Electronic health record-based monitoring of primary care patients at risk of medication-related toxicity

An Electronic Health Record-Integrated Application for Standardizing Care and Monitoring Patients With Autosomal Dominant Polycystic Kidney Disease Enrolled in a Tolvaptan Clinic: Design and Implementation Study

Background

Tolvaptan is the only US Food and Drug Administration-approved drug to slow the progression of autosomal dominant polycystic kidney disease (ADPKD), but it requires strict clinical monitoring due to potential serious adverse events.

Objective

We aimed to share our experience in developing and implementing an electronic health record (EHR)-based application to monitor patients with ADPKD who were initiated on tolvaptan.

Methods

The application was developed in collaboration with clinical informatics professionals based on our clinical protocol with frequent laboratory test monitoring to detect early drug-related toxicity. The application streamlined the clinical workflow and enabled our nursing team to take appropriate actions in real time to prevent drug-related serious adverse events. We retrospectively analyzed the characteristics of the enrolled patients.

Results

As of September 2022, a total of 214 patients were enrolled in the tolvaptan program across all Mayo Clinic sites. Of these, 126 were enrolled in the Tolvaptan Monitoring Registry application and 88 in the Past Tolvaptan Patients application. The mean age at enrollment was 43.1 (SD 9.9) years. A total of 20 (9.3%) patients developed liver toxicity, but only 5 (2.3%) had to discontinue the drug. The 2 EHR-based applications allowed consolidation of all necessary patient information and real-time data management at the individual or population level. This approach facilitated efficient staff workflow, monitoring of drug-related adverse events, and timely prescription renewal.

Conclusions

Our study highlights the feasibility of integrating digital applications into the EHR workflow to facilitate efficient and safe care delivery for patients enrolled in a tolvaptan program. This workflow needs further validation but could be extended to other health care systems managing chronic diseases requiring drug monitoring.

Prevalence of adverse drug reactions in the primary care setting: A systematic review and meta-analysis

BACKGROUND

Adverse drug reactions (ADRs) represent a major cause of iatrogenic morbidity and mortality in patient care. While a substantial body of work has been undertaken to characterise ADRs in the hospital setting, the overall burden of ADRs in the primary care remains unclear.

OBJECTIVES

To investigate the prevalence of ADRs in the primary care setting and factors affecting the heterogeneity of the estimates.

METHODS

Studies were identified through searching of Medline, Embase, CINAHL and IPA databases. We included observational studies that reported information on the prevalence of ADRs in patients receiving primary care. Disease and treatment specific studies were excluded. Quality of the included studies were assessed using Smyth ADRs adapted scale. A random-effects model was used to calculate the pooled estimate. Potential source of heterogeneity, including age groups, ADRs definitions, ADRs detection methods, study setting, quality of the studies, and sample size, were investigated using sub-group analysis and meta-regression.

RESULTS

Thirty-three studies with a total study population of 1,568,164 individuals were included. The pooled prevalence of ADRs in the primary care setting was 8.32% (95% CI, 7.82, 8.83). The percentage of preventable ADRs ranged from 12.35-37.96%, with the pooled estimate of 22.96% (95% CI, 7.82, 38.09). Cardiovascular system drugs were the most commonly implicated medication class. Methods of ADRs detection, age group, setting, and sample size contributed significantly to the heterogeneity of the estimates.

CONCLUSION

ADRs constitute a significant health problem in the primary care setting. Further research should focus on examining whether ADRs affect subsequent clinical outcomes, particularly in high-risk therapeutic areas. This information may better inform strategies to reduce the burden of ADRs in the primary care setting.

The association between use of a clinical decision support tool and adherence to monitoring for medication-laboratory guidelines in the ambulatory setting

BACKGROUND

Stage 2 Meaningful Use criteria require the use of clinical decision support systems (CDSS) on high priority health conditions to improve clinical quality measures. Although CDSS hold great promise, implementation has been fraught with challenges, evidence of their impact is mixed, and the optimal method of content delivery is unknown.

OBJECTIVE

The authors investigated whether implementation of a simple clinical decision support (CDS) tool was associated with improved prescriber adherence to national medication-laboratory monitoring guidelines for safety (hepatic function, renal function, myalgias/rhabdomyolysis) and intermediate outcomes for antidiabetic (Hemoglobin A(1c); HbA(1c)) and antihyperlipidemic (low density lipoprotein; LDL) medications prescribed within a diabetes registry.

METHODS

This was a retrospective observational study conducted in three phases of CDS implementation (2008-2009): pre-, transition-, and post-Prescriptions evaluated were ordered from an electronic health record within a multispecialty medical group. Adherence was evaluated within and without applying guideline-imposed time constraints.

RESULTS

Forty-thousand prescriptions were ordered over three timeframes. For hepatic and renal function, the proportion of prescriptions for which labs were monitored at any time increased from 52% to 65% (p<0.001); those that met time guidelines, from 14% to 21% (p<0.001). Only 6% of required labs were drawn to monitor for myalgias/rhabdomyolysis, regardless of timeframe. Over 90% of safety labs were within normal limits. The proportion of labs monitored at any time for LDL increased from 56% to 64% (p<0.001); those that met time guidelines from 11% to 17% (p<0.001). The proportion of labs monitored at any time for HbA(1c) remained the same (72%); those that met time guidelines decreased from 45% to 41% (p<0.001).

CONCLUSION

A simple CDS tool may be associated with improved adherence to guidelines. Efforts are needed to confirm findings and improve the timeliness of monitoring; investigations to optimize alerts should be ongoing.