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Graafsma J, Murphy RM, van de Garde EMW, Karapinar-Çarkit F, Derijks HJ, Hoge RHL, Klopotowska JE, van den Bemt PMLA. The use of artificial intelligence to optimize medication alerts generated by clinical decision support systems: a scoping review. J Am Med Inform Assoc 2024:ocae076. [PMID: 38641410 DOI: 10.1093/jamia/ocae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/21/2024] [Accepted: 03/28/2024] [Indexed: 04/21/2024] Open
Abstract
OBJECTIVE Current Clinical Decision Support Systems (CDSSs) generate medication alerts that are of limited clinical value, causing alert fatigue. Artificial Intelligence (AI)-based methods may help in optimizing medication alerts. Therefore, we conducted a scoping review on the current state of the use of AI to optimize medication alerts in a hospital setting. Specifically, we aimed to identify the applied AI methods used together with their performance measures and main outcome measures. MATERIALS AND METHODS We searched Medline, Embase, and Cochrane Library database on May 25, 2023 for studies of any quantitative design, in which the use of AI-based methods was investigated to optimize medication alerts generated by CDSSs in a hospital setting. The screening process was supported by ASReview software. RESULTS Out of 5625 citations screened for eligibility, 10 studies were included. Three studies (30%) reported on both statistical performance and clinical outcomes. The most often reported performance measure was positive predictive value ranging from 9% to 100%. Regarding main outcome measures, alerts optimized using AI-based methods resulted in a decreased alert burden, increased identification of inappropriate or atypical prescriptions, and enabled prediction of user responses. In only 2 studies the AI-based alerts were implemented in hospital practice, and none of the studies conducted external validation. DISCUSSION AND CONCLUSION AI-based methods can be used to optimize medication alerts in a hospital setting. However, reporting on models' development and validation should be improved, and external validation and implementation in hospital practice should be encouraged.
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Affiliation(s)
- Jetske Graafsma
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, 9713GZ, The Netherlands
| | - Rachel M Murphy
- Department of Medical Informatics Amsterdam UMC, University of Amsterdam, Amsterdam, 1000GG, The Netherlands
- Amsterdam Public Health Institute, Digital Health and Quality of Care, Amsterdam, 1105AZ, The Netherlands
| | - Ewoudt M W van de Garde
- Department of Pharmacy, St Antonius Hospital, Utrecht, 3430AM, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, 3584CS, The Netherlands
| | - Fatma Karapinar-Çarkit
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, Maastricht, 6229HX, The Netherlands
- Department of Clinical Pharmacy, CARIM, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, 6229ER, The Netherlands
| | - Hieronymus J Derijks
- Department of Pharmacy, Jeroen Bosch Hospital, Den Bosch, 5200ME, The Netherlands
| | - Rien H L Hoge
- Department of Pharmacy, Wilhelmina Hospital, Assen, 9401RK, The Netherlands
| | - Joanna E Klopotowska
- Department of Medical Informatics Amsterdam UMC, University of Amsterdam, Amsterdam, 1000GG, The Netherlands
- Amsterdam Public Health Institute, Digital Health and Quality of Care, Amsterdam, 1105AZ, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, 9713GZ, The Netherlands
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van Uden RCAE, Jaspers TCC, Meijer K, van Stralen KJ, Maat B, Khorsand N, van Onzenoort HAW, Swart EL, Huls HJ, Mathôt RAA, Lukens MV, van den Bemt PMLA, Becker ML. Smaller nadroparin dose reductions required for patients with renal impairment: A multicenter cohort study. Thromb Res 2024; 236:4-13. [PMID: 38377636 DOI: 10.1016/j.thromres.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/31/2024] [Accepted: 02/05/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Guidelines advise 50 % and 25 % dose reduction of the therapeutic nadroparin dose (86 IU/kg) in patients with eGFR 15-29 and 30-60 ml/min respectively. For monitoring, peak anti-Xa levels are suggested. Data lack whether this results in therapeutic anti-Xa levels or in anti-Xa levels that are comparable to those of patients without renal impairment. AIMS To determine dose ranges in patients with renal impairment that result in therapeutic anti-Xa levels and to determine the percentage of the 86 IU/kg dose that results in anti-Xa levels normally occurring in patients without renal impairment. METHODS A retrospective cohort study was conducted in five hospitals. Patients ≥18 years of age, with an eGFR ≥ 15 ml/min were included. The first correctly sampled peak (i.e. 3-5 h after ≥ third administration, regardless of dose per patient) was included. Simulated prediction models were developed using multiple linear regression. RESULTS 770 patients were included. eGFR and hospital affected the association between dose and anti-Xa level. The doses for peak anti-Xa levels of 0.75 IU/ml differed substantially between hospitals and ranged from 55 to 91, 65-359 and 68-168 IU/kg in eGFR 15-29, 30-60 and > 60 ml/min/1.73m2, respectively. In eGFR 15-29 and 30-60 ml/min/1.73m2, doses of 75 % and 91 % of 86 IU/kg respectively, were needed for anti-Xa levels normally occurring in patients with eGFR > 60 ml/min. CONCLUSION We advise against anti-Xa based dose-adjustments as long as anti-Xa assays between laboratories are not harmonized and an anti-Xa target range is not validated. A better approach might be to target levels similar to eGFR > 60 ml/min/1.73m2, which are achieved by smaller dose reductions.
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Affiliation(s)
- Renate C A E van Uden
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, the Netherlands; Pharmacy Foundation of Haarlem Hospitals, Haarlem, the Netherlands; Department of Clinical Pharmacy, Spaarne Gasthuis Hospital, Haarlem/Hoofddorp, the Netherlands.
| | - Tessa C C Jaspers
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, the Netherlands; Department of Hospital Pharmacy, Elisabeth TweeSteden Hospital, Tilburg, the Netherlands
| | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Barbara Maat
- Department of Hospital Pharmacy, Elisabeth TweeSteden Hospital, Tilburg, the Netherlands
| | - Nakisa Khorsand
- Department of Hospital Pharmacy, OLVG, Amsterdam, the Netherlands
| | | | - Eleonora L Swart
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Harmen J Huls
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Ron A A Mathôt
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Michaël V Lukens
- Department of Laboratory Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, the Netherlands
| | - Matthijs L Becker
- Pharmacy Foundation of Haarlem Hospitals, Haarlem, the Netherlands; Department of Clinical Pharmacy, Spaarne Gasthuis Hospital, Haarlem/Hoofddorp, the Netherlands
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Koot C, Rook M, Pols PAM, van den Bemt PMLA, Becker ML. A quality improvement study on the effect of electronic transmission of a basic discharge medication report on medication discrepancies in patients discharged from the hospital. Int J Clin Pharm 2024; 46:131-140. [PMID: 37934347 DOI: 10.1007/s11096-023-01650-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 09/08/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Medication discrepancies can occur in transitions of care because of a lack of communication between hospitals and community pharmacies. These discrepancies can lead to preventable adverse drug events (ADEs). AIM To investigate the effect of electronic transmission of the basic discharge medication report on unintentional medication discrepancies observed between this report and the 28-day post-discharge status in the community pharmacy. METHOD The study took place in a Dutch teaching hospital and 8 community pharmacies. A quality improvement study with a nonrandomized, historically controlled intervention design was performed. The intervention consisted of the electronic transmission of a basic discharge medication report to the community pharmacies. Unintentional medication discrepancies were identified by comparing the basic discharge medication report to the 28-day post-discharge medication record in community pharmacies. The main outcome measure was the proportion of drugs with one or more unintentional discrepancies compared between the historical control group and intervention group, using the chi-square test. Secondary outcome measure was the proportion of patients with one or more unintentional discrepancies. RESULTS The participants used a total of 1078 drugs in the control group and 862 in the intervention group. The intervention significantly reduced the proportion of drugs with an unintentional discrepancy from 230 out of 1078 in the control group (21.3%) to 149 out of 862 drugs in the intervention group (17.3%; p = 0.025). At patient level, a non-significant increase was seen (62.4-78.8%; p = 0.41). CONCLUSION The electronic transmission of the basic discharge medication report reduced the proportion of drugs with an unintentional discrepancy after discharge, but not the proportion of patients.
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Affiliation(s)
- Celine Koot
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC, Haarlem, The Netherlands
- Department of Clinical Pharmacy, Spaarne Gasthuis Hospital, Haarlem, The Netherlands
| | - Marion Rook
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC, Haarlem, The Netherlands
- Department of Clinical Pharmacy, Spaarne Gasthuis Hospital, Haarlem, The Netherlands
| | | | - Patricia M L A van den Bemt
- University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, The Netherlands
| | - Matthijs L Becker
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC, Haarlem, The Netherlands.
- Department of Clinical Pharmacy, Spaarne Gasthuis Hospital, Haarlem, The Netherlands.
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Kingma JS, Brenkman IAM, van den Broek MPH, van den Bemt PMLA, Janssen K, Knibbe CAJ, Burgers DMT. Documentation of the Patient Characteristics Morbid Obesity and Bariatric Surgery in the Hospital Information System and the Influence on the Number of Medication-Related Problems. Ann Pharmacother 2024:10600280231226243. [PMID: 38268179 DOI: 10.1177/10600280231226243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND As a result of pharmacokinetic changes, individuals with morbid obesity and/or with bariatric surgery may require dose adjustments, additional monitoring or medication should be avoided. Clinical decision support (CDS) may provide automated alerts enabling correct prescribing but requires documentation of these patient characteristics in the Hospital Information System (HIS) to prevent medication-related problems (MRPs). OBJECTIVE The primary objective is to determine the proportion of patients with documentation of the patient characteristics morbid obesity and bariatric surgery in the HIS. The secondary objective is to compare the proportion of patients with an MRP in the group with versus without documentation. Also, the type and severity of MRPs and the medication involved are determined. METHODS A prospective cohort study was performed. Patients admitted to the hospital were identified as morbidly obese and/or with bariatric surgery. In the identified patients, the proportion of patients with documentation of the patient characteristics in the HIS was evaluated as primary outcome. Subsequently, patient records were reviewed for MRPs, which were categorized and associated medication was registered. For the primary objective, descriptive statistics was used. For the secondary outcome, the Fisher's exact test was used. RESULTS In 43 (21.4%, 95% confidence interval [CI]: 15.7%-27.1%) of 201 included patient (113 morbid obesity, 70 bariatric surgery and 18 both), the patient characteristics were documented. An MRP occurred in 2.3% versus 13.9% (P = 0.032) of patients with and without documentation, respectively. The most common MRP was underdosing in morbid obesity, while in patients with bariatric surgery it was prescription of contra-indicated medication. CONCLUSION AND RELEVANCE The proportion of patients with documentation of the patient characteristics bariatric surgery and/or morbid obesity in the HIS is low, which appears to be associated with more MRPs. To improve medication safety, it is important to document these patient characteristics.
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Affiliation(s)
- Jurjen S Kingma
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Iris A M Brenkman
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Pharmaceutics, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Marcel P H van den Broek
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Pharmaceutics, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Karin Janssen
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Desirée M T Burgers
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
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Hendrix MRS, Yasar M, Mohammad AK, Hugtenburg JG, Vanhommerig JW, Gündoğan-Yilmaz R, van den Bemt PMLA, Denig P, Karapinar-Carkıt F. Prescription Sequence Symmetry Analysis (PSSA) to assess prescribing cascades: a step-by-step guide. BMC Med Res Methodol 2024; 24:8. [PMID: 38212730 PMCID: PMC10782776 DOI: 10.1186/s12874-023-02108-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 11/20/2023] [Indexed: 01/13/2024] Open
Abstract
Prescribing cascades occur when patients are prescribed medication to treat the adverse drug reaction of previously prescribed medication. Prescription sequence symmetry analysis (PSSA) can be used to assess the association between two medications in prescription or dispensing databases and thus the potential occurrence of prescribing cascades. In this article, a step-by-step guide is presented for conducting PSSA to assess prescribing cascades. We describe considerations for medication data collection and setting time periods for relevant parameters, including washout window, exposure window, continued exposure interval and blackout period. With two examples, we illustrate the impact of changes in these parameters on the strengths of associations observed. Given the impact seen, we recommend that researchers clearly specify and explain all considerations regarding medication included and time windows set when studying prescribing cascades with PSSA, and conduct subgroup and sensitivity analyses.
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Affiliation(s)
- Mandy R S Hendrix
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
| | - Mustafa Yasar
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
| | - Atiya K Mohammad
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Amsterdam, The Netherlands
| | - Jacqueline G Hugtenburg
- Department of Clinical Pharmacology, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands
| | - Joost W Vanhommerig
- Department of Research and Epidemiology, OLVG Hospital, Amsterdam, The Netherlands
| | | | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Amsterdam, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Amsterdam, The Netherlands
| | - Fatma Karapinar-Carkıt
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands.
- Department of Clinical Pharmacy & Toxicology, Maastricht University Medical Center +, Maastricht, the Netherlands.
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.
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Adrien O, Mohammad AK, Hugtenburg JG, McCarthy LM, Priester-Vink S, Visscher R, van den Bemt PMLA, Denig P, Karapinar-Carkıt F. Prescribing Cascades with Recommendations to Prevent or Reverse Them: A Systematic Review. Drugs Aging 2023; 40:1085-1100. [PMID: 37863868 PMCID: PMC10682291 DOI: 10.1007/s40266-023-01072-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND To reduce prescribing cascades occurring in clinical practice, healthcare providers require information on the prescribing cascades they can recognize and prevent. OBJECTIVE This systematic review aims to provide an overview of prescribing cascades, including dose-dependency information and recommendations that healthcare providers can use to prevent or reverse them. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. Relevant literature was identified through searches in OVID MEDLINE, OVID Embase, OVID CINAHL, and Cochrane. Additionally, Web of Science and Scopus were consulted to analyze reference lists and citations. Publications in English were included if they analyzed the occurrence of prescribing cascades. Prescribing cascades were included if at least one study demonstrated a significant association and were excluded when the adverse drug reaction could not be confirmed in the Summary of Product Characteristics. Two reviewers independently extracted and grouped similar prescribing cascades. Descriptive summaries were provided regarding dose-dependency analyses and recommendations to prevent or reverse these prescribing cascades. RESULTS A total of 95 publications were included, resulting in 115 prescribing cascades with confirmed adverse drug reactions for which at least one significant association was found. For 52 of these prescribing cascades, information regarding dose dependency or recommendations to prevent or reverse prescribing cascades was found. Dose dependency was analyzed and confirmed for 12 prescribing cascades. For example, antipsychotics that may cause extrapyramidal syndrome followed by anti-parkinson drugs. Recommendations focused on dosage lowering, discontinuing medication, and medication switching. Explicit recommendations regarding alternative options were given for three prescribing cascades. One example was switching to ondansetron or granisetron when extrapyramidal syndrome is experienced using metoclopramide. CONCLUSIONS In total, 115 prescribing cascades were identified and an overview of 52 of them was generated for which recommendations to prevent or reverse them were provided. Nonetheless, information regarding alternative options for managing prescribing cascades was scarce.
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Affiliation(s)
- Oriane Adrien
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
| | - Atiya K Mohammad
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jacqueline G Hugtenburg
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
| | - Lisa M McCarthy
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Leslie Dan Faculty of Pharmacy and Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Robbert Visscher
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Fatma Karapinar-Carkıt
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands.
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, The Netherlands.
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van Uden RCAE, Bakker MA, Joosten SGL, Meijer K, van den Bemt PMLA, Becker ML, Vervloet M. Implementation of a Patient Questionnaire in Community Pharmacies to Improve Care for Patients Using Combined Antithrombotic Therapy: A Qualitative Study. Pharmacy (Basel) 2023; 11:80. [PMID: 37218962 PMCID: PMC10204406 DOI: 10.3390/pharmacy11030080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/12/2023] [Accepted: 04/24/2023] [Indexed: 05/24/2023] Open
Abstract
For several indications or combinations of indications the use of more than one antithrombotic agent is required. The duration of combined antithrombotic therapy depends on indication and patient characteristics. This study investigated the use of an antithrombotic questionnaire tool that had been developed for pharmacists to detect patients with possible incorrect combined antithrombotic therapy. The objective of this study was to identify potential barriers and facilitators that could influence the implementation of the developed antithrombotic questionnaire tool in daily community pharmacy practice. A qualitative study was conducted at 10 Dutch community pharmacies in which the antithrombotic questionnaire tool had been used with 82 patients. Semi-structured interviews were conducted with pharmacy staff who used the antithrombotic questionnaire tool. The interview questions to identify barriers and facilitators were based on the Consolidated Framework for Implementation Research. The interview data were analysed using a deductive thematic analysis. Ten staff members from nine different pharmacies were interviewed. Facilitators for implementation were that the questionnaire was easily adaptable and easy to use, as well as the relative short duration to administer the questionnaire. A possible barrier for using the questionnaire was a lower priority for using the questionnaire at moments when the workload was high. The pharmacists estimated that the questionnaire could be used for 70-80% of the patient population and they thought that it was a useful addition to regular medication surveillance. The antithrombotic questionnaire tool can be easily implemented in pharmacy practice. To implement the tool, the focus should be on integrating its use into daily activities. Pharmacists can use this tool in addition to regular medication surveillance to improve medication safety in patients who use combined antithrombotic therapy.
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Affiliation(s)
- Renate C. A. E. van Uden
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC Haarlem, The Netherlands
- Department of Clinical Pharmacy, Spaarne Gasthuis Hospital, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Marit A. Bakker
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC Haarlem, The Netherlands
| | - Stephan G. L. Joosten
- Community Pharmacy BENU Pharmacy Nieuwpoort, Jan van der Heydenweg 352, 3401 RJ IJsselstein, The Netherlands
| | - Karina Meijer
- Department of Haematology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Patricia M. L. A. van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Matthijs L. Becker
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC Haarlem, The Netherlands
- Department of Clinical Pharmacy, Spaarne Gasthuis Hospital, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands
| | - Marcia Vervloet
- Nivel, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN Utrecht, The Netherlands
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Hek K, Lghoul-Oulad Saïd F, Korevaar JC, Flinterman LE, van Dijk L, van den Bemt PMLA. Adherence to coprescribing of laxatives with opioids and associated characteristics in general practices in the Netherlands. BMC Prim Care 2022; 23:312. [PMID: 36464672 PMCID: PMC9721085 DOI: 10.1186/s12875-022-01911-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/07/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Guidelines recommend to prescribe a laxative with an opioid to prevent constipation. We aimed to determine the adherence by general practitioners (GPs) to this recommendation and to explore which GP- and patient related factors were associated with it from the perspective of the GP. METHODS: We conducted an observational study using GPs' prescription data from the Nivel Primary Care Database combined with a questionnaire asking for reasons of non-adherence. The proportion of first opioid prescriptions prescribed together with a laxative was determined as primary outcome. Possible explanatory factors such as the quality of registration, the level of collaboration with the pharmacy, familiarity with the recommendation and use of a clinical decision support system were explored, as were the self-reported reasons for non-adherence (classified as either GP-related or patient-related). We assessed the association of factors with the primary outcome using univariable multilevel logistic regression analysis. RESULTS The recommendation was measured in 195 general practices. The median proportion of first opioid prescriptions prescribed together with a laxative in these practices was 54% (practice range 18-88%). None of the determinants was consistently associated with the primary outcome. GPs from 211 practices filled out the questionnaire and the most frequently mentioned reason not to prescribe a laxative was that the patient has laxatives in stock, followed by that the patient doesn't want a laxative; both were patient-related factors. CONCLUSION There was room for improvement in following the guideline on laxative prescribing in opioid use. A main reason seemed to be that the patient refuses a laxative. Improvement measures should therefore focus on communication between GPs and patients on the relevance of co-using a laxative with opioids. Future studies need to establish the effect of such improvement measures, and determine whether reasons for non-adherence to the guideline changed over time.
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Affiliation(s)
- Karin Hek
- grid.416005.60000 0001 0681 4687Nivel, Netherlands Institute for Health Services Research, PO box 1568, 3500 BN Utrecht, The Netherlands
| | - Fouzia Lghoul-Oulad Saïd
- grid.5132.50000 0001 2312 1970Division of BioTherapeutics, Leiden Academic Centre for Drug Research (LACDR), Gorlaeus Laboratories, Leiden University, Leiden, The Netherlands ,grid.4494.d0000 0000 9558 4598Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands ,grid.5645.2000000040459992XDepartment of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joke C. Korevaar
- grid.416005.60000 0001 0681 4687Nivel, Netherlands Institute for Health Services Research, PO box 1568, 3500 BN Utrecht, The Netherlands
| | - Linda E. Flinterman
- grid.416005.60000 0001 0681 4687Nivel, Netherlands Institute for Health Services Research, PO box 1568, 3500 BN Utrecht, The Netherlands
| | - Liset van Dijk
- grid.416005.60000 0001 0681 4687Nivel, Netherlands Institute for Health Services Research, PO box 1568, 3500 BN Utrecht, The Netherlands ,grid.4830.f0000 0004 0407 1981Department of PharmacoTherapy, -Epidemiology and -Economics (PTEE), Groningen Research Institute of Pharmacy, Faculty of Science and Engineering, University of Groningen, Groningen, the Netherlands
| | - Patricia M. L. A. van den Bemt
- grid.4494.d0000 0000 9558 4598Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
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Hassan D, Versmissen J, Hek K, van Dijk L, van den Bemt PMLA. Feasibility of a protocol for deprescribing antihypertensive medication in older patients in Dutch general practices. BMC Prim Care 2022; 23:280. [PMID: 36352363 PMCID: PMC9644553 DOI: 10.1186/s12875-022-01894-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Older patients using antihypertensive medication may experience Adverse Drug Events (ADEs), and thus benefit from deprescribing. The lack of a practical protocol may hamper deprescribing. Therefore, we aimed to develop a deprescribing protocol, based on a review of literature, combined with a feasibility test in a small number of patients. METHODS A deprescribing protocol for general practitioners was drafted and tested in older patients using multiple antihypertensive medication in a single arm intervention. Patients were included if they were 75 years or older, were using two or more antihypertensives, had at least one ADE linked to antihypertensive medication and deprescribing was considered to be safe by their general practitioner. The primary outcome was the percentage of patients for whom one or more antihypertensive drugs were stopped or reduced in dose after 12 months of follow up while maintaining safe blood pressures. Secondary outcomes were the proportion of patients reporting no ADEs after 12 months and the number of deprescribed antihypertensives. Patient's opinions on deprescribing and enablers and barriers for study participation were also collected. RESULTS Nine general practitioners included 14 patients to deprescribe antihypertensive medication using the deprescribing protocol. After 12 months antihypertensive drug use was lowered in 11 patients (79%). These patients had a mean systolic blood pressure increase of 16 mmHg and a mean diastolic blood pressure increase of 8 mmHg. Nine patients (64%) reported experiencing no ADEs anymore after twelve months. The mean number of deprescribed antihypertensives was 1.1 in all patients and 1.4 (range: 0.5 to 3.5) in patients who successfully lowered their medication. At baseline, being able to use less medication was the most frequently mentioned enabler to participate in this study. The most frequently mentioned positive experience at the end of the study was using less medication, which was in line with the most mentioned enabler to participate in this study. CONCLUSION A protocol for deprescribing antihypertensives in older patients was considered feasible, as it resulted in a substantial degree of safe deprescribing in this pilot study. Larger studies are needed to demonstrate the effect and safety of deprescribing antihypertensives in older patients.
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Affiliation(s)
- Dimokrat Hassan
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Jorie Versmissen
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Karin Hek
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Liset van Dijk
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Unit of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
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10
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Aalouch O, Duisenberg-van Essenberg M, van Eijs F, Spoor AB, Maat B, van den Bemt PMLA. Prolonged oxycodone use and potential risk factors in postoperative patients: a case control study. Int J Clin Pharm 2022; 44:1259-1268. [PMID: 35819594 DOI: 10.1007/s11096-022-01441-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/06/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Prolonged exposure to opioids has a negative influence on the physical and mental health of a person. Currently, little is known about the risk of prolonging opioids after first postoperative use. AIM A study was conducted to define the proportion of postoperative patients that use oxycodone longer than prescribed to determine risk factors of prolonged use. METHOD This retrospective single-center nested case-control study was performed in the Elisabeth Tweesteden Hospital. The study population consisted of postoperative adult patients who received an oxycodone prescription at discharge between April 2018 and June 2020. The primary outcome was the proportion of patients with at least one refill of oxycodone during a follow-up period of 30 days. The secondary outcome was the association of potential risk factors with oxycodone refills. Univariate and multivariate logistic regression analyses were performed to determine the association between the variables and outcome. RESULTS 1203 patients were included of which 280 (23.3%) received one or more refill. Age (adjusted odds ratio 1.01 [95% confidence interval 1.00-1.02]), length of stay (1.10 [1.06-1.14], a Numeric Rating Scale pain score of four or higher (1.52 [1.14-2.01]), use of the continuous release form only (2.15 [1.60-2.89]) and admission to various hospital departments were associated with a refill of oxycodone . CONCLUSION The proportion of patients with a refill of oxycodone is 23.3%. This could result in chronic oxycodone use and potential misuse. Patients with the determined risk factors may be a suitable population for future interventions to minimize prolonged use.
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Affiliation(s)
- Oumaima Aalouch
- School of Pharmacy, Utrecht University, Utrecht, The Netherlands.
| | | | - Frank van Eijs
- Department of Anesthesiology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Andy B Spoor
- Department of Orthopedics, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Barbara Maat
- Department of Hospital Pharmacy, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
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11
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van Herpen-Meeuwissen LJM, van den Bemt BJF, Derijks HJ, van den Bemt PMLA, Maat B, van Onzenoort HAW. The effect of Patient's Own Medication use on patient's self-reported medication knowledge during hospitalisation: a pre-post intervention study. BMC Health Serv Res 2022; 22:423. [PMID: 35354464 PMCID: PMC8969375 DOI: 10.1186/s12913-022-07752-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/04/2022] [Indexed: 11/30/2022] Open
Abstract
Background Improving patient’s medication knowledge and consequently medication use is essential for optimal treatment outcomes. As patient knowledge about medication is currently suboptimal, interventions to optimise medication knowledge are necessary. Implementation of Patient’s Own Medication (POM) in which patients bring their outpatient medication to the hospital, and nurses administer these during admission, may increase medication knowledge. The aim of this study is to explore the impact of POM use on self-reported medication knowledge of hospitalised patients compared to standard care. Patient’s sense of medication safety, attitude to the provision of information, and to inpatient medication use were studied in both standard care and during POM use too. Method In this nationwide intervention study perceived medication knowledge was assessed with a questionnaire pre and post implementing POM use. The questionnaire assessed perceived medication knowledge at admission and discharge, medication safety during hospitalisation, the provision of information during hospitalisation and at discharge, and inpatient medication use during hospitalisation. Patients’ answers were categorised into positive and negative/neutral. The proportion of patients with adequate medication knowledge, in the standard care and POM use group at hospital admission and discharge, were calculated and compared with adjustment for potential confounders. Results Among the 731 patients (393 received standard care and 338 POM) who completed the questionnaire (80.2%), POM use seemed to be positively associated with self-reported knowledge on how to use medication at discharge (adjusted OR: 3.22 [95% CI 2.01–5.16]). However, for the other two knowledge related statements POM use was not associated. Medication knowledge at admission was the most important variable associated with perceived medication knowledge at discharge. The majority perceived POM use to be safer (52.9% of standard care patients versus 74.0% POM users; P < 0.01), POM users knew better which medicines they still used during hospitalisation (85.8% versus 92.3% resp.; P = 0.01), and most patients preferred POM use regardless of having experienced it (68.2% versus 82.2% resp.; P < 0.01). Conclusion POM use positively affects patient’s medication knowledge about how to use medication and patients’ perception of medication safety. With POM use more patients have a positive attitude towards the provision of information. The majority of patients prefer POM use. In conclusion, POM use seems a valuable intervention and requires further investigation. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07752-6.
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Affiliation(s)
- Loes J M van Herpen-Meeuwissen
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands. .,Department of Pharmacy, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.
| | - Bart J F van den Bemt
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Hieronymus J Derijks
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Department of Pharmacy, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Barbara Maat
- Department of Pharmacy, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Hein A W van Onzenoort
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, Netherlands
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12
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van Herpen-Meeuwissen LJM, van Onzenoort HAW, van den Bemt PMLA, Maat B, van den Bemt BJF. The Effect of Self-Administration of Medication During Hospitalization on Patient's Self-Efficacy and Medication Adherence After Discharge. Patient Prefer Adherence 2022; 16:2683-2693. [PMID: 36196066 PMCID: PMC9527028 DOI: 10.2147/ppa.s375295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/19/2022] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The effect of self-administration of medication (SAM), in which capable hospitalized patients administer medication themselves on medication self-efficacy is inconclusive. The aim of this study was to evaluate the effect of SAM on medication self-efficacy, adherence and patient satisfaction. PATIENTS AND METHODS A prospective pre-post intervention study on the orthopedic ward of the Sint Maartenskliniek (Nijmegen) was conducted from January 2020 to July 2021. All adults admitted to this ward were eligible for participation. The primary outcome was the level of medication self-efficacy measured by the Self-Efficacy for Appropriate Medication Use Scale (SEAMS) one week after discharge. Secondary outcomes were SEAMS-score three months after hospitalization, medication adherence measured by the Medication Adherence Rating Scale (MARS) one week and three months after hospitalization and patient satisfaction expressed on a five-point Likert scale in patients who experienced SAM. The differences in median SEAMS-scores and non-adherence pre- versus post-implementation of SAM were statistically analyzed. Patients' agreement regarding satisfaction with SAM was calculated as proportion per Likert scale answer. RESULTS Of the 197 patients participating in the study, 96 were included pre- and 101 post-implementation of SAM. Median SEAMS-scores one week after discharge were 35 [IQR 31-38] and 34 [IQR 30-36] pre- and post-intervention respectively (p = 0.08). There was no difference in the proportion of non-adherent patients at one week and three months after discharge pre- and post-intervention, 52.4%, 53.2%, 57.9% and 64.4% respectively. Of the patients that experienced SAM 32% agreed and 49% strongly agreed that they would like to self-manage medication again during a future hospitalization. CONCLUSION In this orthopedic population with high medication self-efficacy scores at discharge, SAM did not affect patients' medication self-efficacy nor medication adherence after hospitalization. Most patients preferred SAM. Additional studies should focus on the effect of SAM in other patient populations.
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Affiliation(s)
- Loes J M van Herpen-Meeuwissen
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
- Department of Pharmacy, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
- Correspondence: Loes JM van Herpen-Meeuwissen, Department of Pharmacy, Radboud University Medical Centre, PO Box 9101, Nijmegen, the Netherlands, Tel +31 624 3617744, Email
| | - Hein A W van Onzenoort
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Barbara Maat
- Department of Pharmacy, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, the Netherlands
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13
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Berger FA, van Weteringen W, van der Sijs H, Hunfeld NGM, Bunge JJH, de Groot NMS, van den Bemt PMLA, van Gelder T. Dynamics of the QTc interval over a 24-h dose interval after start of intravenous ciprofloxacin or low-dose erythromycin administration in ICU patients. Pharmacol Res Perspect 2021; 9:e00865. [PMID: 34697899 PMCID: PMC8546217 DOI: 10.1002/prp2.865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 08/07/2021] [Accepted: 08/10/2021] [Indexed: 11/17/2022] Open
Abstract
QTc interval prolongation is an adverse effect associated with the use of fluoroquinolones and macrolides. Ciprofloxacin and erythromycin are both frequently prescribed QTc-prolonging drugs in critically ill patients. Critically ill patients may be more vulnerable to developing QTc prolongation, as several risk factors can be present at the same time. Therefore, it is important to know the QTc-prolonging potential of these drugs in the intensive care unit (ICU) population. The aim of this study was to assess the dynamics of the QTc interval over a 24-hour dose interval during intravenous ciprofloxacin and low-dose erythromycin treatment. Therefore, an observational study was performed in ICU patients (≥18 years) receiving ciprofloxacin 400 mg t.i.d. or erythromycin 100 mg b.i.d. intravenously. Continuous ECG data were collected from 2 h before to 24 h after the first administration. QT-analyses were performed using high-end holter software. The effect was determined with a two-sample t-test for clustered data on all QTc values. A linear mixed model by maximum likelihood was applied, for which QTc values were assessed for the available time intervals and therapy. No evident effect over time on therapy with ciprofloxacin and erythromycin was observed on QTc time. There was no significant difference (p = 0.22) in QTc values between the ciprofloxacin group (mean 393 ms) and ciprofloxacin control group (mean 386 ms). The erythromycin group (mean 405 ms) and erythromycin control group (mean 404 ms) neither showed a significant difference (p = 0.80). In 0.6% of the registrations (1.138 out of 198.270 samples) the duration of the QTc interval was longer than 500 ms. The index groups showed slightly more recorded QTc intervals over 500 ms. To conclude, this study could not identify differences in the QTc interval between the treatments analyzed.
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Affiliation(s)
- Florine A. Berger
- Department of Hospital PharmacyErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - Willem van Weteringen
- Department of Paediatric SurgeryErasmus MC Sophia Children’s Hospital, University Medical Center RotterdamRotterdamthe Netherlands
| | - Heleen van der Sijs
- Department of Hospital PharmacyErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - Nicole G. M. Hunfeld
- Department of Hospital PharmacyErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
- Department of Intensive CareErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - Jeroen J. H. Bunge
- Department of Intensive CareErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
- Department of CardiologyErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - Natasja M. S. de Groot
- Department of CardiologyErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - Patricia M. L. A. van den Bemt
- Department of Hospital PharmacyErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
- Department of Clinical Pharmacy and PharmacologyUniversity Medical Center GroningenGroningenthe Netherlands
| | - Teun van Gelder
- Department of Hospital PharmacyErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
- Department of Clinical Pharmacy and ToxicologyLeiden University Medical CenterLeidenthe Netherlands
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14
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Tauritz Bakker LA, van Dijk L, van den Bemt PMLA. Exploring the Prescribing Process of Domperidone for Low Milk Supply: A Qualitative Study Among Mothers, IBCLCs, and Family Doctors. J Hum Lact 2021; 37:748-760. [PMID: 33180685 PMCID: PMC8641033 DOI: 10.1177/0890334420964070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND When mothers are confronted with milk supply problems, taking domperidone is regularly suggested. However, domperidone has been associated with sudden cardiac death and caution in prescribing is advised. In 2016, a multidisciplinary group of authors from a tertiary academic hospital (Erasmus MC) published a clinical protocol in a leading Dutch physicians' journal to support Dutch family physicians in prescribing domperidone to stimulate lactation. RESEARCH AIM To explore consumer and health care provider perspectives and experiences regarding the prescribing of domperidone for lactation insufficiency following publication of a national clinical protocol. METHODS A cross-sectional qualitative study was performed using semi-structured interviews (N = 40) based on a topic list covering the prescribing process. Participants were mothers (n = 18) who had been advised to try domperidone to boost their milk supply between November 2016 and May 2018, their International Board Certified Lactation Consultants (n = 9), and their family physicians (n = 15). Another group of participants (mothers; n = 6) answered short questionnaires. All interviews were recorded, transcribed and analyzed using ATLAS.ti software. The resulting list of codes was organized according to the topics. RESULTS In the process leading to domperidone use to stimulate lactation, participant family physicians relied on the IBCLC, pharmacist, or mother to guide the prescription of domperidone, often citing the published national clinical protocol as back up. The medical safeguards incorporated in the protocol (e.g., taking medical history, physical exam, performing electrocardiograms, limiting dosage) were usually not implemented. CONCLUSIONS Though the availability of a national clinical protocol in which the prescribing of domperidone for lactation is supported appeared to increase the willingness of participant family physicians to prescribe, gaps were identified between clinical practice and this clinical protocol for prescribing domperidone.
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Affiliation(s)
| | - Liset van Dijk
- 8123 NIVEL (Netherlands Institute for Health Services Research), Utrecht, The Netherlands.,Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, Groningen, The Netherlands
| | - Patricia M L A van den Bemt
- 10173 Hospital Pharmacist and Professor of Medication Safety, Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
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15
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Cornelissen N, Karapinar-Çarkit F, Heer SEND, Uitvlugt EB, Hugtenburg JG, van den Bemt PMLA, van den Bemt BJF, Bekker CL. Application of intervention mapping to develop and evaluate a pharmaceutical discharge letter to improve information transfer between hospital and community pharmacists. Res Social Adm Pharm 2021; 18:3297-3302. [PMID: 34690086 DOI: 10.1016/j.sapharm.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/27/2021] [Accepted: 10/01/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Insufficient information transfer is a major barrier in the transition from hospital to home. This study describes the systematic development and evaluation of an intervention to improve medication information transfer between hospital and community pharmacists. OBJECTIVE To develop and evaluate an intervention to improve the medication information transfer between hospital and community pharmacists based on patients', community and hospital pharmacists' needs. METHODS The intervention development and evaluation was guided by the six-step Intervention Mapping (IM) approach: (1) needs assessment to identify determinants of the problem, with a scoping review and focus groups with patients and healthcare providers, (2) formulation of intervention objectives with an expert group, (3) inventory of communication models to design the intervention, (4) using literature review and qualitative research with pharmacists and patients to develop the intervention (5) pilot-testing of the intervention in two hospitals, and (6) a qualitative evaluation of the intervention as part of a multicenter before-after study with hospital and community pharmacists. RESULTS Barriers in the information transfer are mainly time and content related. The intervention was designed to target a complete, accurate and timely medication information transfer between hospital and community pharmacists. A pharmaceutical discharge letter was developed to improve medication information transfer. Hospital and community pharmacists were positive about the usability, content, and comprehensiveness of the pharmaceutical discharge letter, which gave community pharmacists sufficient knowledge about in-hospital medication changes. However, hospital pharmacists reported that it was time-consuming to draft the discharge letter and not always feasible to send it on time. The intervention showed that pharmacists are positive about the usability, content and comprehensiveness. CONCLUSION This study developed an intervention systematically to improve medication information transfer, consisting of a discharge letter to be used by hospital and community pharmacists supporting continuity of care.
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Affiliation(s)
- Nicky Cornelissen
- Department of Clinical Pharmacy, Jan Tooropstraat 164, 1061AE, Amsterdam, the Netherlands
| | - Fatma Karapinar-Çarkit
- Department of Clinical Pharmacy, Jan Tooropstraat 164, 1061AE, Amsterdam, the Netherlands.
| | - Selma En-Nasery-de Heer
- Amsterdam UMC, Location Vumc, Department of Clinical Pharmacology and Pharmacy, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| | - Elien B Uitvlugt
- Department of Clinical Pharmacy, Jan Tooropstraat 164, 1061AE, Amsterdam, the Netherlands.
| | - Jacqueline G Hugtenburg
- Amsterdam UMC, Location Vumc, Department of Clinical Pharmacology and Pharmacy, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| | - Patricia M L A van den Bemt
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy. University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands.
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, the Netherlands; Department of Pharmacy, Radboud University Medical Centre, Nijmegen, 6525 GA, the Netherlands.
| | - Charlotte L Bekker
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, 6525 GA, the Netherlands.
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16
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Uitvlugt EB, Heer SEND, van den Bemt BJF, Bet PM, Sombogaard F, Hugtenburg JG, van den Bemt PMLA, Karapinar-Çarkit F. The effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge from hospital in patients with polypharmacy. Res Social Adm Pharm 2021; 18:2651-2658. [PMID: 34049802 DOI: 10.1016/j.sapharm.2021.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 05/13/2021] [Accepted: 05/16/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Transitional care programs (i.e. interventions delivered both in hospital and in primary care), could increase continuity and consequently quality of care. However, limited studies on the effect of these programs on Adverse Drug Events (ADEs) post-discharge are available. Therefore, the aim of this study was to investigate the effect of a transitional pharmaceutical care program on the occurrence of ADEs 4 weeks post-discharge. METHODS A multicentre prospective before-after study was performed in a general teaching hospital, a university hospital and 49 community pharmacies. The transitional pharmaceutical care program consisted of: teach-back to the patient at discharge, a pharmaceutical discharge letter, a home visit by a community pharmacist and a clinical medication review by both the community and the clinical pharmacist, on top of usual care. Usual care consisted of medication reconciliation at admission and discharge by pharmacy teams. The primary outcome was the proportion of patients who reported at least 1 ADE 4 weeks post-discharge. Multivariable logistic regression was used to adjust for potential confounders. RESULTS In total, 369 patients were included (control: n = 195, intervention: n = 174). The proportion of patients with at least 1 ADE did not statistically significant differ between the intervention and control group (general teaching hospital: 59% vs. 67%, ORadj 0.70 [95% CI 0.38-1.31], university hospital: 63% vs 50%, OR adj 1.76 [95% CI 0.75-4.13]). CONCLUSION The transitional pharmaceutical care program did not decrease the proportion of patients with ADEs after discharge. ADEs after discharge were common and more than 50% of patients reported at least 1 ADE. A process evaluation is needed to gain insight into how a transitional pharmaceutical care program could diminish those ADEs.
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Affiliation(s)
- Elien B Uitvlugt
- Department of Clinical Pharmacy, Jan Tooropstraat 164, 1061AE, Amsterdam, the Netherlands.
| | - Selma En-Nasery-de Heer
- Department of Clinical Pharmacology and Pharmacy, De Boelelaan 1117, 1081, HV, Amsterdam, the Netherlands.
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands. Department of Pharmacy, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - Pierre M Bet
- Department of Clinical Pharmacology and Pharmacy, De Boelelaan 1117, 1081, HV, Amsterdam, the Netherlands.
| | - Ferdi Sombogaard
- Department of Clinical Pharmacology and Pharmacy, De Boelelaan 1117, 1081, HV, Amsterdam, the Netherlands.
| | - Jacqueline G Hugtenburg
- Department of Clinical Pharmacology and Pharmacy, De Boelelaan 1117, 1081, HV, Amsterdam, the Netherlands.
| | - Patricia M L A van den Bemt
- University Medical Center Rotterdam, Department of Hospital Pharmacy. University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands.
| | - Fatma Karapinar-Çarkit
- Department of Clinical Pharmacy, Jan Tooropstraat 164, 1061AE, Amsterdam, the Netherlands.
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17
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Cox JM, van Doorn L, Malmberg R, Oomen-de Hoop E, Bosch TM, van den Bemt PMLA, Boere IA, Jager A, Mathijssen RHJ, van Leeuwen RWF. The added value of H 2 antagonists in premedication regimens during paclitaxel treatment. Br J Cancer 2021; 124:1647-1652. [PMID: 33762718 PMCID: PMC8110571 DOI: 10.1038/s41416-021-01313-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/17/2020] [Accepted: 01/27/2021] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Ranitidine, a histamine 2 blocker, is the standard of care to prevent hypersensitivity reactions (HSRs) caused by paclitaxel infusion. However, the added value of ranitidine in this premedication regimen is controversial. Therefore, we compared the incidence of HSRs during paclitaxel treatment between a standard regimen including ranitidine and a regimen without ranitidine. METHODS This prospective, pre-post interventional, non-inferiority study compared the standard premedication regimen (N = 183) with dexamethasone, clemastine and ranitidine with a premedication regimen without ranitidine (N = 183). The primary outcome was the incidence of HSR grade ≥3. Non-inferiority was determined by checking whether the upper bound of the two-sided 90% confidence interval (CI) for the difference in HSR rates excluded the +6% non-inferiority margin. RESULTS In both the pre-intervention (with ranitidine) and post-intervention (without ranitidine) group 183 patients were included. The incidence of HSR grade ≥3 was 4.4% (N = 8) in the pre-intervention group and 1.6% (N = 3) in the post-intervention group: difference -2.7% (90% CI: -6.2 to 0.1). CONCLUSIONS As the upper boundary of the 90% CI does not exceed the predefined non-inferiority margin of +6%, it can be concluded that a premedication regimen without ranitidine is non-inferior to a premedication regimen with ranitidine. CLINICAL TRIAL REGISTRATION www.trialregister.nl ; NL8173.
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Affiliation(s)
- Juul M. Cox
- grid.416213.30000 0004 0460 0556Department of Clinical Pharmacy and Maasstad Lab, Maasstad Hospital, Rotterdam, The Netherlands
| | - Leni van Doorn
- grid.508717.c0000 0004 0637 3764Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ruben Malmberg
- grid.508717.c0000 0004 0637 3764Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands ,grid.5645.2000000040459992XDepartment of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Esther Oomen-de Hoop
- grid.508717.c0000 0004 0637 3764Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Tessa M. Bosch
- grid.416213.30000 0004 0460 0556Department of Clinical Pharmacy and Maasstad Lab, Maasstad Hospital, Rotterdam, The Netherlands
| | - Patricia M. L. A. van den Bemt
- grid.4494.d0000 0000 9558 4598Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Ingrid A. Boere
- grid.508717.c0000 0004 0637 3764Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Agnes Jager
- grid.508717.c0000 0004 0637 3764Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ron H. J. Mathijssen
- grid.508717.c0000 0004 0637 3764Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Roelof W. F. van Leeuwen
- grid.508717.c0000 0004 0637 3764Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands ,grid.5645.2000000040459992XDepartment of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
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18
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Ebbens MM, Gombert-Handoko KB, Wesselink EJ, van den Bemt PMLA. The Effect of Medication Reconciliation via a Patient Portal on Medication Discrepancies: A Randomized Noninferiority Study. J Am Med Dir Assoc 2021; 22:2553-2558.e1. [PMID: 33905738 DOI: 10.1016/j.jamda.2021.03.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/08/2021] [Accepted: 03/20/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Medication reconciliation has become standard care to prevent medication transfer errors. However, this process is time-consuming but could be more efficient when patients are engaged in medication reconciliation via a patient portal. OBJECTIVES To explore whether medication reconciliation by the patient via a patient portal is noninferior to medication reconciliation by a pharmacy technician. DESIGN (INCLUDING INTERVENTION) Open randomized controlled noninferiority trial. Patients were randomized between medication reconciliation via a patient portal (intervention) or medication reconciliation by a pharmacy technician at the preoperative screening (usual care). SETTING AND PARTICIPANTS Patients scheduled for elective surgery using at least 1 chronic medication were included. MEASURES The primary endpoint was the number of medication discrepancies compared to the electronic nationwide medication record system (NMRS). For the secondary endpoint, time investment of the pharmacy technician for the medication reconciliation interview and patient satisfaction were studied. Noninferiority was analyzed with an independent t test, and the margin was set at 20%. RESULTS A total of 499 patients were included. The patient portal group contained 241 patients; the usual care group contained 258 patients. The number of medication discrepancies was 2.6 ± 2.5 in the patient portal group and 2.8 ± 2.7 in the usual care group. This was not statistically different and within the predefined noninferiority margin. Patients were satisfied with the use of the patient portal tool. Also, the use of the portal can save on average 6.8 minutes per patient compared with usual care. CONCLUSIONS AND IMPLICATIONS Medication reconciliation using a patient portal is noninferior to medication reconciliation by a pharmacy technician with respect to medication discrepancies, and saves time in the medication reconciliation process. Future studies should focus on identifying patient characteristics for successful implementation of patient portal medication reconciliation.
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Affiliation(s)
- Marieke M Ebbens
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands; Department of Hospital Pharmacy, St Jansdal Hospital, Harderwijk, the Netherlands; Department of Hospital Pharmacy, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Kim B Gombert-Handoko
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Elsbeth J Wesselink
- Department of Clinical Pharmacy, Zaans Medical Centre, Zaandam, the Netherlands
| | - Patricia M L A van den Bemt
- Department of Hospital Pharmacy, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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19
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Uitvlugt EB, Janssen MJA, Siegert CEH, Kneepkens EL, van den Bemt BJF, van den Bemt PMLA, Karapinar-Çarkit F. Medication-Related Hospital Readmissions Within 30 Days of Discharge: Prevalence, Preventability, Type of Medication Errors and Risk Factors. Front Pharmacol 2021; 12:567424. [PMID: 33927612 PMCID: PMC8077030 DOI: 10.3389/fphar.2021.567424] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 02/11/2021] [Indexed: 02/04/2023] Open
Abstract
Background: Hospital readmission rates are increasingly used as a measure of healthcare quality. Medicines are the most common therapeutic intervention but estimating the contribution of adverse drug events as a cause of readmissions is difficult. Objectives: To assess the prevalence and preventability of medication-related readmissions within 30 days after hospital discharge and to describe the risk factors, type of medication errors and types of medication involved in these preventable readmissions. Design: A cross-sectional observational study. Setting: The study took place across the cardiology, gastroenterology, internal medicine, neurology, psychiatry, pulmonology and general surgery departments in the OLVG teaching hospital, Netherlands. Participants: Patients with an unplanned readmission within 30 days after discharge from an earlier hospitalization (index hospitalization: IH) were reviewed. Measurements: The prevalence and preventability of medication-related readmissions were assessed by residents in multidisciplinary meetings. A senior internist and hospital pharmacist reassessed the prevalence and preventability of identified cases. Generalized estimating equation with logistic regression was performed to identify risk factors of potentially preventable medication-related readmissions. Results: Of 1,111 included readmissions, 181 (16%) were medication-related, of which 72 (40%) were potentially preventable. The number of medication changes at IH (Adjusted odds ratio [ORadj]: 1.14; 95% CI: 1.05–1.24) and having ≥3 hospitalizations 6 months before IH (ORadj: 2.11; 95% CI: 1.12–3.98) were risk factors of a preventable medication-related readmission. Of these preventable readmissions, 35% were due to prescribing errors, 35% by non-adherence and 30% by transition errors. Medications most frequently involved were diuretics and antidiabetics. Conclusion: This study shows that 16% of readmissions are medication-related, of which 40% are potentially preventable. If the results are confirmed in larger multicentre studies, this may indicate that more attention should be paid to medication-related harm in order to lower the overall readmission rates.
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Affiliation(s)
- Elien B Uitvlugt
- Onze Lieve Vrouwe Gasthuis OLVG, Department of Hospital Pharmacy, Amsterdam, Netherlands
| | - Marjo J A Janssen
- Onze Lieve Vrouwe Gasthuis OLVG, Department of Hospital Pharmacy, Amsterdam, Netherlands
| | - Carl E H Siegert
- Onze Lieve Vrouwe Gasthuis OLVG, Department of Internal Medicine, Amsterdam, Netherlands
| | - Eva L Kneepkens
- Onze Lieve Vrouwe Gasthuis OLVG, Department of Hospital Pharmacy, Amsterdam, Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, Netherlands.,Department of Pharmacy, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, Netherlands
| | - Fatma Karapinar-Çarkit
- Onze Lieve Vrouwe Gasthuis OLVG, Department of Hospital Pharmacy, Amsterdam, Netherlands
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20
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Ebbens MM, van Dorp ELA, Gombert-Handoko KB, van den Bemt PMLA. Pre-operative medication reconciliation by pharmacy technicians or anaesthesiologists. Eur J Anaesthesiol 2021; 38 Suppl 1:S71-S72. [PMID: 33645936 DOI: 10.1097/eja.0000000000001390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Marieke M Ebbens
- From the Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden (MME, KBG-H), Department of Pharmacy, St Jansdal Hospital, Harderwijk (MME), Department of Anesthesiology, Leiden University Medical Center, Leiden (ELAvD), Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen (PMLAvdB), Erasmus University Medical Center Rotterdam, Department of Hospital Pharmacy, Rotterdam. Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlands (MME, PMLAvdB)
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21
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Berger FA, van der Sijs H, van Gelder T, van den Bemt PMLA. The use of a clinical decision support tool to assess the risk of QT drug-drug interactions in community pharmacies. Ther Adv Drug Saf 2021; 12:2042098621996098. [PMID: 33708374 PMCID: PMC7907715 DOI: 10.1177/2042098621996098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/22/2021] [Indexed: 01/05/2023] Open
Abstract
Introduction: The handling of drug–drug interactions regarding QTc-prolongation (QT-DDIs) is not well defined. A clinical decision support (CDS) tool will support risk management of QT-DDIs. Therefore, we studied the effect of a CDS tool on the proportion of QT-DDIs for which an intervention was considered by pharmacists. Methods: An intervention study was performed using a pre- and post-design in 20 community pharmacies in The Netherlands. All QT-DDIs that occurred during a before- and after-period of three months were included. The impact of the use of a CDS tool to support the handling of QT-DDIs was studied. For each QT-DDI, handling of the QT-DDI and patient characteristics were extracted from the pharmacy information system. Primary outcome was the proportion of QT-DDIs with an intervention. Secondary outcomes were the type of interventions and the time associated with handling QT-DDIs. Logistic regression analysis was used to analyse the primary outcome. Results: Two hundred and forty-four QT-DDIs pre-CDS tool and 157 QT-DDIs post-CDS tool were included. Pharmacists intervened in 43.0% and 35.7% of the QT-DDIs pre- and post-CDS tool respectively (odds ratio 0.74; 95% confidence interval 0.49–1.11). Substitution of interacting agents was the most frequent intervention. Pharmacists spent 20.8 ± 3.5 min (mean ± SD) on handling QT-DDIs pre-CDS tool, which was reduced to 14.9 ± 2.4 min (mean ± SD) post-CDS tool. Of these, 4.5 ± 0.7 min (mean ± SD) were spent on the CDS tool. Conclusion: The CDS tool might be a first step to developing a tool to manage QT-DDIs via a structured approach. Improvement of the tool is needed in order to increase its diagnostic value and reduce redundant QT-DDI alerts. Plain Language Summary The use of a tool to support the handling of QTc-prolonging drug interactions in community pharmacies Introduction: Several drugs have the ability to cause heart rhythm disturbances as a rare side effect. This rhythm disturbance is called QTc-interval prolongation. It may result in cardiac arrest. For health care professionals, such as physicians and pharmacists, it is difficult to decide whether or not it is safe to proceed treating a patient with combinations of two or more of these QT-prolonging drugs. Recently, a tool was developed that supports the risk management of these QT drug–drug interactions (QT-DDIs). Methods: In this study, we studied the effect of this tool on the proportion of QT-DDIs for which an intervention was considered by pharmacists. An intervention study was performed using a pre- and post-design in 20 community pharmacies in The Netherlands. All QT-DDIs that occurred during a before- and after-period of 3 months were included. Results: Two hundred and forty-four QT-DDIs pre-implementation of the tool and 157 QT-DDIs post-implementation of the tool were included. Pharmacists intervened in 43.0% of the QT-DDIs before the tool was implemented and in 35.7% after implementation of the tool. Substitution of one of the interacting agents was the most frequent intervention. Pharmacists spent less time on handling QT-DDIs when the tool was used. Conclusion: The clinical decision support tool might be a first step to developing a tool to manage QT-DDIs via a structured approach.
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Affiliation(s)
- Florine A Berger
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Department of Hospital Pharmacy, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Heleen van der Sijs
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
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22
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van Uden RCAE, Houtenbos I, Griffioen-Keijzer A, Odekerken DAM, van den Bemt PMLA, Becker ML. Guidelines for mono, double and triple antithrombotic therapy. Postgrad Med J 2021; 97:730-737. [PMID: 33441477 DOI: 10.1136/postgradmedj-2020-138938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/13/2020] [Accepted: 11/23/2020] [Indexed: 12/24/2022]
Abstract
Guidelines for antithrombotic therapy are complex, especially if a patient has several indications that require antithrombotic therapy. In general, no patient should receive lifelong double or triple antithrombotic therapy. In this overview, we outline the most common indications for mono, double and triple antithrombotic therapy; the preferred antithrombotic therapy and the recommended duration of therapy. Both antiplatelet therapy and therapeutic anticoagulation therapy with vitamin K antagonists or direct oral anticoagulants were included. European guidelines were used or, if no European guidelines were available, the Dutch guidelines were used.
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Affiliation(s)
- Renate C A E van Uden
- Hospital Pharmacy, Spaarne Gasthuis, Haarlem, Noord-Holland, Netherlands.,Pharmacy Foundation of Haarlem Hospitals, Haarlem, Noord-Holland, Netherlands
| | - Ilse Houtenbos
- Internal Medicine, Spaarne Gasthuis, Haarlem, Noord-Holland, Netherlands
| | | | | | - Patricia M L A van den Bemt
- Clinical Pharmacy and Pharmacology, Universitair Medisch Centrum Groningen, Groningen, Groningen, Netherlands
| | - Matthijs L Becker
- Hospital Pharmacy, Spaarne Gasthuis, Haarlem, Noord-Holland, Netherlands .,Pharmacy Foundation of Haarlem Hospitals, Haarlem, Noord-Holland, Netherlands
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23
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Berger FA, van der Sijs H, van Gelder T, Kuijper AFM, van den Bemt PMLA, Becker ML. Comparison of two algorithms to support medication surveillance for drug-drug interactions between QTc-prolonging drugs. Int J Med Inform 2020; 145:104329. [PMID: 33181445 DOI: 10.1016/j.ijmedinf.2020.104329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 09/09/2020] [Accepted: 11/01/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND QTc-prolongation is an independent risk factor for developing life-threatening arrhythmias. Risk management of drug-induced QTc-prolongation is complex and digital support tools could be of assistance. Bindraban et al. and Berger et al. developed two algorithms to identify patients at risk for QTc-prolongation. OBJECTIVE The main aim of this study was to compare the performances of these algorithms for managing QTc-prolonging drug-drug interactions (QT-DDIs). MATERIALS AND METHODS A retrospective data analysis was performed. A dataset was created from QT-DDI alerts generated for in- and outpatients at a general teaching hospital between November 2016 and March 2018. ECGs recorded within 7 days of the QT-DDI alert were collected. Main outcomes were the performance characteristics of both algorithms. QTc-intervals of > 500 ms on the first ECG after the alert were taken as outcome parameter, to which the performances were compared. Secondary outcome was the distribution of risk scores in the study cohort. RESULTS In total, 10,870 QT-DDI alerts of 4987 patients were included. ECGs were recorded in 26.2 % of the QT-DDI alerts. Application of the algorithms resulted in area under the ROC-curves of 0.81 (95 % CI 0.79-0.84) for Bindraban et al. and 0.73 (0.70-0.75) for Berger et al. Cut-off values of ≥ 3 and ≥ 6 led to sensitivities of 85.7 % and 89.1 %, and specificities of 60.8 % and 44.3 % respectively. CONCLUSIONS Both algorithms showed good discriminative abilities to identify patients at risk for QTc-prolongation when using ≥ 2 QTc-prolonging drugs. Implementation of digital algorithms in clinical decision support systems could support the risk management of QT-DDIs.
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Affiliation(s)
- Florine A Berger
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Heleen van der Sijs
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - T van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Aaf F M Kuijper
- Department of Cardiology, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Patricia M L A van den Bemt
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, the Netherlands
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24
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Berger FA, van der Sijs H, Becker ML, van Gelder T, van den Bemt PMLA. Development and validation of a tool to assess the risk of QT drug-drug interactions in clinical practice. BMC Med Inform Decis Mak 2020; 20:171. [PMID: 32703198 PMCID: PMC7376881 DOI: 10.1186/s12911-020-01181-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 07/07/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The exact risk of developing QTc-prolongation when using a combination of QTc-prolonging drugs is still unknown, making it difficult to interpret these QT drug-drug interactions (QT-DDIs). A tool to identify high-risk patients is needed to support healthcare providers in handling automatically generated alerts in clinical practice. The main aim of this study was to develop and validate a tool to assess the risk of QT-DDIs in clinical practice. METHODS A model was developed based on risk factors associated with QTc-prolongation determined in a prospective study on QT-DDIs in a university medical center inthe Netherlands. The main outcome measure was QTc-prolongation defined as a QTc interval > 450 ms for males and > 470 ms for females. Risk points were assigned to risk factors based on their odds ratios. Additional risk factors were added based on a literature review. The ability of the model to predict QTc-prolongation was validated in an independent dataset obtained from a general teaching hospital against QTc-prolongation as measured by an ECG as the gold standard. Sensitivities, specificities, false omission rates, accuracy and Youden's index were calculated. RESULTS The model included age, gender, cardiac comorbidities, hypertension, diabetes mellitus, renal function, potassium levels, loop diuretics, and QTc-prolonging drugs as risk factors. Application of the model to the independent dataset resulted in an area under the ROC-curve of 0.54 (95% CI 0.51-0.56) when QTc-prolongation was defined as > 450/470 ms, and 0.59 (0.54-0.63) when QTc-prolongation was defined as > 500 ms. A cut-off value of 6 led to a sensitivity of 76.6 and 83.9% and a specificity of 28.5 and 27.5% respectively. CONCLUSIONS A clinical decision support tool with fair performance characteristics was developed. Optimization of this tool may aid in assessing the risk associated with QT-DDIs. TRIAL REGISTRATION No trial registration, MEC-2015-368.
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Affiliation(s)
- Florine A Berger
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands.
| | - Heleen van der Sijs
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands
| | - Matthijs L Becker
- Pharmacy Foundation of Haarlem Hospitals, Haarlem, the Netherlands
- Department of Clinical Pharmacy, Spaarne Gasthuis, Haarlem, the Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Patricia M L A van den Bemt
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, the Netherlands
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25
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Dreijer AR, Kruip MJHA, Diepstraten J, Polinder S, Brouwer R, Mol PGM, Croles FN, Kragten E, Leebeek FWG, van den Bemt PMLA. Effect of antithrombotic stewardship on the efficacy and safety of antithrombotic therapy during and after hospitalization. PLoS One 2020; 15:e0235048. [PMID: 32584857 PMCID: PMC7316339 DOI: 10.1371/journal.pone.0235048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 06/05/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although the benefits of antithrombotic drugs are indisputable to reduce thrombotic events, they carry a high risk of compromising patient safety. No previous studies investigated the implementation and (cost-) effectiveness of a hospital-based multidisciplinary antithrombotic team on bleeding and thrombotic outcomes. The primary aim of this study was to compare the proportion of patients with a composite end point consisting of one or more bleeding episodes or one or more thrombotic event from hospitalization until three months after hospitalization. METHODS AND FINDINGS A prospective, multicenter before-after intervention study was conducted in two Dutch hospitals. Adult patients hospitalized between October 2015 and December 2017 treated with anticoagulant therapy were included. The primary aim was to estimate the proportion of patients with a composite end point consisting of one or more bleeding episodes or one or more thrombotic event from hospitalization until three months after hospitalization. The intervention was the implementation of a multidisciplinary antithrombotic team focusing on education, medication reviews by pharmacists, implementing of local anticoagulant therapy guidelines based on national guidelines, patient counselling and medication reconciliation at admission and discharge. The primary endpoint was analysed using segmented linear regression. We obtained data for 1,886 patients: 941 patients were included in the usual care period and 945 patients in the intervention period. The S-team study showed that implementation of a multidisciplinary antithrombotic team over time significantly reduced the composite end point consisting of one or more bleeding episodes or one or more thrombotic event from hospitalization until three months after hospitalization in patients using anticoagulant drugs (-1.83% (-2.58% to -1.08%) per 2 month period). CONCLUSIONS This study shows that implementation of a multidisciplinary antithrombotic team over time significantly reduces the composite end point consisting of one or more bleeding episodes or one or more thrombotic event from hospitalization until three months after hospitalization in patients using anticoagulant drugs. TRIAL REGISTRATION Trialregister.nl NTR4887.
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Affiliation(s)
- Albert R. Dreijer
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Marieke J. H. A. Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Thrombosis Service STAR-SHL, Rotterdam, The Netherlands
| | - Jeroen Diepstraten
- Department of Hospital Pharmacy, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rolf Brouwer
- Department of Hematology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Peter G. M. Mol
- Department of Clinical Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - F. Nanne Croles
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Esther Kragten
- Department of Hematology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Frank W. G. Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Patricia M. L. A. van den Bemt
- Department of Clinical Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Becker ML, van Uden RCAE, Giezen TJ, Meijer K, Houtenbos I, van den Bemt PMLA. Drug-drug interactions with metronidazole and itraconazole in patients using acenocoumarol. Eur J Clin Pharmacol 2020; 76:1457-1464. [PMID: 32524154 DOI: 10.1007/s00228-020-02930-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/05/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Various population-based cohort studies have shown that antimicrobial agents increase the risk of overanticoagulation in patients using coumarins. In this study, we assessed this association in hospitalized patients. METHODS We included all patients hospitalized in the Spaarne Gasthuis (Haarlem/Hoofddorp, the Netherlands), who started using an antimicrobial agent during acenocoumarol treatment or vice versa between 1 January 2015 and 1 July 2019. Patients were followed from start of concomitant therapy until 48 h after termination of the concomitant therapy or discharge, whichever came first. We analyzed the association between the antimicrobial agents and the risk of overanticoagulation, defined as an interpolated INR above 6, using Cox regression analysis. We corrected for multiple testing with the Bonferroni correction. Patients who started using acenocoumarol and amoxicillin/clavulanic acid were used as reference group. RESULTS In the study population, sixteen antimicrobial agents were started frequently concomitantly with acenocoumarol treatment. We included 2157 interaction episodes in 1172 patients. Patients who started using the combination of co-trimoxazole (HR 3.76; 95% CI 1.47-9.62; p = 0.006), metronidazole (HR 2.55; 95% CI 1.37-4.76; p = 0.003), or itraconazole (HR 4.11; 95% CI 1.79-9.45; p = 0.001) concomitantly with acenocoumarol treatment had an increased risk of overanticoagulation compared with patients using acenocoumarol and amoxicillin/clavulanic acid concomitantly. The associations for metronidazole (p = 0.045) and itraconazole (p = 0.015) remained statistically significant after correction for multiple testing. CONCLUSION Co-trimoxazole, metronidazole, and itraconazole increase the risk of overanticoagulation in patients using acenocoumarol. These combinations should be avoided if possible or otherwise acenocoumarol doses should be reduced and INR measured more frequently.
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Affiliation(s)
- Matthijs L Becker
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC, Haarlem, The Netherlands. .,Department of Clinical Pharmacy, Spaarne Gasthuis, Haarlem / Hoofddorp, The Netherlands.
| | - Renate C A E van Uden
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC, Haarlem, The Netherlands.,Department of Clinical Pharmacy, Spaarne Gasthuis, Haarlem / Hoofddorp, The Netherlands
| | - Thijs J Giezen
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC, Haarlem, The Netherlands.,Department of Clinical Pharmacy, Spaarne Gasthuis, Haarlem / Hoofddorp, The Netherlands
| | - Karina Meijer
- Department of Hematology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ilse Houtenbos
- Department of Internal Medicine, Spaarne Gasthuis, Haarlem / Hoofddorp, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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van der Veen W, Taxis K, Wouters H, Vermeulen H, Bates DW, van den Bemt PMLA. Factors associated with workarounds in barcode-assisted medication administration in hospitals. J Clin Nurs 2020; 29:2239-2250. [PMID: 32043705 PMCID: PMC7328795 DOI: 10.1111/jocn.15217] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/11/2020] [Accepted: 02/03/2020] [Indexed: 01/25/2023]
Abstract
Aims and objectives To identify that workarounds (defined as “informal temporary practices for handling exceptions to normal procedures or workflow”) by nurses using information technology potentially compromise medication safety. Therefore, we aimed to identify potential risk factors associated with workarounds performed by nurses in Barcode‐assisted Medication Administration in hospitals. Background Medication errors occur during the prescribing, distribution and administration of medication. Errors could harm patients and be a tragedy for both nurses and medical doctors involved. Interventions to prevent errors have been developed, including those based on information technology. To cope with shortcomings in information technology‐based interventions as Barcode‐assisted Medication Administration, nurses perform workarounds. Identification of workarounds in information technology is essential to implement better‐designed software and processes which fit the nurse workflow. Design We used the data from our previous prospective observational study, performed in four general hospitals in the Netherlands using Barcode techniques, to administer medication to inpatients. Methods Data were collected from 2014–2016. The disguised observation was used to gather information on potential risk factors and workarounds. The outcome was a medication administration with one or more workarounds. Logistic mixed models were used to determine the association between potential risk factors and workarounds. The STROBE checklist was used for reporting our data. Results We included 5,793 medication administrations among 1,230 patients given by 272 nurses. In 3,633 (62.7%) of the administrations, one or more workarounds were observed. In the multivariate analysis, factors significantly associated with workarounds were the medication round at 02 p.m.–06 p.m. (adjusted odds ratio [OR]: 1.60, 95% CI: 1.05–2.45) and 06 p.m.–10 p.m. (adjusted OR: 3.60, 95% CI: 2.11–6.14) versus the morning shift 06 a.m.–10 a.m., the workdays Monday (adjusted OR: 2.59, 95% CI: 1.51–4.44), Wednesday (adjusted OR: 1.92, 95% CI: 1.2–3.07) and Saturday (adjusted OR: 2.24, 95% CI: 1.31–3.84) versus Sunday, the route of medication, nonoral (adjusted OR: 1.28, 95% CI: 1.05–1.57) versus the oral route of drug administration, the Anatomic Therapeutic Chemical classification‐coded medication “other” (consisting of the irregularly used Anatomic Therapeutic Chemical classes [D, G, H, L, P, V, Y, Z]) (adjusted OR: 1.49, 95% CI: 1.05–2.11) versus Anatomic Therapeutic Chemical class A (alimentary tract and metabolism), and the patient–nurse ratio ≥6–1 (adjusted OR: 5.61, 95% CI: 2.9–10.83) versus ≤5–1. Conclusions We identified several potential risk factors associated with workarounds performed by nurses that could be used to target future improvement efforts in Barcode‐assisted Medication Administration. Relevance to clinical practice Nurses administering medication in hospitals using Barcode‐assisted Medication Administration frequently perform workarounds, which may compromise medication safety. In particular, nurse workload and the patient–nurse ratio could be the focus for improvement measures as these are the most clearly modifiable factors identified in this study.
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Affiliation(s)
- Willem van der Veen
- Unit PharmacoTherapy, Epidemiology & Economics, Faculty of Science and Engineering, University of Groningen, Groningen, The Netherlands
| | - Katja Taxis
- Unit PharmacoTherapy, Epidemiology & Economics, Faculty of Science and Engineering, University of Groningen, Groningen, The Netherlands
| | - Hans Wouters
- General Practitioners Research Institute, University of Groningen, Groningen, The Netherlands
| | - Hester Vermeulen
- Department of IQ Healthcare, Scientific Center for Quality of Healthcare, Radboud Institute of Health Sciences, Nijmegen, The Netherlands
| | - David W Bates
- Harvard Medical School and Brigham and Woman's Hospital, Boston, MA, USA
| | - Patricia M L A van den Bemt
- Department Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
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Zaal RJ, den Haak EW, Andrinopoulou ER, van Gelder T, Vulto AG, van den Bemt PMLA. Physicians' acceptance of pharmacists' interventions in daily hospital practice. Int J Clin Pharm 2020; 42:141-149. [PMID: 32026348 PMCID: PMC7162822 DOI: 10.1007/s11096-020-00970-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 12/06/2019] [Indexed: 12/13/2022]
Abstract
Background The physicians' acceptance rate of pharmacists' interventions to improve pharmacotherapy can vary depending on the setting. The acceptance rate of interventions proposed by pharmacists located in the hospital pharmacy over the telephone and factors associated with acceptance are largely unknown. Objective To determine the physicians' acceptance rate of pharmacists' interventions proposed over the telephone in daily hospital practice and to identify factors associated with acceptance. Setting A retrospective case-control study was performed concerning adult patients admitted to a university hospital in the Netherlands. Method Pharmacists' interventions, based on alerts for drug-drug interactions and drug dosing in patients with renal impairment, recorded between January 2012 and June 2013 that were communicated over the telephone were included. Factors associated with physicians' acceptance were identified with the use of a mixed-effects logistic model. Main outcome measure The primary outcome was the proportion of accepted interventions. Results A total of 841 interventions were included. Physicians accepted 599 interventions, resulting in an acceptance rate of 71.2%. The mixed-effects logistic model showed that acceptance was significantly associated with the number of prescribed drugs (16 to ≤ 20 drugs ORadj 1.88; 95% CI 1.05-3.35, > 20 drugs ORadj 2.90; 95% CI 1.41-5.96, compared to ≤ 10 drugs) and the severity of the drug-related problem (problem without potential harm ORadj 6.36; 95% CI 1.89-21.38; problem with potential harm OR 6.78; 95% CI 2.09-21.99, compared to clinically irrelevant problems), and inversely associated with continuation of pre-admission treatment (ORadj 0.55; 95% CI 0.35-0.87). Conclusion Over the study period, the majority of pharmacists' interventions proposed over the telephone were accepted by physicians. The probability for acceptance increased for patients with an increasing number of medication orders, for clinically relevant problems and for problems related to treatment initiated during admission.
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Affiliation(s)
- Rianne J Zaal
- Department of Hospital Pharmacy, Erasmus Medical Center, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Edwin W den Haak
- Utrecht University, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - Elrozy R Andrinopoulou
- Department of Biostatistics, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus Medical Center, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Arnold G Vulto
- Department of Hospital Pharmacy, Erasmus Medical Center, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Hospital Pharmacy, Erasmus Medical Center, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Uitvlugt EB, Janssen MJA, Siegert CEH, Leenders AJA, van den Bemt BJF, van den Bemt PMLA, Karapinar-Çarkit F. Patients' and providers' perspectives on medication relatedness and potential preventability of hospital readmissions within 30 days of discharge. Health Expect 2019; 23:212-219. [PMID: 31733100 PMCID: PMC6978863 DOI: 10.1111/hex.12993] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 10/03/2019] [Accepted: 10/08/2019] [Indexed: 12/02/2022] Open
Abstract
Background Hospital readmissions are increasingly used as an indicator of quality in health care. One potential risk factor of readmissions is polypharmacy. No studies have explored the patients’ perspectives on the medication relatedness and potential preventability of their readmissions. Objective To compare the patients’ perspectives on the medication relatedness and potential preventability of their readmissions with the providers’ perspectives. Methods Patients unplanned readmitted within 30 days after discharge at one of the participating departments of OLVG Hospital in Amsterdam were interviewed during their readmission. Patients’ perspectives regarding medication relatedness of their readmissions, the potential preventability, possible preventable interventions, and satisfaction with medication information were examined. Health‐care providers also reviewed files of these readmitted patients. Primary outcome was the percentage of medication‐related and potentially preventable readmissions according to the patient vs the provider. Descriptive data analysis was used. Results According to patients, 36 of 172 (21%) readmissions were medication‐related, and of these, 21 (58%) were potentially preventable. According to providers, 26 (15%) readmissions were medication‐related and 6 (23%) of these were potentially preventable. Patients and providers agreed on the medication relatedness in 11 of the 172 readmissions, and in two of these, agreement on the potential preventability existed. According to patients, preventive interventions belonged mostly to the hospital level, followed by the primary care level and patient level. Conclusion Patients and providers differ substantially on their perspectives regarding the medication relatedness and preventability of readmissions. Patients were more likely to view medication‐related readmissions as preventable.
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Affiliation(s)
- Elien B Uitvlugt
- Department of Hospital Pharmacy, OLVG, Amsterdam, The Netherlands
| | | | - Carl E H Siegert
- Department of Internal Medicine, OLVG, Amsterdam, The Netherlands
| | | | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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van Herpen-Meeuwissen LJM, van den Bemt BJF, Derijks HJ, van den Bemt PMLA, de Vries F, Maat B, van Onzenoort HAW. Economic impact of Patient's Own Medication use during hospitalisation: a multicentre pre-post implementation study. Int J Clin Pharm 2019; 41:1658-1665. [PMID: 31705458 DOI: 10.1007/s11096-019-00932-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/28/2019] [Indexed: 11/28/2022]
Abstract
Background Medication is frequently thrown away after a patient's discharge from hospital, with undesirable economic and environmental consequences. Because of the rising costs of healthcare, interventions to reduce medication wastage (and associated costs) are warranted. Using Patient's Own Medication during hospitalisation might decrease medication wastage and associated costs. Objective To study the economic impact of patient's own medication use on medication waste and hospital staff's time spent during hospitalisation. Setting In seven Dutch hospitals, of which university, teaching, general, and specialised hospitals, eight different hospital wards, surgical and medical, were selected. Method In this prospective pre-post intervention study data on the economic value of medication waste and time spent by healthcare professionals were collected for a 2 months period each. The economic value of medication waste was defined as the value (€) of wasted medication per 100 patient days. For each ward, time spent on medication process activities was measured 10 times per staff member. The average time spent (in hours) on medication process steps (multiple activities) per staff member per 100 patients and associated salary costs were calculated for both periods. Main outcome measure The primary outcome of the study was the total economic value (€) of wasted medication per 100 patient days. Results Implementation of Patient's Own Medication decreased the economic value of wasted medication by 39.5% from €3983 to €2411 per 100 patient days. The mean time spent on the total medication process was reduced with 5.2 h per 100 patients (from 112.7 to 104.4 h per 100 patients). We observed a shift in professional activities, as physicians and nurses spent less time on the medication process, whereas pharmacy technicians had a greater role in it. When time spent was expressed as salary; €1219 could be saved per 100 patients. Conclusions This study showed that 'Patient's Own Medication' implementation may have a positive economic impact, as the value of medication waste decreases, hospital staff devoted less time on the medication process, and staff deployment is more efficient.
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Affiliation(s)
- Loes J M van Herpen-Meeuwissen
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Department of Pharmacy, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Hieronymus J Derijks
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Department of Pharmacy, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frank de Vries
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center +, Maastricht, The Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Barbara Maat
- Department of Pharmacy, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
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van der Louw EJTM, Olieman JF, van den Bemt PMLA, Bromberg JEC, Oomen-de Hoop E, Neuteboom RF, Catsman-Berrevoets CE, Vincent AJPE. Ketogenic diet treatment as adjuvant to standard treatment of glioblastoma multiforme: a feasibility and safety study. Ther Adv Med Oncol 2019; 11:1758835919853958. [PMID: 31258628 PMCID: PMC6589986 DOI: 10.1177/1758835919853958] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/17/2019] [Indexed: 01/09/2023] Open
Abstract
Background: High-grade glioma cells consume mainly glucose and cannot compensate for glucose restriction. Apoptosis may potentially occur under carbohydrate restriction by a ketogenic diet (KD). We explored the feasibility and safety of KD during standard treatment of chemoradiation in patients with glioblastoma multiforme. Methods: A full liquid KD induced ketosis within 2 weeks before start of chemoradiation. After 6 weeks, the KD was modified with solid foods and medium-chain-triglyceride emulsions and used for an additional 6 weeks while maintaining ketosis. During the total study period (14 weeks), feasibility, safety, coping (both patient and partner), quality of life (QoL), neurological functioning and impairment were measured. Overall survival was analyzed with actuarial estimates. Results: Eleven patients started the study protocol, nine reached ketosis and six (67%) completed the study. Severe adverse effects did not occur. The majority of coping scores ranged from 3 to 6 on a 10-point scale at all timepoints; QoL, neurological functioning, and impairment did not essentially change over time; overall survival ranged between 9.8 and 19.0 months. Conclusion: KD was feasible and safe as an adjuvant to standard chemoradiation treatment of glioblastoma multiforme. A supportive partner and intensive counseling were essential for coping. Future research should identify possible beneficial effects on overall survival. Clinical trial registration: Netherlands Trial Registry: NTR5167 (registration date 29-01-2015), http://www.trialregister.nl/trialreg/index.asp
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Affiliation(s)
- Elles J T M van der Louw
- Department of Dietetics, Erasmus MC, University Medical Center, Dr. Molewaterplein 40, Rotterdam, Zuid Holland 3015 GD, The Netherlands
| | - Joanne F Olieman
- Department of Dietetics Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | | | - Esther Oomen-de Hoop
- Department of Medical Oncology, University Medical Center, Rotterdam, The Netherlands
| | - Rinze F Neuteboom
- Department of Neurology, University Medical Center, Rotterdam, The Netherlands
| | | | - Arnaud J P E Vincent
- Department of Neurosurgery, University Medical Center, Rotterdam, The Netherlands
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Bosma LBE, van Rein N, Hunfeld NGM, Steyerberg EW, Melief PHGJ, van den Bemt PMLA. Development of a multivariable prediction model for identification of patients at risk for medication transfer errors at ICU discharge. PLoS One 2019; 14:e0215459. [PMID: 31039162 PMCID: PMC6490883 DOI: 10.1371/journal.pone.0215459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 04/02/2019] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Discharge from the intensive care unit (ICU) is a high-risk process, leading to numerous potentially harmful medication transfer errors (PH-MTE). PH-MTE could be prevented by medication reconciliation by ICU pharmacists, but resources are scarce, which renders the need for predicting which patients are at risk for PH-MTE. The aim of this study was to develop a prognostic multivariable model in patients discharged from the ICU to predict who is at increased risk for PH-MTE after ICU discharge, using predictors of PH-MTE that are readily available at the time of ICU discharge. MATERIAL AND METHODS Data for this study were derived from the Transfer ICU Medication reconciliation study, which included ICU patients and scored MTE at discharge of the ICU. The potential harm of every MTE was estimated with a validated score, where after MTE with potential for harm were indicated as PH-MTE. Predictors for PH-MTE at ICU discharge were identified using LASSO regression. The c statisticprovided a measure of the overall discriminative ability of the prediction model and the prediction model was internally validated by bootstrap resampling. Based on sensitivity and specificity, the cut-off point of the prediction model was determined. RESULTS The cohort contained 258 patients and six variables were identified as predictors for PH-MTE: length of ICU admission, number of home medications and patient taking one of the following medication groups at home: vitamin/mineral supplements, cardiovascular medication, psycholeptic/analeptic medication and medication for obstructive airway disease. The c of the final prediction model was 0.73 (95%CI 0.67-0.79) and decreased to 0.62 according to bootstrap resampling. At a cut-off score of two the prediction model yielded a sensitivity of 70% and a specificity of 61%. CONCLUSIONS A multivariable prediction model was developed to identify patients at risk for PH-MTE after ICU discharge. The model contains predictors that are available on the day of ICU discharge. Once external validation and evaluation of this model in daily practice has been performed, its incorporation into clinical practice could potentially allow institutions to identify patients at risk for PH-MTE after ICU discharge, on the day of ICU discharge, thus allowing for efficient, patient-specific allocation of clinical pharmacy services. TRIAL REGISTRATION Dutch trial register: NTR4159, 5 September 2013, retrospectively registered.
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Affiliation(s)
- Liesbeth B. E. Bosma
- Haga Teaching Hospital, Department of Clinical Pharmacy, Els Borst-Eilersplein CH, The Hague, The Netherlands
- Erasmus University Medical Center, Department of Hospital Pharmacy, CA, Rotterdam, The Netherlands
| | - Nienke van Rein
- Haga Teaching Hospital, Department of Clinical Pharmacy, Els Borst-Eilersplein CH, The Hague, The Netherlands
- Leiden University Medical Center, Department of Clinical Pharmacy and Toxicology, Leiden, The Netherlands
| | - Nicole G. M. Hunfeld
- Erasmus University Medical Center, Department of Hospital Pharmacy, CA, Rotterdam, The Netherlands
- Erasmus University Medical Center, Department of Intensive Care, CA, Rotterdam, The Netherlands
| | - Ewout W. Steyerberg
- Clinical Biostatistics and Medical Decision Making at Erasmus MC, Rotterdam and Leiden University Medical Center, ZA Leiden, The Netherlands
| | - Piet H. G. J. Melief
- Haga Teaching Hospital, Department of Intensive Care, CH, The Hague, The Netherlands
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Uitvlugt EB, van den Bemt BJF, Chung WL, Dik J, van den Bemt PMLA, Karapinar-Çarkit F. Validity of a nationwide medication record system in the Netherlands. Int J Clin Pharm 2019; 41:687-690. [PMID: 31028600 DOI: 10.1007/s11096-019-00839-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 04/19/2019] [Indexed: 11/26/2022]
Abstract
Background In the Netherlands, a nationwide Medication Record System based on pharmacy dispensing data is used to obtain information about patients' actual medication use. However, it is not clear to what extent the information of the Nationwide Medication Record System corresponds to the medication information obtained with the Best Possible Medication History. Objective To examine the validity of medication dispensing records collected from the Nationwide Medication Record System by comparing them to the Best Possible Medication History. Method An observational study was performed. Patients from several hospital departments were included at admission. To obtain the Best Possible Medication History, pharmacy technicians performed medication reconciliation at admission, using dispensing records from the Nationwide Medication Record System and information from the patient himself. Primary outcome is percentage of patients with no discrepancies between the Nationwide Medication Record System and the Best Possible Medication History. Descriptive analysis was used. Results Eighty-two patients were approached and 66 (80%) were included, with in total 478 medicines in the Best Possible Medication History. Seventeen percent of the patients had no discrepancies and 33% (n = 156) of the medication records contained a discrepancy between the Nationwide Medication Record System and the Best Possible Medication History. Most common type of discrepancy was omission (44%). Conclusion Even with a Nationwide Medication Record System medication reconciliation with the patient remains essential to obtain complete information about patient's actual medication use.
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Affiliation(s)
- Elien B Uitvlugt
- Department of Hospital Pharmacy, OLVG, Jan Tooropstraat 164, 1061AE, Amsterdam, The Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Wai Lung Chung
- Department of Hospital Pharmacy, OLVG, Jan Tooropstraat 164, 1061AE, Amsterdam, The Netherlands
| | - Jaap Dik
- Pharmacy Monnikenhof, Vianen, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Fatma Karapinar-Çarkit
- Department of Hospital Pharmacy, OLVG, Jan Tooropstraat 164, 1061AE, Amsterdam, The Netherlands.
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Dreijer AR, Diepstraten J, Brouwer R, Croles FN, Kragten E, Leebeek FWG, Kruip MJHA, van den Bemt PMLA. Risk of bleeding in hospitalized patients on anticoagulant therapy: Prevalence and potential risk factors. Eur J Intern Med 2019; 62:17-23. [PMID: 30686662 DOI: 10.1016/j.ejim.2019.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Bleeding is the most important complication of treatment with anticoagulant therapy. Although several studies have identified risk factors of bleeding in outpatients, no studies have been performed that evaluated prevalence and potential risk factors of bleeding in hospitalized patients treated with anticoagulant therapy. METHODS The primary objective of this study was to determine the prevalence of bleeding in anticoagulant users during hospitalization. The secondary objective was to identify potential risk factors of bleeding in hospitalized patients on anticoagulant therapy. A prospective, observational cohort study was conducted in two Dutch hospitals. Adult patients hospitalized between October 2015 and October 2016 treated with anticoagulant therapy were included. Bleeding was defined as a composite endpoint of major bleeding and non-major bleeding according to the International Society on Thrombosis and Heamostasis (ISTH) criteria. Data analysis was performed by multivariate logistic regression. RESULTS The prevalence of in-hospital bleeding in patients using anticoagulant therapy was 7.2%; 95% confidence interval [95% CI] 5.5-9.1 (65 out of 906 patients). Multivariate logistic regression analysis indicated that female gender (adjusted odds ratio [ORadj] 2.1; 95% CI 1.2-3.7), high-bleeding-risk surgical procedure (ORadj 5.3; 95% CI 2.7-10.2), low-bleeding-risk surgical procedure (ORadj 4.9; 95% CI 1.9-12.6), and non-surgical interventions (ORadj 6.2; 95% CI 3.0-12.6) were associated with bleeding events in hospitalized patients treated with anticoagulants. CONCLUSIONS The prevalence of bleeding in anticoagulant users during hospitalization was 7.2%. This study detected potential risk factors that can help to identify patients on anticoagulants who have an increased risk of bleeding during hospitalization.
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Affiliation(s)
- Albert R Dreijer
- Erasmus University Medical Center, Rotterdam, Department of Hospital Pharmacy, The Netherlands; Reinier de Graaf Hospital, Department of Hospital Pharmacy, Delft, The Netherlands.
| | - Jeroen Diepstraten
- Reinier de Graaf Hospital, Department of Hospital Pharmacy, Delft, The Netherlands
| | - Rolf Brouwer
- Reinier de Graaf Hospital, Department of Hematology, Delft, The Netherlands
| | - F Nanne Croles
- Erasmus University Medical Center, Department of Hematology, Rotterdam, The Netherlands
| | - Esther Kragten
- Reinier de Graaf Hospital, Department of Hematology, Delft, The Netherlands
| | - Frank W G Leebeek
- Erasmus University Medical Center, Department of Hematology, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Erasmus University Medical Center, Department of Hematology, Rotterdam, The Netherlands
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35
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van der Veen W, van den Bemt PMLA, Wouters H, Bates DW, Twisk JWR, de Gier JJ, Taxis K, Duyvendak M, Luttikhuis KO, Ros JJW, Vasbinder EC, Atrafi M, Brasse B, Mangelaars I. Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. J Am Med Inform Assoc 2019; 25:385-392. [PMID: 29025037 DOI: 10.1093/jamia/ocx077] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 06/27/2017] [Indexed: 11/14/2022] Open
Abstract
Objective To study the association of workarounds with medication administration errors using barcode-assisted medication administration (BCMA), and to determine the frequency and types of workarounds and medication administration errors. Materials and Methods A prospective observational study in Dutch hospitals using BCMA to administer medication. Direct observation was used to collect data. Primary outcome measure was the proportion of medication administrations with one or more medication administration errors. Secondary outcome was the frequency and types of workarounds and medication administration errors. Univariate and multivariate multilevel logistic regression analysis were used to assess the association between workarounds and medication administration errors. Descriptive statistics were used for the secondary outcomes. Results We included 5793 medication administrations for 1230 inpatients. Workarounds were associated with medication administration errors (adjusted odds ratio 3.06 [95% CI: 2.49-3.78]). Most commonly, procedural workarounds were observed, such as not scanning at all (36%), not scanning patients because they did not wear a wristband (28%), incorrect medication scanning, multiple medication scanning, and ignoring alert signals (11%). Common types of medication administration errors were omissions (78%), administration of non-ordered drugs (8.0%), and wrong doses given (6.0%). Discussion Workarounds are associated with medication administration errors in hospitals using BCMA. These data suggest that BCMA needs more post-implementation evaluation if it is to achieve the intended benefits for medication safety. Conclusion In hospitals using barcode-assisted medication administration, workarounds occurred in 66% of medication administrations and were associated with large numbers of medication administration errors.
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Affiliation(s)
- Willem van der Veen
- Faculty of Science and Engineering, Department of PharmacoTherapy, PharmacoEpidemiology and PharmaEconomics, University of Groningen, Groningen, the Netherlands
| | | | - Hans Wouters
- Faculty of Science and Engineering, Department of PharmacoTherapy, PharmacoEpidemiology and PharmaEconomics, University of Groningen, Groningen, the Netherlands
| | - David W Bates
- Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA
| | - Jos W R Twisk
- Department of Clinical Epidemiology and Biostatistics of the Vrije Universiteit Medical Centre, and the Institute of Health Science of the Vrije Universiteit, Amsterdam, the Netherlands
| | - Johan J de Gier
- Faculty of Science and Engineering, Department of PharmacoTherapy, PharmacoEpidemiology and PharmaEconomics, University of Groningen, Groningen, the Netherlands
| | - Katja Taxis
- Faculty of Science and Engineering, Department of PharmacoTherapy, PharmacoEpidemiology and PharmaEconomics, University of Groningen, Groningen, the Netherlands
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36
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Dreijer AR, Diepstraten J, Bukkems VE, Mol PGM, Leebeek FWG, Kruip MJHA, van den Bemt PMLA. Anticoagulant medication errors in hospitals and primary care: a cross-sectional study. Int J Qual Health Care 2018; 31:346-352. [DOI: 10.1093/intqhc/mzy177] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/20/2018] [Accepted: 07/29/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objective
To assess the proportion of all medication error reports in hospitals and primary care that involved an anticoagulant. Secondary objectives were the anticoagulant involved, phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. Additional secondary objectives were the total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month and the proportion of causes of 1000 anticoagulant medication errors (comparing the pre- and post-guideline phase).
Design
A cross-sectional study.
Setting
Medication errors reported to the Central Medication incidents Registration reporting system.
Participants
Between December 2012 and May 2015, 42 962 medication errors were reported to the CMR.
Intervention
N/A.
Main outcome measure
Proportion of all medication error reports that involved an anticoagulant. Phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. The total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month (comparing the pre- and post-guideline phase) and the total number of causes of 1000 anticoagulant medication errors before and after introduction of the LSKA 2.0 guideline.
Results
Anticoagulants were involved in 8.3% of the medication error reports. A random selection of 1000 anticoagulant medication error reports revealed that low-molecular weight heparins were most often involved in the error reports (56.2%). Most reports concerned the prescribing phase of the medication process (37.1%) and human factors were the leading cause of medication errors mentioned in the reports (53.4%). Publication of the national guideline on integrated antithrombotic care had no effect on the proportion of anticoagulant medication error reports. Human factors were the leading cause of medication errors before and after publication of the guideline.
Conclusions
Anticoagulant medication errors occurred in 8.3% of all medication errors. Most error reports concerned the prescribing phase of the medication process. Leading cause was human factors. The publication of the guideline had no effect on the proportion of anticoagulant medication errors.
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Affiliation(s)
- Albert R Dreijer
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 CN, Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Reinier de Graaf Hospital, 2625 AD, Delft, The Netherlands
| | - Jeroen Diepstraten
- Department of Hospital Pharmacy, Reinier de Graaf Hospital, 2625 AD, Delft, The Netherlands
| | - Vera E Bukkems
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 CN, Rotterdam, The Netherlands
| | - Peter G M Mol
- Department of Clinical Pharmacology, University of Groningen, University Medical Center Groningen, 9700 RB, Groningen, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, 3015 CN, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus University Medical Center, 3015 CN, Rotterdam, The Netherlands
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37
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Bos JM, Timmermans MJC, Kalkman GA, van den Bemt PMLA, De Smet PAGM, Wensing M, Kramers C, Laurant MGH. The effects of substitution of hospital ward care from medical doctors to physician assistants on non-adherence to guidelines on medication prescribing. PLoS One 2018; 13:e0202626. [PMID: 30138432 PMCID: PMC6107206 DOI: 10.1371/journal.pone.0202626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 08/07/2018] [Indexed: 11/18/2022] Open
Abstract
AIM This study determined the effect of substitution of inpatient care from medical doctors (MDs) to physician assistants (PAs) on non-adherence to guidelines on medication prescribing. METHODS A multicenter matched-controlled study was performed comparing wards on which PAs provide medical care in collaboration with MDs (PA/MD model), with wards on which only MDs provide medical care (MD model). A set of 17 quality indicators to measure non-adherence to guidelines on medication prescribing by PAs and MDs was composed by 14 experts in a modified Delphi procedure. The indicators covered different pharmacotherapeutic subjects, such as gastric protection in case of use of NSAID or prevention of obstipation in case of use of opioids. These indicators were expressed in proportions by dividing the number of patients in which the prescriber did not adhere to a guideline, by all patients that were applicable. Multivariable regression analysis was performed in order to adjust for potential confounders. RESULTS 1021 patients from 17 hospital wards in the 'PA/MD model' group and 1286 patients from 17 hospital wards in the 'MD model' group were included. Two of the 17 quality indicators showed significantly less non-adherence to guidelines for the PA/MD model; the indicators concerning prescribing gastric protection in case of use of NSAID in combination with corticosteroids (OR 0.42, 95% CI 0.19-0.90) and in case of use of NSAID in patients older than 70 years (OR 0.47, 95% 0.23-0.95). For none of the other quality indicators for prescribing of medication a difference between the MD model and the PA/MD model was found. CONCLUSION This study suggests that the non-adherence to guidelines on medication prescribing on wards with the PA/MD model does not differ from wards with traditional house staffing by MDs only. Further research is needed to determine quality, efficiency and safety of prescribing behavior of PAs.
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Affiliation(s)
- Jacqueline M. Bos
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
- * E-mail:
| | - Marijke J. C. Timmermans
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, the Netherlands
| | - Gerard A. Kalkman
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | | | - Peter A. G. M. De Smet
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michel Wensing
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Cornelis Kramers
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
- Department of Clinical Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Miranda G. H. Laurant
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, the Netherlands
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38
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Bindraban AN, Rolvink J, Berger FA, van den Bemt PMLA, Kuijper AFM, van der Hoeven RTM, Mantel-Teeuwisse AK, Becker ML. Development of a risk model for predicting QTc interval prolongation in patients using QTc-prolonging drugs. Int J Clin Pharm 2018; 40:1372-1379. [PMID: 30051227 DOI: 10.1007/s11096-018-0692-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 07/09/2018] [Indexed: 01/08/2023]
Abstract
Background Numerous drugs prolong the QTc interval on the ECG and potentially increase the risk of cardiac arrhythmia. This risk is clinically relevant in patients with additional risk factors. Objective The objective was to develop and validate a risk model to predict QTc interval prolongation of eligible ECGs. Setting Spaarne Gasthuis (Haarlem/Hoofddorp, The Netherlands). Method A dataset was created from ECGs recorded in patients using one or more QTc prolonging drugs, in the period January 2013 and October 2016. In the development set, independent risk factors for QTc interval prolongation were determined using binary logistic regression. Risk scores were assigned based on the beta coefficient. In the risk-score validation set, the area under the ROC-curve, sensitivity and specificity were calculated. Main outcome measure QTc interval prolongation, defined as a QTc interval > 500 ms. Results In the development set 12,949 ECGs were included and in the risk-score validation set 6391 ECGs. The proportion of ECGs with a prolonged QTc interval in patients with no risk factors in the risk-score validation set was 2.7%, while in patients with a high risk score the proportion was 26.1%. The area under the ROC curve was 0.71 (95% CI 0.68-0.73). The sensitivity and specificity were 0.81 and 0.48, respectively. Conclusion A risk model was developed and validated for the prediction of QTc interval prolongation. This risk model can be implemented in a clinical decision support system, supporting the management of the risks involved with QTc interval prolonging drugs.
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Affiliation(s)
- Anita N Bindraban
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC, Haarlem, The Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Universiteitsweg 99, 3584 CG, Utrecht, The Netherlands
| | - José Rolvink
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC, Haarlem, The Netherlands
| | - Florine A Berger
- Department of Hospital Pharmacy, Erasmus University Medical Centre, 's-Gravendijkwal 230, Rotterdam, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Hospital Pharmacy, Erasmus University Medical Centre, 's-Gravendijkwal 230, Rotterdam, The Netherlands
| | - Aaf F M Kuijper
- Department of Cardiology, Spaarne Gasthuis, Spaarnepoort 1, Hoofddorp, The Netherlands
| | - Ruud T M van der Hoeven
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC, Haarlem, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Universiteitsweg 99, 3584 CG, Utrecht, The Netherlands
| | - Matthijs L Becker
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC, Haarlem, The Netherlands.
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39
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Ebbens MM, Laar SAV, Wesselink EJ, Gombert-Handoko KB, van den Bemt PMLA. Prospective Validation of a Risk Prediction Model to Identify High-Risk Patients for Medication Errors at Hospital Admission. Ann Pharmacother 2018; 52:1211-1217. [DOI: 10.1177/1060028018784905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Pharmacy-led medication reconciliation in elective surgery patients is often performed at the preoperative screening (POS). Because of the time lag between POS and admission, changes in medication may lead to medication errors at admission (MEAs). In a previous study, a risk prediction model for MEA was developed. Objective: To validate this risk prediction model to identify patients at risk for MEAs in a university hospital setting. Methods: The risk prediction model was derived from a cohort of a Dutch general hospital and validated within a comparable cohort from a Dutch University Medical Centre. MEAs were assessed by comparing the POS medication list with the reconciled medication list at hospital admission. This was considered the gold standard. For every patient, a risk score using the risk prediction model was calculated and compared with the gold standard. The risk prediction model was assessed with receiver operating characteristic (ROC) analysis. Results: Of 368 included patients, 167 (45.4%) had at least 1 MEA. ROC analysis revealed significant differences in the area under the curve of 0.535 ( P = 0.26; validation cohort) versus 0.752 ( P < 0.0001; derivation cohort). The sensitivity in this validating cohort was 66%, with a specificity of 40%. Conclusion and Relevance: The risk prediction model developed in a general hospital population is not suitable to identify patients at risk for MEA in a university hospital population. However, number of medications is a common risk factor in both patient populations and should, thus, form the basis of an adapted risk prediction model.
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Affiliation(s)
- Marieke M. Ebbens
- Leiden University Medical Center, Leiden, Netherlands
- St Jansdal Hospital, Harderwijk, Netherlands
- Erasmus University Medical Center, Rotterdam, Netherlands
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40
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Dreijer AR, Biedermann JS, Diepstraten J, Lindemans AD, Kruip MJHA, van den Bemt PMLA, Vergouwe Y. Development of a clinical prediction model for an international normalised ratio ≥ 4·5 in hospitalised patients using vitamin K antagonists. Br J Haematol 2018; 181:102-110. [PMID: 29536532 PMCID: PMC5900910 DOI: 10.1111/bjh.15161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 01/21/2018] [Indexed: 11/28/2022]
Abstract
Vitamin K antagonists (VKAs) used for the prevention and treatment of thromboembolic disease, increase the risk of bleeding complications. We developed and validated a model to predict the risk of an international normalised ratio (INR) ≥ 4·5 during a hospital stay. Adult patients admitted to a tertiary hospital and treated with VKAs between 2006 and 2010 were analysed. Bleeding risk was operationalised as an INR value ≥4·5. Multivariable logistic regression analysis was used to assess the association between potential predictors and an INR ≥ 4·5 and validated in an independent cohort of patients from the same hospital between 2011 and 2014. We identified 8996 admissions of patients treated with VKAs, of which 1507 (17%) involved an INR ≥ 4·5. The final model included the following predictors: gender, age, concomitant medication and several biochemical parameters. Temporal validation showed a c statistic of 0·71. We developed and validated a clinical prediction model for an INR ≥ 4·5 in VKA-treated patients admitted to our hospital. The model includes factors that are collected during routine care and are extractable from electronic patient records, enabling easy use of this model to predict an increased bleeding risk in clinical practice.
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Affiliation(s)
- Albert R Dreijer
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Joseph S Biedermann
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Jeroen Diepstraten
- Department of Hospital Pharmacy, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Anouk D Lindemans
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | | | - Yvonne Vergouwe
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, the Netherlands
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41
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Bosma LBE, Hunfeld NGM, Quax RAM, Meuwese E, Melief PHGJ, van Bommel J, Tan S, van Kranenburg MJ, van den Bemt PMLA. 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. Ann Intensive Care 2018; 8:19. [PMID: 29417295 PMCID: PMC5803169 DOI: 10.1186/s13613-018-0361-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 01/23/2018] [Indexed: 02/06/2023] Open
Abstract
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% (ORadj 0.18 [95% CI 0.11–0.30]) and after discharge from 73.9 to 41.2% (ORadj 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% (ORadj 0.13 [95% CI 0.07–0.24]) and after discharge from 69.5 to 36.2% (ORadj 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
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Affiliation(s)
- Liesbeth B E Bosma
- Department of Pharmacy, Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545 CH, The Hague, The Netherlands. .,Apotheek Haagse Ziekenhuizen, PO Box 43100, 2504 AC, The Hague, The Netherlands. .,Department of Hospital Pharmacy, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Nicole G M Hunfeld
- Department of Hospital Pharmacy, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Intensive Care, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Rogier A M Quax
- Department of Intensive Care, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Internal Medicine, Maasstad Teaching Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands
| | - Edmé Meuwese
- Department of Hospital Pharmacy, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Piet H G J Melief
- Department of Intensive Care, Haga Teaching Hospital, PO Box 43100, 2504 AC, The Hague, The Netherlands
| | - Jasper van Bommel
- Department of Intensive Care, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - SiokSwan Tan
- Department of Public Health, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Maaike J van Kranenburg
- Department of Hospital Pharmacy, Gelre Hospitals, PO Box 9014, 7300 DS, Apeldoorn, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Hospital Pharmacy, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
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42
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Berger FA, Monadian N, de Groot NMS, Santbergen B, van der Sijs H, Becker ML, Broers AEC, van Gelder T, van den Bemt PMLA. QTc prolongation during ciprofloxacin and fluconazole combination therapy: prevalence and associated risk factors. Br J Clin Pharmacol 2017; 84:369-378. [PMID: 29057492 DOI: 10.1111/bcp.13457] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/29/2017] [Accepted: 10/16/2017] [Indexed: 12/25/2022] Open
Abstract
AIM(S) Ciprofloxacin and fluconazole combination therapy is frequently used as prophylaxis for, and treatment of, infections in patients with haematological malignancies. However, both drugs are known to prolong the heart rate-corrected QT (QTc) interval, which is a serious risk factor for torsade de pointes (TdP). Therefore, the aim of the current study was to assess the prevalence of QTc prolongation during ciprofloxacin and fluconazole use. The secondary objective was to determine associated risk factors of QTc prolongation in these patients. METHODS A prospective observational study was performed in patients admitted to the Erasmus University Medical Centre and treated with ciprofloxacin and fluconazole. A 12-lead electrocardiogram (ECG) was recorded at the estimated time to peak concentration (Tmax ) for the last added drug. The main outcome was the proportion of patients with QTc prolongation during treatment. Data on the following potential risk factors were collected: patient characteristics, serum electrolyte levels, dosage of ciprofloxacin and fluconazole, renal and liver function and concomitant use of other QTc-prolonging drugs and cytochrome P450 3A4 inhibitors. RESULTS A total of 170 patients were included, of whom 149 (87.6%) were treated for haematological malignancies. The prevalence of QTc prolongation was 4.7%. No risk factors were found to be associated with QTc prolongation. The QTc interval increased by 10.7 ms [95% confidence interval (CI) 7.2, 14.1 ms] during ciprofloxacin and fluconazole combination therapy. CONCLUSION The prevalence of QTc prolongation in patients using ciprofloxacin and fluconazole is low compared with the prevalence in the general population, which varies from 5% to 11%. In addition, no risk factors were found. Given the low prevalence, routine ECG monitoring in patients on this therapy should be reconsidered.
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Affiliation(s)
- Florine A Berger
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - Natasja M S de Groot
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Bart Santbergen
- Department of Internal Medicine, IJsselland Hospital, Capelle a/d Ijssel, The Netherlands
| | - Heleen van der Sijs
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - Annoek E C Broers
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
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43
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Bos JM, Natsch S, van den Bemt PMLA, Pot JLW, Nagtegaal JE, Wieringa A, van der Wilt GJ, De Smet PAGM, Kramers C. A multifaceted intervention to reduce guideline non-adherence among prescribing physicians in Dutch hospitals. Int J Clin Pharm 2017; 39:1211-1219. [PMID: 29101616 PMCID: PMC5694513 DOI: 10.1007/s11096-017-0553-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 10/23/2017] [Indexed: 12/18/2022]
Abstract
Background Despite the potential of clinical practice guidelines to improve patient outcomes, adherence to guidelines by prescribers is inconsistent. Objective The aim of the study was to determine whether an approach of introducing an educational programme for prescribers in the hospital combined with audit and feedback by the hospital pharmacist reduces non-adherence of prescribing physicians to key pharmacotherapeutic guidelines. Setting This prospective intervention study with a before–after design evaluated patients at surgical, urological and orthopaedic wards. Method An educational program covering pain management, antithrombotics, fluid and electrolyte management, prescribing in case of renal insufficiency, application of radiographic contrast agents and surgical antibiotic prophylaxis was presented to prescribers on the participating wards. Hospital pharmacists performed medication safety consultations, combining medication review of patients who are at risk for drug related problems with visits to ward physicians. Main outcome measure The outcome measure was the proportion of the admissions of patients in which the physician did not adhere to one or more of the included guidelines. Difference was expressed in odds ratios (OR) with 95% confidence intervals (CI). Multivariable logistic regression analysis was performed. Results 1435 Admissions of 1378 patients during the usual care period and 1195 admissions of 1090 patients during the intervention period were included. Non-adherence was observed significantly less often during the intervention period [21.8% (193/886)] as compared to the usual care period [30.5% (332/1089)]. The adjusted OR was 0.61 (95% CI 0.49–0.76). Conclusion This study shows that education and support of the prescribing physician can reduce guideline non-adherence at surgical wards.
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Affiliation(s)
- Jacqueline M Bos
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands.
| | - Stephanie Natsch
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Johan L W Pot
- Department of Clinical Pharmacy, Meander Medical Centre, Amersfoort, The Netherlands
| | - J Elsbeth Nagtegaal
- Department of Clinical Pharmacy, Meander Medical Centre, Amersfoort, The Netherlands
| | - Andre Wieringa
- Department of Clinical Pharmacy, Isala Hospital, Zwolle, The Netherlands
| | - Gert Jan van der Wilt
- Department of Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Peter A G M De Smet
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.,Department Scientific Institute for Quality of Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Cornelis Kramers
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands.,Department of Clinical Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, The Netherlands
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44
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Egberts A, van der Craats ST, van Wijk MD, Alkilabe S, van den Bemt PMLA, Mattace-Raso FUS. Anticholinergic drug exposure is associated with delirium and postdischarge institutionalization in acutely ill hospitalized older patients. Pharmacol Res Perspect 2017; 5:e00310. [PMID: 28603629 PMCID: PMC5464339 DOI: 10.1002/prp2.310] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 01/17/2023] Open
Abstract
Several studies investigated the possible association between anticholinergic drugs and diverse clinical outcomes in older persons, but the results are inconsistent. The aim of this study was to investigate whether anticholinergic drug exposure is associated with delirium on admission, length of hospital stay, postdischarge institutionalization and in-hospital mortality in acutely ill hospitalized older patients. In this observational chart review study, we included acutely ill patients aged 65 and older who were admitted to the geriatric ward of the Erasmus University Medical Center, Rotterdam, The Netherlands, between 2012 and 2015 (n = 905). Anticholinergic drug exposure on admission was defined as the use of anticholinergic drugs, total number of anticholinergic drugs and anticholinergic drug burden score (ADB), quantified with the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden scale (ACB) and the list of Chew et al. (Chew). Logistic regression analyses were performed to investigate possible associations between anticholinergic drug exposure and the aforementioned outcomes. Analyses were adjusted for age, sex, comorbidities, non-anticholinergic drugs and delirium, where appropriate. Moderate and high ADB measured with the ARS were associated with delirium on admission with odds ratios (OR) of 1.70 (95% confidence interval (CI) = 1.16-2.49) and 1.83 (95% CI = 1.06-3.15), respectively. High ADB measured with the ARS was also associated with postdischarge institutionalization (OR = 2.43, 95% CI = 1.24-4.75). No associations were found using the ACB and Chew. Future studies are warranted to investigate the clinical usefulness of the ARS in reducing complications in older persons.
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Affiliation(s)
- Angelique Egberts
- Section of Geriatric Medicine Department of Internal Medicine Erasmus University Medical Center Rotterdam The Netherlands
| | - Saskia T van der Craats
- Section of Geriatric Medicine Department of Internal Medicine Erasmus University Medical Center Rotterdam The Netherlands
| | - Melissa D van Wijk
- Section of Geriatric Medicine Department of Internal Medicine Erasmus University Medical Center Rotterdam The Netherlands
| | - Shams Alkilabe
- Section of Geriatric Medicine Department of Internal Medicine Erasmus University Medical Center Rotterdam The Netherlands
| | | | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine Department of Internal Medicine Erasmus University Medical Center Rotterdam The Netherlands
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45
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Karapinar-Çarkıt F, van der Knaap R, Bouhannouch F, Borgsteede SD, Janssen MJA, Siegert CEH, Egberts TCG, van den Bemt PMLA, van Wier MF, Bosmans JE. Cost-effectiveness of a transitional pharmaceutical care program for patients discharged from the hospital. PLoS One 2017; 12:e0174513. [PMID: 28445474 PMCID: PMC5406030 DOI: 10.1371/journal.pone.0174513] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 03/10/2017] [Indexed: 11/30/2022] Open
Abstract
Background To improve continuity of care at hospital admission and discharge and to decrease medication errors pharmaceutical care programs are developed. This study aims to determine the cost-effectiveness of the COACH program in comparison with usual care from a societal perspective. Methods A controlled clinical trial was performed at the Internal Medicine department of a general teaching hospital. All admitted patients using at least one prescription drug were included. The COACH program consisted of medication reconciliation, patient counselling at discharge, and communication to healthcare providers in primary care. The primary outcome was the proportion of patients with an unplanned rehospitalisation within three months after discharge. Also, the number of quality-adjusted life-years (QALYs) was assessed. Cost data were collected using cost diaries. Uncertainty surrounding cost differences and incremental cost-effectiveness ratios between the groups was estimated by bootstrapping. Results In the COACH program, 168 patients were included and in usual care 151 patients. There was no significant difference in the proportion of patients with unplanned rehospitalisations (mean difference 0.17%, 95% CI -8.85;8.51), and in QALYs (mean difference -0.0085, 95% CI -0.0170;0.0001). Total costs for the COACH program were non-significantly lower than usual care (-€1160, 95% CI -3168;847). Cost-effectiveness planes showed that the program was not cost-effective compared with usual care for unplanned rehospitalisations and QALYs gained. Conclusion The COACH program was not cost-effective in comparison with usual care. Future studies should focus on high risk patients and include other outcomes (e.g. adverse drug events) as this may increase the chances of a cost-effective intervention. Dutch trial register NTR1519
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Affiliation(s)
| | | | | | | | | | | | - Toine C. G. Egberts
- Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, The Netherlands
- Division Pharmacoepidemiology & Clinical Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | | | - Marieke F. van Wier
- Department of Epidemiology and Biostatistics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Judith E. Bosmans
- Department of Health Sciences and EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
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46
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Bos JM, van den Bemt PMLA, de Smet PAGM, Kramers C. The effect of prescriber education on medication-related patient harm in the hospital: a systematic review. Br J Clin Pharmacol 2017; 83:953-961. [PMID: 27918623 DOI: 10.1111/bcp.13200] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 11/25/2016] [Accepted: 11/25/2016] [Indexed: 12/14/2022] Open
Abstract
AIMS Educating prescribers is a strategy to reduce prescription errors in hospitals. The present systematic review gives an overview of original research papers on the education of prescribers and reporting outcomes on (potential) patient harm. METHODS A search of the databases Embase and Medline, using the Ovid interface, was performed. Research on the effect of physician education in order to prevent medication-related problems in inpatients, and on reporting original data and outcomes on prescribing errors and/or (potential) patient harm, was included. The assessment of methodological quality and risk of bias was performed using the Methodological Index for Non-Randomized studies (MINORS) checklist and the suggested risk of bias criteria for Effective Practice and Organization of Care (EPOC) reviews. RESULTS Eight studies investigated an intervention on education alone, and in seven studies education was the main part of a multifaceted intervention. All studies were small and had short follow-up periods. The educational programmes varied and were given to physicians of different specialties and levels of experience. Most studies reported intermediate process parameters as the outcome. The risk of performance and reporting bias were high. CONCLUSION All included studies suffered from poor methodology. The majority, especially studies in which education was part of a multifaceted intervention, reported effectiveness on intermediate outcome markers as prescription errors and potential adverse drug events. However, we found no firm evidence that educating prescribers in the hospital leads to a decrease in patient harm. Further work is needed to develop educational programmes, accompanied by more high-quality research with outcomes on the improvement of patient care.
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Affiliation(s)
- Jacqueline M Bos
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | | | - Peter A G M de Smet
- Department of Clinical Pharmacy and Scientific Institute for Quality of Healthcare, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Cornelis Kramers
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands.,Departement of Clinical Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, the Netherlands
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47
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Dreijer AR, Kruip MJHA, Diepstraten J, Polinder S, Brouwer R, Leebeek FWG, Vulto AG, van den Bemt PMLA. Antithrombotic stewardship: a multidisciplinary team approach towards improving antithrombotic therapy outcomes during and after hospitalisation: a study protocol. BMJ Open 2016; 6:e011537. [PMID: 27998897 PMCID: PMC5223636 DOI: 10.1136/bmjopen-2016-011537] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Antithrombotic therapy carries high risks for patient safety. Antithrombotics belong to the top 5 medications involved in potentially preventable hospital admissions related to medication. To provide a standard for antithrombotic therapy and stress the importance of providing optimal care to patients on antithrombotic therapy, the Landelijke Standaard Ketenzorg Antistolling (LSKA; Dutch guideline on integrated antithrombotic care) was drafted. However, the mere publication of this guideline does not guarantee its implementation. This may require a multidisciplinary team effort. Therefore, we designed a study aiming to determine the influence of hospital-based antithrombotic stewardship on the effect and safety of antithrombotic therapy outcomes during and after hospitalisation. METHODS AND ANALYSIS In this study, the effect of the implementation of a multidisciplinary antithrombotic team is compared with usual care using a pre-post study design. The study is performed at the Erasmus University Medical Center Rotterdam and the Reinier de Graaf Hospital Delft. Patients who are or will be treated with antithrombotics are included in the study. We aim to include 1900 patients, 950 in each hospital. Primary outcome is the proportion of patients with a composite end point consisting of ≥1 bleeding or ≥1 thrombotic event from the beginning of antithrombotic therapy (or hospitalisation) until 3 months after hospitalisation. Bleeding is defined according to the International Society of Thrombosis and Haemostasis (ISTH) classification. A thrombotic event is defined as any objectively confirmed arterial or venous thrombosis, including acute myocardial infarction or stroke for arterial thrombosis and deep venous thrombosis or pulmonary embolism or venous thrombosis. An economic evaluation is performed to determine whether the implementation of the multidisciplinary antithrombotic team will be cost-effective. ETHICS AND DISSEMINATION This protocol was approved by the Medical Ethical Committee of the Erasmus University Medical Center. The findings of the study will be disseminated through peer-reviewed journals and presented at relevant conferences. TRIAL REGISTRATION NUMBER NTR4887; pre-results.
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Affiliation(s)
- Albert R Dreijer
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jeroen Diepstraten
- Department of Hospital Pharmacy, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rolf Brouwer
- Department of Hematology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Arnold G Vulto
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
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48
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Bos JM, van den Bemt PMLA, Kievit W, Pot JLW, Nagtegaal JE, Wieringa A, van der Westerlaken MML, van der Wilt GJ, de Smet PAGM, Kramers C. A multifaceted intervention to reduce drug-related complications in surgical patients. Br J Clin Pharmacol 2016; 83:664-677. [PMID: 27670813 DOI: 10.1111/bcp.13141] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/31/2016] [Accepted: 09/21/2016] [Indexed: 12/14/2022] Open
Abstract
AIM The P-REVIEW study was a prospective, multicenter, open intervention study, designed to determine whether a multifaceted intervention of educating the prescriber combined with medication review and pharmaceutical visits to the ward by the hospital pharmacist could lead to a reduction in drug-related complications among surgical patients. METHODS A total of 6780 admissions of 5940 patients to surgical, urological and orthopaedic wards during the usual care period and 6484 admissions of 5711 patients during the intervention period were included. An educational programme covering pain management, antithrombotics, fluid and electrolyte management, prescription in case of renal insufficiency and antibiotics was developed. National and local hospital guidelines were included. Hospital pharmacists performed medication safety consultations, combining medication review of high-risk patients and a visit to the physician on the ward. RESULTS A significantly lower proportion of admissions with one or more clinically relevant, potentially preventable, drug-related problems (including death, temporary or sustained disability, increased length of hospital stay or readmission within 30 days) occurred in the intervention period (1.1% (73/6484) compared to the usual care period [1.6% (106/6780)] (P = 0.029). The relative risk (RR) was 0.72 (95% CI 0.53-0.97). Several types of drug-related problems occurred less frequently. Costs incurred as result of time spent on study-related activities were not different before and after the intervention. CONCLUSIONS The P-REVIEW study shows that education and support of the prescribing physician with respect to high-risk patients in surgical departments leads to a significant, clinically relevant benefit for patients without generating additional costs.
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Affiliation(s)
- Jacqueline M Bos
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | | | - Wietske Kievit
- Department of Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Johan L W Pot
- Department of Clinical Pharmacy, Meander Medical Centre, Amersfoort, the Netherlands
| | - J Elsbeth Nagtegaal
- Department of Clinical Pharmacy, Meander Medical Centre, Amersfoort, the Netherlands
| | - André Wieringa
- Department of Clinical Pharmacy, Isala Hospital, Zwolle, the Netherlands
| | | | - Gert Jan van der Wilt
- Department of Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Peter A G M de Smet
- Department Scientific Institute for Quality of Healthcare, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Cornelis Kramers
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands.,Department of Clinical Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, the Netherlands
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Zaal RJ, Ebbers S, Borms M, Koning BD, Mombarg E, Ooms P, Vollaard H, van den Bemt PMLA, Evenhuis HM. Medication review using a Systematic Tool to Reduce Inappropriate Prescribing (STRIP) in adults with an intellectual disability: A pilot study. Res Dev Disabil 2016; 55:132-142. [PMID: 27065309 DOI: 10.1016/j.ridd.2016.03.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 07/15/2015] [Accepted: 03/24/2016] [Indexed: 06/05/2023]
Abstract
A Systematic Tool to Reduce Inappropriate Prescribing (STRIP), which includes the Screening Tool to Alert doctors to Right Treatment (START) and the Screening Tool of Older Peoples' Prescriptions (STOPP), has recently been developed in the Netherlands for older patients with polypharmacy in the general population. Active involvement of the patient is part of this systematic multidisciplinary medication review. Although annual review of pharmacotherapy is recommended for people with an intellectual disability (ID), a specific tool for this population is not yet available. Besides, active involvement can be compromised by ID. Therefore, the objective of this observational pilot study was to evaluate the process of medication review using STRIP in adults with an ID living in a centralized or dependent setting and the identification of drug-related problems using this tool. The study was performed in three residential care organizations for ID. In each organization nine clients with polypharmacy were selected by an investigator (a physician in training to become a specialized physician for individuals with an ID) for a review using STRIP. Clients as well as their legal representatives (usually a family member) and professional caregivers were invited to participate. Reviews were performed by an investigator together with a pharmacist. First, to evaluate the process time-investments of the investigator and the pharmacist were described. Besides, the proportion of reviews in which a client and/or his legal representative participated was calculated as well as the proportion of professional caregivers that participated. Second, to evaluate the identification of drug-related problems using STRIP, the proportion of clients with at least one drug-related problem was calculated. Mean time investment was 130minutes for the investigator and 90minutes for the pharmacist. The client and/or a legal representatives were present during 25 of 27 reviews (93%). All 27 professional caregivers (100%) were involved. For every client included at least one drug-related problem was identified. In total 127 drug-related problems were detected, mainly potentially inappropriate or unnecessary drugs. After six months, 15.7% of the interventions were actually implemented. Medication review using STRIP seems feasible in adults with an ID and identifies drug-related problems. However, in this pilot study the implementation rate of suggested interventions was low. To improve the implementation rate, the treating physician should be involved in the review process. Besides, specific adaptations to STRIP to address drug-related problems specific for this population are required.
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Affiliation(s)
- Rianne J Zaal
- Erasmus Medical Center, Department of Hospital Pharmacy, Rotterdam, The Netherlands.
| | | | - Mirka Borms
- Het Raamwerk, Noordwijkerhout, The Netherlands
| | | | | | - Piet Ooms
- De Katwijkse Apotheek, Katwijk, The Netherlands
| | | | | | - Heleen M Evenhuis
- Erasmus Medical Center, Department of General Practice, Intellectual Disability Medicine, Rotterdam, The Netherlands
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50
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Vasbinder EC, Goossens LMA, Rutten-van Mölken MPMH, de Winter BCM, van Dijk L, Vulto AG, Blankman EIM, Dahhan N, Veenstra-van Schie MTM, Versteegh FGA, Wolf BHM, Janssens HM, van den Bemt PMLA. e-Monitoring of Asthma Therapy to Improve Compliance in children (e-MATIC): a randomised controlled trial. Eur Respir J 2016; 48:758-67. [PMID: 27230437 DOI: 10.1183/13993003.01698-2015] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 04/17/2016] [Indexed: 01/28/2023]
Abstract
Real-time medication monitoring (RTMM) is a promising tool for improving adherence to inhaled corticosteroids (ICS), but has not been sufficiently tested in children with asthma. We aimed to study the effects of RTMM with short message service (SMS) reminders on adherence to ICS, asthma control, asthma-specific quality of life and asthma exacerbation rate; and to study the associated cost-effectiveness.In a multicentre, randomised controlled trial, children (aged 4-11 years) using ICS were recruited from five outpatient clinics and were given an RTMM device for 12 months. The intervention group also received tailored SMS reminders, sent only when a dose was at risk of omission. Outcome measures were adherence to ICS (RTMM data), asthma control (childhood asthma control test questionnaire), quality of life (paediatric asthma quality of life questionnaire) and asthma exacerbations. Costs were calculated from a healthcare and societal perspective.We included 209 children. Mean adherence was higher in the intervention group: 69.3% versus 57.3% (difference 12.0%, 95% CI 6.7%-17.7%). No differences were found for asthma control, quality of life or asthma exacerbations. Costs were higher in the intervention group, but this difference was not statistically significant.RTMM with tailored SMS reminders improved adherence to ICS, but not asthma control, quality of life or exacerbations in children using ICS for asthma.
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Affiliation(s)
- Erwin C Vasbinder
- Dept of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands Dept of Hospital Pharmacy, Groene Hart Ziekenhuis, Gouda, The Netherlands
| | - Lucas M A Goossens
- Erasmus University Institute for Medical Technology Assessment, Rotterdam, The Netherlands
| | | | - Brenda C M de Winter
- Dept of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Arnold G Vulto
- Dept of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Nordin Dahhan
- Division of Paediatric Respiratory Medicine, Academic Medical Center/Emma Children's Hospital, Amsterdam, The Netherlands
| | | | | | - Bart H M Wolf
- Dept of Paediatrics, Sint Lucas Andreas Ziekenhuis, Amsterdam, The Netherlands
| | - Hettie M Janssens
- Division of Paediatric Respiratory Medicine, Erasmus University Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
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