Exploring the domains of appropriateness of drug therapy, using the Nominal Group Technique

Objective: To explore the domains encompassed within the assessment of the appropriateness of prescribing for an individual patient.Method: The Nominal Group Technique was used to address the question "How can we assess inappropriate drug therapy of individual patients that is responsive to pharmaceutical care?" The group participants were a self-selected group of nine pharmacists and one pharmacologist attending an international working conference on the Outcomes of Pharmaceutical Care. Item generation was followed by discussion for clarification and operationalisation. Voting achieved a consensus, defined as 70%, agreement on the importance of items for inclusion in an instrument to assess appropriateness.Results: Sixty-seven items were initially generated. During discussion, similar items were combined and items were grouped into domains. Items that considered the patient's perspective were commonly suggested, but many were discarded after discussing their operationalisation. Consensus was obtained that eighteen items, in seven domains, should be included in the instrument. The domains were indication and drug choice (5 items), effectiveness (2), risks and safety (2), dosage (3), interactions (1), practical use (4), and monitoring (1).Conclusion: It is hoped that, with adequate testing, these indicators of appropriateness of prescribing can be used by pharmacists to begin to routinely assess the impact of pharmaceutical care on the quality of prescribing for patients under their care.     

A ten-step quality assurance program for regional poison information centers.

BACKGROUND: Our regional poison information center (RPIC) has developed and implemented an ongoing quality assurance (QA) initiative, using performance indicators and evaluation thresholds to permit a planned and systematic process for monitoring the quality, appropriateness and effectiveness of service. METHODS: A 10-step QA plan was designed that included delineating the scope of care, identifying the most important aspects of care, identifying indicators and thresholds to monitor performance and outcomes, and establishing a formal medical audit review process to resolve questions and/or problems. RESULTS: This QA program has resulted in verification of the validity of the RPIC's data and services. Threshold indicators (the incidence of accidental poisoning in children less than 6 y, incidence of intentional poisoning among children less than 18 y, appropriateness of home versus hospital management, and reduction in major/mortal outcomes in children less than 6 y) have all been successfully met during the past 12 mo. A medical audit committee objectively reviews and meets to discuss all unique poison exposures or those suffering major/mortal outcomes. Examples of identified problems include the lack of utilizing standard abbreviations during documentation and the need to standardize indications for consulting medical back-up. DISCUSSION: RPICs are innovative health services with unique and increasing responsibilities and liabilities. A QA program, designed to objectively and systematically monitor and evaluate the quality and appropriateness of care rendered the poisoned patient, can improve care and resolve identified problems in a timely manner. CONCLUSIONS: A formalized QA program is essential for all RPICs.     

Development of medication-use indicators by the Joint Commission on Accreditation of Healthcare Organizations

The development of indicators for monitoring medication use is described. The Joint Commission on Accreditation of Healthcare Organizations is establishing a national database for use in measuring performance. Initially, indicators were developed for specialties or clinical departments and for disease entities or procedures; now, indicators for key functions that cross departmental and specialty lines, such as medication use, are under development. An interdisciplinary core group constructed a medication-use flow chart depicting prescribing, dispensing, administering, and monitoring patient response; systems management/control was recognized as a fifth component. Sixteen processes were identified for which indicators were developed. Proposed indicators are now being tested in a small number of hospitals. The indicator data will enable institutions to identify areas for improvement. Although the Joint Commission will not use indicator rates per se to determine accreditation, it will ask an institution to provide an interpretation of indicator data that differ markedly from previous data or data for comparable institutions and to review its strategy for analyzing the rates. Use of indicator data will enhance the accreditation process by allowing for ongoing monitoring of particular aspects of performance between onsite surveys.     

Evidence-based strategies for the optimization of pharmacotherapy in older people

Geriatric pharmacotherapy represents one of the biggest achievements of modern medical interventions. However, geriatric pharmacotherapy is a complex process that encompasses not only drug prescribing but also age-appropriate drug development and manufacturing, appropriate drug testing in clinical trials, rational and safe prescribing, reliable administration and assessment of drug effects, including adherence measurement and age-appropriate outcomes monitoring. During this complex process, errors can occur at any stage, and intervention strategies to improve geriatric pharmacotherapy are targeted at improving the regulatory processes of drug testing, reducing inappropriate prescribing, preventing beneficial drug underuse and use of potentially harmful drugs, and preventing adverse drug interactions. The aim of this review is to provide an update on selected recent developments in geriatric pharmacotherapy, including age discrimination in drug trials, a new healthcare professional qualification and shared competence in geriatric drug therapy, the usefulness of information and communication technologies, and pharmacogenetics. We also review optimizing strategies aimed at medication adherence focusing on complex elderly patients. Among the current information technologies, there is sufficient evidence that computerized decision-making support systems are modestly but significantly effective in reducing inappropriate prescribing and adverse drug events across healthcare settings. The majority of interventions target physicians, for whom the scientific concept of appropriate prescribing and the acceptability of the alert system used play crucial roles in the intervention's success. For prescribing optimization, results of educational intervention strategies were inconsistent. The more promising strategies involved pharmacists or multidisciplinary teams including geriatric medicine services. However, methodological weaknesses including population and intervention heterogeneity do not allow for comprehensive meta-analyses to determine the clinical value of individual approaches. In relation to drug adherence, a recent meta-analysis of 33 randomized clinical trials in older patients found behavioural interventions had significant effects, and these interventions were more effective than educational interventions. For patients with multiple conditions and polypharmacy, successful interventions included structured medication review, medication regimen simplification, administration aids and medication reminders, but no firm conclusion in favour of any particular intervention could be made. Interventions to optimize geriatric pharmacotherapy focused most commonly on pharmacological outcomes (drug appropriateness, adverse drug events, adherence), providing only limited information about clinical outcomes in terms of health status, morbidity, functionality and overall healthcare costs. Little attention was given to psychosocial and behavioural aspects of pharmacotherapy. There is sufficient potential for improvements in geriatric pharmacotherapy in terms of drug safety and effectiveness. However, just as we require evidence-based, age-specific, pharmacological information for efficient clinical decision making, we need solid evidence for strategies that consistently improve the quality of pharmacological treatments at the health system level to shape 'age-attuned' health and drug policy.     

国际合理用药评价指标研究概述

目的：整理国内外合理用药评价指标,为构建科学的合理用药评价体系提供思路。方法：通过检索中国知网、万方、Pubmed和Proquest等数据库,对有关合理用药评价的文献进行归纳、分析,总结目前国内外有关合理用药的评价指标。结果：合理用药评价的宏观标准包括世界卫生组织不合理用药指标、医院处方点评管理规范等。微观标准主要为潜在不适当处方（PIP）指标,其中明确标准包括比尔斯标准（Beers）、老年人不适当处方和处方遗漏筛查工具（STOPP/START）、虚弱老年人治疗评估标准（ACOVE）、中国老年人疾病状态下潜在不适当用药初级判断标准等;隐含式标准包括处方优化方法、药物合理指数等。结论：无论是宏观还是微观标准都是很好的处方评价工具,但研究者在实际应用中需要关注每个标准中指标设置的理由和建议,根据不同标准的特点,充分考虑评价对象、数据特征、药品目录、地区用药习惯等因素,对评价工具进行选择和调整。     

The pattern of the discovery of medication errors in a tertiary hospital in Hong Kong

Background The primary goal of reducing medication errors is to eliminate those that reach the patient. Objective We aimed to study the pattern of interceptions to tackle medication errors along the medication use processes. Setting Tertiary care hospital in Hong Kong. Method The ‘Swiss Cheese Model’ was used to explain the interceptions targeting medication error reporting over 5 years (2006–2010). Main outcome measures Proportions of prescribing, dispensing and drug administration errors intercepted by pharmacists and nurses; proportions of prescribing, dispensing and drug administration errors that reached the patient. Results Our analysis included 1,268 in-patient medication errors, of which 53.4 % were related to prescribing, 29.0 % to administration and 17.6 % to dispensing. 34.1 % of all medication errors (4.9 % prescribing, 26.8 % drug administration and 2.4 % dispensing) were not intercepted. Pharmacy staff intercepted 85.4 % of the prescribing errors. Nurses detected 83.0 % of dispensing and 5.0 % of prescribing errors. However, 92.4 % of all drug administration errors reached the patient. Conclusions Having a preventive measure at each stage of the medication use process helps to prevent most errors. Most drug administration errors reach the patient as there is no defense against these. Therefore, more interventions to prevent drug administration errors are warranted.     

Application of system-level root cause analysis for drug quality and safety problems: A case study

BackgroundAutomated surveillance indicators are used to identify problems with drug therapy. A previous study automated 39 indicators of possible drug-related emergency department visits and hospitalizations. These indicators were used to investigate the quality and safety of drug use in a large health care coalition in Florida. This study describes a method of capturing this input with an aim of applying it to a root cause analysis (RCA), which may be useful for improving system-level flaws and weaknesses in medication use.ObjectiveTo apply results of a computerized surveillance system containing selected indicators of potential drug-related emergency department and hospital admissions to an RCA for evaluation. Such evaluation might prove effective in determining criteria useful in improving the quality and safety of systemic responses to individual types of drug therapy problems.MethodsThis was a case study that brought together a study group of 6 coalition stakeholders to evaluate findings from 4 indicators. The indicators represented problems in the prescribing, adherence, and monitoring steps in the ambulatory care medication use system. The RCA included the following procedures: brainstorming of possible system failures, organizing proposed system failures into groups and corresponding system levels, voting to prioritize proposed system failures, tree diagramming to illustrate how the system failures are interconnected among system levels, and determining whether system conditions or failure sequences are common among indicator types.ResultsThe group judged 3 themes to be important contributors to drug-related problems identified by the 4 indicators, including lack of patient knowledge, patient nonadherence to medical recommendations, and lack of medication management systems. The group believed that these barriers were interconnected and the result of subsystem influences.ConclusionDrug therapy problems represented by the indicators have certain system failures, flaws, or defects in common, allowing them to occur and persist. RCA may be a useful method for evaluating population-level indicator findings to identify potential failures with the medication use system and develop interventions.     

Application of a prescribing indicators tool to assist in identifying drug-related problems in a cohort of older Australians

Objective Drug‐related problems (DRPs) are common in older people, resulting in a disproportionate number of serious medication adverse events. Pharmacist‐led interventions have been shown to be effective in identifying and reducing DRPs such as medication interactions, omission of recommended medications and use of ineffective medications. In 2008 we proposed a prescribing indicators tool to assist in identifying DRPs as part of the Australian medication review process. The objective was to apply the proposed prescribing indicators tool to a cohort of older Australians, to assess its use in detecting potential DRPs. Methods The prescribing indicators tool was applied in a cross‐sectional observational study to 126 older (aged ≥65 years) English‐speaking Australians taking five or more medications, as they were being discharged from a small private hospital into the community. Indicators were unmet when prescribing did not adhere to indicator tool guidelines. Key findings We found a high incidence of under‐treatment, and use of inappropriate medications. There were on average 18 applicable indicators per patient, with each patient having on average seven unmet indicators. Conclusion The use of a prescribing indicators tool for commonly used medications and common medical conditions in older Australians may contribute to the efficient identification of DRPs.     

某医院合理用药国际指标调研及处方合理性的分析

目的对某院门诊处方合理性进行调研,为制定促进合理用药干预措施提供依据。方法根据世界卫生组织/基本药物行动计划/合理用药国际网络联合制定的国际指标及我国的《医院处方点评管理规范(试行)》,对2011年5月至6月的1440张门诊处方和同期380例门诊患者进行调研,分别统计处方指标、关怀指标及不合理处方。结果处方指标中,平均用药品种数为2.04种,通用名使用率为99.56%,抗菌药物使用率为28.96%,注射剂使用率为25.07%,基本药物使用率为56.92%,处方平均金额为86.79元;关怀指标中,患者平均就诊时间为6.90min,平均发药交代时间为32s,调配药物率为100%,药品标签标示完整率为100%,患者了解正确用药方法率为90.43%;处方合格率为97.99%。结论该医院门诊处方在处方平均用药品种数、药品通用名使用率、基本药物使用率、处方平均金额、平均就诊时间、实际调配药物率、药品标签完整率、患者了解药品用法率等方面均符合合理用药标准。但在抗菌药物使用率、注射剂使用率、平均发药交待时间等方面不符合合理用药标准;不合理处方主要是药物选择、用法用量、联合用药不适宜,需采取有效干预措施。     

Medication prescribing in frail older people

Purpose

While some people remain fit and active as they grow older, others experience complex problems: disease, dependency and disability. Frailty is a term used to describe this latter group, capturing differences in health status among older people. Many frail older people have multiple chronic co-morbidities and functional impairments and, according to guidelines for the management of individual conditions, should be prescribed long lists of medications. However, older people (particularly those who are frail) are often excluded from drug trials, and treatment decisions are therefore based on evidence extrapolated from more robust patient groups with fewer physiological deficits. The risk of adverse drug reactions (ADRs) increases with increasing patient frailty, and polypharmacy has negative consequences above and beyond the risks of individual drugs. Increasing numbers of medications are associated with a higher likelihood of non-adherence and a significantly greater risk of ADRs. Older people taking five or more medications are at higher risk of delirium and falls, independent of medication indications.

Methods

This is a short review of the different approaches to defining and measuring frailty. We summarise the factors contributing to ADRs in frail older people and describe the pharmacokinetic and pharmacodynamics changes associated with ageing and frailty. By considering goals of care for frail older people, we explore how the appropriateness of medication prescribing for older people could be improved.

Conclusion

Since all physicians are likely to provide care for this group of vulnerable patients, understanding the concept of frailty may help to optimise medication prescribing for older people. The incorporation of frailty measures into future clinical studies of drug effects and pharmacokinetics is important if we are to improve medication use and guide drug doses for fit and frail older people.     

临床药师对 1 例慢性阻塞性肺疾病急性加重期患者的药学监护

目的：探索临床药师对慢性阻塞性肺疾病患者的药学监护方案.方法：针对1例慢性阻塞性肺疾病急性加重期患者,通过临床查房,掌握慢性阻塞性肺疾病的防治指南,根据掌握的药学知识,与临床医师共同制定治疗方案,对患者住院期间的用药进行全程监护,重点针对药物选择适宜性、药品不良反应以及药物的配伍对患者进行具体化药学服务和制定个体化监护计划.结果与结论：临床药师积极参与临床的治疗过程,可减少药品不良反应和药物配伍禁忌的发生,提高患者的依从性,从安全性、经济性方面提高整体治疗水平.