Development and implementation of "Check of Medication Appropriateness" (CMA): advanced pharmacotherapy-related clinical rules to support medication surveillance

Evaluation and implementation of optimized antimicrobial dosing strategies in obese and underweight patients

PURPOSE

We aimed to develop and implement dosing recommendations for antimicrobials in obese and underweight patients within an academic hospital, and assess their impact on antibiotic prescribing.

METHODS

A multi-step approach project was performed. First, obese and underweight patient prevalence and antimicrobial prescription frequency was determined in a point prevalence study. Second and third, a literature review and e-survey provided dosing evidence. Fourth, a consensus meeting was organized to formulate dosing recommendations. Fifth, these were implemented in our clinical validation service as six clinical rules continuously screening patients' records for potentially inappropriate prescriptions (PIPs). Uptake was evaluated by documenting the number of advices and acceptance rate. Last, an interrupted time series analysis (ITS) compared pre- and post-implementation periods to measure the impact of the intervention on residual PIPs/day. A residual PIP was defined as a PIP which persisted up to 48 h.

RESULTS

First, 41% of 15.896 hospitalized patients received antimicrobials over 20 days; of which 12% were obese and 9% underweight. Antibiotics were predominantly prescribed according to standard dosing regimens, adjusted to renal function. Next, six dosing recommendations, derived from literature, survey, and consensus, were implemented. In the fifth step, during an 18-week period, 219 advices were given, with 86% acceptance rate. Last, in the ITS analysis, at preintervention, a median of 75% residual PIPs/day existed, reduced to 0% postintervention. Use of clinical rules resulted in a significant immediate 84% relative reduction in residual PIPs (95% CI 0.55-0.94).

CONCLUSION

After conducting a literature review, e-survey, and seeking consensus from a panel of experts, dosing recommendations for antimicrobial treatment in both obese and underweight patients were developed. These recommendations have been successfully implemented into clinical practice, addressing the specific needs of these patient populations.

Development and implementation of medication-related clinical rules for obstetrics, gynaecology, and paediatric outpatients

OBJECTIVES

Prescription errors can cause serious adverse drug events. Clinical decision support systems prevent prescription errors; however, real-time clinical rules in obstetrics, gynaecology, and paediatric outpatients remain unexplored. We evaluated the effects of localised, real-time clinical rules on alert rates and acceptance rates compared with manual prescription review.

METHODS

We developed real-time clinical rules that incorporate information systems to obtain characteristic information and laboratory values. We conducted a retrospective cohort study to compare the alert and recommendation acceptance rates of all prescription error types before and after clinical rule implementation in obstetrics, gynaecology, and paediatrics. Clinical rules, prescription error types, and alerts were determined by a prescribing review committee comprising physicians, pharmacists, nurses, and administrators. The difference in alert and acceptance rates between the groups was analysed using relative risk.

RESULTS

The number of alerts increased after clinical rules implementation; the number of on-duty pharmacists for review decreased from 10 to 2. Compared with those with manual review, the alert rates for paediatrics and obstetrics and gynaecology increased with the clinical rules by 3.97- and 11.26-fold, respectively, and the alert rates for drug-drug interactions (DDIs) and combined medication errors in obstetrics and gynaecology increased with the clinical rules by 26.10- and 26.54-fold, respectively. In paediatrics, the alert rate for all prescription error types was higher with the clinical rules review than with the manual review; the alert rates for DDI, dosage, and combination medication errors were significantly different between the clinical rules and the manual review. However, there was no difference in the recommendation acceptance rate between the manual review and the clinical rules.

CONCLUSIONS

Clinical rules can identify prescription errors that manual review cannot detect and ensure real-time review efficiency in high-volume outpatient prescription settings. The high acceptance rate and modification of prescriptions may be relevant to highly customised and localised clinical rules.

Enhancing pharmaceutical decision support system: evaluating antithrombotic-focused algorithms for addressing drug-related problems

OBJECTIVES

To evaluate the efficacy of integrating antithrombotic-focused pharmaceutical algorithms (PAs) into a pharmaceutical decision support system (PDSS) for detecting drug-related problems (DRPs) and facilitating pharmaceutical interventions.

METHODS

A set of 26 PAs (12.4%) out of a total of 210 were created to model patient situations involving antithrombotics, and their contributions were compared with the entire PDSS system.The observational prospective study was conducted between November 2019 and June 2023 in two health facilities with 1700 beds. Pharmacists, who followed a DRP resolution strategy to support human supervision, analysed alerts generated by these encoded PAs. They registered their interventions and the acceptance by physicians.

RESULTS

From 3290 alerts analysed targeting antithrombotics, the pharmacists issued 1170 interventions of which 676 (57.8%) were accepted by physicians. With the 184 other PAs, from 9484 alerts the pharmacists issued 3341 interventions of which 1785 were accepted (53.4%).Results indicate that the detection of DRPs related to antithrombotics usage represents a high proportion of those detected by the PDSS, highlighting the importance of incorporating tailored PA elements at the modelling stage.

CONCLUSIONS

The system evolves alongside the physiological changes associated to the patient situations, adapts the alerts and complements the current care. Therefore, we recommend that all PDSS should integrate specific algorithms targeting DRPs associated with antithrombotics to enhance pharmaceutical interventions and improve patient safety.

Development and retrospective evaluation of a clinical decision support system for the efficient detection of drug-related problems by clinical pharmacists

BACKGROUND

Clinical decision support systems (CDSS) can help identify drug-related problems (DRPs). However, the alert specificity remains variable. Defining more relevant alerts for detecting DRPs would improve CDSS.

AIM

Develop electronic queries that assist pharmacists in conducting medication reviews and an assessment of the performance of this model to detect DRPs.

METHOD

Electronic queries were set up in CDSS using "triggers" from electronic health records: drug prescriptions, laboratory values, medical problems, vital signs, demographics. They were based on a previous study where 315 patients admitted in internal medicine benefited from a multidisciplinary medication review (gold-standard) to highlight potential DRPs. Electronic queries were retrospectively tested to assess performance in detecting DRPs revealed with gold-standard. For each electronic query, sensitivity, specificity, positive and negative predictive value were computed.

RESULTS

Of 909 DRPs, 700 (77.8%) were used to create 366 electronic queries. Electronic queries correctly detected 77.1% of DRPs, median sensitivity and specificity reached 100.0% (IQRs, 100.0%-100.0%) and 99.7% (IQRs, 97.0%-100.0%); median positive predictive value and negative predictive value reached 50.0% (IQRs, 12.5%-100.0%) and 100.0% (IQRs, 100.0%-100.0%). Performances varied according to "triggers" (p < 0.001, best performance in terms of predictive positive value when exclusively involving drug prescriptions).

CONCLUSION

Electronic queries based on electronic heath records had high sensitivity and negative predictive value and acceptable specificity and positive predictive value and may contribute to facilitate medication review. Implementing some of these electronic queries (the most effective and clinically relevant) in current practice will allow a better assessment of their impact on the efficiency of the clinical pharmacist.

Detection of Drug-Related Problems through a Clinical Decision Support System Used by a Clinical Pharmacy Team

Clinical decision support systems (CDSSs) are intended to detect drug-related problems in real time and might be of value in healthcare institutions with a clinical pharmacy team. The objective was to report the detection of drug-related problems through a CDSS used by an existing clinical pharmacy team over 22 months. It was a retrospective single-center study. A CDSS was integrated in the clinical pharmacy team in July 2019. The investigating clinical pharmacists evaluated the pharmaceutical relevance and physician acceptance rates for critical alerts (i.e., alerts for drug-related problems arising during on-call periods) and noncritical alerts (i.e., prevention alerts arising during the pharmacist’s normal work day) from the CDSS. Of the 3612 alerts triggered, 1554 (43.0%) were critical, and 594 of these 1554 (38.2%) prompted a pharmacist intervention. Of the 2058 (57.0%) noncritical alerts, 475 of these 2058 (23.1%) prompted a pharmacist intervention. About two-thirds of the total pharmacist interventions (PI) were accepted by physicians; the proportion was 71.2% for critical alerts (i.e., 19 critical alerts per month vs. 12.5 noncritical alerts per month). Some alerts were pharmaceutically irrelevant—mainly due to poor performance by the CDSS. Our results suggest that a CDSS is a useful decision-support tool for a hospital pharmacist’s clinical practice. It can help to prioritize drug-related problems by distinguishing critical and noncritical alerts. However, building an appropriate organizational structure around the CDSS is important for correct operation.

Electronic monitoring of potential adverse drug events related to lopinavir/ritonavir and hydroxychloroquine during the first wave of COVID-19

During Switzerland's first wave of COVID-19, clinical pharmacy activities during medical rounds in Geneva University Hospitals were replaced by targeted remote interventions. We describe using the electronic PharmaCheck system to screen high-risk situations of adverse drug events (ADEs), particularly targeting prescriptions of lopinavir/ritonavir (LPVr) and hydroxychloroquine (HCQ) in the presence of contraindications or prescriptions outside institutional guidelines. Of 416 patients receiving LPVr and/or HCQ, 182 alerts were triggered for 164 (39.4%) patients. The main associated risk factors of ADEs were drug-drug interactions, QTc interval prolongation, electrolyte disorder and inadequate LPVr dosage. Therapeutic optimisation recommended by a pharmacist or proposals for additional monitoring were accepted in 80% (n=36) of cases. Combined with pharmacist contextualisation to the clinical context, PharmaCheck made it possible to successfully adapt clinical pharmacist activities by switching from a global to a targeted analysis mode in an emergency context.

Consensus validation of a screening tool for cardiovascular pharmacotherapy in geriatric patients: the RASP_CARDIO list (Rationalization of Home Medication by an Adjusted STOPP list in Older Patients)

PURPOSE

Cardiovascular agents commonly used in geriatric patients, are linked to potentially avoidable harm and might hence be a suitable substrate for medication review practices. Therefore, we sought to update and validate the content of the cardiovascular segment of the previously published Rationalization of Home Medication by an Adjusted STOPP list in Older Patients (RASP) List.

METHODS

A three-step study was conducted by the pharmacy department in collaboration with the geriatric medicine and cardiology department at the University Hospitals Leuven, Belgium. First, the cardiovascular segment of the RASP list version 2014 was updated taking into account published research, other screening tools and the input of end-users. Secondly, this draft was reviewed during three panel discussions with five expert cardiologists and three clinical pharmacists, all of whom had relevant expertise in geriatric pharmacotherapy. Thirdly, the content was validated using a modified Delphi Technique by a panel of European hospital pharmacists, cardiologists, geriatricians and an internal medicine physician.

RESULTS

After the first and second step, the RASP_CARDIO list comprised 94 statements. Consensus (≥ 80% agreement) of all statements and one new statement about gliflozins in heart failure was achieved by a panel of seventeen experts across four European countries after two validation rounds. The final construct comprised a list of 95 statements related to potentially inappropriate prescribing of cardiovascular agents.

CONCLUSION

The RASP_CARDIO list is an updated and validated explicit screening tool to optimize cardiovascular pharmacotherapy in geriatric patients.

Interventions and Impact of Pharmacist-Delivered Services for People Infected with COVID-19: A Systematic Review

Pharmacists are essential members of the healthcare team. The emergence of the novel coronavirus disease 2019 (COVID-19) pandemic has led pharmacists to undertake additional clinical roles. We aim to conduct a systematic review on the interventions and impact of pharmacist-delivered services in managing COVID-19 patients. We searched PubMed, Embase, Scopus, CINAHL plus, International Pharmaceutical Abstracts, and Web of Science from 1 December 2019 (the first case of COVID-19 emerged) to 13 January 2022 to retrieve the articles. Cochrane handbook and PRISMA guidelines were followed respectively to perform and report the review. The pharmacist-led interventions were reported following the Descriptive Elements of Pharmacist Intervention Characterization Tool (DEPICT) version 2. The protocol of systematic review was registered on PROSPERO (CRD42021277128). Studies quality was assessed with the modified NOS scale. In total, 7 observational studies were identified from 10,838 studies. Identification of dosage errors (n = 6 studies), regimen modifications (n = 5), removal of obsolete/duplicate medications (n = 5), identification and management of adverse drug reactions (n = 4), drug interactions prevention (n = 2), and physicians acceptance rate (n = 3) of therapy-related services delivered in-person or via tele-pharmacy were among the pharmacist-delivered services. Common interventions delivered by pharmacists also included optimizing the use of antibacterial, antivirals, and anticoagulants in COVID-19 infected patients. The acceptance of pharmacist-delivered services by physicians was high (88.5-95.5%). Included studies have described pharmacists' beneficial role in managing patients with COVID-19 including detection, resolution, and prevention of medication-related problems, with physicians demonstrating high trust in pharmacists' advice. Future research should assess the feasibility and scalability of such roles in real-world settings.

End-users feedback and perceptions associated with the implementation of a clinical-rule based Check of Medication Appropriateness service

Background

To support appropriate prescribing hospital-wide, the ‘Check of Medication Appropriateness’ (CMA) service was implemented at the University Hospitals Leuven. The CMA concerns a clinical rule based and pharmacist-led medication review service. The aim of this study was to explore both physicians’ and pharmacists’ feedback on the optimised CMA service to further improve the service.

Methods

An anonymous e-questionnaire was sent to all physicians active in the University Hospitals Leuven (n = 1631) and to all clinical pharmacists performing the CMA service (n = 16). Feedback was collected using multiple choice questions. During a 5-month period, physicians were also contacted in case of non-acceptance of recommendations to investigate barriers affecting implementation. Thematic analysis was performed and additional acceptance after telephone contact within 24 h was registered.

Results

A total of 119 physicians (7.3%) and 16 pharmacists (100%) completed the e-questionnaire. The overall service was assessed as clinically relevant to highly relevant by 77.7% of physicians. The main reasons for non-acceptance of recommendations were related to workload, work environment and time constraints. About two thirds (66.3%) of initially not-accepted recommendations were accepted after phone contact. A nearly full consensus was reached among pharmacists (15/16) on the centralised CMA being complementary to current clinical pharmacy activities. Two major barriers were reported by pharmacists: (1) too limited time allocation and (2) a large number of irrelevant alerts.

Conclusions

The CMA was perceived as clinically relevant by the majority of end-users. Acceptance rate of pharmaceutical recommendations was further increased by calling the physician. Increasing the specificity of clinical rules in the future is imperative.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01921-7.

Development and assessment of PharmaCheck: an electronic screening tool for the prevention of twenty major adverse drug events

BACKGROUND

Adverse drug events (ADEs) can be prevented by deploying clinical decision support systems (CDSS) that directly assist physicians, via computerized order entry systems, and clinical pharmacists performing medication reviews as part of medical rounds. However, physicians using CDSS are known to be exposed to the alert-fatigue phenomenon. Our study aimed to assess the performance of PharmaCheck-a CDSS to help clinical pharmacists detect high-risk situations with the potential to lead to ADEs-and its impact on clinical pharmacists' activities.

METHODS

Twenty clinical rules, divided into four risk classes, were set for the daily screening of high-risk situations in the electronic health records of patients admitted to our General Internal Medicine Department. Alerts to clinical pharmacists encouraged them to telephone prescribers and suggest any necessary treatment adjustments. PharmaCheck's performance was assessed using the intervention's positive predictive value (PPV), which characterizes the proportion of interventions for each alert triggered. PharmaCheck's impact was assessed by considering clinical pharmacists as a filter for ruling out futile alerts and by comparing the final clinical PPV with a pharmacist (the proportion of interventions that led to a change in the medical regimen) to the final clinical PPV without a pharmacist.

RESULTS

Over 132 days, 447 alerts were triggered for 383 patients, leading to 90 interventions (overall intervention PPV = 20.1%). By risk class, intervention PPVs made up 26.9% (n = 65/242) of abnormal laboratory value alerts, 3.1% (4/127) of alerts for contraindicated medications or medications to be used with caution, 28.2% (20/71) of drug-drug interaction alerts, and 14.3% (1/7) of inadequate mode of administration alerts. Clinical PPVs reached 71.0% (64/90) when pharmacists filtered alerts and 14% (64/242) if they were not doing it.

CONCLUSION

PharmaCheck enabled clinical pharmacists to improve their traditional processes and broaden their coverage by focusing on 20 high-risk situations. Alert management by pharmacists seemed to be a more effective way of preventing risky situations and alert-fatigue than a model addressing alerts to physicians exclusively. Some fine-tuning could enhance PharmaCheck's performance by considering the information quality of triggers, the variability of clinical settings, and the fact that some prescription processes are already highly secured.

From basic to advanced computerised intravenous to oral switch for paracetamol and antibiotics: an interrupted time series analysis

OBJECTIVES

Early switch from intravenous to oral therapy of bioequivalent drugs has major advantages but remains challenging. At our hospital, a basic clinical rule was designed to automatically alert the physician to review potential intravenous to oral switch (IVOS). A rather low acceptance rate was observed. In this study, we aimed to develop, validate and investigate the effect of more advanced clinical rules for IVOS, as part of a centralised pharmacist-led medication review service.

DESIGN AND SETTING

A quasi-experimental study was performed in a large teaching hospital in Belgium using an interrupted time series design.

INTERVENTION

A definite set of 13 criteria for IVOS, focusing on the ability of oral absorption and type of infection, was obtained by literature search and validated by a multidisciplinary expert panel. Based on these criteria, we developed a clinical rule for paracetamol and one for ten bioequivalent antibiotics to identify patients with potentially inappropriate intravenous prescriptions (PIVs). Postintervention, the clinical rule alerts were reviewed by pharmacists, who provided recommendations to switch in case of eligibility.

PRIMARY AND SECONDARY OUTCOME MEASURES

A regression model was used to assess the impact of the intervention on the number of persistent PIVs between the preintervention and the postintervention period. The total number of recommendations, acceptance rate and financial impact were recorded for the 8-month postintervention period.

RESULTS

At baseline, a median number of 11 (range: 7-16) persistent PIVs per day was observed. After the intervention, the number reduced to 3 (range: 1-7) per day. The advanced IVOS clinical rules showed an immediate relative reduction of 79% (incidence rate ratio=0.21, 95% CI 0.13 to 0.32; p<0.01) in the proportion of persistent PIVs. No significant underlying time trends were observed during the study. Postintervention, 1091 recommendations were provided, of which 74.1% were accepted, resulting in a total 1-day cost saving of €4648.35.

CONCLUSIONS

We showed the efficacy of advanced clinical rules combined with a pharmacist-led medication review for IVOS of bioequivalent drugs.

Optimizing Hospital Electronic Prescribing Systems: A Systematic Scoping Review

OBJECTIVE

Considerable international investment in hospital electronic prescribing (ePrescribing) systems has been made, but despite this, it is proving difficult for most organizations to realize safety, quality, and efficiency gains in prescribing. The objective of this work was to develop policy-relevant insights into the optimization of hospital ePrescribing systems to maximize the benefits and minimize the risks of these expensive digital health infrastructures.

METHODS

We undertook a systematic scoping review of the literature by searching MEDLINE, Embase, and CINAHL databases. We searched for primary studies reporting on ePrescribing optimization strategies and independently screened and abstracted data until saturation was achieved. Findings were theoretically and thematically synthesized taking a medicine life-cycle perspective, incorporating consultative phases with domain experts.

RESULTS

We identified 23,609 potentially eligible studies from which 1367 satisfied our inclusion criteria. Thematic synthesis was conducted on a data set of 76 studies, of which 48 were based in the United States. Key approaches to optimization included the following: stakeholder engagement, system or process redesign, technological innovations, and education and training packages. Single-component interventions (n = 26) described technological optimization strategies focusing on a single, specific step in the prescribing process. Multicomponent interventions (n = 50) used a combination of optimization strategies, typically targeting multiple steps in the medicines management process.

DISCUSSION

We identified numerous optimization strategies for enhancing the performance of ePrescribing systems. Key considerations for ePrescribing optimization include meaningful stakeholder engagement to reconceptualize the service delivery model and implementing technological innovations with supporting training packages to simultaneously impact on different facets of the medicines management process.

Overall performance of a drug-drug interaction clinical decision support system: quantitative evaluation and end-user survey

BACKGROUND

Clinical decision support systems are implemented in many hospitals to prevent medication errors and associated harm. They are however associated with a high burden of false positive alerts and alert fatigue. The aim of this study was to evaluate a drug-drug interaction (DDI) clinical decision support system in terms of its performance, uptake and user satisfaction and to identify barriers and opportunities for improvement.

METHODS

A quantitative evaluation and end-user survey were performed in a large teaching hospital. First, very severe DDI alerts generated between 2019 and 2021 were evaluated retrospectively. Data collection comprised alert burden, override rates, the number of alert overrides reviewed by pharmacists and the resulting pharmacist recommendations as well as their acceptance rate. Second, an e-survey was carried out among prescribers to assess satisfaction, usefulness and relevance of DDI alerts as well as reasons for overriding.

RESULTS

A total of 38,409 very severe DDI alerts were generated, of which 88.2% were overridden by the prescriber. In 3.2% of reviewed overrides, a recommendation by the pharmacist was provided, of which 79.2% was accepted. False positive alerts were caused by a too broad screening interval and lack of incorporation of patient-specific characteristics, such as QTc values. Co-prescribing of a non-vitamin K oral anticoagulant and a low molecular weight heparin accounted for 49.8% of alerts, of which 92.2% were overridden. In 88 (1.1%) of these overridden alerts, concurrent therapy was still present. Despite the high override rate, the e-survey revealed that the DDI clinical decision support system was found useful by prescribers.

CONCLUSIONS

Identified barriers were the lack of DDI-specific screening intervals and inclusion of patient-specific characteristics, both leading to a high number of false positive alerts and risk for alert fatigue. Despite these barriers, the added value of the DDI clinical decision support system was recognized by prescribers. Hence, integration of DDI-specific screening intervals and patient-specific characteristics is warranted to improve the performance of the DDI software.

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.

EAHP European Statements Survey 2018, focusing on Section 1: Introductory Statements and Governance, Section 3: Production and Compounding, and Section 4: Clinical Pharmacy Services

OBJECTIVES

The 2018 EAHP European Statements Survey focused on sections 1, 3 and 4 of the European Statements of Hospital Pharmacy. Statistical data on the level of implementation and on the main barriers to implementation of the Statements were collected. A further aim was to identify barriers in general, such as lack of awareness.

METHODS

An online questionnaire was sent to all hospital pharmacies in EAHP member countries. Data were analysed at Keele University School of Pharmacy, UK. As with previous reports, the survey was divided into three sections: section A, asking general questions about the hospital pharmacy; Section B, addressing questions about the current activity of pharmacists around each statement from Sections 1, 3 and 4; and Section C, focusing on their ability to implement the statements.

RESULTS

719 complete responses were obtained from a sample of 5164 hospital pharmacies, giving a response rate of 14% (719/5164). Section A results indicated that 45% (323/719) of responders worked in teaching hospitals, 79% (568/719) of hospital pharmacies had 10 or fewer pharmacists, and 48% (345/719) of hospital pharmacies served over 500 beds. Section B results found a high percentage of positive responses for activity in section 1 (introductory statements and governance) and section 3 (production and compounding). However, responses to questions in section 4 (clinical pharmacy services) were more variable, with 6 of the 15 questions being answered positively by less than half of respondents. The five questions that revealed the lowest implementation levels were then analysed in greater detail. These questions corresponded to Statements 4.4, 4.5, 4.8, 1.1, and 4.2, which need the greatest effort for implementation. The major identified barriers to implementation were 'lack of capacity' and that 'other health professionals in the hospital fulfil the tasks'.

CONCLUSIONS

This survey provides useful information on the implementation status (and the barriers to, and drivers of implementation) of sections 1, 3 and 4 of the Statements. This will allow the EAHP to plan its implementation support programme for its members. To increase the quality of data, as well as the feedback to hospital pharmacies, the EAHP is planning to combine the survey with the self-assessment tool of the European Statements of Hospital Pharmacy.

Association Between Physicians' Workload and Prescribing Quality in One Tertiary Hospital in China

BACKGROUND

Alarming increasing trends in physician workload have attracted much attention in recent years. Heavy workload may compromise the quality of medication use. Previous studies have identified a series of factors contributing to inappropriate prescribing; however, there is no demonstrated evidence supporting an association between workload and the appropriateness of physicians' prescriptions in China. This study aimed to investigate the relationship between physician workload and prescription quality in a tertiary hospital in Beijing, China.

METHODS

Our study was a single-center, retrospective study, with all outpatient electronic health records extracted from hospital information system of a tertiary hospital in Beijing from July 1 to November 30, 2015. We used outpatient volume in each 5-hour shift as the measure of physician workload. The evaluation of prescribing quality was based on the Rational Drug Use System. Generalized linear models with a γ distribution and a log link were used to explore factors associated with inappropriate prescribing, and we undertook a series of robustness tests with respect to different exclusion criteria.

RESULTS

A total of 457,784 prescriptions from 502 physicians were included in the study. Physicians had an average workload of 34.3 (±19.8) patients per shift, and the mean rate of inappropriate prescribing per shift was 14.1% (±14.6%). Higher rates of inappropriate prescribing were associated with heavier workloads (P < 0.001). Physicians who worked in the afternoon, chief physicians, those working in surgical department, males, and those with more than 20-year experience had higher rates of inappropriate prescribing with increasing workload.

CONCLUSIONS

Heavier workload was associated with higher risk of prescribing inappropriately. It requires great efforts to determine optimal physician workloads and mitigate the potential adverse effects on the prescription quality.

Clinical validation of clinical decision support systems for medication review: A scoping review

The aim of this scoping review is to summarize approaches and outcomes of clinical validation studies of clinical decision support systems (CDSSs) to support (part of) a medication review. A literature search was conducted in Embase and Medline. In total, 30 articles validating a CDSS were ultimately included. Most of the studies focused on detection of adverse drug events, potentially inappropriate medications and drug‐related problems. We categorized the included articles in three groups: studies subjectively reviewing the clinical relevance of CDSS's output (21/30 studies) resulting in a positive predictive value (PPV) for clinical relevance of 4–80%; studies determining the relationship between alerts and actual events (10/30 studies) resulting in a PPV for actual events of 5–80%; and studies comparing output of CDSSs to chart/medication reviews in the whole study population (10/30 studies) resulting in a sensitivity of 28–85% and specificity of 42–75%. We found heterogeneity in the methods used and in the outcome measures. The validation studies did not report the use of a published CDSS validation strategy. To improve the effectiveness and uptake of CDSSs supporting a medication review, future research would benefit from a more systematic and comprehensive validation strategy.

The effectiveness of Check of Medication Appropriateness for antimicrobial stewardship: an interrupted time series analysis

OBJECTIVES

Inappropriate prescribing of antimicrobials in hospitals contributes to the emergence of resistance and adverse drug events. To support antimicrobial stewardship (AMS), clinical decision rules focusing on antimicrobial therapy were implemented in the 'Check of Medication Appropriateness' (CMA). The CMA is a hospital-wide pharmacist-led medication review service consisting of a clinical rule-based screening for potentially inappropriate prescriptions (PIPs). We aimed to investigate the impact of the CMA on antimicrobial prescribing.

METHODS

An interrupted time series study was performed at the University Hospitals Leuven. The pre-implementation cohort was exposed to standard-of-care AMS. Afterwards, an AMS-focused CMA comprising 41 specific clinical rules, targeting six AMS objectives, was implemented in the post-implementation period. A regression model was used to assess the impact of the intervention on the number of AMS-related residual PIPs between both periods. The total number of recommendations and acceptance rate was recorded for the 2 year post-implementation period.

RESULTS

Pre-implementation, a median proportion of 75% (range: 33%-100%) residual PIPs per day was observed. After the CMA intervention, the proportion was reduced to 8% (range: 0%-33%) per day. Use of clinical rules resulted in an immediate relative reduction of 86.70% (P < 0.0001) in AMS-related residual PIPs. No significant underlying time trends were observed during the study period. Post-implementation, 2790 recommendations were provided of which 81.32% were accepted.

CONCLUSIONS

We proved that the CMA approach reduced the number of AMS-related residual PIPs in a highly significant and sustained manner, with the potential to further expand the service to other AMS objectives.

Determinants for under- and overdosing of direct oral anticoagulants and physicians' implementation of clinical pharmacists' recommendations

AIMS

To analyse the appropriateness of direct oral anticoagulant (DOAC) dosing and determinants for under-and overdosing as well as acceptance and implementation rates of pharmacists' interventions.

METHODS

Cross-sectional study in a tertiary hospital in hospitalized patients with atrial fibrillation on DOACs in 2019 (n = 1688). Primary outcome was the proportion of patients with inappropriate DOAC prescribing with identification of determinants for under-and overdosing. Secondary outcomes included acceptance and implementation rates of pharmacists' recommendations and determination of reasons for nonacceptance/nonimplementation.

RESULTS

Inappropriate prescribing was observed in 16.9% of patients (n = 286) with underdosing (9.7%) being more prevalent than overdosing (6.9%). For all DOACs considered together, body weight<60 kg (odds ratio [OR] 0.46 [0.27-0.77]), edoxaban use (OR 0.42 [0.24-0.74]), undergoing surgery (OR 0.57 [0.37-0.87]) and being DOAC naïve (OR 0.45 [0.29-0.71]) were associated with significantly lower odds of underdosing. Bleeding history (OR 1.86 [1.24-2.80]) and narcotic use (OR 1.67 [1.13-2.46]) were associated with significantly higher odds for underdosing. Determinants with a significantly higher odds of overdosing were renal impairment (OR 11.29 [6.23-20.45]) and body weight<60 kg (OR 2.34 [1.42-3.85]), whereas dabigatran use (OR 0.24 [0.08-0.71]) and apixaban (OR 0.18 [0.10-0.32]) were associated with a significantly lower odds of overdosing compared to rivaroxaban. Physicians accepted the pharmacists' advice in 179 cases (79.2%) consisting of 92 (51.4%) recommendations for underdosing, 82 (45.8%) for overdosing and 5 (2.8%) for contraindications.

CONCLUSION

Inappropriate DOAC prescribing remains common, although there is a slight improvement compared to our study of 2016. Clinical services led by pharmacists help physicians to reduce the number of inadequate prescriptions for high-risk medications such as DOACs.

Comparing the Prevalence of Polypharmacy and Potential Drug-Drug Interactions in Nursing Homes and in the Community Dwelling Elderly of Emilia Romagna Region

Backround: We aimed at assessing the prevalence of polypharmacy and potential drug-drug interactions (DDIs) with clinical relevance in elderly patient on Emilia Romagna area. Both outpatients and residents in nursing homes were assessed, with only partially overlapping strategies.

Methods: We defined a list of 190 pairs of potentially interacting drugs, based on literature appraisal and availability of therapeutic alternatives. January-June 2018 data on drug use in patients over 65 years-old were collected from nine Local Health Authorities of Emilia Romagna: data on community-dwelling subjects were extracted from archives of reimbursed prescriptions, while drug use in a sample of nursing homes was recorded from clinical charts in one index day within the same semester. The frequency of polypharmacy (at least five or at least 10 concurrent drugs) and of each DDI was calculated.

Results: In line with different rates of polypharmacy (80% vs 16%), the risk of exposure to at least one interaction was 53.7% in nursing homes and 26.4% in outpatients. Among DDIs, in nursing homes antidepressants—anxiolytics (11.9%) ranked first, followed by antidepressants—aspirin (7.4%). In outpatients, ACE-inhibitors—non-steroidal anti-inflammatory drugs (NSAIDs) reached 7.2% followed by the calcium channel blockers—α-blockers (2.4%).

Discussion: Polypharmacy and risk of DDIs appeared very different in the two settings, due to both technical and clinical reasons. In order to reduce use of benzodiazepines, NSAIDs, antidepressants and relevant DDIs, 1) defining alternative options for pain relief in elderly outpatients, and 2) implementing non-pharmacological management of insomnia and anxiety in nursing homes should be prioritized.

Practice-enhancing publications about the medication-use process in 2019

PURPOSE

This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2019 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles that evaluated one of the steps were gauged for their usefulness in promoting daily practice change.

SUMMARY

A PubMed search was conducted in January 2020 for calendar year 2019 using targeted Medical Subject Headings keywords; in addition, searches of the table of contents of selected pharmacy journals were conducted. A total of 4,317 articles were identified. A thorough review identified 66 potentially practice-enhancing articles: 17 for prescribing/transcribing, 17 for dispensing, 7 for administration, and 25 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why each article is important within health-system pharmacy. The other articles are listed for further review and evaluation.

CONCLUSION

It is important to routinely review the published literature and to incorporate significant findings into daily practice; this article assists in identifying and summarizing the most impactful recently published literature in this area. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the significant published studies can assist in changing practice at the institutional level.

Impact of Check of Medication Appropriateness (CMA) in optimizing analgesic prescribing: An interrupted time series analysis

BACKGROUND

Pain therapy in inpatients is regularly suboptimal and might be improved by clinical pharmacy services. In our hospital, we have implemented a software-supported 'Check of Medication Appropriateness' (CMA), which is a centralized pharmacist-led service consisting of a clinical rule-based screening for potentially inappropriate prescriptions (PIPs), and a subsequent medication review by pharmacists. We aimed to investigate the impact of the CMA on pain-related prescribing.

METHODS

A quasi-experimental study was performed in a large teaching hospital, using an interrupted time series design. Pre-implementation, patients were exposed to standard of care. Afterwards, a pain-focused CMA comprising 12 specific clinical rules pertaining to analgesic prescribing were implemented in the post-implementation period. A regression model was used to assess the impact of the intervention on the number of pain-related residual PIPs between both periods. The total number of recommendations and acceptance rate was recorded for the post-implementation period.

RESULTS

At baseline, a median number of 13.1 (range: 9.5-15.8) residual PIPs per day was observed. After the CMA intervention, the number was reduced to 2.2 (range: 0-9.5) per day. Clinical rules showed an immediate relative reduction of 66% (p < .0001) in pain-related residual PIPs. A significant decreasing time trend was observed during the post-implementation period. Post-implementation, 1683 recommendations were given over 1 year with an acceptance rate of 74.3%.

CONCLUSIONS

We proved that the CMA approach reduced the number of pain-related residual PIPs. More pharmacist involvement and the use of clinical rules during hospital stay should be further promoted to optimize appropriate prescribing of analgesics.

SIGNIFICANCE

Prescribing of analgesics should be improved in inpatients to optimize pain control and to reduce iatrogenic harm. The Check of Medication Appropriateness (CMA) approach, comprising a clinical rule-based screening for patients at risk and a targeted medication review by pharmacists, reduced the number of pain-related potentially inappropriate prescriptions in a highly significant and sustained manner. This study presents the opportunities of a centralized clinical pharmacy service to help clinicians to further improve analgesic prescribing.

Prevention of adverse drug reactions in hospitalized older patients with multi-morbidity and polypharmacy: the SENATOR* randomized controlled clinical trial

BACKGROUND

Multi-morbidity and polypharmacy increase the risk of non-trivial adverse drug reactions (ADRs) in older people during hospitalization. Despite this, there are no established interventions for hospital-acquired ADR prevention.

METHODS

We undertook a pragmatic, multi-national, parallel arm prospective randomized open-label, blinded endpoint (PROBE) controlled trial enrolling patients at six European medical centres. We randomized 1,537 older medical and surgical patients with multi-morbidity and polypharmacy on admission in a 1:1 ratio to SENATOR software-guided medication optimization plus standard care (intervention, n = 772, mean number of daily medications = 9.34) or standard care alone (control, n = 765, mean number of daily medications = 9.23) using block randomization stratified by site and admission type. Attending clinicians in the intervention arm received SENATOR-generated advice at a single time point with recommendations they could choose to adopt or not. The primary endpoint was occurrence of probable or certain ADRs within 14 days of randomization. Secondary endpoints were primary endpoint derivatives; tertiary endpoints included all-cause mortality, re-hospitalization, composite healthcare utilization and health-related quality of life.

RESULTS

For the primary endpoint, there was no difference between the intervention and control groups (24.5 vs. 24.8%; OR 0.98; 95% CI 0.77-1.24; P = 0.88). Similarly, with secondary and tertiary endpoints, there were no significant differences. Among attending clinicians in the intervention group, implementation of SENATOR software-generated medication advice points was poor (~15%).

CONCLUSIONS

In this trial, uptake of software-generated medication advice to minimize ADRs was poor and did not reduce ADR incidence during index hospitalization.

The Impact of Physicians' Working Hours on Inappropriate Use of Outpatient Medicine in a Tertiary Hospital in China

BACKGROUND

Inappropriate prescribing is an important health system problem in China. Several studies have identified critical factors influencing prescription quality, but the impact of physicians' working hours remains unknown. In China, tertiary hospitals face ever-increasing outpatient volumes. Physicians are asked to work long hours and the impact of shift duration on prescription quality is unknown.

OBJECTIVE

We aimed to investigate the association between consecutive working hours and the quality of physicians' prescriptions in a Chinese tertiary hospital.

METHODS

We obtained all outpatient electronic health records from the hospital information system (HIS) of a tertiary hospital in Beijing, China from 1 July to 30 November 2015. Prescriptions made during two periods were analyzed: a morning shift from 7:30 to 12:30, and an afternoon shift from 13:30 to 18:30. The time when a physician issued the first prescription was considered the beginning of the work shift and prescriptions within the next 4 consecutive hours were included. Potentially inappropriate prescriptions were based on the Rational Drug Use (RDU) system that was developed and validated for this study. We used multivariable logistic regression to examine the impact of shift duration and other clinical and physician factors on potentially inappropriate prescribing.

RESULTS

Of the total 560,529 prescriptions, 15.3% were classified as inappropriate by the RDU system. Physicians' inappropriate prescribing increased in the last hour in each work shift (odds ratio (OR) for the fourth hour compared to the first = 1.12 (95% CI, 1.09-1.15)). We also found that physicians who worked all day had a higher rate of inappropriate prescribing than those who only worked half a day (OR = 1.05 (95% CI, 1.04-1.07)).

CONCLUSIONS

Longer working hours are a risk factor for inappropriate prescribing. Relevant interventions are urgently needed to establish working hour limits in China to reduce the likelihood of inappropriate prescribing by physicians.

The patient pathway in cardiovascular care: A position paper from the International Pharmacists for Anticoagulation Care Taskforce (iPACT)

BACKGROUND

This position paper highlights the opportunistic integral role of the pharmacist across the patient pathway utilizing cardiovascular care as an example. The paper aims to highlight the potential roles that pharmacists worldwide can have (or already have) to provide efficient patient care in the context of interprofessional collaboration.

METHODS

It results from a literature review and experts seeking advice to identify existing interventions and potential innovative interventions. We developed a conceptual framework highlighting seven critical phases in the patient pathway and for each of those listed some of the initiatives identified by our experts worldwide.

RESULTS

Existing pharmacists' interventions in each of these phases have been identified globally. Various examples in the area of prevention and self-management were found to exist for long; the contribution for early detection and subsequently to timely diagnosis were also quite clear; integration of care was perhaps one of the areas needing greater development, although interventions in secondary care were also quite common. Tertiary care and end of life interventions were found to often be left for other healthcare professionals.

CONCLUSION

On the basis of the findings, we can argue that much has been done but globally consider that pharmacists are still an untapped resource potentially useful for improved patient care.

Analysis of Medication Errors and near Misses Made by Nursing Students

Despite extensive research and technological advancements, errors related to medication administration continue to rise annually. The body of evidence surrounding medication errors has focused largely on licensed practicing nurses. Nursing students can offer a unique perspective regarding medication administration as their foundation for professional psychomotor skills and cognitive abilities are developed. The purpose of this study was to explore the variables related to medication errors made by pre-licensure nursing students. Data were collected from 2013–2015 in a pre-licensure program. Students completed a post-error survey available in Google Forms. One hundred thirteen responses to the error report were completed. By exploring the factors related to medication errors among nursing students, teaching and learning strategies forming the foundations of medication administration can improve professional nursing practice and improve safety and quality of care.

Identifying potential prescribing safety indicators related to mental health disorders and medications: A systematic review

BACKGROUND

Prescribing errors and medication related harm may be common in patients with mental illness. However, there has been limited research focusing on the development and application of prescribing safety indicators (PSIs) for this population.

OBJECTIVE

Identify potential PSIs related to mental health (MH) medications and conditions.

METHODS

Seven electronic databases were searched (from 1990 to February 2019), including the bibliographies of included studies and of relevant review articles. Studies that developed, validated or updated a set of explicit medication-specific indicators or criteria that measured prescribing safety or quality were included, irrespective of whether they contained MH indicators or not. Studies were screened to extract all MH related indicators before two MH clinical pharmacists screened them to select potential PSIs based on established criteria. All indicators were categorised into prescribing problems and medication categories.

RESULTS

79 unique studies were included, 70 of which contained at least one MH related indicator. No studies were identified that focused on development of PSIs for patients with mental illness. A total of 1386 MH indicators were identified (average 20 (SD = 25.1) per study); 245 of these were considered potential PSIs. Among PSIs the most common prescribing problem was 'Potentially inappropriate prescribing considering diagnoses or conditions' (n = 91, 37.1%) and the lowest was 'omission' (n = 5, 2.0%). 'Antidepressant' was the most common PSI medication category (n = 85, 34.7%).

CONCLUSION

This is the first systematic review to identify a comprehensive list of MH related potential PSIs. This list should undergo further validation and could be used as a foundation for the development of new suites of PSIs applicable to patients with mental illness.