Evaluation of an electronic health record Drug Interaction Customization Editor (DICE).

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: Due to the low specificity of drug-drug interaction (DDI) warnings, hospitals and healthcare systems would benefit from the ability to customize alerts, thereby reducing the burden of alerts while simultaneously preventing harm. We developed a tool, called the Drug Interaction Customization Editor (DICE), as a prototype to identify features and functionality that could assist healthcare organizations in customizing DDI alerts. METHODS: A team of pharmacists, physicians, and DDI experts identified attributes expected to be useful for filtering DDI warnings. A survey was sent to pharmacists with informatics responsibilities and other medication safety committee members to obtain their opinions about the tool. The survey asked participants to evaluate the 4 sections of the DICE tool (General, Medication, Patient, and Visit) on a scale ranging from 0 (not useful) to 100 (very useful). The survey provided an opportunity for participants to express their opinions on the overall usefulness of the DICE tool and to provide other comments. RESULTS: The 50 survey respondents were mainly pharmacists (n = 47, 94%) with almost half (n = 23, 47%) having health information technology/informatics training. Most respondents (n = 33, 80%) were employed by organizations with over 350 beds. Respondents indicated the most useful features of the DICE tool were the ability to filter DDI warnings based on routes of administrations (mean [SD] rating scale score, 86.5 [21.6]), primary drug properties (85.7 [20.5]) patient attributes (85.6 [16.7]) and laboratory attributes (88.8 [18.0]). The overall impression of the DICE tool was rated at 82.8 (19.0), and when asked about the potential to reduce DDI alerts, respondents rated the tool at 83.7 (21.8). CONCLUSION: The ability to customize DDI alerts using data elements currently within the EHR has the potential to decrease alert fatigue and override rates. This prototype DICE tool could be used by end users and vendors as a template for developing a more advanced DDI filtering tool within EHR systems.

Tailoring high-energy storage NaNbO3-based materials from antiferroelectric to relaxor states.

Reversible field-induced phase transitions define antiferroelectric perovskite oxides and lay the foundation for high-energy storage density materials, required for future green technologies. However, promising new antiferroelectrics are hampered by transition´s irreversibility and low electrical resistivity. Here, we demonstrate an approach to overcome these problems by adjusting the local structure and defect chemistry, delivering NaNbO3-based antiferroelectrics with well-defined double polarization loops. The attending reversible phase transition and structural changes at different length scales are probed by in situ high-energy X-ray diffraction, total scattering, transmission electron microcopy, and nuclear magnetic resonance spectroscopy. We show that the energy-storage density of the antiferroelectric compositions can be increased by an order of magnitude, while increasing the chemical disorder transforms the material to a relaxor state with a high energy efficiency of 90%. The results provide guidelines for efficient design of (anti-)ferroelectrics and open the way for the development of new material systems for a sustainable future.

[Evolution of use of antibiotics of restricted prescription and trend of bacterial susceptibility in Concepcion Regional Hospital, Chile]. / Evolución del consumo de antimicrobianos de uso restringido y tendencia de la susceptibilidad in vitro en el Hospital Regional de Concepción, Chile.

The aim of this study was analyze the use of restricted antibiotics by patients hospitalized between 2004 and 2008 in Guillermo Grant Benavente Hospital in Concepcion. Also we attempted to identify possible correlations between antibiotic consumption and patterns of bacterial susceptibility. We performed a retrospective observational study that quantified the use of restricted antibiotics using DDD/100-bed-days, and cumulative susceptibility reports informed by the hospital's microbiology laboratory for bacterial susceptibility. The consumption of restricted antibiotics significantly increased between 2004 and 2008 (35%, p = 0.005). The groups with largest use were glycopeptides (37%) and carbapenems (30 %). These results can be explained by the emergence of endemic Methicillin-resistant Staphylococcus aureus (MRSA) and of Extended-spectrum beta-lactamase (ESBL) Gram negative bacilli. Results showed a decrease in susceptibility of P. aeruginosa to imipenem (p = 0.038) and K. pneumoniae to ciprofloxacin (p = 0.021). The total consumption of restricted antibiotic has significantly increased, especially among complex medical services. A significant decrease in bacterial susceptibility has been observed mainly in gram-negative bacilli. The monitoring of antimicrobial prescribing practices and local susceptibility patterns are essential to promote the rational use of antibiotics.

Hierarchical modeling of blood pressure determinants and outcomes following valsartan treatment in hypertensive patients with known comorbidities: pooled analysis of six prospective real-world studies including 11,999 patients.

AIMS: Six prospective real-world studies of antihypertensive treatment with valsartan-centric regimens were pooled to: (1) examine the effectiveness of ∼90 days of second- or later-line valsartan treatment in hypertensive patients with known comorbidities; and (2) identify physician- and patient-related determinants associated with systolic (SBP) and diastolic blood pressure (DBP) outcomes in these patients. METHODS AND MATERIALS: A pooled analysis was performed of an evaluable sample of 11,999 hypertensive patients with known comorbidities treated ∼90 days with valsartan-centric regimens. We applied hierarchical linear and logistic regression models to identify determinants of blood pressure (BP) outcomes and a potential physician class effect. RESULTS: Valsartan regimens resulted in mean (SD) SBP and DBP reductions of 18.0 (15.8) mmHg and 9.5 (10.1) mmHg, respectively, at ∼90 days, yielding SBP, DBP and combined SBP/DBP control rates of 44.0%, 67.2% and 39.3%, respectively. About a quarter of the variance in 90 day BP values was attributable to a physician class effect. BP outcomes declined with physicians' increasing years in practice and being male. At the patient level, BP outcomes declined with SBP and DBP at diagnosis; diabetes; higher cholesterol and BMI; lower valsartan and hydrochlorothiazide (HCTZ) doses; and concomitant anti-hypertensives. Older age was associated with improved DBP. A proxy of physician vigilance, cardiovascular disease history, was associated with improved BP outcomes, as were patient adherence and higher doses of valsartan in combination with HCTZ. CONCLUSIONS: Valsartan-centric regimens have significant BP lowering benefits in this pooled sample of patients with known comorbidities. Many observed determinants of BP outcomes are modifiable or manageable.

Evaluating the Role of Clinical Pharmacists in Providing Pharmaceutical Care to Improve Adherence in Hypertensive Patients at a Rural Hospital in Southern Chile: A Pilot Study.

OBJECTIVE: The majority of patients who receive antihypertensive treatment do not achieve adequate blood pressure (BP) outcomes. Adherence to antihypertensive therapy contributes to adequate control of BP and is a substantial reason for therapeutic success. This study aims to evaluate the role of clinical pharmacists in improving patient adherence to pharmacological treatment and in improving BP outcomes. METHODS: A pre- and postpharmaceutical care interventional study was provided to hypertensive patients in the Cardiovascular Health Program of the Family Health Community Hospital in rural Coelemu, Chile. Patients received pharmaceutical care in three individualized sessions over 6 months. Written educational materials including basic information on high BP were provided to each patient in every session using easy-to-understand language. BP was measured at the beginning and end of each session using an electronic tensiometer, and patients reported their adherence to therapy using indirect, self-reported measures. FINDINGS: Over the study period, patients experienced average decreases in systolic and diastolic BP of 7.68 mmHg (P < 0.001) and 2.91 mmHg (P < 0.001), respectively. Patient adherence to medication, according to self-reported measures, increased from 22% to 60% over the study period. CONCLUSION: Pharmaceutical care, including education about hypertension, healthy lifestyle habits, and adherence, was associated with improved adherence to antihypertensive drug treatment and control of BP in hypertensive patients at a rural hospital in Chile.

Using two tools to identify Potentially Inappropriate Medications (PIM) in elderly patients in Southern Chile.

OBJECTIVES: To assess and compare the prevalence of prescribing of potentially inappropriate medications (PIMs) identified using the Beers and STOPP criteria; and to determine the clinical variables related with the prescription of PIMs in older adults. METHODS: An observational study of 250 patients aged 65 years or older was conducted in a large teaching hospital. Beers (2012) and STOPP (2008) criteria were utilized to identify PIMs. Data on age, sex, admission and discharge dates, diagnoses, and medications prescribed were obtained from medical records. Multivariate logistic regression was used to determine patient variables related with the prescription of PIMs. KEY FINDINGS: Using Beers criteria, 375 PIMs were identified in 198 patients. 32% of these patients were prescribed one PIM, 20% were prescribed two PIMs, and 48% were prescribed more than two PIMs. Using STOPP criteria, 148 PIMs were identified in 120 patients. 41% of these patients were prescribed one PIM, 51% were prescribed two PIMs, and 8% were prescribed more than two PIMs. An association between PIM prescribing and polypharmacy was detected with both criteria. After adjusting for confounding variables, the prescription of Beers-identified PIMs was significantly associated with patients older than 80 (OR: 2.99; 95% CI: 1.13-7.89) and with length of hospital stay of more than 15days (OR: 2.78; 95% CI: 1.20-6.44). CONCLUSION: These two criteria showed that the prescription of PIMs is prevalent in hospitalized elderly patients. It may be beneficial to educate healthcare teams about these criteria to reduce the prescription of PIMs.

Impact of a pharmacotherapy plan to improve adherence for patients with type-2 diabetes and hypertension in a Chilean hospital.

BACKGROUND: Non-adherence to prescribed treatment is a principle cause of treatment failure in patients with chronic diseases, such as type 2 diabetes mellitus (T2DM) and hypertension. Improved patient monitoring and education have been shown to improve adherence and clinical outcomes. OBJECTIVE: This study evaluates the impact of a pharmacotherapy optimization plan centered on patient education that was implemented at a hospital in Arauco, Chile. METHODS: A prospective study was conducted using 50 randomly selected patients diagnosed with both T2DM and hypertension. Each patient participated in three successive interview sessions over 6 months. At each session, the following variables were evaluated by a pharmacist: blood pressure, HbA1c, adherence to prescribed medication, and patient knowledge of disease. RESULTS: Significant decreases were observed for HbA1c (<0.001), and SBP (<0.001), with stronger and more significant decreases observed for females. Patient adherence to prescribed medication also improved, but not significantly. The number of patients with full knowledge of their diseases increased significantly (p < 0.001) from 10 to 66%. CONCLUSION: This study suggests that the incorporation of a pharmacotherapeutic optimization plan for patients with chronic diseases can have a positive impact on the control of chronic diseases, such as T2DM and hypertension.

Predicting blood pressure outcomes using single-item physician-administered measures: a retrospective pooled analysis of observational studies in Belgium.

BACKGROUND: Patient adherence is often not monitored because existing methods of evaluating adherence are either burdensome or do not accurately predict treatment outcomes. AIM: To examine whether two simple, single-item physician-administered measures of patient adherence to antihypertensive medication are predictive of blood pressure outcomes. DESIGN AND SETTING: Retrospective database analysis of patients with hypertension treated in Belgian primary care. METHOD: Using pooled data from five observational studies, a sample was identified of 9725 patients who were assessed using two single-item physician-administered measures of adherence to antihypertensive medication: the first item of the Basel Assessment of Adherence Scale (BAAS) and the Visual Analogue Scale (VAS). These two assessment tools were administered by GPs during regular appointments with patients. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and combined SBP/DBP were measured at baseline and at 90 days. RESULTS: BAAS-identified adherent patients achieved lower mean SBP and DBP compared with non-adherent patients at 90 days (P<0.001), and had odds ratios of achieving blood pressure control of 0.66 (95% confidence intervals (CI) = 0.61 to 0.73, P<0.001) for SBP, 0.69 (95% CI = 0.62 to 0.76, P<0.001) for DBP, and 0.65 (95% CI = 0.59 to 0.72, P<0.001) for combined SBP/DBP. For VAS-identified adherent patients, the odds ratios of achieving blood pressure control were 0.93 (95% CI = 0.86 to 1.00, P<0.001) for SBP, 0.79 (95% CI = 0.73 to 0.85, P<0.001) for DBP, and 0.91 (95% CI = 0.84 to 0.99, P<0.001) for combined SBP/DBP. CONCLUSIONS: The first item of the BAAS and the VAS are independent predictors of blood pressure control. These methods can be integrated seamlessly into routine clinical practice by allowing GPs to quickly evaluate a patient's adherence and tailor treatment recommendations accordingly.

A Rasch analysis of a questionnaire designed to evaluate psychiatric patient attitudes and knowledge after attending a pharmacist-led patient medication education group.

BACKGROUND: There are many barriers that prevent persons with mental health disorders from achieving remission, including medication nonadherence. Research on the impact of pharmacist-led patient medication education groups on patient attitudes, knowledge and adherence is limited. OBJECTIVE: To evaluate the reliability and validity of the Medication Attitudes and Knowledge Questionnaire (MAKQ). METHODS: A retrospective pre-post questionnaire was distributed to patients. Variables collected included: patient self-reported medication knowledge and attitudes, patient demographics, number of previous psychiatric hospitalizations, whether the patient attended the whole meeting or only a portion, and outpatient pharmacist relationships. Knowledge and attitude items were measured on a 4-point scale with a range of options from "Agree" to "Disagree." Rasch analysis was conducted to ensure all items measured the same construct and to assess scale and item reliability and validity. Additionally, the Rasch technique evaluated the change in each person's self-perceived attitudes, knowledge, and confidence in self-managing medications from pre- to post-intervention if the data fit the model. A z-test was used to evaluate gaps in content validity. RESULTS: Sixty patients responded to the MAKQ over the 16-week data collection period. Analysis showed that the 4-point rating scale was not useful and that negatively worded items should be eliminated. Gaps identified in instrument item content were not statistically significant (p > 0.05), indicating comprehensive content validity. CONCLUSIONS: Medication attitudes and knowledge items on the retrospective pre-post questionnaire were valid and reliable.

Evaluating the efficacy and safety of apixaban, a new oral anticoagulant, using Bayesian meta-analysis.

Apixaban is a direct inhibitor of factor Xa, and is a potential alternative for the treatment of acute venous thromboembolism. This study sought to evaluate the efficacy and safety of apixaban versus enoxaparin. A systematic search of the literature for randomized controlled trials of apixaban thromboprophylaxis versus enoxaparin was conducted using three databases: PubMed, EMBASE, and the Cochrane library. Five studies that included a total of 12,938 patients were analyzed using Bayesian random-effects meta-analysis. To evaluate efficacy, a composite of venous thromboembolism and death during follow-up was measured. To evaluate safety, major and total bleeding events were considered. The odds ratio (OR) for the composite outcome of efficacy was 0.66 (95 % CI 0.33-1.29) for apixaban compared to enoxaparin, while there was a similar risk of major bleeding (OR 1.03, 95 % CI 0.36-3.73) and total bleeding (OR 0.92, 95 % CI 0.64-1.20). These results suggest a lack of clear superiority of apixaban relative to enoxaparin. Apixaban is an oral alternative with similar efficacy and safety to existing anticoagulant therapies.

Hierarchical modeling of patient and physician determinants of blood pressure outcomes in adherent vs nonadherent hypertensive patients: pooled analysis of 6 studies with 14,646 evaluable patients.

The authors used pooled data from 6 valsartan-related studies including 3983 adherent and 10,663 nonadherent patients to evaluate blood pressure (BP) outcomes in both groups after 90 days of treatment, applying hierarchical linear and logistic regression to identify determinants of BP outcomes. The principal findings were that: (1) BP outcomes were consistently better in adherent patients; (2) approximately a quarter of the variance in 90-day BP values was attributable to a physician class effect; (3) common and unique patient- and physician-related variables were associated with BP outcomes in both groups; (4) physician vigilance was associated with better outcomes, especially in adherent patients; and (5) adherent patients were more likely to exhibit target organ damage and associated events while being prescribed more complex medication regimens. Adherence to antihypertensive medication may be a function of prior line treatment failure, severity of illness, and sequelae, and the ensuing patient resolution to change medication behavior.

Health care decision makers' use of comparative effectiveness research: report from a series of focus groups.

BACKGROUND: Comparative effectiveness research (CER) is a helpful approach to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision makers about the most effective interventions. OBJECTIVES: To (a) identify the factors necessary to increase the use of the Agency for Healthcare Research and Quality's (AHRQ) CER reviews in hospitals and managed care organizations; (b) assess current awareness and implementation of CER materials in these facilities and organizations; and (c) inform development of content for a workshop on CER. METHODS: Pharmacy and therapeutics (PT) committee members and supportive personnel were recruited to participate in focus groups conducted at national health professional meetings. Prior to the sessions, each participant completed a prefocus group questionnaire evaluating the organization and process of the respondent's PT committee, as well as the respondent's role in the PT committee and awareness of AHRQ CER reports. Each session consisted of a focused discussion about CER and sources of evidence for PT monographs, and each participant completed a ballot to rank topics of importance for inclusion in a CER workshop for health care professionals involved in the PT process. Overarching themes were later identified using qualitative analysis of the transcripts of the focus group sessions. RESULTS: Thirty-nine (68%) pharmacists and 18 (32%) physicians involved in the PT process participated in 1 of 7 focus groups. Almost half of the participants had 6-15 years experience with the PT process. Participants represented health plans, hospitals, and health care systems. Two-thirds indicated they were aware of AHRQ's Effective Health Care Program's CER reviews, yet only 26% reported using the reviews in their organizations. The overarching themes reflected the need for timely and conclusive CER information; the role of the pharmacist as central to evidence synthesis for the PT process; and the need for educational programs in online formats that are designed primarily for pharmacists. CONCLUSION: Health care decision makers identified timeliness as a key factor for facilitating the use of AHRQ CER reviews and guides in hospitals and managed care organizations. To facilitate integration of CER into the decision-making process, it is imperative that key stakeholders have access to comprehensive and timely information. While the majority of participants indicated that they were aware of AHRQ CER reviews, few had used them in the PT process.

Evolución del consumo de antimicrobianos de uso restringido y tendencia de la susceptibilidad in vitro en el Hospital Regional de Concepción, Chile / Evolution of use of antibiotics of restricted prescription and trend of bacterial susceptibility in Concepcion Regional Hospital, Chile

The aim of this study was analyze the use of restricted antibiotics by patients hospitalized between 2004 and 2008 in Guillermo Grant Benavente Hospital in Concepcion. Also we attempted to identify possible correlations between antibiotic consumption and patterns of bacterial susceptibility. We performed a retrospective observational study that quantified the use of restricted antibiotics using DDD/100-bed-days, and cumulative susceptibility reports informed by the hospital's microbiology laboratory for bacterial susceptibility. The consumption of restricted antibiotics significantly increased between 2004 and 2008 (35%, p = 0.005). The groups with largest use were glycopeptides (37%) and carbapenems (30 %). These results can be explained by the emergence of endemic Methicillin-resistant Staphylococcus aureus (MRSA) and of Extended-spectrum beta-lactamase (ESBL) Gram negative bacilli. Results showed a decrease in susceptibility of P. aeruginosa to imipenem (p = 0.038) and K. pneumoniae to ciprofloxacin (p = 0.021). The total consumption of restricted antibiotic has significantly increased, especially among complex medical services. A significant decrease in bacterial susceptibility has been observed mainly in gram-negative bacilli. The monitoring of antimicrobial prescribing practices and local susceptibility patterns are essential to promote the rational use of antibiotics.

En Chile no existen estudios para cuantificar el consumo de antimicrobianos de uso restringido al interior de los hospitales. Objetivo: Analizar el consumo de antimicrobianos de uso restringido en pacientes hospitalizados durante los años 2004-2008 en el Hospital Guillermo Grant Benavente de Concepción. Además, se analizaron las correlaciones entre este consumo y el patrón de susceptibilidad in vitro. Material y Método: Se diseñó un estudio observacional retrospectivo empleando las DDD/100-días-cama para evaluar el consumo de antimicrobianos, y el informe acumulado de susceptibilidad in vitro entregado por el laboratorio local, para analizar la evolución de la susceptibilidad. Resultados: El consumo de antimicrobianos se incrementó en 35% (p = 0,005) durante los años 2004-2008, donde los más consumidos fueron glicopéptidos (37%) y carbapenémicos (30%). Estos resultados se pueden explicar por la aparición de cepas de Staphylococcus aureus resistente a meticilina y bacilos gramnegativos productores de Q-lactamasas de espectro extendido. Además, se observó una disminución de la susceptibilidad de Pseudomonas aeruginosa a imipenem (p = 0,038) y de Klebsiella pneumoniae a ciprofloxacina (p = 0,021). Conclusiones: El consumo total de antimicrobianos de uso restringido se incrementó significativamente en los servicios clínicos más complejos, observándose una disminución de la susceptibilidad de algunos bacilos gramnegativos. El monitoreo de la prescripción de antimicrobianos así como de la susceptibilidad in vitro local constituyen medidas esenciales para promover el uso racional de antimicrobianos.

[Digoxin plasma levels in four different prescription schedules of common use in clinical practice]. / Concentraciones plasmáticas de digoxina en cuatro esquemas terapéuticos de uso común en la práctica clínica.

BACKGROUND: The different therapeutic schedules used for the prescription of digoxin have little theoretical support. AIM: To measure digoxin plasma levels in patients using four different prescription schedules. PATIENTS AND METHODS: Four groups of patients were studied. Group I corresponded to 56 patients taking digoxin 0.25 mg/day, from Monday to Friday. Group II corresponded to 30 patients taking digoxin 0.25 mg/day, from Monday to Saturday. Group III corresponded to 53 patients taking digoxin 0.25 mg/day continuously. Group IV corresponded to 36 patients taking digoxin 0.125 mg/day continuously. Plasma digoxin levels were measured in two consecutive Mondays before taking the daily dose of the drug. Serum creatinine was also measured and creatinine clearance was calculated. The therapeutic plasma concentration range was set between 0.5 and 2 ng/ml. RESULTS: Mean plasma digoxin levels were 1.15 +/- 0.8 ng/ml in group I, 1.4 +/- 0.55 ng/ml in group II, 1.68 +/- 0.7 ng/ml in group III and 1.14 +/- 0.43 ng/ml in group IV. 93% of patients in group I, 80% of patients in group II, 75% of patients in group III and 94% of patients in group IV had therapeutic digoxin levels. A low creatinine clearance, an age over 65 and interactions with other drugs were risk factors associated with supratherapeutic levels, mostly seen in group II and group III with 20% and 24% respectively. CONCLUSIONS: Most patients using digoxin with different therapeutic schedules had plasma drug levels within the therapeutic range.