Effect of electronic medication reconciliation at the time of hospital discharge on inappropriate medication use in the community: an interrupted time-series analysis

Electronic pharmaceutical record for best possible medication history at preoperative evaluation to prevent postoperative adverse events: a quasi-experimental study

BACKGROUND

Access to reliable data about patient's medications before surgery represents a challenge for reducing the risk of postoperative adverse events (AE) potentially related to preoperative treatment.

OBJECTIVE

To evaluate the impact on AE of a nationwide ambulatory electronic pharmaceutical record (EPR) used by a pharmacist for best possible medication history (BPMH), associated with the preoperative evaluation.

METHODS

This quasi-experimental comparative interventional study included 750 adult patients with an available EPR, admitted to the preoperative clinic for elective orthopaedic surgery, between April 2014 and April 2017. Data analysis was completed in September 2022. In the intervention group, a pharmacist performed the BPMH using the EPR, before the patient's medical evaluation. In the control group, there was conventional preoperative evaluation. The primary outcome was the number of patients with at least one AE collected by using the trigger tool method, within 30 days after surgery. Secondary outcomes were the number of medications reported in the medical record and the number of patients with at least one documented adverse drug event (ADE) by an independent committee within 30 days after surgery.

RESULTS

Of 1924 patients admitted to the preoperative clinic, 750 patients who had a record (39%) were included (153 (41%) men; median age 61 (49-71 and 50-70) years in both groups), 375 in each group. There was a 29% reduction in the proportion of patients with at least one AE in the intervention group (110/374 patients (29%) with 165 AE vs 156/372 patients (42%) with 233 AE) (OR 0.58 (0.43-0.78), p<0.01). There were significantly more drugs reported on the medical record in the intervention group (3 (1-5) vs 2 (1-4), p<0.01). There was no significant difference between the two groups in the number of patients with ADE (71/374 patients (19%) with 96 ADE vs 80/372 patients (22%) with 108 ADE, p=0.44).

CONCLUSIONS AND RELEVANCE

A BPMH performed by a pharmacist using a nationwide EPR at the time of preoperative evaluation contributed to reducing AE, potentially preventing harm to patients.

TRIAL REGISTRATION NUMBER

NCT02071472.

Impact of Chinese criteria on potentially inappropriate medication use in China

Background

In 2018, China issued a set of criteria for effectively identifying and managing potentially inappropriate medication (PIM) use in older adults. However, there is currently a lack of evidence regarding the impact of these criteria on PIM use among older Chinese adults.

Methods

We used interrupted time series analysis on the prescription data of older outpatients from 59 hospitals in six major geographic regions of China to compare changes in the overall prevalence of PIM use, the prevalence of PIM use stratified by different numbers of PIMs, and the prevalence of top five PIMs (i.e. clopidogrel, estazolam, zolpidem, sliding-scale insulin, and alprazolam) from 2015 (before) to 2021 (after) the release of criteria in 2018.

Results

We included 982 605 older outpatients. Compared with trends prior to the publication of the criteria, there were significant decreases in the coefficient for change in the slope of the overall prevalence of PIM use (β = -0.607; 95% confidence interval (CI) = -0.881, -0.482; P < 0.001), the prevalence of single PIM use (β = -0.368; 95% CI = -0.465, -0.272; P < 0.001), the prevalence of multiple PIM use (β = -0.104; 95% CI = -0.173, -0.080; P = 0.019), the prevalence of clopidogrel (β = -0.342; 95% CI = -0.463, -0.227; P = 0.006), and the prevalence of estazolam (β = -0.077; 95% CI = -0.124, -0.037; P = 0.009) post-publication. Conversely, there was a significant increase in the prevalence of zolpidem, after the criteria were released (β = 0.030; 95% CI = 0.002, 0.057; P = 0.036).

Conclusions

We found that the release of criteria for effectively identifying and managing PIM use has had a positive effect on its prevalence among older outpatients in China.

Practice-enhancing publications about the medication-use process in 2021

PURPOSE

This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2021 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, and monitoring/medication reconciliation. Articles evaluating at least one step of the MUP were assessed for their usefulness toward practice improvement.

SUMMARY

A PubMed search was conducted in January 2022 for articles published in calendar year 2021 using targeted Medical Subject Headings (MeSH) keywords, and searches of the table of contents of selected pharmacy journals were conducted, providing a total of 7,178 articles. A thorough review identified 79 potentially practice-enhancing articles: 15 for prescribing/transcribing, 17 for dispensing, 4 for administration, 21 for monitoring, and 22 for monitoring/medication reconciliation. 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 their importance 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 publications. 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.

Development and validation of a nomogram to predict the risk of potentially inappropriate medication use in older lung cancer outpatients with multimorbidity

BACKGROUND

At present, there is no predictive model that can predict the prevalence of potentially inappropriate medication (PIM) use in older lung cancer outpatients.

RESEARCH DESIGN AND METHODS

We measured PIM by the 2019 Beers criteria. Significant factors were identified to develop the nomogram using logistic regression. We validated the nomogram internally and externally in two cohorts. The discrimination, calibration, and clinical practicability of the nomogram were verified using receiver operating characteristic (ROC) curve analysis, Hosmer-Lemeshow test, and decision curve analysis (DCA), respectively.

RESULTS

A total of 3300 older lung cancer outpatients were divided into a training cohort (n = 1718) and two validation cohorts, including an internal validation cohort (n = 739) and an external validation cohort (n = 843). A nomogram for predicting PIM use patients was developed using six significant factors. ROC curve analysis showed that the area under the curve was 0.835 in the training cohort and 0.810 and 0.826 in the internal validation and external validation cohorts, respectively. The Hosmer‒Lemeshow test yielded P = 0.180, 0.779 and 0.069, respectively. The nomogram demonstrated a high net benefit in DCA.

CONCLUSIONS

The nomogram could be a convenient, intuitive, and personalized clinical tool for assessing the risk of PIM in older lung cancer outpatients.

Barriers and Facilitators of Communication in the Medication Reconciliation Process during Hospital Discharge: Primary Healthcare Professionals' Perspectives

The WHO established that medication errors are the most common and preventable errors and represent an expenditure of 42 billion U.S. dollars annually. The risk of medication errors increases in transitions between levels of care, mainly from hospital care to primary healthcare after hospital discharge. In this context, communication is a key element in the safety of the medication reconciliation process. The aim of this paper was to describe the barriers to, and facilitators of, effective communication during the medication reconciliation process at hospital discharge in people over 65 years of age, from the perspective of primary healthcare professionals. A qualitative descriptive study was designed, and in-depth interviews were conducted with 21 individuals, of whom 13 were nurses and 8 were physicians. This study was carried out with healthcare professionals belonging to primary healthcare centres in Huelva (Spain). Following content analysis of the discourses we identified 19 categories, grouped into three areas: interlevel communication, communication between primary healthcare professionals, and communication between healthcare professionals and patients/caregivers. The barriers found mainly relate to the adequacy and use of technological tools, time available, workload and the level of collaboration of patients/caregivers. Facilitating elements for communication in medication reconciliation included technologies, such as computerized medical history, protocolization of clinical sessions, the presence of case management nurse and interdisciplinary teamwork.

Impact of the expert consensus on polypharmacy and potentially inappropriate medication use in elderly lung cancer outpatients with multimorbidity: An interrupted time series analysis, 2016–2021

Objectives: Elderly lung cancer patients often have chronic diseases other than lung cancer. Therefore, this kind of population is often accompanied by polypharmacy. This situation and the resulting potentially inappropriate medication (PIM) use are an increasing global concern. In this context, the Chinese Association of Geriatric Research issued an expert consensus on the safety management of polypharmacy. However, the long- and short-term effects of the expert consensus on polypharmacy and PIM use are not clear.

Methods: The study was conducted in Chengdu, a city in southwestern China, consisting of prescriptions for elderly lung cancer outpatients with multimorbidity (cancer with other diseases) from January 2016 to December 2021. The 2019 Beers criteria were used to evaluate PIM use, and interrupted time series analysis was used to evaluate the longitudinal effectiveness of expert consensus by measuring the prevalence of polypharmacy and PIM use. We used R software version 4.2.0 for data analysis.

Results: A total of 7,238 elderly lung cancer outpatient prescriptions were included in the study. After the publication of the expert consensus, the level (β = -10.273, P &lt; 0.001) of the prevalence of polypharmacy decreased, but the trend (β = 0.158, p = 0.855) of polypharmacy increased. The prevalence of PIM use decreased abruptly (β = -22.828, p &lt; 0.001) after the intervention, but the long-term trend was still upward (β = 0.907, p = 0.916).

Conclusion: The long-term effects of the publication of the expert consensus on the prevalence of polypharmacy and PIM use in hospitals in Chengdu were not optimal. Future research on interventions rationing polypharmacy and PIM use is needed.