Prospective prescription review system correlated with more rational PPI medication use, better clinical outcomes and reduced PPI costs: experience from a retrospective cohort study.

INTRODUCTION: Proton pump inhibitor (PPI) abuse poses an overwhelming threat to the allocation of medical resources and places a heavy burden on global medical expenses. In this study, we put forward our prospective prescription review system and evaluated the effects of this system on clinical outcomes, rational medication use and costs related to PPIs. METHODS: A retrospective cohort study was conducted in which the included patients were divided into a preintervention group (2019.10-2020.09) and a postintervention group (2020.10-2021.09). To reduce the bias of patients' baseline characteristics, the propensity score matching (PSM) method was employed. The primary endpoints were the incidence of stress ulcers (SUs), the improvement and cure rates of gastrointestinal haemorrhage, the defined daily dose (DDD), the drug utilization index (DUI) and the DDD/100 patient-days. The secondary endpoints included the types of unreasonable medication orders for PPIs, the PPI utilization rate and PPI costs. RESULTS: A total of 53,870 patients were included to evaluate the secondary endpoints, and 46,922 patients were paired by PSM and assessed to evaluate the primary endpoints. The number of PPIs used and PPI costs were significantly lower in the postintervention group than in the preintervention group (P < 0.001). The rationality evaluation results showed that the frequency of PPI use and the number of drug interactions were significantly higher in the preintervention group than in the postintervention group (P < 0.01). The proportion of patients taking oral PPIs was significantly increased in the postintervention group (29.30% vs. 34.56%, p < 0.01). For the utilization of PPIs both for prevention and treatment, the DUI and DDD/100 patient-days were substantially decreased in the postintervention group (P < 0.001 and P < 0.05, respectively). The incidence of SUs in the postintervention group was 44.95%, and that in the preintervention group was 51.93% (p < 0.05). CONCLUSION: The implementation of the prospective prescription review system on rational PPI use correlated with reduced PPI costs, more rational PPI medication use and better clinical outcomes, and this system is worthy of long-term implementation for further improvement of rational drug use.

Application of information-intelligence technologies in pharmacy intravenous admixture services in a Chinese third-class a hospital.

BACKGROUND: Pharmacy intravenous admixture service (PIVAS) center has emerged as an important department of hospital as it can improve occupational protection and ensure the safety and effectiveness of intravenous infusions. However, medication errors were considered to be a significant challenge in PIVAS, so information-intelligence technologies were introduced to optimize the management of PIVAS. Our article summarized the application of information-intelligence technologies in PIVAS of a large third-class A hospital in China, and provided an example for PIVAS in other hospitals at home and abroad. METHODS: Prescription-reviewing rules containing intravenous medications and infusion solution guideline were recorded in the database of prescription-cheking system. Drugs information were recorded in the PIVAS management system with special identification and warning labels to reduce intravenous infusion errors. Automatic labeling device was used to label the infusion bags, and the quality control program database of intelligent compounding robot for cytotoxic drugs was established ingeniously. Automatic sorting devices were applied for the third batch of finished infusion admixtures, and intelligent logistics robots were used to transport the infusion to the ward. RESULTS: After establishing and implementing of prescription-reviewing rules in the prescription-cheking system database, the number of prescriptions checked by pharmacists increased from 18 to 43 per minute. The success rate of intervention with irrational medical orders increased from 85.89% to 99.06% (P < 0.05). By introducing various intelligent devices, automatic labeling significantly enhanced work efficiency and reduced the error rate (P < 0.001). Furthermore, the use of intelligent intravenous compounding robots significantly reduced the risk of errors (P < 0.001). CONCLUSIONS: The application of information-intelligence technologies in PIVAS can improve work efficiency and reduce error risk. However, some intelligent devices have failed to achieve the expected effect in practical use, and further improvements are needed to meet the demands of PIVAS in the future.

An inventory of collaborative medication reviews for older adults - evolution of practices.

BACKGROUND: Collaborative medication review (CMR) practices for older adults are evolving in many countries. Development has been under way in Finland for over a decade, but no inventory of evolved practices has been conducted. The aim of this study was to identify and describe CMR practices in Finland after 10 years of developement. METHODS: An inventory of CMR practices was conducted using a snowballing approach and an open call in the Finnish Medicines Agency's website in 2015. Data were quantitatively analysed using descriptive statistics and qualitatively by inductive thematic content analysis. Clyne et al's medication review typology was applied for evaluating comprehensiveness of the practices. RESULTS: In total, 43 practices were identified, of which 22 (51%) were designed for older adults in primary care. The majority (n = 30, 70%) of the practices were clinical CMRs, with 18 (42%) of them being in routine use. A checklist with criteria was used in 19 (44%) of the practices to identify patients with polypharmacy (n = 6), falls (n = 5), and renal dysfunction (n = 5) as the most common criteria for CMR. Patients were involved in 32 (74%) of the practices, mostly as a source of information via interview (n = 27, 63%). A medication care plan was discussed with the patient in 17 practices (40%), and it was established systematically as usual care to all or selected patient groups in 11 (26%) of the practices. All or selected patients' medication lists were reconciled in 15 practices (35%). Nearly half of the practices (n = 19, 44%) lacked explicit methods for following up effects of medication changes. When reported, the effects were followed up as a routine control (n = 9, 21%) or in a follow-up appointment (n = 6, 14%). CONCLUSIONS: Different MRs in varying settings were available and in routine use, the majority being comprehensive CMRs designed for primary outpatient care and for older adults. Even though practices might benefit from national standardization, flexibility in their customization according to context, medical and patient needs, and available resources is important.

Effectiveness of Pharmacist Interventions on Cardiovascular Risk in Patients With CKD: A Subgroup Analysis of the Randomized Controlled RxEACH Trial.

BACKGROUND: Affecting a substantial proportion of adults, chronic kidney disease (CKD) is considered a major risk factor for cardiovascular (CV) events. It has been reported that patients with CKD are underserved when it comes to CV risk reduction efforts. STUDY DESIGN: Prespecified subgroup analysis of a randomized controlled trial. SETTING & PARTICIPANTS: Adults with CKD and at least 1 uncontrolled CV risk factor were enrolled from 56 pharmacies across Alberta, Canada. INTERVENTION: Patient, laboratory, and individualized CV risk assessments; treatment recommendations; prescription adaptation(s) and/or initiation as necessary; and regular monthly follow-up for 3 months. OUTCOMES: The primary outcome was change in estimated CV risk from baseline to 3 months after randomization. Secondary outcomes were change between baseline and 3 months after randomization in individual CV risk factors (ie, low-density lipoprotein cholesterol, blood pressure, and hemoglobin A1c), risk for developing end-stage renal disease, and medication use and dosage; tobacco cessation 3 months after randomization for those who used tobacco at baseline; and the impact of rural versus urban residence on the difference in change in estimated CV risk. MEASUREMENTS: CV risk was estimated using the Framingham, UK Prospective Diabetes Study, and international risk assessment equations depending on the patients' comorbid conditions. RESULTS: 290 of the 723 participants enrolled in RxEACH had CKD. After adjusting for baseline values, the difference in change in CV risk was 20% (P<0.001). Changes of 0.2mmol/L in low-density lipoprotein cholesterol concentration (P=0.004), 10.5mmHg in systolic blood pressure (P<0.001), 0.7% in hemoglobin A1c concentration (P<0.001), and 19.6% in smoking cessation (P=0.04) were observed when comparing the intervention and control groups. There was a larger reduction in CV risk in patients living in rural locations versus those living in urban areas. LIMITATIONS: The 3-month follow-up period can be considered relatively short. It is possible that larger reduction in CV risk could have been observed with a longer follow up period. CONCLUSIONS: This subgroup analysis demonstrated that a community pharmacy-based intervention program reduced CV risk and improved control of individual CV risk factors. This represents a promising approach to identifying and managing patients with CKD that could have important public health implications.

The impact of a prescription review and prescriber feedback system on prescribing practices in primary care clinics: a cluster randomised trial.

BACKGROUND: To evaluate the effectiveness of a structured prescription review and prescriber feedback program in reducing prescribing errors in government primary care clinics within an administrative region in Malaysia. METHODS: This was a three group, pragmatic, cluster randomised trial. In phase 1, we randomised 51 clinics to a full intervention group (prescription review and league tables plus authorised feedback letter), a partial intervention group (prescription review and league tables), and a control group (prescription review only). Prescribers in these clinics were the target of our intervention. Prescription reviews were performed by pharmacists; 20 handwritten prescriptions per prescriber were consecutively screened on a random day each month, and errors identified were recorded in a standardised data collection form. Prescribing performance feedback was conducted at the completion of each prescription review cycle. League tables benchmark prescribing errors across clinics and individual prescribers, while the authorised feedback letter detailed prescribing performance based on a rating scale. In phase 2, all clinics received the full intervention. Pharmacists were trained on data collection, and all data were audited by researchers as an implementation fidelity strategy. The primary outcome, percentage of prescriptions with at least one error, was displayed in p-charts to enable group comparison. RESULTS: A total of 32,200 prescriptions were reviewed. In the full intervention group, error reduction occurred gradually and was sustained throughout the 8-month study period. The process mean error rate of 40.7% (95% CI 27.4, 29.5%) in phase 1 reduced to 28.4% (95% CI 27.4, 29.5%) in phase 2. In the partial intervention group, error reduction was not well sustained and showed a seasonal pattern with larger process variability. The phase 1 error rate averaging 57.9% (95% CI 56.5, 59.3%) reduced to 44.8% (95% CI 43.3, 46.4%) in phase 2. There was no evidence of improvement in the control group, with phase 1 and phase 2 error rates averaging 41.1% (95% CI 39.6, 42.6%) and 39.3% (95% CI 37.8, 40.9%) respectively. CONCLUSIONS: The rate of prescribing errors in primary care settings is high, and routine prescriber feedback comprising league tables and a feedback letter can effectively reduce prescribing errors. TRIAL REGISTRATION: National Medical Research Register: NMRR-12-108-11,289 (5th March 2012).

Computerized pharmacy surveillance and alert system for drug-related problems.

WHAT IS KNOWN AND OBJECTIVE: Because of the impact of drug-related problems (DRPs) on morbidity and mortality, there is a need for computerized strategies to increase drug safety. The detection and identification of the causes of potential DRPs can be facilitated by the incorporation of a pharmacy warning system (PWS) in the computerized prescriber order entry (CPOE) and its application in the routine validation of inpatient drug therapy. A limited number of studies have evaluated a clinical decision support system to monitor drug treatment. Most of these applications have utilized a small range of drugs with alerts and/or types of alert. The objective of this study was to describe the implementation of a PWS integrated in the electronic medical record (EMR). METHODS: The PWS was developed in 2003-2004. Pharmacological information to generate drug alerts was entered on demographic data, drug dosage, laboratory tests related to the prescribed drug and drug combinations (interactions, duplications and necessary combinations). The PWS was applied in the prescription reviews conducted in patients admitted to the hospital in 2012. RESULTS AND DISCUSSION: Information on 83% of the drugs included in the pharmacopeia was introduced into the PWS, allowing detection of 2808 potential DRPs, representing 79·1% of all potential DRPs detected during the study period. Twenty per cent of PWS DRPs were clinically relevant, requiring pharmacist intervention. WHAT IS NEW AND CONCLUSION: The PWS detected most potential DRPs, thus increasing inpatient safety. The detection ability of the PWS was higher than that reported for other tools described in the literature.

Impact of the automated dose dispensing with medication review on geriatric primary care patients drug use in Finland: a nationwide cohort study with matched controls.

OBJECTIVE: In an automated dose dispensing (ADD) service, medicines are dispensed in unit-dose bags according to administration times. When the service is initiated, the patient's medication list is reconciled and a prescription review is conducted. The service is expected to reduce drug use. The aim of this national controlled study was to investigate whether the ADD service with medication review reduces drug use among geriatric primary care patients. DESIGN, SETTING AND PATIENTS: This is a nationwide cohort study with matched controls. The study group consisted of all primary care patients ≥65 years enrolled in the ADD service in Finland during 2007 (n = 2073). Control patients (n = 2073) were matched by gender, age, area of patient's residence and number of the prescription drugs reimbursed. The data on all prescription drugs reimbursed during the 1 year periods before and after the ADD service enrollment were extracted from the Finnish National Prescription Register. Drug use was calculated as defined daily doses (DDD) per day. RESULTS: The studied 20 most used drugs covered 86% of all reimbursed drug use (in DDD) of the study group. The use of 11 out of these 20 active substances studied was reduced significantly (p < .001-.041) when the drug use was adjusted by the number of chronic diseases. Two of these drugs were hypnotics and six were cardiovascular system drugs. CONCLUSIONS: Drug use was decreased after initiation of the ADD service in primary care patients ≥65 years compared to matched controls in this 1 year cohort study. Further studies should be conducted in order to explore the causality, assess the ADD service's impact on drug use quality and costs, as well as impact of accompanied prescription review on positive outcomes.

The impact of meropenem shortage and post-prescription review and feedback on broad-spectrum antimicrobial use: An interrupted time-series analysis.

Background: Meropenem (MEPM) holds significance in treating severe infections and drug-resistant bacteria. There are concerns that antimicrobial shortages may lead to the use of alternative antimicrobials that are less effective and safer. We have responded to the MEPM shortage with post-prescription monitoring and feedback (PPRF) with no restrictions on MEPM initiation. We aimed to assess the impact of the MEPM shortage and the PPRF on broad-spectrum antimicrobial use and mortality. Methods: This retrospective study was conducted in a single hospital in Japan. The period from October 2021 to August 2022 was defined as the period before the MEPM shortage, and the period from September 2022 to March 2023 was defined as the period during the MEPM shortage. To support the appropriate use of antimicrobials during MEPM shortages, the antimicrobial stewardship team (AST) developed a list of alternatives to MEPM. An interrupted time series analysis was used to assess changes in use and mortality among patients receiving broad-spectrum antimicrobials over the study period. Discussion: The shortage of MEPM and PPRF temporarily increased the use of alternative cefepime; however, the subsequent change in days of therapy and days of coverage of broad-spectrum antimicrobials suggests a decrease in the use of these antimicrobials. Despite these shifts, the mortality rates remained stable, suggesting that the response to the shortage did not adversely affect treatment outcomes. Conclusion: In the context of antimicrobial shortages, AST support plays an important role in enabling physicians to make optimal use of antimicrobials.

Pharmaceutical Decision Support System Using Machine Learning to Analyze and Limit Drug-Related Problems in Hospitals.

The health product circuit corresponds to the chain of steps that a medicine goes through in hospital, from prescription to administration. The safety and regulation of all the stages of this circuit are major issues to ensure the safety and protect the well-being of hospitalized patients. In this paper we present an automatic system for analyzing prescriptions using Artificial Intelligence (AI) and Machine Learning (ML), with the aim of ensuring patient safety by limiting the risk of prescription errors or drug iatrogeny. Our study is made in collaboration with Lille University Hospital (LUH). We exploited the MIMIC-III (Medical Information Mart for Intensive Care) a large, single-center database containing information corresponding to patients admitted to critical care units at a large tertiary care hospital.

Evaluation and Analysis of the Rationality of Clinical Use of Carbapenems in Surgical Departments of a Tertiary Hospital in Southwest China.

Purpose: With the increasing frequency and intensity of carbapenem consumption, carbapenem-resistant organisms (CRO) have become a focus of anti-infection research. This study aimed to evaluate the rationality of the clinical use of carbapenems among inpatients in the surgical departments of a tertiary hospital in southwest China. Patients and methods: A point-score system was established for evaluation based on the clinical practices in surgical departments and selected carbapenem prescriptions from June 2020 to June 2021 for hepatobiliary surgery, gastrointestinal surgery, and neurosurgery in the study hospital. Prescriptions with a total score ≥ 270 were defined as rational. Descriptive statistics were used to describe the characteristics and rationality of the prescriptions. The chi-square test, Mann-Whitney U-test, and Kruskal-Wallis H-test were used to compare characteristics between rational and irrational prescriptions. Linear regression analysis was used to determine the factors affecting the rationality of carbapenem prescriptions. Results: According to 192 carbapenem prescription records, the median age of patients was 62 years [IQR, 48.0-73.0], and 20% of patients had abdominal infections, 10% had lung infections, 14% had intracranial infections, and 3% had urinary tract infections. 56% of carbapenem prescriptions were irrational. Compared with rational carbapenem prescriptions, irrational prescriptions had a higher proportion of those with inappropriate indications (49% vs 0%, p < 0.05), incorrect variety selection (15% vs 0%, p<0.05), and unreasonable assessment of etiology and efficacy (46% vs 8%, p < 0.05). Linear regression analysis suggested that the diagnosis of cholecystitis (standardized regression coefficient=0.183, p<0.05) and replaced medication (standardized regression coefficient = 0.154, p<0.05) influenced the rationality of carbapenem prescriptions. Conclusion: Our study shows that the irrational use of carbapenems deserves attention, especially in surgical departments. Interventions for carbapenem use that are based on evaluation criteria should be developed to reduce the emergence and spread of carbapenem-resistant bacteria.

Prescribing Patterns for Upper Respiratory Tract Infections: A Prescription-Review of Primary Care Practice in Quetta, Pakistan and the Implications.

Background: To identify and address the potential overuse of antibiotics, it is important to ascertain the prescribing practices of physicians. We, therefore, conducted this prescription analysis to document URTI-specific antibiotic prescription frequency in a public primary healthcare setting of Quetta city, Pakistan. Methods: A retrospective record review was conducted of all prescriptions for URTIs in Combined Military Hospital, Quetta from 1 March to 31st May 2021. The Mann-Whitney U and Jonckheere-Terpstra test was used to evaluate the association between the tendencies of a different group of prescribers. p-value of <0.05 was of statistical significance. Results: Over the 3 months, 50,705 prescriptions were screened and analyzed according to the established inclusion and exclusion criteria. A total of 4,126 (8.13%) URTI prescriptions met the inclusion criteria, of which 2,880 (69.80%) prescriptions contained antibiotics. Among all antibiotics, penicillins (Amoxicillin + Clavulanate) were the most prescribed antibiotic, constituting 1,323 (45.9%) of total antibiotics prescribed for all cases, followed by the Macrolide group 527 (18.2%). The Jonckheere-Terpstra test revealed a statistically significant association between the status of the prescriber and the diagnosis (p = 0.002). Furthermore, a moderate positive trend was reported with specialists being more competent in antibiotic prescribing based on their diagnosis, followed by postgraduates and house officers (τ = 0.322). Conclusion: The prescribing patterns for the management of URTIs in the hospital were inconsistent with current guidelines. Strict adherence to guidelines must be ensured and antibiotic prescribing for URTIs should be discouraged.

A Multiview Model for Detecting the Inappropriate Use of Prescription Medication: Machine Learning Approach.

BACKGROUND: The inappropriate use of prescription medication has recently garnered worldwide attention, but most national policies do not effectively provide for early detection or timely intervention. OBJECTIVE: This study aimed to develop and assess the validity of a model that can detect the inappropriate use of prescription medication. This effort combines a multiview and topic matching method. The study also assessed the validity of this approach. METHODS: A multiview extension of the latent Dirichlet allocation algorithm for topic modeling was chosen to generate diagnosis-medication topics, with data obtained from the Chinese Monitoring Network for Rational Use of Drugs (CMNRUD) database. Topic mapping allowed for calculating the degree to which diagnoses and medications were similarly distributed and, by setting a threshold, for identifying prescription misuse. The Beijing Regional Prescription Review Database (BRPRD) database was used as the gold standard to assess the model's validity. We also conducted a sensitivity analysis using random samples of validated prescriptions and evaluated the model's performance. RESULTS: A total of 44 million prescriptions were used to generate topics using the diagnoses and medications from the CMNRUD database. A random sample (15,000 prescriptions) from the BRPRD was used for validation, and it was found that the model had a sensitivity of 81.8%, specificity of 47.4%, positive-predictive value of 14.5%, and negative-predictive value of 96.0%. The model showed superior stability under different sampling proportions. CONCLUSIONS: A method that combines multiview topic modeling and topic matching can detect the inappropriate use of prescription medication. This model, which has mediocre specificity and moderate sensitivity, can be used as a primary screening tool and will likely complement and improve the process of manually reviewing prescriptions.

A novel clinical pharmacy management system in improving the rational drug use in department of general surgery.

Hospital information system is widely used to improve work efficiency of hospitals in China. However, it is lack of the function providing pharmaceutical information service for clinical pharmacists. A novel clinical pharmacy management system developed by our hospital was introduced to improve the work efficiency of clinical pharmacists in our hospital and to carry out large sample statistical analyzes by providing pharmacy information services and promoting rational drug use. Clinical pharmacy management system was developed according to the actual situation. Taking prescription review in the department of general surgery as the example, work efficiency of clinical pharmacists, quality and qualified rates of prescriptions before and after utilizing clinical pharmacy management system were compared. Statistics of 48,562 outpatient and 5776 inpatient prescriptions of the general surgical department were analyzed. Qualified rates of both the inpatient and outpatient prescriptions of the general surgery department increased, and the use of antibiotics decreased. This system apparently improved work efficiency, standardized the level and accuracy of drug use, which will improve the rational drug use and pharmacy information service in our hospital. Meanwhile, utilization of prophylactic antibiotics for the aseptic operations also reduced.