Identifying and Communicating Clinically Meaningful Drug-Drug Interactions.

OBJECTIVE: Providing care to patients with comorbid medical problems may result in complicated, multiple drug therapy regimens, increasing the risk of clinically meaningful drug-drug interactions (DDIs). The purpose of this article is to describe the prevalence of DDIs and provide examples on how to identify and intervene on DDIs. METHODS: We described DDI data from the Utah Drug Regimen Review Center, where adult Medicaid patients were reviewed by pharmacists from 2005 to 2009. Patients were selected by the number of prescriptions filled per month (>7) or having a high RxRisk score. SUMMARY: A total of 8860 patients were reviewed, and 16.6% had at least 1 clinically meaningful DDI. Patients with DDIs were slightly younger (mean age 45.2 vs 48.2), more likely to be female (75.0% vs 68.9%), and had more prescriptions per month (13.4 vs 12.5) compared to patients without (P < .001). Pharmacodynamic DDIs were more prevalent (80.2%) than pharmacokinetic. Pharmacodynamic DDIs mainly occurred with drugs used to treat psychiatric/seizure/sleep disorders (69.4%) and pain/migraine (56.6%). Pharmacokinetic DDIs mainly occurred with drugs used to treat psychiatric/seizure/sleep disorders (53.2%), cardiovascular diseases (46.3%), and infectious diseases (29.6%). CONCLUSIONS: Clinically meaningful DDIs are common in patients with complex medication regimens. A systematic approach for identifying DDIs, determining clinical significance, formulating patient-specific recommendations, and communicating recommendations is important in pharmacy practice.

Agreement between pharmacists for problem identification: an initial quality measurement of cognitive services.

BACKGROUND: Recent changes in national reimbursement policies expand the ability of pharmacists to seek reimbursement for cognitive services. The quality of pharmacist-provided cognitive services has, until now, remained unassessed. Pharmacists should demonstrate the quality and value of their work to ensure the continued and expanded acceptance of reimbursement for their services. A preliminary step in assessing quality is to compare agreement between pharmacists for basic problem identification. OBJECTIVE: To quantify agreement between pharmacist reviewers for problem identification among Utah Medicaid recipients. METHODS: Five pharmacists retrospectively reviewed drug regimens, patient characteristics, diagnosis codes, and procedures for 80 Medicaid patients in September 2008 and identified drug-related problems (DRPs) in 15 predetermined categories. Data for each patient were reviewed twice, and each combination of 2 pharmacists reviewed the same 8 patients' information. We calculated a reliability coefficient to compare the number of DRPs identified and used prevalence and bias adjusted kappa (PABAK) to determine interrater reliability for the presence of a specific DRP. RESULTS: Of the 15 DRPs categorized by pharmacist reviewers, 1 (untreated indications) had a PABAK coefficient of 0.20, indicating a relatively low level of agreement between reviewers. All other DRP categories had good to excellent agreement, with PABAK coefficients ranging between 0.43 and 0.98. CONCLUSIONS: Pharmacist reviewers exhibited less variability in DRP identification or categorization than had been expected for most categories. This work supports the conclusion that pharmacists in our center provide a basic and necessary level of quality for problem assessment. Future work is needed to document the impact of this quality on patient outcomes.

Prevalence of drug-related problems and cost-savings opportunities in medicaid high utilizers identified by a pharmacist-run drug regimen review center.

BACKGROUND: Despite numerous reports of state Medicaid drug utilization review (DUR) programs, little data are available about the prevalence of drugrelated problems (DRPs) in Medicaid patients. A university-based, pharmacist-run DUR program for high utilizers was created as an alternative to imposition of a statutory limit of 7 medications per month in the Utah Medicaid program in 2002. The DUR program was designed to suggest ways that high-utilizing patients could decrease their total number of medications to 7 or fewer prior to imposition of the 7-medication limit at some time in the future. OBJECTIVE: To describe the experience in 1 Medicaid DUR program and to report the prevalence of DRPs and cost-saving opportunities (CSOs) among a population of Medicaid recipients who were high utilizers of prescription drugs. METHODS: DRPs were identified by 5 clinical pharmacists employed by the Drug Regimen Review Center (DRRC) in Salt Lake City. The purpose of the center was to provide drug therapy review services for a select number of Utah Medicaid recipients (200-300 per month) who exceeded a 7-medication limit during the calendar years 2003 and 2004. RESULTS: Out of 391,890 eligible Medicaid recipients, 242,411 (62%) received at least 1 medication, and 16,958 (4.3%) exceeded the 7-medication limit during the review period. Of those exceeding the limit, the DRRC reviewed a total of 3,706 (21.9%) patients, representing the highest utilizers by volume of medication. The prevalence of DRPs considered clinically important in the review cohort was 79.7% of patients, including therapeutic duplications in 54.6% of patients, dose form optimization in 29.7%, and inappropriate uncoordinated care in 25.3%. The average pharmacy cost per month for patients with at least 1 DRP was 1,081 dollars; by contrast, the average pharmacy cost per month for all other patients receiving at least 1 prescription was 91 dollars. CONCLUSIONS: Approximately 4% of Medicaid recipients exceeded the 7-medication monthly limit. Among the 22% highest utilizers in this group, 48% of nursing home residents and 87% of ambulatory recipients had at least 1 DRP, or an overall rate of 80% of high-use Medicaid recipients or as much as 3.2% of the Medicaid population.