Benefit of medication reviews by renal pharmacists in the setting of a computerized physician order entry system with clinical decision support.

WHAT IS KNOWN AND OBJECTIVE: A 'renal pharmacist consultant service' (RPCS) reviewing patients' charts with renal impairment (RI) for drug-related problems (DRP) can foster patient safety. However, the benefit of this service in the new setting of a computerized physician order entry (CPOE)-system with a clinical decision support (CDS)-system is unknown. The aim of our study was to evaluate the general need for an RPCS on wards with a CPOE-CDS-system already in use and its effectiveness on prescription changes to ensure in-hospital patient safety. METHODS: Over a period of 3 months (02-04/2021), elective orthopaedic and trauma patients with eGFRabsolute /CrCl <60 ml/min at a German University Hospital received a medication review by a renal pharmacist for all medication entered into the CPOE-system (Meona®) by the treating physicians. Written consultations explaining identified DRP and recommending interventions to solve them, for example, dose or drug adaptation, were shared with the physicians directly in the drug chart tab of Meona®. In complex cases, DRP were additionally discussed via phone. The prescription changes were evaluated retrospectively. RESULTS AND DISCUSSION: During 53 working days, 712 (30.5%) of 2331 screened patients were included with an eGFRnon-indexed /CrCl <60 ml/min and a pharmacist-led medication review was performed for all medication presented in the CPOE-system (Meona®). In 79 of 712 (11.1%) patients, one or more DRP were detected (median 1 DRP (1-3) per patient) and written recommendations concerning 106 of 1090 (9.7%) drugs were shared via Meona®. In total, 104 DRP were identified, mostly caused by 'dosage too high' (n = 55, 52.9%), 'dosage regime wrong' (n = 13, 12.5%), and 'contraindication' (n = 9, 8.7%). Acceptance rate of recommendations was 74.0% (n = 77/104). In nine cases (8.7%), despite of specific recommendations, no adjustment of drugs was made because of lack of alternatives. In 11 (10.6%) cases, prescription remained unchanged for unknown reasons and in seven (6.7%) cases, the result was unknown due to discharge. WHAT IS NEW AND CONCLUSION: In the setting of prescribing in a CPOE-CDS-system, that provides physicians with advice for drug or dose adaption, the pharmacist-led medication reviews still identified DRP in orthopaedic and trauma patients with RI. A RPCS forwarding recommendations to solve DRP via the electronic medical record increased appropriate prescribing by physicians and, thus, may further improve patient safety.

Trastuzumab Biosimilars in the Therapy of Breast Cancer - "Real World" Experiences from four Bavarian University Breast Centres.

Introduction With the introduction of the first trastuzumab biosimilar in the summer of 2018, biosimilar antibodies for breast cancer have found their way into the area of gynaecological oncology. The switch of anti-human epidermal growth factor receptor 2 (HER2) therapy from the reference drug Herceptin ® to a biosimilar has presented challenges to the clinics. In addition to structural and organisational measures, training of employees as well as patient briefing and acceptance were major challenges. The study presented here records - within the context of quality assurance - how the switch to a trastuzumab biosimilar was implemented at four Bavarian university clinics in the Purchasing Association of Bavarian University Pharmacies. Materials/Methods Questionnaires on treatment figures and the switching process were sent to breast centres and pharmacies of four Bavarian university clinics between July and December 2019. The neoadjuvant, adjuvant and metastasised anti-HER2 therapy with trastuzumab with or without pertuzumab was recorded, evaluated and summarised. Results In the anti-HER2-therapy, trastuzumab was used intravenously (i. v.) and subcutaneously. Between July and December 2018, all four clinics in the Purchasing Association switched the i. v. trastuzumab therapy from the reference drug (Herceptin) to a biosimilar (for 2018: Kanjinti ® ). Over 200 patients were treated with trastuzumab i. v. in each of the two half-years of 2018 (before and after the switch). The spectrum of side effects and pCR rates under therapy with the biosimilar were comparable to the experiences made with the reference drug. Three out of four clinics provided training to employees and informed patients by means of a defined information leaflet. Patient acceptance was high. Summary The anti-HER2 therapy could be switched successfully and safely to trastuzumab biosimilars at the Bavarian university hospitals. This may serve as guideline for the further implementation of biosimilars. The structures necessary for this initial switching process have been prepared with trastuzumab as an example.

Screening for impaired liver function as a risk factor for drug safety at hospital admission of surgical patients.

Background Hepatic insufficiency can affect patient safety and should therefore be considered during drug therapy. Hospital admission offers an ideal point to screen for patients at risk and to adjust drug therapy accordingly. Objective To assess the number of patients admitted to hospital with clinically elevated liver parameters. To identify high-risk patients in need of potential drug therapy adjustment to liver function by calculation of liver scores. Finally, to investigate whether pre-hospital medication needed adjustment to liver function. Setting Patients admitted to surgical wards of a tertiary teaching hospital. Method Surgical patients were included in a 3-month retrospective study. A pharmacist-led screening process, including recording of elevated liver parameters and calculation of liver scores (Child-Pugh-score, Model of End-stage Liver Disase [MELD], MELDNa), was used to assess frequency of hepatic insufficiency and patients potentially needing medication adjustment. Additionally, pre-hospital medication was checked for contraindications and correct dosage with regard to liver function. Main outcome measure Percentage of surgical patients with clinically elevated liver parameters at admission, percentage of patients with hepatic insufficiency potentially needing drug therapy adjustment, and percentage of pre-hospital drug intakes not adjusted to liver function. Results Of 1200 patients, 130 (11%) had at least one clinically relevant elevated liver parameter at hospital admission. Of these, need for drug adjustment to liver function was found for 16-36%, depending on the liver score used (equivalent to 2-4% of all patients), with the highest number of patients detected by the MELD- and MELDNa-score. Pre-hospital medication concerned 719 drug intakes and was contraindicated in 2%, dosage not adjusted in 3%, and evaluation not possible in 44% of all drug intakes due to lack of information on the drug. Conclusion A significant proportion of patients admitted for surgery have clinically elevated liver parameters and potentially need medication adjustment. A pharmacist-led screening already at hospital admission can support the identification of patients with clinically relevant elevated liver parameters and patients at risk by calculating liver scores under routine conditions. Evaluation of drug adjustment to liver function is challenging, since no data are available in routine resources for a considerable number of drugs.

Effects of malnutrition on complication rates, length of hospital stay, and revenue in elective surgical patients in the G-DRG-system.

OBJECTIVE: Malnutrition is known to independently affect patient outcomes. The aim of this study was to investigate the prevalence of patients at risk for malnutrition in an elective surgery patient cohort and to analyze the effects of malnutrition on morbidity, mortality, and hospital length of hospital (LOS). Furthermore, we aimed to evaluate the economic effect of a diligent coding of malnutrition, as a side diagnosis, in a simulation of the German Diagnosis-Related Group system. METHODS: The nutritional status of 1244 patients undergoing elective surgery was standardized on the day of admission by the Nutritional Risk Screening (NRS) 2002. To quantify the influence of malnutrition on revenue, the real DRGs of all patients were grouped. In simulation, an appropriate International Classification of Diseases code was used as a secondary diagnosis for all malnourished patients based on the NRS rating. A multivariate logistic regression analysis and a Cox regression were performed to identify potential confounders and to determine the adjusted effect of nutritional status on the occurrence of complications and hospital LOS. RESULTS: The prevalence of patients at risk for malnutrition (NRS ≥3) was 24.1% (300 of 1244). These patients showed a significant increase in hospital LOS (13 versus 7 d). Additionally, postoperative complications were significantly higher in this group (7.23% versus 6.91%). Including malnutrition in the Diagnosis-Related Group coding system resulted in a reimbursement of €1979.67 per patient at risk for malnutrition and a total reimbursement of €79,186.73 for all patients at risk for malnutrition in the present study. CONCLUSION: Establishment of a structured, comprehensive assessment of the nutritional status of hospitalized patients can repetitiously identify patients at risk for malnutrition. Additionally, the diligent codification of malnutrition can lead to cost compensation in the German Diagnosis-Related Group system.