Development and Validation of a Uremic Pruritus Treatment Algorithm and Patient Information Toolkit in Patients With Chronic Kidney Disease and End Stage Kidney Disease.

CONTEXT: Uremic pruritus (UP) affects up to half of all patients with kidney disease and has been independently associated with poor patient outcomes. UP is a challenging symptom for clinicians to manage as there are no validated guidelines for its treatment. OBJECTIVES: The study aimed to develop and validate an algorithm and patient information toolkit for the treatment of UP in patients with kidney disease. METHODS: The study involved a literature search and development of an initial draft algorithm, followed by content and face validation of this algorithm. Validation entailed three rounds of interviews with six nephrology clinicians per round. Participants assessed the relevance of each component of the algorithm and then rated a series of statements on a scale of 1-5 to assess face validity of the algorithm. After each round, the content validity index (CVI) of each algorithm component was calculated, and the algorithm was revised by the study team in response to findings. This process was followed by a second study that developed and validated a patient information pamphlet and video. RESULTS: Algorithm validation participants were affiliated with three institutions and included seven physicians, four registered nurses, three nurse practitioners, three pharmacists, and a dietician. The average CVI of the algorithm components across all three rounds was 0.89, with 0.80 commonly cited as the lower acceptable limit for content validation. More than 78% of participants rated each face validity statement as "Agree" or "Strongly Agree". For the patient information tools, five clinicians and 15 patients were included in validation. The average CVI was 1.00 for both tools, and the average face validity was 92%. CONCLUSION: A treatment algorithm and patient information toolkit for managing UP in patients with kidney disease were developed and validated through expert review. Further research will be conducted on implementation of the treatment algorithm and evaluating patient-reported outcomes.

Medication reconciliation at hospital discharge: evaluating discrepancies.

BACKGROUND: Hospital discharge is an interface of care when patients are at a high risk of medication discrepancies as they transition from hospital to home. These discrepancies are important, as they may contribute to drug-related problems, medication errors, and adverse drug events. OBJECTIVE: To identify, characterize, and assess the clinical impact of unintentional medication discrepancies at hospital discharge. METHODS: All consecutive general internal medicine patients admitted for at least 72 hours to a tertiary care teaching hospital were prospectively assessed. Patients were excluded if they were discharged with verbal prescriptions; died during hospitalization; or transferred from or to a nursing home, another institution, or another unit within the same hospital. The primary endpoint was to determine the number of patients with at least one unintended medication discrepancy on hospital discharge. Medication discrepancies were assessed through comparison of a best possible medication discharge list with the actual discharge prescriptions. Secondary objectives were to characterize and assess the potential clinical impact of the unintentional discrepancies. RESULTS: From March 14, 2006, to June 2, 2006, 430 patients were screened for eligibility; 150 patients were included in the study. Overall, 106 (70.7%) patients had at least one actual or potential unintentional discrepancy. Sixty-two patients (41.3%) had at least one actual unintentional medication discrepancy at hospital discharge and 83 patients (55.3%) had at least one potential unintentional discrepancy. The most common unintentional discrepancies were an incomplete prescription requiring clarification, which could result in a patient delay in obtaining medications (49.5%), and the omission of medications (22.9%). Of the 105 unintentional discrepancies, 31(29.5%) had the potential to cause possible or probable patient discomfort and/or clinical deterioration. CONCLUSIONS: Medication discrepancies occur commonly on hospital discharge. Understanding the type and frequency of discrepancies can help clinicians better understand ways to prevent them. Structured medication reconciliation may help to prevent discharge medication discrepancies.

The EMITT study: development and evaluation of a medication information transfer tool.

BACKGROUND: Continuity of care is required as patients move from the care of one pharmacist to another. The appropriate transfer of medication information between pharmacists as well as to patients at these times is essential in order to prevent drug-related problems (DRPs). OBJECTIVE: To develop a tool to transfer medication information between various pharmacists caring for the same patients. Secondary objectives were to evaluate the tool based on utility in practice and satisfaction of pharmacists. METHODS: The project consisted of a needs assessment involving in-depth interviews with patients and pharmacists and a literature review. These data were used to develop an optimal tool for medication information transfer between pharmacists in different practice settings. The tool was evaluated in a feasibility pilot for potential utility and pharmacist satisfaction. RESULTS: The tool created called EMITT (electronic medication information transfer tool) facilitates the communication of information to outpatient pharmacists including a letter and an up-to-date list of the patient's drugs. A total of 187 medication issues were communicated within 40 transferred letters, 61 of which required active follow-up, which potentially prevented 348 DRPs if the receiver of the information acted on the information that was provided. The 3 most common issues that required follow-up were restarting a held medication (n = 13), adjustment of doses based on laboratory results (n = 11), and starting a new indicated medication in the future (n = 7). CONCLUSIONS: A tool can be created to help address the gap in communication between pharmacists when patients move between interfaces of care by evaluating the needs of healthcare professionals involved in the information transfer process. It is envisioned that the elements of our tool can be easily adapted to other institutions to improve medication information transfer.

Drug-related problems on hospital admission: relationship to medication information transfer.

BACKGROUND: Patients with end-stage renal disease (ESRD) are at risk for drug-related problems (DRPs), especially on hospital admission. OBJECTIVE: To identify and characterize the DRPs experienced by patients with ESRD on admission and investigate how these DRPs could be related to gaps in medication information transfer. METHODS: Patients with ESRD admitted to the hospital were prospectively identified and clinically assessed by a pharmacist to identify and categorize DRPs on admission. Each DRP was evaluated to determine whether it could have been caused by a gap in medication information transfer. For DRPs caused in this manner, the interface in the information transfer process where the gap may have occurred was determined. RESULTS: A total of 199 DRPs were identified in 47 patients with ESRD over a 12 week period. Ninety-two percent of patients had at least one DRP on admission, with an average of 4.2 +/- 2.2 DRPs per patient. The most common DRP identified was indication for drug therapy--patient requires drug but is not receiving it (51.3%). Of the total DRPs, 130 (65%) were related to gaps in medication information transfer, with 21.5% occurring between the inpatient hospital and the ambulatory clinic pharmacists and 17.7% between the admitting physician and the patient. CONCLUSIONS: Results of this study demonstrate that, in patients with ESRD, DRPs on admission are frequently related to gaps in medication information transfer between healthcare professionals and also between healthcare providers and patients. Improved communication is required at medication information transfer interfaces to prevent these DRPs.

Bisphosphonate use for the management of breast cancer patients with bone metastases: a survey of Canadian Medical Oncologists.

BACKGROUND: The use of bisphosphonates (BP) in breast cancer patients with bone metastases (BM) has been shown to reduce bone pain and lower the risk of skeletal-related events (SREs). Many practice guidelines exist for the use of BPs in patients with BM. Unfortunately, none clearly address whether the benefits of BP use apply equally to all subgroups of patients, the duration of therapy, and when to discontinue BP therapy. A questionnaire was therefore developed and administered to determine how medical oncologists in Canada use BPs in clinical practice. METHODS: A structured mailing strategy was adopted. The population consisted of 100 medical oncologists with active breast cancer practices in Canada. All regions of Canada were represented. The questionnaire was developed to capture data on respondent demographics, BPs used, major factors influencing decision making, and clinical practice in situations where there is a lack of high-quality data. RESULTS: Completed questionnaires were returned by 76 medical oncologists. All treated breast cancer and the majority (68%) were based at teaching hospitals. Ninety-six percent of respondents regularly prescribed BPs, initiating therapy at the time the patient presented with BM. Although 79% of respondents recognized that there was no clear data to support the continued use of BP after bony progression, 53% stated that they rarely or never discontinue a BP once started. In situations where a BP was discontinued, the majority of respondents report the reason for discontinuation was a decrease in patient performance status. In the patient with clearly progressive visceral metastases and an estimated prognosis of less than 6 months, 75% of respondents would still commence BP therapy. CONCLUSIONS: This study confirms that most medical oncologists in Canada, while acknowledging lack of evidence, maintain patients on BP therapy when patients have an expected survival of less than 6 months or even after patients progress while on a BP. More research is needed to determine the role of continuing, switching, or discontinuing BP therapy in the context of disease progression or shortened expected survival.

Do physicians follow systemic treatment and funding policy guidelines?

BACKGROUND: The use of bisphosphonates for the prevention of skeletal related events in women with bone metastases from breast cancer is well established. We undertook an evaluation of bisphosphonate use in clinical practice in three Canadian cancer centres. In addition we assessed whether or not physicians at these centres are following their local treatment guidelines and funding policies. METHODS: Charts and electronic files of patients who had received either clodronate or pamidronate at any time between January 2000 and December 2001 at three Canadian cancer centres were retrospectively reviewed. RESULTS: There has been a marked improvement in the time between the diagnosis of bone metastases and the commencement of bisphosphonates from a median of 155 days in 1998 to 24 days in 2001. However, despite a local funding policy requiring that oral clodronate be the first bisphosphonate used, this was the case in only 67% of patients. In addition, despite one centre's guidelines recommending that bisphosphonates be stopped once the patient was progressing, 90% of their patients remained on bisphosphonates until they died. CONCLUSIONS: A considerable amount of effort is spent on the creation of "evidence based" treatment guidelines. Funding agencies develop policies based on these treatment guidelines, but often funding is more restrictive than the treatment guideline would suggest. It is clear from this review that physicians still appear to manage a substantial proportion of patients outside of funding policies, but within evidence based recommendations. Therefore, a need exists for either the creation of guidelines and policies that physicians will follow or the implementation of methods to ensure that restrictive policies are actually followed.