Hege Salvesen Blix

The majority of hospitalised patients have drug-related problems: results from a prospective study in general hospitals

Objective: To describe the frequency and types of drug-related problems (DRPs) in hospitalised patients, and to identify risk factors for DRPs and the drugs most frequently causing them.Methods From May to December 2002, 827 patients from six internal medicine and two rheumatology departments in five hospitals in Norway were included in this study. We recorded demographic data, drugs used, relevant medical history, laboratory data and clinical/pharmacological risk factors, i.e. reduced renal function, reduced liver function, heart failure, diabetes, compliance problems, drugs with a narrow therapeutic index and drug allergy. DRPs were documented after reviewing medical records and participation in multidisciplinary team discussions. An independent quality assessment team retrospectively assessed the DRPs in a randomly selected number of the study population.ResultsOf the patients, 81% had DRPs, and an average of 2.1 clinically relevant DRPs was recorded per patient. The DRPs most frequently recorded were dose-related problems (35.1% of the patients) followed by need for laboratory tests (21.6%), non-optimal drugs (21.4%), need for additional drugs (19.7%), unnecessary drugs (16.7%) and medical chart errors (16.3%). The patients used an average of 4.6 drugs at admission. A multivariate analysis showed that the number of drugs at admission and the number of clinical/pharmacological risk factors were both independent risk factors for the occurrence of DRPs, whereas age and gender were not. The drugs most frequently causing a DRP were warfarin, digitoxin and prednisolone, with calculated risk ratios 0.48, 0.42 and 0.26, respectively. The drug groups causing most DRPs were B01A-antithrombotic agents, M01A-non-steroidal anti-inflammatory agents, N02A-opioids and C09A-angiotensin converting enzyme inhibitors, with risk ratios of 0.22, 0.49, 0.21 and 0.35, respectively.ConclusionsThe majority of hospitalised patients in our study had DRPs. The number of drugs used and the number of clinical/pharmacological risk factors significantly and independently influenced the risk for DRPs. Procedures for identification of, and intervention on, actual and potential DRPs, along with awareness of drugs carrying a high risk for DRPs, are important elements of drug therapy and may contribute to diminishing drug-related morbidity and mortality.

The Impact of Clinical Pharmacists on Drug‐Related Problems and Clinical Outcomes

Drug-related problems are frequent and may result in reduced quality of life, and even morbidity and mortality. Many studies have shown that clinical pharmacists can effectively identify and prevent clinically significant drug-related problems and that physicians acknowledge and act on the clinical pharmacists suggestions for interventions to the drug-related problems. A pro-active rather than a reactive approach on the part of the pharmacists seems prudent for obtaining most benefit. This includes participation of pharmacists in the multidisciplinary team discussions - at the stage of ordering and prescribing - where all types of drug-related problems, including also potential problems, should be discussed. In addition, counselling by pharmacists about medication on discharge and follow-up after discharge resulted in better outcomes. Furthermore, clinical pharmacists can positively influence other outcomes, such as improvement of levels of markers for drug use (e.g. optimization of lipid levels, anticoagulation levels and blood pressure). Some studies have reported positive effects on hard clinical outcomes, such as reduced length of stay, fewer re-admissions and fewer disease events (e.g. heart failure events and thromboembolism). However, more studies should be undertaken with larger patient populations, including patients from multiple sites. More knowledge about patient-specific factors that predict improved care is also needed. In conclusion, there is increasing evidence that participation and interventions of clinical pharmacists in health care positively influence clinical practice.

Different versions of the anatomical therapeutic chemical classification system and the defined daily dose : are drug utilisation data comparable?

Abstract. Objective: To investigate whether published drug utilisation studies contain satisfactory references to the ATC/DDD version applied and thus are usable for comparative purposes. Methods and results: A literature survey of drug utilisation studies was made. Seventy-three articles were identified by two Medline searches, one in 1996 and another in 1998. The articles were classified into four different groups. Groups 1 and 2 give proper references to the defined daily doses (DDDs) used in the studies, either by full reference to the version of the ATC Index with DDDs or by listing the actual DDDs used. The articles in groups 1 and 2 represent 46% of the articles in the survey. The articles classified in groups 3 and 4 give references only to general articles about the anatomical therapeutic chemical classification (ATC)/DDD system or no references at all. Fifty-four percent of the articles in the survey were classified in these groups. In these articles it is not possible to identify which DDDs have been used in the presentation of drug consumption data. Conclusions: According to the results from our literature survey, it is not common practice to include the ATC codes and the DDD values used or to make reference to the versions of the ATC/DDD index used when results from drug utilisation studies are published. One possible reason for this might be little or no knowledge about the ATC/DDD system as a dynamic system in which alterations are made annually. The lack of references to the actual DDDs used in the studies make comparisons between different data sets difficult and misleading.

Characteristics of drug-related problems discussed by hospital pharmacists in multidisciplinary teams

ObjectiveTo investigate pharmacist contribution in the therapeutic hospital team by studying drug-related problems (DRPs), pharmacist therapy advice and consequences of the advice.MethodsFrom May to December 2002, 827 patients in five Norwegian hospitals were included in the study. Demographic data, drugs used, relevant medical history, laboratory data and clinical/pharmacological risk factors were recorded prospectively at the wards.Main outcome measureDRPs, patients characteristics, pharmacist advice to physicians, nurses or patients, response to the pharmacist advice, and reasons (stated by the pharmacist) for not discussing an identified DRP, were reported. An independent quality assessment team retrospectively assessed the DRPs for a randomly selected number of the study population.ResultsOn average 2.6 DRPs per patient were found. A total of 2128 DRPs were registered and of these 1583 (74%) DRPs were brought up for discussion. Physician immediate acceptance rates varied from 80% (for extremely important clinically signififcant DRPs) to 50% (for DRPs of minor clinical significance). High age, use of many drugs at admission, existence of many DRPs and many clinical/pharmacological risk factors for DRPs were associated with low immediate acceptance rate. Type of DRP influenced how the DRP was discussed; adverse drug reaction (ADR) and unnecessary drug were discussed with physicians while e.g. medical chart error and need for patient education were discussed with nurses/patients. Reasons for not discussing DRPs in the team were: not given priority (37%), no longer relevant (31%) and others (31%). DRPs of minor clinical significance were most often excluded from discussion (37%) as opposed to 14% and 22% of those of moderate and major clinical significance.ConclusionsThe majority of patients had one or more DRPs. The problems identified as DRPs by the pharmacists were accepted as such by the physicians and to a high degree acted upon. Both clinical significance of the DRP and patient characteristics influenced physician immediate acceptance rate. Some DRPs could be solved by direct contact with nurses or the patients. Awareness of DRPs increases through participation of pharmacists in the multidisciplinary therapeutic hospital team.

Problems in collecting comparable national drug use data in Europe: the example of antibacterials

ObjectiveTo describe the methodological problems in collecting retrospectively comparable data on drug use and to compare the use of antibacterials in some European countries.MethodsA spreadsheet was distributed in 2000 through the European Drug Utilisation Research Group (EuroDURG) network, requesting 1994–1999 data on use of antibacterials for systemic use (ATC group J01), from ambulatory, hospital, or total care, aggregated at ATC 4th level, and presented in defined daily doses per 1000 inhabitants per day (in the 1999 ATC/DDD version or specified other version).ResultsThe network was able to provide national utilization data for two or more years in the requested period from 16 countries (4 only from primary care, 3 both from primary care and total use, and 9 only total use data). The main methodological problems identified were: use of divergent ATC/DDD versions, divergent assignment of DDDs for combination products and the use of unofficial or national DDDs. It was possible to correct for the different ATC/DDD versions to some extent, except for the cephalosporin group (not included in the analysis), as the collection of data at the ATC 4th level precluded recalculation of DDDs. In the seven countries with primary care data the total J01 antibacterials use varied by a factor of 2.5 (Belgium 23.4 and The Netherlands 9.5 DDDs per 1000inhabitants per day). The use of J01A tetracyclines varied fourfold, and the use of J01C penicillins and J01F macrolides and lincosamides approximately threefold. Significant reduction over time was seen in J01A and an increase in J01F.ConclusionsIn the scientific and regulatory community it is still difficult to perform a valid and comprehensive cross-national collection of utilization data on antibacterials. White spots on the European map persist for ambulatory care data, and data are missing for the hospital sector in most countries. For a thorough explanation of the considerable intercountry variability (especially in antibacterial subgroups and time trends analysis) a sustained and concerted effort is necessary to implement a validation process of the ATC/DDD use in the various countries and to adopt a common methodological approach to the collection of utilization data at the substance level (ATC 5th level).

How are antibacterials used in nursing homes? Results from a point-prevalence prescription study in 44 Norwegian nursing homes†

To describe the use of antibacterials among nursing home residents in Norway according to diagnosis, therapy choice, doses and expected duration of treatment.

Identification of drug interactions in hospitals – computerized screening vs. bedside recording

Background and objective:  Managing drug interactions in hospitalized patients is important and challenging. The objective of the study was to compare two methods for identification of drug interactions (DDIs) – computerized screening and prospective bedside recording – with regard to capability of identifying DDIs.

Large variation in antibacterial use among Norwegian nursing homes

A cross-sectional descriptive study among Norwegian nursing homes was conducted in 2003 to examine pharmacoepidemiological characteristics of antibacterials in nursing homes and also to estimate their share of overall antibacterial use in Norway. Antibacterial data were collected for ATC group J01 antibacterials for systemic use, A07AA09 vancomycin and P01AB01 metronidazole in DDDs/y. The amount of drugs principally prescribed for urinary tract infections (UTI) were depicted and used as an indicator for the treatment frequency for UTI in the nursing homes. Prescription of antibacterials in the 133 nursing homes that delivered data varied – from 4 to 44 DDD/100 bed-d. The urinary prophylactic agent, methenamine, represented nearly half of DDDs used, mean 7.3 DDD/100 bed-d. Penicillins with extended spectrum (J01CA) were most frequently used, followed by trimethoprim and sulfonamides (J01E), mean 2.3 and 1.5 DDD/100 bed-d, respectively. On average, 49% of the therapeutic antibacterials were drugs used for UTI, range 12%–88%. In 2003, the nursing home setting purchased an estimated 6% of human antibacterial use in Norway. Nursing homes represent an important share of national human use of antibacterials. The large variation in antibacterial use between facilities underlines the need for increased focus on rational prescribing in nursing homes.

How are drug regimen changes during hospitalisation handled after discharge: a cohort study

Objectives To investigate drug regimen changes during hospitalisation and explore how these changes are handled after patients are transferred back into the care of their general practitioners (GPs). Design Cohort study. Setting Patients in this multicentre study had undergone at least one change in their drug regimens at discharge from the general medicine departments at six hospitals in Norway. These changes were altered doses, discontinuation of drugs or start of new drugs. Clinical pharmacists visited the patients’ GPs 4–5 months after patient discharge and recorded any additional drug regimen changes. Results In total, 105 patients (mean age 76.1 years, 54.3% women) completed the study. On average, they used 5.6 drugs at admission (range 0–16) and 7.6 drugs at discharge (range 1–17). On average, 4.4 drug changes per patient (SD 2.7, range 1–16) were made at the hospital, and 3.4 drug changes per patient (SD 2.9, range 0–14) within 4–5 months of discharge. Of the 465 drug changes made in hospital, 153 were changed again after discharge (mean 1.5 per patient, SD 1.8, range 0–13). The drug regimens of 90 of these 105 patients were changed after discharge. The OR for extensive drug changes after discharge (≥ 4 changes) increased significantly with the number of drugs used at discharge from hospital (OR=1.29, 95% CI 1.04 to 1.59). Only 68 of 105 discharge notes contained complete drug lists, and only 24 of the discharge notes were received by the GPs within 7 days. Conclusions In addition to the extensive changes in drug regimens during hospitalisation, almost equally extensive changes were made in the initial months after discharge. Surveillance of drug regimens is particularly necessary in the period immediately after hospital discharge.

Drugs with narrow therapeutic index as indicators in the risk management of hospitalised patients

Drugs with narrow therapeutic index (NTI-drugs) are drugs with small differences between therapeutic and toxic doses. The pattern of drug-related problems (DRPs) associated with these drugs has not been explored. Objective To investigate how, and to what extent drugs, with a narrow therapeutic index (NTI-drugs), as compared with other drugs, relate to different types of drug-related problems (DRPs) in hospitalised patients. Methods Patients from internal medicine and rheumatology departments in five Norwegian hospitals were prospectively included in 2002. Clinical pharmacists recorded demographic data, drugs used, medical history and laboratory data. Patients who used NTI-drugs (aminoglycosides, ciclosporin, carbamazepine, digoxin, digitoxin, flecainide, lithium, phenytoin, phenobarbital, rifampicin, theophylline, warfarin) were compared with patients not using NTI-drugs. Occurrences of eight different types of DRPs were registered after reviews of medical records and assessment by multidisciplinary hospital teams. The drug risk ratio, defined as number of DRPs divided by number of times the drug was used, was calculated for the various drugs. Results Of the 827 patients included, 292 patients (35%) used NTI-drugs. The NTI-drugs were significantly more often associated with DRPs than the non-NTI-drugs, 40% versus 19% of the times they were used. The drug risk ratio was 0.50 for NTI-drugs and 0.20 for non-NTI-drugs. Three categories of DRPs were significantly more frequently found for NTI-drugs: non-optimal dose, drug interaction, and need for monitoring. Conclusion DRPs were more frequently associated with NTI-drugs than with non-NTI-drugs, but the excess occurrence was solely related to three of the eight DRP categories recorded. The drug risk ratio is a well-suited tool for characterising the risk attributed to various drugs.