Lorenz Van der Linden

Predictors for unintentional medication reconciliation discrepancies in preadmission medication: a systematic review

PurposeDiscrepancies in preadmission medication (PAM) are common and potentially harmful. Medication reconciliation is able to reduce the discrepancy rate, yet implementation is challenging. In order for reconciliation efforts to be more cost-effective, patients at high risk for reconciliation errors should be identified. The purpose of this systematic review is to identify predictors for unintentional discrepancies in PAM.MethodsMedline and Embase were searched systematically until June 2017. Only studies concerning adult subjects were retained. Quantitative studies were included if predictors for unintentional discrepancies in the PAM had been determined on hospital admission. Variables were divided into patient-, medication-, and setting-related predictors based on a thematic analysis. Studies on identification of predictors for discrepancies and potentially harmful discrepancies were handled separately.ResultsThirty-five studies were eligible, of which 5 studies focused on potentially harmful discrepancies. The following 16 significant variables were identified using multivariable prediction models: number of preadmission drugs, patient’s age, availability of a drug list, patients’ understanding of medication, usage of different outpatient pharmacies, number of high-risk drugs, discipline for which the patient is admitted, admitting physician’s experience, number and type of consulted sources, patient’s gender, type of care before admission, number of outpatient visits during the past year, class of medication, number of reimbursements, use of an electronic prescription system, and type of admission (elective vs emergency). The number of preadmission drugs was identified as a predictor in 20 studies. Potentially harmful discrepancies were ascertained in 5 studies with age found to have a predictive value in all 5 studies.ConclusionMultiple suitable predictors for PAM-related discrepancies were identified of which higher age and polypharmacy were reported most frequently.

Erratum to: Reduced length of stay in radical cystectomy patients with oral versus parenteral post-operative nutrition protocol

Background In Europe, parenteral nutrition is often used after radical cystectomy to avoid postoperative malnourishment. To the best of our knowledge, however, there is a paucity of data to conclude on the best modality for delivering nutritional support to this patient group. Objective The parenteral nutrition policy was reconsidered and an oral nutrition protocol was implemented by the clinical pharmacist and evaluated in terms of length of stay, number and type of postoperative complications and parenteral nutrition avoided costs. Setting A prospective interventional non-randomized before-after study was conducted. Regular radical cystectomy patients presenting without preoperative contra-indications for enteral nutrition were eligible. Methods Postoperatively, in the control group, the parenteral nutrition policy from the ward was applied. Parenteral nutrition was initiated systematically and continued until the patient was able to tolerate solid food. In the interventional group, an oral nutrition protocol was implemented. Parenteral nutrition could be initiated if oral intake remained insufficient after 5 days. Main outcome measure The primary end point was postoperative length of stay. Secondary endpoints included the number of patients in whom the oral nutrition protocol was implemented successfully, as well as the number and type of postoperative complications. Results A total of 94 eligible patients was assigned consecutively to the control (n = 48) and to the interventional group (n = 46). Baseline demographics were comparable. A significant reduction in median length of stay was associated with the oral nutrition protocol [18 days (IQR 15–22) in the control group vs. 14 days (IQR 13–18) in the interventional group (p < 0.001)]. In 40 out of 46 patients from the interventional group, the oral nutrition protocol was implemented successfully. The number and type of postoperative complications did not differ significantly. Implementing the oral nutrition protocol resulted in a direct parenteral nutrition infusion bag cost saving of approximately €512 and a reduction in hospitalization cost of €2,608 per patient. Conclusion The findings of our study showed that an oral nutrition protocol, when compared to the systematic postoperative use of parenteral nutrition, was associated with a decreased length of stay and costs in a regular radical cystectomy patient population.

Medication review versus usual care to improve drug therapies in older inpatients not admitted to geriatric wards: a quasi-experimental study (RASP-IGCT)

BackgroundInterdisciplinary geriatric consultation teams (IGCT) are regularly requested to provide comprehensive geriatric assessments in older inpatients. Our primary aim was to evaluate whether medication reviews increased the number of IGCT-provided drug-related recommendations. Secondary aims were to reduce the number of potentially inappropriate medications (PIMs), and to identify the acceptance rate of and determinants for the number of recommendations.MethodsA before-after study was performed in older inpatients not admitted to acute geriatric wards. The before cohort received usual care (UC); the after cohort was subjected to the intervention (I), consisting of a systematic medication review, based on but not limited to the RASP (Rationalization of Home Medication by an Adjusted STOPP in Older Patients) list. The primary outcome measure was the number of IGCT-provided drug-related recommendations. Age, sex, Charlson Comorbidity Index, creatinine clearance and serum creatinine were ascertained upon enrolment. Following variables were determined on admission and at discharge: number of drugs and number as well as type of RASP-identified PIMs. Acceptance by ward-based physicians was also determined. Poisson regression was performed to identify determinants for the primary outcome measure.ResultsFifty-nine participants were enrolled (nUC = 29; nI = 30). The intervention increased the number of drug-related recommendations from a median of 0 (IQR: 0–1) to 8 (IQR: 6.75–10) (p < 0.001). The median number of accepted recommendations differed significantly as well (UC vs. I: 0.0 (0.0–0.5) vs. 3.0 (0.0–5.3); p < 0.001). In the intervention cohort, patients were discharged with fewer drugs compared to admission (UC vs. I: 108.5%, IQR: 100.0–135.8% vs. 92%, IQR: 80.5–103.5%; p = 0.002). More RASP PIMs were discontinued in the intervention cohort, with a mean difference of 1.49 RASP PIMs (95% confidence interval (CI): 0.70, 2.23; p < 0.001). Regression analysis identified two determinants: allocation to the intervention cohort with an incidence rate ratio (IRR) of 14.1 (95% CI: 8.30, 23.8) and the number of preadmission drugs with an IRR of 1.06 (95% CI: 1.03, 1.09).ConclusionsA structured medication review as part of usual IGCT care may contribute to an increased detection of drug-related problems and help to further reduce polypharmacy in older inpatients, not admitted to acute geriatric care wards.Trial registrationNCT02165618, retrospectively registered June 17, 2014.

Hoe omgaan met nierfunctieschatters bij dosisaanpassing van geneesmiddelen bij ouderen met chronische nierinsufficiëntie

Veel geneesmiddelen worden hoofdzakelijk via de nieren uitgescheiden. Bijgevolg dient men waakzaam te zijn bij een verminderde nierfunctie en kan voor dergelijke geneesmiddelen een dosisverlaging noodzakelijk zijn. Dit is onder andere het geval voor bepaalde anti-infectieuze middelen, anticoagulantia, orale antidiabetica, remmers van het renine-angiotensine-aldosteron systeem (RAAS) en cytostatica. In de dagelijkse klinische praktijk wordt de nierfunctie zelden gemeten, maar eerder geschat op basis van de glomerulaire filtratiesnelheid (GFR). De GFR kan rekenkundig worden benaderd gebruikmakend van verschillende schattende formules (eGFR). Het bestaan van meerdere formules kan leiden tot verschillende adviezen voor dosisaanpassing van geneesmiddelen. Enerzijds bestaat het risico op overdosering met accumulatie en toxiciteit tot gevolg. Anderzijds wordt de werkelijke nierfunctie mogelijk onderschat, wat aanleiding kan geven tot subtherapeutische serumconcentraties van een geneesmiddel met risico op therapiefalen. Een bijzondere populatie met een verhoogde incidentie van een verlaagde nierfunctie betreft de groep van oudere patienten. Bij deze patienten is het belangrijk om de oordeelkundige afweging te maken om de dosis van een geneesmiddel al dan niet te verlagen. In de onderstaande casussen worden twee voorbeelden toegelicht.

Medicatienazicht bij een oudere patiënt met polyfarmacie

Het stimuleren en verzekeren van het correcte gebruik van geneesmiddelen bij ouderen vormt een belangrijke uitdaging voor artsen en apothekers, aangezien geneesmiddel-gerelateerde problemen vaker voorkomen naarmate de leeftijd stijgt. Uit een meta-analyse uitgevoerd in 2002 is gebleken dat 15 a 20% van de ziekenhuisopnamen bij ouderen kan toegeschreven worden aan geneesmiddelgerelateerde problemen. Een observationeel onderzoek in Nederland (in 2008) heeft aangetoond dat gemiddeld 6% van alle ongeplande ziekenhuisopnamen rechtstreeks te wijten was aan een geneesmiddelgerelateerd probleem waarbij de helft daarvan waarschijnlijk vermijdbaar was en dat prevalentie toenam met de leeftijd. Men onderscheidt in het algemeen drie soorten problemen, m.n. overbodig gebruik, zonder indicatie („overuse”), verkeerd gebruik bv. verkeerde geneesmiddelkeuze, dosis of vorm („misuse”) en onderbehandeling („underuse”). Waar vroeger het aantal geneesmiddelen als een indicator beschouwd werd voor correcte farmacotherapie bij ouderen, en de term polyfarmacie dus een negatieve bijklank had, is er nu een evolutie naar „maatwerk” bij ouderen, waarbij niet het aantal geneesmiddelen, maar wel de oordeelkundige keuze van farmacotherapie op maat van de patient primeert. Meer en meer wordt vastgesteld dat ook het stoppen van niet (meer) zinvolle farmacotherapie („deprescribing”) een onderdeel uitmaakt van een oordeelkundig voorschrijfgedrag. Het doel is te komen tot farmacotherapie die rekening houdt met de geindividualiseerde therapiedoelen, de huidige functionaliteit, de levensverwachting en voorkeuren van de patient. In de onderstaande casus wordt het belang aangetoond van medicatienazicht bij een oudere patiente die in het ziekenhuis werd opgenomen via de dienst spoedgevallen.

Pharmacokinetic changes after placement of a transjugular intrahepatic portosystemic shunt

To the Editor, Cirrhotic patients with a transjugular intrahepatic portosystemic shunt (TIPS) may be particularly vulnerable to exaggerated effects of drugs [1, 2]. We report for the first time a case with ß-adrenergic blocker (BB) and calcium channel antagonist (CCA) toxicity caused by pharmacokinetic alterations after placement of TIPS. A 76-year-old man with end-stage liver cirrhosis (ChildPugh score B8) was admitted electively to the hepatology ward for placement of a TIPS [expanded polytetrafluorethylene-