was conducted to identify studies that estimated cost avoidance from pharmacist interventions in acute care settings. We included studies with human participants and articles published in English from July 2010 to January 2021, with the intent of summarizing the evidence most relevant to contemporary practice.

RESULTS

The database search retrieved 129 articles, of which 39 were included. Among these publications, less than half (18 of 39) mentioned whether the researchers assigned a probability for the occurrence of a harmful consequence in the absence of an intervention; thus, a 100% probability of a harmful consequence was assumed. Eleven of the 39 articles identified the specific harm that would occur in the absence of intervention. No clear methods of estimating cost avoidance could be identified for 7 studies. Among all 39 included articles, only 1 attributed both a probability to the potential harm and identified the cost specific to that harm.

CONCLUSION

Cost-avoidance studies of pharmacists' interventions in acute care settings over the last decade have common flaws and provide estimates that are likely to be inflated. There is a need for guidance on consistent methodology for such investigations for reporting of results and to confirm the validity of their economic implications.

In-hospital adverse drug events: analysis of trend in Portuguese public hospitals

The objectives of this study were to analyze in-hospital adverse drug events (ADEs) in Portuguese public hospitals, and their association with mortality and the duration of hospitalization. We analyzed an administrative database containing the registration of all hospitalizations occurring in Portuguese public hospitals in 2013-2015. ADEs were identified using the codes E850-858.9 and E930-949.9 from ICD-9-CM. We identified all episodes with registration of in-hospital ADE and we compared them with a random sample of an equal number of episodes with no events recorded. A total of 3,041,443 cases were analyzed, 60,521 presented at least one ADE from which 17,213 occurred in hospital context. The most frequent drug classes associated with ADE were the antineoplastics/immunosuppressant drugs, antibiotics and steroids. Patient characteristics associated with a greater occurrence of in-hospital ADEs (all with p < 0.001) were medical admissions (OR = 1.29), the diagnosis - myeloid leukaemia (OR = 18.63), nephrotic syndrome (OR = 15.75), pneumonia (OR = 1.33) -, a higher number of secondary diagnoses (OR = 1.27), and increased duration of hospital stay (OR = 1.06). Hospitalizations with records of in-hospital ADEs presented a significantly higher mortality (9.6% vs. 4.5) and duration of hospitalization (22.6 vs. 6.4 days). ADEs were shown to be directly associated with an increase in the duration of hospital stay of 8.18 days. This study adds some interesting insights related to the most frequent drug classes and patient characteristics that can influence the frequency of ADEs in Portuguese public hospitals and also the burden of injury resulting from them.

Improving drug safety in hospitals: a retrospective study on the potential of adverse drug events coded in routine data

BACKGROUND

Adverse drug events (ADEs) that occur during hospitalization are an ongoing medical concern. Systematic strategies for ADE identification are lacking. The aim of this study was to evaluate the potential to identify adverse drug events caused by medication errors (preventable ADEs, pADEs), and previously unknown adverse drug reactions (ADRs or non-preventable ADEs, npADEs) in inpatients by combining diagnosis codes in routine data with a chart review.

METHODS

Diagnoses of inpatients are routinely coded using the International Classification of Diseases, 10th Revision (ICD-10). A total of 2326 cases were sampled from routine data of four hospitals using a set of ICD-10 German Modification ADE codes. Following a chart review, cases were evaluated in a standardized process with regard to drug relation and preventability of events.

RESULTS

By chart review, 1302 cases were classified as hospital-acquired and included in the evaluation. This yielded 1285 cases indicating an ADE. 96.8% of ADEs (1244 ADEs) were classified as known npADEs, only three cases as suspected previously unknown npADEs, one case as event after drug abuse. A total of 37 ADEs were classified as preventable (2.9% of all ADEs) by identifying a medication error as probable cause. The prevalence of pADEs varied considerably between included ADE codes, with hemorrhagic diathesis due to coumarins and localized skin eruptions showing the highest rates (8.7 and 9.1%, respectively). Most frequent medication errors were non-compliance to a known allergy, and improper dose.

CONCLUSIONS

When focusing on specific ADE codes, routine data can be used as markers for npADEs and medication errors, thus providing a meaningful complement to existing drug surveillance systems. However, the prevalence of medication errors is lower than in former studies on the frequency of pADEs.

Cost implications of adverse drug event-related emergency department visits - a multicenter study in South Korea

Background: Adverse drug reactions (ADRs) increase health-care resource utilization, including that for emergency department (ED) visits. However, cost analyses of ADRs resulting in ED visits are scarce. Therefore, we aimed to estimate the direct medical costs before and after ADR occurrence and analyzed the cost-driving factors.Methods: The ADR cases were identified by a retrospective review of medical records of patients who visited the ED of three tertiary hospitals in South Korea from July to December 2014. The direct medical cost was estimated by the difference in costs six months before and after the ED visit. A generalized linear model was used to identify the ADR-associated cost-driving factors.Results: The mean cost per ADR increased by 26.1% (±SD = 4.3) during the six-month follow-up compared with that during the six months before the ED visit (p < 0.05). Preventable ADRs accounted for approximately 19.9% of the cost increase among all ADR cases. The regression analysis revealed that 'ADR-related hospitalization' was a significant (p < 0.05) factor leading to an increase in the direct medical costs.Conclusion: Drug-related ED visits increase the burden on health insurance systems and patients' out-of-pocket costs, mostly due to the hospitalization costs.

International Group for Reducing Inappropriate Medication Use & Polypharmacy (IGRIMUP): Position Statement and 10 Recommendations for Action

Globally, the number of drug prescriptions is increasing causing more adverse drug events, which is now a significant cause of mortality, morbidity, and disability that has reached epidemic proportions. The risk of adverse drug events is correlated to very old age, multiple co-morbidities, dementia, frailty, and limited life expectancy, with the major contributor being polypharmacy. Each characteristic alters the risk-benefit balance of medications, typically reducing anticipated benefits and amplifying risk. Current clinical guidelines are based on evidence proven in younger/healthier adult populations using a single disease model and their application to older adults with multimorbidity, in whom testing has not been conducted, yields a different risk-benefit prospect and makes inappropriate medication use and polypharmacy inevitable. Applying inappropriate clinical practice guidelines to older adults is antithetical to good healthcare, is likely to increase health inequity, and is associated with substantial negative clinical, economic, and social implications for health systems. The casualties are on the scale of a war or epidemic, yet are usually invisible in measures of healthcare quality and formal recommendations. Radical and rapid action is required to achieve a better quality of life for older populations and to remain true to the principles of medical professionalism and evidence-based medicine that place patients' interests and autonomy at the fore. This first International Group for Reducing Inappropriate Medication Use & Polypharmacy position statement briefly details the causes, consequences, and extent of inappropriate medication use and polypharmacy. This article outlines current strategies to reduce inappropriate medication use, provides evidence for their effect, and then proposes recommendations for moving forward with 10 recommendations for action and 12 recommendations for research. We conclude that an urgent integrated effort to reduce inappropriate medication use and polypharmacy should be a leading global target of the highest priority. The cornerstone of this position statement from the International Group for Reducing Inappropriate Medication Use & Polypharmacy is the understanding that without evidence of definite relevant benefit, when it comes to prescribing, for many older patients 'less is more'. This approach differs from most other current recommendations and guidance in medical care, as the focus is on what, when, and how to stop, rather than on when to start medications/interventions. Disrupting the framework that indiscriminately applies standard guidelines to older adults requires a new approach that better serves patients with multimorbidity. This transition requires a shift in medical education, research, and diagnostic frameworks, and re-examination of the measures used as quality indicators. In achieving this objective, we promote a return to some of the original concepts of evidence-based medicine: which considers scientific data (where it exists), clinical judgment, patient/family preference, and context. A shift is needed: from the current model that focuses on single conditions to one that simultaneously considers multiple conditions and patient priorities. This approach reframes the clinician's role as a professional providing care, rather than a disease technician.

Potential Direct Costs of Adverse Drug Events and Possible Cost Savings Achievable by their Prevention in Tuscany, Italy: A Model-Based Analysis

INTRODUCTION

Adverse drug events (ADEs) may represent an important item of expenditure for healthcare systems and their prevention could be associated with a relevant cost saving.

OBJECTIVE

The objective of this study was to simulate the annual economic burden for ADEs in Tuscany (Italy) and the potential cost savings related to avoidable ADEs.

METHODS

A systematic review was performed, according to the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) statements, on observational studies published from 2006 to 2016 in MEDLINE and EMBASE, focusing on direct costs of ADEs in the inpatient setting from high-income countries. The mean probability of preventable ADEs was estimated over the included studies. The mean ADE cost was calculated by means of Monte Carlo simulation. We then extrapolated the spontaneous reports of ADEs in Tuscany, Italy in 2016 from the Italian National Pharmacovigilance Network (Rete Nazionale di Farmacovigilanza), and we assumed the same costs and preventability probability for these as obtained in the systematic review. Finally, we simulated the possible costs of ADEs and preventable ADEs in Tuscany. Three sensitivity analyses were also performed to test the robustness of the results.

RESULTS

Of 11,936 articles initially selected, 12 observational studies were included. The estimated mean [± standard deviation (SD)] ADE cost was €2471.46 (± €1214.13). The mean (± SD) probability of preventable ADEs was 45% (± 21). The Tuscan expenditure for ADEs was €3,406,280.63 per million inhabitants (95% confidence interval (CI) 1,732,910.44-5,079,664.61) and the potential cost saving was €1,532,760.25 per million inhabitants (95% CI 779,776.1-2,285,750.60). Sensitivity analyses confirmed the robustness of the results.

CONCLUSIONS

The present simulation showed that ADEs could have a relevant economic impact on the Tuscan healthcare system. In this setting, the prevention of ADEs would result in important cost savings. These results could be likely extended to other healthcare systems.

The effect of a medication reconciliation program in two intensive care units in the Netherlands: a prospective intervention study with a before and after design

Background

Medication errors occur frequently in the intensive care unit (ICU) and during care transitions. Chronic medication is often temporarily stopped at the ICU. Unfortunately, when the patient improves, the restart of this medication is easily forgotten. Moreover, temporal ICU medication is often unintentionally continued after ICU discharge. Medication reconciliation could be useful to prevent such errors. Therefore, the aim of this study was to determine the effect of medication reconciliation at the ICU.

Methods

This prospective 8-month study with a pre- and post-design was carried out in two ICU settings in the Netherlands. Patients were included when they used ≥ 1 chronic medicine and when the ICU stay exceeded 24 h. The intervention consisted of medication reconciliation by pharmacists at the moment of ICU admission and prior to ICU discharge. Medication transfer errors (MTEs) were collected and the severity of potential harm of these MTEs was measured, based on a potential adverse drug event score (pADE = 0; 0.01; 0.1; 0.4; 0.6). Primary outcome measures were the proportions of patients with ≥ 1 MTE at ICU admission and after discharge. Secondary outcome measures were the proportions of patients with a pADE score ≥ 0.01 due to these MTEs, the severity of the pADEs and the associated costs. Odds ratio and 95% confidence intervals were calculated, by using a multivariate logistic regression analysis.

Results

In the pre-intervention phase, 266 patients were included and 212 in the post-intervention phase. The proportion of patients with ≥ 1 MTE at ICU admission was reduced from 45.1 to 14.6% (OR_adj 0.18 [95% CI 0.11–0.30]) and after discharge from 73.9 to 41.2% (OR_adj 0.24 [95% CI 0.15–0.37]). The proportion of patients with a pADE ≥ 0.01 at ICU admission was reduced from 34.8 to 8.0% (OR_adj 0.13 [95% CI 0.07–0.24]) and after discharge from 69.5 to 36.2% (OR_adj 0.26 [95% CI 0.17–0.40]). The pADE reduction resulted in a potential net cost–benefit of € 103 per patient.

Conclusions

Medication reconciliation by pharmacists at ICU transfers is an effective safety intervention, leading to a significant decrease in the number of MTE and a cost-effective reduction in potential harm.

Trial registration Dutch trial register: NTR4159, 5 September 2013, retrospectively registered

Comparative Cost-Effectiveness Analysis of Three Different Automated Medication Systems Implemented in a Danish Hospital Setting

INTRODUCTION

Automated medication systems have been found to reduce errors in the medication process, but little is known about the cost-effectiveness of such systems. The objective of this study was to perform a model-based indirect cost-effectiveness comparison of three different, real-world automated medication systems compared with current standard practice.

METHODS

The considered automated medication systems were a patient-specific automated medication system (psAMS), a non-patient-specific automated medication system (npsAMS), and a complex automated medication system (cAMS). The economic evaluation used original effect and cost data from prospective, controlled, before-and-after studies of medication systems implemented at a Danish hematological ward and an acute medical unit. Effectiveness was described as the proportion of clinical and procedural error opportunities that were associated with one or more errors. An error was defined as a deviation from the electronic prescription, from standard hospital policy, or from written procedures. The cost assessment was based on 6-month standardization of observed cost data. The model-based comparative cost-effectiveness analyses were conducted with system-specific assumptions of the effect size and costs in scenarios with consumptions of 15,000, 30,000, and 45,000 doses per 6-month period.

RESULTS

With 30,000 doses the cost-effectiveness model showed that the cost-effectiveness ratio expressed as the cost per avoided clinical error was €24 for the psAMS, €26 for the npsAMS, and €386 for the cAMS. Comparison of the cost-effectiveness of the three systems in relation to different valuations of an avoided error showed that the psAMS was the most cost-effective system regardless of error type or valuation.

CONCLUSION

The model-based indirect comparison against the conventional practice showed that psAMS and npsAMS were more cost-effective than the cAMS alternative, and that psAMS was more cost-effective than npsAMS.

Comparing Methods for Estimating Direct Costs of Adverse Drug Events

OBJECTIVES

To estimate how direct health care costs resulting from adverse drug events (ADEs) and cost distribution are affected by methodological decisions regarding identification of ADEs, assigning relevant resource use to ADEs, and estimating costs for the assigned resources.

METHODS

ADEs were identified from medical records and diagnostic codes for a random sample of 4970 Swedish adults during a 3-month study period in 2008 and were assessed for causality. Results were compared for five cost evaluation methods, including different methods for identifying ADEs, assigning resource use to ADEs, and for estimating costs for the assigned resources (resource use method, proportion of registered cost method, unit cost method, diagnostic code method, and main diagnosis method). Different levels of causality for ADEs and ADEs' contribution to health care resource use were considered.

RESULTS

Using the five methods, the maximum estimated overall direct health care costs resulting from ADEs ranged from Sk10,000 (Sk = Swedish krona; ~€1,500 in 2016 values) using the diagnostic code method to more than Sk3,000,000 (~€414,000) using the unit cost method in our study population. The most conservative definitions for ADEs' contribution to health care resource use and the causality of ADEs resulted in average costs per patient ranging from Sk0 using the diagnostic code method to Sk4066 (~€500) using the unit cost method.

CONCLUSIONS

The estimated costs resulting from ADEs varied considerably depending on the methodological choices. The results indicate that costs for ADEs need to be identified through medical record review and by using detailed unit cost data.

Association of preventable adverse drug events with inpatients' length of stay-A propensity-matched cohort study

PURPOSE

Using clinical administrative data (CAD) of inpatients, we aimed to identify ICD-10 codes coding for potentially preventable inhospital adverse drug events (ADE) that affect the length of hospital stay (LOS) and thus patient well-being and cost.

METHODS

We retrospectively assessed CAD of all inpatient stays in 2012 of a German university hospital. Predefined ICD-10 codes indicating ADE (ADE codes) were further specified based on expert ratings of the ADE mechanism and ADE preventability in clinical routine to particularly identify preventable inhospital ADE. In a propensity-matched cohort design, we compared patients with one or more ADE codes to control patients with regard to differences in LOS for three situations: all cases with an ADE code, cases with an inhospital ADE code, and cases with a preventable inhospital ADE code.

RESULTS

Out of 54 032 cases analysed, in 8.3% (N=4 462) at least one ADE code was present. Nine of 128 evaluated ADE codes were rated as preventable in clinical routine, relating to 220 inpatients (4.9% of all identified inpatients with at least one ADE code and 0.4% of the entire cohort, respectively). Out of 48 072 evaluable inpatients for propensity score matching, 7 938 controls without ADE code and 4 006 cases with ADE code were selected. In all three settings, cases showed prolonged LOS vs controls (delta 1.13 d; 0.88 d and 1.88 d, respectively), significantly exceeding the maximum LOS as defined for each Diagnosis-Related Group.

CONCLUSION

Inpatients with ADE codes referring to inhospital, potentially preventable ADE exceeded the maximum hospital stay fully reimbursed by insurance companies, indicating unnecessary long and costly inpatient stays.

Impact assessment of an automated drug-dispensing system in a tertiary hospital

OBJECTIVE

To evaluate the costs and patient safety of a pilot implementation of an automated dispensing cabinet in a critical care unit of a private tertiary hospital in São Paulo/Brazil.

METHODS

This study considered pre- (January-August 2013) and post- (October 2013-October 2014) intervention periods. We considered the time and cost of personnel, number of adverse events, audit adjustments to patient bills, and urgent requests and returns of medications to the central pharmacy. Costs were evaluated based on a 5-year analytical horizon and are reported in Brazilian Reals (R$) and US dollars (USD).

RESULTS

The observed decrease in the mean number of events reported with regard to the automated drug-dispensing system between pre- and post-implementation periods was not significant. Importantly, the numbers are small, which limits the power of the mean comparative analysis between the two periods. A reduction in work time was observed among the nurses and administrative assistants, whereas pharmacist assistants showed an increased work load that resulted in an overall 6.5 hours of work saved/day and a reduction of R$ 33,598 (USD 14,444) during the first year. The initial investment (R$ 206,065; USD 88,592) would have been paid off in 5 years considering only personnel savings. Other findings included significant reductions of audit adjustments to patient hospital bills and urgent requests and returns of medications to the central pharmacy.

CONCLUSIONS

Evidence of the positive impact of this technology on personnel time and costs and on other outcomes of interest is important for decision making by health managers.

The cost-saving effect and prevention of medication errors by clinical pharmacist intervention in a nephrology unit

Medication errors may lead to adverse drug events (ADEs), which endangers patient safety and increases healthcare-related costs. The on-ward deployment of clinical pharmacists has been shown to reduce preventable ADEs, and save costs. The purpose of this study was to evaluate the ADEs prevention and cost-saving effects by clinical pharmacist deployment in a nephrology ward.This was a retrospective study, which compared the number of pharmacist interventions 1 year before and after a clinical pharmacist was deployed in a nephrology ward. The clinical pharmacist attended ward rounds, reviewed and revised all medication orders, and gave active recommendations of medication use. For intervention analysis, the numbers and types of the pharmacist's interventions in medication orders and the active recommendations were compared. For cost analysis, both estimated cost saving and avoidance were calculated and compared.The total numbers of pharmacist interventions in medication orders were 824 in 2012 (preintervention), and 1977 in 2013 (postintervention). The numbers of active recommendation were 40 in 2012, and 253 in 2013. The estimated cost savings in 2012 and 2013 were NT$52,072 and NT$144,138, respectively. The estimated cost avoidances of preventable ADEs in 2012 and 2013 were NT$3,383,700 and NT$7,342,200, respectively. The benefit/cost ratio increased from 4.29 to 9.36, and average admission days decreased by 2 days after the on-ward deployment of a clinical pharmacist.The number of pharmacist's interventions increased dramatically after her on-ward deployment. This service could reduce medication errors, preventable ADEs, and costs of both medications and potential ADEs.

Cost-Effectiveness Analysis of an Automated Medication System Implemented in a Danish Hospital Setting

OBJECTIVES

To evaluate the cost-effectiveness of an automated medication system (AMS) implemented in a Danish hospital setting.

METHODS

An economic evaluation was performed alongside a controlled before-and-after effectiveness study with one control ward and one intervention ward. The primary outcome measure was the number of errors in the medication administration process observed prospectively before and after implementation. To determine the difference in proportion of errors after implementation of the AMS, logistic regression was applied with the presence of error(s) as the dependent variable. Time, group, and interaction between time and group were the independent variables. The cost analysis used the hospital perspective with a short-term incremental costing approach. The total 6-month costs with and without the AMS were calculated as well as the incremental costs. The number of avoided administration errors was related to the incremental costs to obtain the cost-effectiveness ratio expressed as the cost per avoided administration error.

RESULTS

The AMS resulted in a statistically significant reduction in the proportion of errors in the intervention ward compared with the control ward. The cost analysis showed that the AMS increased the ward's 6-month cost by €16,843. The cost-effectiveness ratio was estimated at €2.01 per avoided administration error, €2.91 per avoided procedural error, and €19.38 per avoided clinical error.

CONCLUSIONS

The AMS was effective in reducing errors in the medication administration process at a higher overall cost. The cost-effectiveness analysis showed that the AMS was associated with affordable cost-effectiveness rates.

Performance and cost evaluation of health information systems using micro-costing and discrete-event simulation

Innovation and health-care funding reforms have contributed to the deployment of Information and Communication Technology (ICT) to improve patient care. Many health-care organizations considered the application of ICT as a crucial key to enhance health-care management. The purpose of this paper is to provide a methodology to assess the organizational impact of high-level Health Information System (HIS) on patient pathway. We propose an integrated performance evaluation of HIS approach through the combination of formal modeling using the Architecture of Integrated Information Systems (ARIS) models, a micro-costing approach for cost evaluation, and a Discrete-Event Simulation (DES) approach. The methodology is applied to the consultation for cancer treatment process. Simulation scenarios are established to conclude about the impact of HIS on patient pathway. We demonstrated that although high level HIS lengthen the consultation, occupation rate of oncologists are lower and quality of service is higher (through the number of available information accessed during the consultation to formulate the diagnostic). The provided method allows also to determine the most cost-effective ICT elements to improve the care process quality while minimizing costs. The methodology is flexible enough to be applied to other health-care systems.

The economic burden of nurse-sensitive adverse events in 22 medical-surgical units: retrospective and matching analysis

AIMS

The aim of this study was to assess the economic burden of nurse-sensitive adverse events in 22 acute-care units in Quebec by estimating excess hospital-related costs and calculating resulting additional hospital days.

BACKGROUND

Recent changes in the worldwide economic and financial contexts have made the cost of patient safety a topical issue. Yet, our knowledge about the economic burden of safety of nursing care is quite limited in Canada in general and Quebec in particular.

DESIGN

Retrospective analysis of charts of 2699 patients hospitalized between July 2008 - August 2009 for at least 2 days of 30-day periods in 22 medical-surgical units in 11 hospitals in Quebec.

METHODS

Data were collected from September 2009 to August 2010. Nurse-sensitive adverse events analysed were pressure ulcers, falls, medication administration errors, pneumonia and urinary tract infections. Descriptive statistics identified numbers of cases for each nurse-sensitive adverse event. A literature analysis was used to estimate excess median hospital-related costs of treatments with these nurse-sensitive adverse events. Costs were calculated in 2014 Canadian dollars. Additional hospital days were estimated by comparing lengths of stay of patients with nurse-sensitive adverse events with those of similar patients without nurse-sensitive adverse events.

RESULTS

This study found that five adverse events considered nurse-sensitive caused nearly 1300 additional hospital days for 166 patients and generated more than Canadian dollars 600,000 in excess treatment costs.

CONCLUSION

The results present the financial consequences of the nurse-sensitive adverse events. Government should invest in prevention and in improvements to care quality and patient safety. Managers need to strengthen safety processes in their facilities and nurses should take greater precautions.

Direct and indirect costs for adverse drug events identified in medical records across care levels, and their distribution among payers

BACKGROUND

Adverse drug events (ADEs) cause considerable costs in hospitals. However, little is known about costs caused by ADEs outside hospitals, effects on productivity, and how the costs are distributed among payers.

OBJECTIVE

To describe the direct and indirect costs caused by ADEs, and their distribution among payers. Furthermore, to describe the distribution of patient out-of-pocket costs and lost productivity caused by ADEs according to socio-economic characteristics.

METHOD

In a random sample of 5025 adults in a Swedish county, prevalence-based costs for ADEs were calculated. Two different methods were used: 1) based on resource use judged to be caused by ADEs, and 2) as costs attributable to ADEs by comparing costs among individuals with ADEs to costs among matched controls. Payers of costs caused by ADEs were identified in medical records among those with ADEs (n = 596), and costs caused to individual patients were described by socio-economic characteristics.

RESULTS

Costs for resource use caused by ADEs were €505 per patient with ADEs (95% confidence interval €345-665), of which 38% were indirect costs. Compared to matched controls, the costs attributable to ADEs were €1631, of which €410 were indirect costs. The local health authorities paid 58% of the costs caused by ADEs. Women had higher productivity loss than men (€426 vs. €109, p = 0.018). Out-of-pocket costs displaced a larger proportion of the disposable income among low-income earners than higher income earners (0.7% vs. 0.2%-0.3%).

CONCLUSION

We used two methods to identify costs for ADEs, both identifying indirect costs as an important component of the overall costs for ADEs. Although the largest payers of costs caused by ADEs were the local health authorities responsible for direct costs, employers and patients costs for lost productivity contributed substantially. Our results indicate inequalities in costs caused by ADEs, by sex and income.

A systematic review of observational studies evaluating costs of adverse drug reactions

Introduction

The growing evidence of the increased frequency and severity of adverse drug events (ADEs), besides the negative impact on patient’s health status, indicates that costs due to ADEs may be steadily rising. Observational studies are an important tool in pharmacovigilance. Despite these studies being more susceptible to bias than experimental designs, they are more competent in assessing ADEs and their associated costs.

Objective

To identify and characterize the best available evidence on ADE-associated costs.

Methods

MEDLINE, Cochrane Library, and Embase were searched from 1995 to 2015. Observational studies were included. The methodological quality of selected studies was assessed by Cochrane Collaboration tool for experimental and observational studies. Studies were classified according to the setting analyzed in “ambulatory”, “hospital”, or both. Costs were classified as “direct” and “indirect”. Data were analyzed using descriptive statistics. The total incremental cost per patient with ADE was estimated.

Results

Twenty-nine (94%) longitudinal observational studies and two (7%) cross-sectional studies were included. Twenty-three (74%) studies were assessed with the highest methodological quality score. The studies were mainly conducted in the US (61%). Twenty (65%) studies evaluated any therapeutic group. Twenty (65%) studies estimated costs of ADEs leading to or prolonging hospitalization. The “direct costs” were evaluated in all studies, whereas only two (7%) also estimated the “indirect costs”. The “direct costs” in ambulatory ranged from €702.21 to €40,273.08, and the in hospital from €943.40 to €7,192.36.

Discussion

Methodological heterogeneities were identified among the included studies, such as design, type of ADEs, suspected drugs, and type and structure of costs. Despite such discrepancies, the financial burden associated with ADE costs was found to be high. In the light of the present findings, validated methods to measure ADE-associated costs need future research efforts.

A systematic review of approaches for calculating the cost of medication errors

Introduction

Although medication errors may cause significant morbidity and mortality, the true cost of avoidable harm from such errors is unclear. While studies describe different methods for calculating a financial cost from an error, there remains variability in the way calculations are conducted depending on the clinical context. This review aimed to investigate the range of approaches for calculating medication error costs across healthcare settings.

Methods

A systematic review was carried out with a duplicate data extraction approach and mixed methods data synthesis. Medline, Embase and Web of Science were searched for studies published between 1993 and 2015. Studies that explicitly described a method for calculating medication error cost were included. The variables used for the calculations and a description of the approach for calculating errors were reported.

Results

21 studies were included in the final review. There was wide variation in the way calculations were undertaken, with some calculations using a single variable only and others using several variables in a multistep approach. Few calculations included indirect costs, such as loss of earnings for the patient, and only one calculation considered opportunity cost. The majority of studies presented direct medication error costs whereas others approximated error costs from the savings made following an intervention.

Conclusions

There are a wide range of methods used for calculating the cost of medication errors. The diversity arises from the number of variables used in calculations, the perspective from which the calculation is conducted from, and the degree of economic rigour applied by researchers.

Routine deprescribing of chronic medications to combat polypharmacy

The positive benefit-risk ratio of most drugs is decreasing in correlation to very old age, the extent of comorbidity, dementia, frailty and limited life expectancy (VOCODFLEX). First, we review the extent of inappropriate medication use and polypharmacy (IMUP) globally and highlight its negative medical, nursing, social and economic consequences. Second, we expose the main clinical/practical and perceptual obstacles that combine to create the negative vicious circle that eventually makes us feel frustrated and hopeless in treating VOCODFLEX in general, and in our 'war against IMUP' in particular. Third, we summarize the main international approaches/methods suggested and tried in different countries in an attempt to improve the ominous clinical and economic outcomes of IMUP; these include a variety of clinical, pharmacological, computer-assisted and educational programs. Lastly, we suggest a new comprehensive perception for providing good medical practice to VOCODFLEX in the 21st century. This includes new principles for research, education and clinical practice guidelines completely different from the 'single disease model' research and clinical rules we were raised upon and somehow 'fanatically' adopted in the 20th century. This new perception, based on palliative, geriatric and ethical principle, may provide fresh tools for treating VOCODFLEX in general and reducing IMUP in particular.

Excess length of stay and economic consequences of adverse events in Dutch hospital patients

Background

To investigate the average and extrapolated excess length of stay and direct costs of adverse events (AEs) and preventable AEs in Dutch hospitals, and to evaluate patient characteristics associated with excess length of stay and costs.

Methods

Data of a large retrospective patient record review study on AEs was used. A stratified sample of 20 Dutch hospitals was included. Excess length of stay and costs attributable to AEs and preventable AEs were calculated and extrapolated to a national estimate. The association between patient characteristics and excess length of stay (and costs thereof) attributable to AEs and preventable AEs was investigated through multilevel linear regression analyses.

Results

A total of 2975 patient records were included in the analysis, of which 325 experienced one or more AEs. Hospital patients experiencing an AE stayed 5.11 (95 % CI 3.91–6.30) more days in hospital and cost €2600 (95 % CI €1968–€3232) more compared to those without an AE. There was no significant difference in days and costs between preventable and non-preventable AEs. Extrapolated to a national level, AEs cost more than €300 million, which was 1.3 % of the national hospital care budget. Patients with hospital-acquired infections had a statistically significant longer length of stay compared to the reference group (patients with AEs on the cardiovascular system).

Conclusions

This study showed that AEs lead to substantial excess length of stay and increased costs. Special attention should be paid to patients with AEs due to an hospital-acquired infection.

National Incidence of Medication Error in Surgical Patients Before and After Accreditation Council for Graduate Medical Education Duty-Hour Reform

OBJECTIVE

The Accreditation Council for Graduate Medical Education (ACGME) established duty-hour regulations for accredited residency programs on July 1, 2003. It is unclear what changes occurred in the national incidence of medication errors in surgical patients before and after ACGME regulations.

DESIGN

Patient and hospital characteristics for pre- and post-duty-hour reform were evaluated, comparing teaching and nonteaching hospitals. A difference-in-differences study design was used to assess the association between duty-hour reform and medication errors in teaching hospitals.

SETTING

We used the Nationwide Inpatient Sample database, which consists of approximately annual 20% stratified sample of all the United States nonfederal hospital inpatient admissions.

PARTICIPANTS

A query of the database, including 4 years before (2000-2003) and 8 years after (2003-2011) the ACGME duty-hour reform of July 2003, was performed to extract surgical inpatient hospitalizations (N = 13,933,326). The years 2003 and 2004 were discarded in the analysis to allow for a wash-out period during duty-hour reform (though we still provide medication error rates).

RESULTS

The Nationwide Inpatient Sample estimated the total national surgical inpatients (N = 135,092,013) in nonfederal hospitals during these time periods with 68,736,863 patients in teaching hospitals and 66,355,150 in nonteaching hospitals. Shortly after duty-hour reform (2004 and 2006), teaching hospitals had a statistically significant increase in rate of medication error (p = 0.019 and 0.006, respectively) when compared with nonteaching hospitals even after accounting for trends across all hospitals during this period. After 2007, no further statistically significant difference was noted.

CONCLUSIONS

After ACGME duty-hour reform, medication error rates increased in teaching hospitals, which diminished over time. This decrease in errors may be related to changes in training program structure to accommodate duty-hour reform.

The effect of electronic medical record system use on communication between pharmacists and prescribers

BACKGROUND

The Electronic Medical Record (EMR) is becoming increasingly common in health care settings. Research shows that EMRs have the potential to reduce instances of medication errors and improve communication between pharmacists and prescribers; however, more research is required to demonstrate whether this is true. This study aims to determine the effect of a newly implemented EMR system on communication between pharmacists and primary care clinicians.

METHODS

A retrospective chart analysis of primary care EMR data comparing faxed pharmacy communications captured before and after the implementation of an EMR system at an academic family medicine clinic. Communication requests were classified into the following various categories: refill accepted, refill denied, clarification, incorrect dose, interaction, drug insurance/coverage application, new prescription request, supplies request, continued care information, duplicate fax substitution, opioid early release request, confirmation by phone call, and other.

RESULTS

The number and percentage of clarification requests, interaction notifications, and incorrect dose notifications were lower after the implementation of the EMR system. The number and percentage of refills accepted and new prescription requests increased after the implementation of the EMR system.

CONCLUSION

The implementation of an EMR in an academic family medicine clinic had a significant effect on the volume of communication between pharmacists and prescribers. The amount of clarification requests and incorrect dosing communications decreased after EMR implementation. This suggests that EMRs improve prescribing safety. The increased amount of refills accepted and new prescription requests post EMR implementation suggests that the EMR is capable of changing prescription patterns.

Patient stratification and identification of adverse event correlations in the space of 1190 drug related adverse events

Purpose: New pharmacovigilance methods are needed as a consequence of the morbidity caused by drugs. We exploit fine-grained drug related adverse event information extracted by text mining from electronic medical records (EMRs) to stratify patients based on their adverse events and to determine adverse event co-occurrences.

Methods: We analyzed the similarity of adverse event profiles of 2347 patients extracted from EMRs from a mental health center in Denmark. The patients were clustered based on their adverse event profiles and the similarities were presented as a network. The set of adverse events in each main patient cluster was evaluated. Co-occurrences of adverse events in patients (p-value < 0.01) were identified and presented as well.

Results: We found that each cluster of patients typically had a most distinguishing adverse event. Examination of the co-occurrences of adverse events in patients led to the identification of potentially interesting adverse event correlations that may be further investigated as well as provide further patient stratification opportunities.

Conclusions: We have demonstrated the feasibility of a novel approach in pharmacovigilance to stratify patients based on fine-grained adverse event profiles, which also makes it possible to identify adverse event correlations. Used on larger data sets, this data-driven method has the potential to reveal unknown patterns concerning adverse event occurrences.

Adverse drug events in patients admitted to an emergency department: an analysis of direct costs

PURPOSE

Several economic evaluations of adverse drug events (ADEs) exist, but the underlying methodology has not been standardized so far. The aim of the study was to combine prospective, intensive pharmacovigilance methods, and standardized accounting data to calculate direct costs of community-acquired ADEs (caADEs) contributing to emergency department (ED) admission and subsequent hospitalization.

METHODS

A prospective observational study with three phases extending over 2 years was implemented in a 749 bed tertiary care hospital with an annual ED census of approximately 45 000 patients. The patient records of all adult non-trauma ED admissions were systematically analyzed by a team of emergency physicians, clinical pharmacologists, and pharmacists for potential ADE. Associated diagnosis related group costs were extracted from standardized accounting data.

RESULTS

Of 2262 patients attending the ED during the study periods, the hospitalization of 366 patients (16.2%) was related to one or more caADEs of which 97.5% were considered predictable and 62.0% were classified as preventable. The mean caADE-related diagnosis related group costs were €2743 (95% bias-corrected and accelerated CI: €2498 to €3018). Extrapolated to a national scale, this corresponds to caADE-related costs of €2.245bn for the German health insurance funds, annually. Costs of €1.310bn could be attributed to events classified as predictable and preventable.

CONCLUSIONS

In an ED, caADEs are frequent, and a significant proportion of these events and their related costs appear to be predictable and preventable. The ED as a first-line provider for ADE cases appears to be an appropriate environment to implement strategic and operative improvements for enhanced patient safety.

Cost-effectiveness of an electronic medication ordering system (CPOE/CDSS) in hospitalized patients

INTRODUCTION

Prescribing medication is an important aspect of almost all in-hospital treatment regimes. Besides their obviously beneficial effects, medicines can also cause adverse drug events (ADE), which increase morbidity, mortality and health care costs. Partially, these ADEs arise from medication errors, e.g. at the prescribing stage. ADEs caused by medication errors are preventable ADEs. Until now, medication ordering was primarily a paper-based process and consequently, it was error prone. Computerized Physician Order Entry, combined with basic Clinical Decision Support System (CPOE/CDSS) is considered to enhance patient safety. Limited information is available on the balance between the health gains and the costs that need to be invested in order to achieve these positive effects. Aim of this study was to study the balance between the effects and costs of CPOE/CDSS compared to the traditional paper-based medication ordering.

METHODS

The economic evaluation was performed alongside a clinical study (interrupted time series design) on the effectiveness of CPOE/CDSS, including a cost minimization and a cost-effectiveness analysis. Data collection took place between 2005 and 2008. Analyses were performed from a hospital perspective. The study was performed in a general teaching hospital and a University Medical Centre on general internal medicine, gastroenterology and geriatric wards. Computerized Physician Order Entry, combined with basic Clinical Decision Support System (CPOE/CDSS) was compared to a traditional paper based system. All costs of both medication ordering systems are based on resources used and time invested. Prices were expressed in Euros (price level 2009). Effectiveness outcomes were medication errors and preventable adverse drug events.

RESULTS

During the paper-based prescribing period 592 patients were included, and during the CPOE/CDSS period 603. Total costs of the paper-based system and CPOE/CDSS amounted to €12.37 and €14.91 per patient/day respectively. The Incremental Cost-Effectiveness Ratio (ICER) for medication errors was 3.54 and for preventable adverse drug events 322.70, indicating the extra amount (€) that has to be invested in order to prevent one medication error or one pADE.

CONCLUSIONS

CPOE with basic CDSS contributes to a decreased risk of preventable harm. Overall, the extra costs of CPOE/CDSS needed to prevent one ME or one pADE seem to be acceptable.

Personalised, predictive and preventive medication process in hospitals-still rather missing: professional opinion survey on medication safety in Czech hospitals (based on professional opinions of recognised Czech health care experts)

The survey had the following aims: (1) to rationalise the hypothesis that risks and losses relating to medication process' errors in Czech hospitals are at least comparable with the other developed countries and EU countries especially, (2) to get a valid professional opinion/estimate on the rate of adverse drug events happening in Czech hospitals, (3) to point out that medication errors represent real and serious risks and (4) to induce the hospital management readiness to execute fundamental changes and improvements to medication processes. We read through a lot of studies inquiring into hospitals' medication safety. Then, we selected the studies which brought reliable findings and formulated credible conclusions. Finally, we addressed reputable Czech experts in health care and asked them structured questions whether the studies' findings and conclusions corresponded with our respondents' own experience in the Czech hospital clinical practice and what their own estimates of adverse drug events' consequences were like. Based on the reputable Czech health care expert opinions/estimates, the rate of a false drug administration may exceed 5%, and over 7% of those cause serious health complications to Czech hospital inpatients. Measured by an average length of stay (ALOS), the Czech inpatients, harmed by a false drug administration, stay in hospital for more than 2.6 days longer than necessary. Any positive changes to a currently used, traditional, ways of drug dispensing and administration, along with computerisation, automation, electronic traceability, validation, or verification, must well pay off. Referring to the above results, it seems to be wise to follow the EU priorities in health and health care improvements. Thus, a right usage of the financial means provided by the EC—in terms of its new health programmes for the period 2014–2020 (e.g. Horizon 2020)—has a good chance of a good result in doing the right things right, at the right time and in the right way. All citizens of the EU may benefit using the best practice.

Cost-outcome description of clinical pharmacist interventions in a university teaching hospital

BACKGROUND

Pharmacist interventions are one of the pivotal parts of a clinical pharmacy service within a hospital. This study estimates the cost avoidance generated by pharmacist interventions due to the prevention of adverse drug events (ADE). The types of interventions identified are also analysed.

METHODS

Interventions recorded by a team of hospital pharmacists over a one year time period were included in the study. Interventions were assigned a rating score, determined by the probability that an ADE would have occurred in the absence of an intervention. These scores were then used to calculate cost avoidance. Net cost benefit and cost benefit ratio were the primary outcomes. Categories of interventions were also analysed.

RESULTS

A total cost avoidance of €708,221 was generated. Input costs were calculated at €81,942. This resulted in a net cost benefit of €626,279 and a cost benefit ratio of 8.64: 1. The most common type of intervention was the identification of medication omissions, followed by dosage adjustments and requests to review therapies.

CONCLUSION

This study provides further evidence that pharmacist interventions provide substantial cost avoidance to the healthcare payer. There is a serious issue of patient's regular medication being omitted on transfer to an inpatient setting in Irish hospitals.

Direct health care costs of hospital admissions due to adverse events in The Netherlands

BACKGROUND

Health care-related adverse events (AEs) are common, and the economic burden is substantial. Information on costs of health care-related AEs 'leading' to hospitalization is limited and has focused on adverse drug events.

AIM

To provide insight into costs of admissions due to (preventable) health care-related AEs, not limited to adverse drug events.

METHODS

This study was conducted during a 5-month period (May-September 2010) in The Netherlands, in a 600-bed university medical centre. All patients who were admitted via the emergency department to an internal medicine department because of a health care-related AE were included. We retrospectively retrieved all data on medical information as well as health care resource utilization from the patient's medical record. The cost of the admission was estimated (for each patient individually) by multiplying the number of resources by their specific unit cost and then summing all costs per patient.

RESULTS

In total, 324 admissions due to a health care-related AE were included (28.7% of all admissions). Total direct health care costs of these hospitalizations amounted to €1,404,070 in a 5-month period. Medication-related AEs were most common (43.5%) and contributed most to the costs (€587,550; 41.8%). Inpatient days were most expensive (€1,076,385; 77.3%). Preventable health care-related AEs accounted for €277,665 (19.8%).

CONCLUSION

We found that health care-related AEs are expensive, with preventable health care-related AEs accounting for one-fifth of the costs. Awareness of possible health care-related AEs following medical actions is necessary to reduce already high health care costs.

Costs and length of stay of drug-related hospital admissions in cancer patients

BACKGROUND

Most previous studies of the incidence and economic impact of drug-related hospital admissions were not cancer specific, despite the fact that drug-related problems (DRPs) are of particular concern in oncology.

OBJECTIVE

The goals of this study were to assess the economic impact, particularly the length of stay (LOS) and direct medical costs (DMC), of drug-related hospital admissions and the associated factors in cancer patients in Singapore.

METHODS

A prospective study was conducted over a 5-month period in 2 oncology wards at the largest acute tertiary hospital in Singapore. Drug-related admissions were identified from all oncology admissions to these wards, and the demographic, clinical, and cost data of these drug-related admissions were collected. The association between LOS and DMC as well as their associations with age, severity, and preventability of DRPs were examined. A nationwide estimation was made to determine the overall DMC of drug-related hospital admissions among cancer patients.

RESULTS

A total of 151 drug-related admissions that occurred among 137 cancer patients were identified. The mean DMC (in Singapore dollars [SGD]) and LOS per drug-related admission were SGD $4747 and 6.1 days, respectively. A nationwide extrapolation estimated an annual total DMC of SGD $16.2 million. Longer LOS was found to be correlated with higher DMC (rs = 0.86, P < 0.001) and preventable DRPs (P = 0.02).

CONCLUSIONS

Drug-related hospitalization among cancer patients is costly; therefore, more attention is warranted to develop and improve strategies for preventing drug-related morbidity and mortality in cancer patients.

International prevalence of adverse drug events in hospitals: an analysis of routine data from England, Germany, and the USA

BACKGROUND

Adverse drug events (ADEs) are frequent in hospitals, occurring either in patients before admission or as a nosocomial event, and either as a drug reaction or as a consequence of a medication error. Routine data primarily recorded for reimbursement purposes are increasingly being used on a national level both in pharmacoepidemiological studies and in trigger tools. The aim of this study was to compare the prevalence rates of coded ADEs in hospitals on a transnational level.

METHODS

Hospital data for England and the USA were obtained for the fiscal or calendar year 2006. German data for 2006 were accessed via teleprocessing with the Federal Statistical Office. The datasets from England and the USA were adapted to the German data. About 6 million (England), 7 million (USA), and 16 million (Germany) inpatients could be included. ADEs were identified through a list of codes used in the national diagnosis classifications.

RESULTS

The overall prevalence rate (and 95% confidence interval, CI) of coded ADEs was 3.22% (3.20-3.23%) for England, 4.78% (4.73-4.83%) for Germany, and 5.64% (5.63-5.66%) for the USA. Most of the English ADE cases occurred in patients admitted as emergency. A non-surgical status and a longer length of stay were consistently associated with the occurrence of an ADE. Enterocolitis caused by Clostridium difficile was the most frequent ADE in all countries.

CONCLUSIONS

According to routine data, the overall ADE prevalence rates for England, Germany, and the USA are different. However, the differences are narrower than those determined from the rates of ADEs or adverse drug reactions inferred from prospective or retrospective pharmacoepidemiological studies. Since the ADEs in the countries examined in this study share several characteristics, the use of routine data for transnational research on ADEs is feasible.