Utility of an Algorithm to Increase the Accuracy of Medication History in an Obstetrical Setting.

BACKGROUND: In an obstetrical setting, inaccurate medication histories at hospital admission may result in failure to identify potentially harmful treatments for patients and/or their fetus(es). METHODS: This prospective study was conducted to assess average concordance rates between (1) a medication list obtained with a one-page structured medication history algorithm developed for the obstetrical setting and (2) the medication list reported in medical records and obtained by open-ended questions based on standard procedures. Both lists were converted into concordance rate using a best possible medication history approach as the reference (information obtained by patients, prescribers and community pharmacists' interviews). RESULTS: The algorithm-based method obtained a higher average concordance rate than the standard method, with respectively 90.2% [CI95% 85.8-94.3] versus 24.6% [CI95%15.3-34.4] concordance rates (p<0.01). CONCLUSION: Our algorithm-based method strongly enhanced the accuracy of the medication history in our obstetric population, without using substantial resources. Its implementation is an effective first step to the medication reconciliation process, which has been recognized as a very important component of patients' drug safety.

[Drug treatment of inpatients with chronic kidney disease in the acute care ward of a Swiss regional hospital]. / Prise en charge médicamenteuse des patients insuffisants rénaux chroniques hospitalisés en soins aigus dans un hôpital régional suisse.

INTRODUCTION: Optimal drug treatment may slow down the progression of chronic kidney disease (CKD) and reduce the associated complications. We conducted a study to assess the drug treatment of inpatients with CKD at their discharge. METHODS: We retrospectively collected patient data from the electronic medical record of a Swiss regional hospital for two non-consecutive months. Patients were eligible if their glomerular filtration rate at discharge ranged between 15 and 60 mL/min/1.73 m2. Primary outcome was optimal CKD management, defined by drug treatment conforming to the following 3 criteria: (i) appropriate medication dosage relative to kidney function, (ii) absence of contraindicated medication, and (iii) treatment of any comorbidity/complication related to CKD; or alternatively by the recommendation of a kidney-specific follow-up. RESULTS: The primary outcome was achieved by 45.1% of the 71 patients included. A total of 29.6% had at least one inappropriate medication dosage at discharge, 9.9% left with a drug contraindicated in case of CKD, and 73.2% presented at least one untreated comorbidity/complication at discharge. The most common untreated comorbidity was anaemia. A proposition for a specific follow-up was lacking in 39 of the 56 patients discharged with a non-optimal treatment. CONCLUSION: Drug treatment of patients with CKD may be improved in our setting, especially the treatment of comorbidities/complications related to CKD and the specific ambulatory follow-up.

[Quality of treatment after myocardial infarction: impact of hospital guidelines]. / Quatité du traitement après infarctus du myocarde: impact de recommandations hospitalières.

After myocardial infarction (MI), international societies of cardiology recommend an optimal treatment associating four classes of drugs, known as BASI combination (beta-blocker, antiplatelets, statin and inhibitor of the angiotensin converting enzyme). This study shows that the implementation of locally adapted guidelines in a regional hospital (CHCVs, Sion) significantly improve the treatment quality after MI, with a 10% increase of the BASI combination at discharge. Detailed results are discussed. Finally, we provide a table summarizing the optimal treatment strategy with drug examples including doses, which will be helpful to both general practitioners and specialists.

Effect of outpatient pharmacists' non-dispensing roles on patient outcomes and prescribing patterns.

BACKGROUND: The roles of pharmacists in patient care have expanded from the traditional tasks of dispensing medications and providing basic medication counseling to working with other health professionals and the public. Multiple reviews have evaluated the impact of pharmacist-provided patient care on health-related outcomes. Prior reviews have primarily focused on in-patient settings. This systematic review focuses on services provided by outpatient pharmacists in community or ambulatory care settings. This is an update of the Cochrane review published in 2000. OBJECTIVES: To examine the effect of outpatient pharmacists' non-dispensing roles on patient and health professional outcomes. SEARCH STRATEGY: This review has been split into two phases. For Phase I, we searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (January 1966 through March 2007). For Phase II, we searched MEDLINE/EMBASE (January 1966 through March 2008). The Phase I results are reported in this review; Phase II will be summarized in the next update. SELECTION CRITERIA: Randomized controlled trials comparing 1. Pharmacist services targeted at patients versus services delivered by other health professionals; 2. Pharmacist services targeted at patients versus the delivery of no comparable service; 3. Pharmacist services targeted at health professionals versus services delivered by other health professionals; 4. Pharmacist services targeted at health professionals versus the delivery of no comparable service. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed studies for inclusion, extracted data, and assessed risk of bias of included studies. MAIN RESULTS: Forty-three studies were included; 36 studies were pharmacist interventions targeting patients and seven studies were pharmacist interventions targeting health professionals. For comparison 1, the only included study showed a significant improvement in systolic blood pressure for patients receiving medication management from a pharmacist compared to usual care from a physician. For comparison 2, in the five studies evaluating process of care outcomes, pharmacist services reduced the incidence of therapeutic duplication and decreased the total number of medications prescribed. Twenty-nine of 36 studies reported clinical and humanistic outcomes. Pharmacist interventions resulted in improvement in most clinical outcomes, although these improvements were not always statistically significant. Eight studies reported patient quality of life outcomes; three studies showed improvement in at least three subdomains. For comparison 3, no studies were identified meeting the inclusion criteria. For comparison 4, two of seven studies demonstrated a clear statistically significant improvement in prescribing patterns. AUTHORS' CONCLUSIONS: Only one included study compared pharmacist services with other health professional services, hence we are unable to draw conclusions regarding comparisons 1 and 3. Most included studies supported the role of pharmacists in medication/therapeutic management, patient counseling, and providing health professional education with the goal of improving patient process of care and clinical outcomes, and of educational outreach visits on physician prescribing patterns. There was great heterogeneity in the types of outcomes measured across all studies. Therefore a standardized approach to measure and report clinical, humanistic, and process outcomes for future randomized controlled studies evaluating the impact of outpatient pharmacists is needed. Heterogeneity in study comparison groups, outcomes, and measures makes it challenging to make generalised statements regarding the impact of pharmacists in specific settings, disease states, and patient populations.

Electronic screening of medical records to detect inpatients at risk of drug-related problems.

OBJECTIVE: The objective of the study is to develop and validate a screening tool for clinical pharmacists (CPs), comprising electronic queries (EQs) structured to identify inpatients at risk of drug-related problems (DRPs) [1]. SETTING: Internal Medicine and Geriatric Units of the (multi-site) Hôpital du Valais. METHOD: EQs, identifying patients with potential DRPs and/or those requiring a medication review were compared with a CP-conducted manual check of all electronic medical records (EMRs), during their standard activities. The queries were aimed at identifying patients receiving drugs such as cytochrome P450 inducers, inhibitors or high-risk medications, those with renal impairment, those on digoxin with low serum potassium, those with intravenous (i.v.) anti-infectives or i.v. acetaminophen for more than 3 days, and elderly patients with polymedication (>or=80 years and >10 drugs). MAIN OUTCOME MEASURE: Sensitivity and specificity of the screening tool. RESULTS: Five hundred and one patients seen by 4 CPs during 36 ward rounds were screened. The EQs identified 64.7% of the visited inpatients. The CPs detected at least one DRP in 64.9% of all patients. A sensitivity of 85.1% and a specificity of 60.4% were achieved. CONCLUSION: This tool allows for efficient and rapid screening of patients at risk of DRPs in preparation for the ward round. It helps CPs to prioritize their medication reviews and to optimize their workload.

Clinical and economic outcomes of pharmaceutical services related to antibiotic use: a literature review.

AIM OF THE REVIEW: To identify and review the clinical and economic impact of pharmacists' interventions on antibiotic use. METHOD: A literature search was conducted on Medline (1966-2003) to identify original articles measuring the impact of pharmacists' interventions on antimicrobial therapy at patient's or prescriber's level. RESULTS: Forty-three articles were included: 20 uncontrolled before-after studies, four controlled before-after studies, five controlled trials, 12 randomized controlled trials and two interrupted time series (ITS). The described interventions were grouped into four categories: patient-specific recommendations (pharmacists' interventions concerning patient-specific drug therapy), implementation of policies, education, and therapeutic drug monitoring. These interventions were often combined to provide a multifaceted intervention, making it difficult to isolate the impact of one specific intervention. Measured outcomes were: appropriateness of prescribing (evaluated in 17 studies, 16 showing significant improvement), costs (analysed in 22 studies, nine showing a statistically significant reduction in costs after or with the intervention), and length of hospital stay (mixed results). Other measured outcomes were: drug use, prescriptions, length of treatment, dose intervals, switch to oral route, mortality rate, and treatment failure. CONCLUSION: Over the years, the number of studies and quality of methodology has increased. The most frequently observed outcomes with a positive impact were appropriateness of prescribing and cost savings. The vast majority of studies used multiple interventions, in conjunction with pharmacists' recommendations to physicians. Coupled with the use of practice guidelines or educational strategies, these interventions demonstrated a positive impact on economic or clinical outcomes. However, the data are still sparse and sometimes contradictory; therefore, further studies with randomized controlled designs are needed.

Hospital pharmacists' reinforcement of guidelines for switching from parenteral to oral antibiotics: a pilot study.

OBJECTIVE: The cost of antibiotics in hospitals may be reduced by streamlining, and, particularly, by early switching from the intravenous (i.v.) to the oral route of administration. The aim of the study was to evaluate the feasibility and impact of guidelines for switching, reinforced by pharmacists. METHOD: Patients admitted to internal medicine wards and treated with i.v. antibiotics for various infections were included for six weeks before (group A) and six weeks after (group B) the intervention. Differences in patient characteristics and their outcomes were sought between the two groups. RESULTS: The 26 patients in group B stayed longer in hospital than the 29 in group A (13.3 vs. 9.7 days; P = 0.05). They also tended to need more time to reach the pre-defined criteria for switching (3.6 vs. 2.4 days; P = 0.09). From that point on, they were switched more rapidly to oral antibiotics (1.5 vs. 3.2 days; P = 0.02), which resulted in a trend toward a lower treatment cost until their discharge (44 vs. 92 euros; P = 0.08). No difference was found between the 2 groups for the duration of the i.v. therapy, or the total in-hospital cost of antibiotics. CONCLUSION: Pharmacists may help implement and reinforce guidelines for switching to oral antibiotics. The evaluation of such interventions implies the choice of appropriate outcomes and the awareness of confounding factors.

Effect of telephone follow-up on the physical well-being dimension of quality of life in patients with cancer.

OBJECTIVE: To evaluate the effect of telephone follow-up on the physical well-being dimension of health-related quality of life in patients with cancer. DESIGN: Randomized, controlled trial. SETTING: Public teaching hospital. PATIENTS: One hundred fifty patients with cancer who were discharged to home from the hospital. INTERVENTION: Patients received a telephone follow-up call 48-72 hours after discharge. Information was solicited regarding drug-related (and other) problems. Problems were addressed, and advice and support were given. MEASUREMENTS AND MAIN RESULTS: Analysis of variance revealed no differences in the physical well-being dimension of health-related quality of life between patients who received telephone follow-up and a control group who did not. Sixty-eight percent of the follow-up group and 40% of the control group (p = 0.007) reported having had at least one contact with a health professional. CONCLUSION: One possible explanation for the lack of effect of the intervention is that high-risk patients in the control group received a similar intervention from other health care professionals. We suggest that telephone follow-up be coordinated among health professionals.

The direct cost and incidence of systemic fungal infections.

OBJECTIVES: In this study we determined the incidence and direct inpatient and outpatient costs of systemic fungal infections (candidiasis, aspergillosis, cryptococcosis, histoplasmosis) in 1998. METHODS: Using primarily the National Hospital Discharge Survey (NHDS) for incidence and the Maryland Hospital Discharge Data Set (MDHDDS) for costs, we surveyed four systemic fungal infections in patients who also had HIV/AIDS, neoplasia, transplant, and all other concomitant diagnoses. Using a case-control method, we compared the cases with controls (those without fungal infections with the same underlying comorbidity) to obtain the incremental hospitalization costs. We used the Student's t-test to determine significance of incremental hospital costs. We modeled outpatient costs on the basis of discharge status to calculate the total annual cost for systemic fungal infections in 1998. RESULTS: For 1998, the projected average incidence was 306 per million US population, with candidiasis accounting for 75% of cases. The estimated total direct cost was $2.6 billion and the average per-patient attributable cost was $31,200. The most commonly reported comorbid diagnoses with fungal infections (HIV/AIDS, neoplasms, transplants) accounted for only 45% of all infections. CONCLUSIONS: The cost burden is high for systemic fungal infections. Additional attention should be given to the 55% with fungal disease and other comorbid diagnoses.