How are drug regimen changes during hospitalisation handled after discharge: a cohort study.

OBJECTIVES: To investigate drug regimen changes during hospitalisation and explore how these changes are handled after patients are transferred back into the care of their general practitioners (GPs). DESIGN: Cohort study. SETTING: Patients in this multicentre study had undergone at least one change in their drug regimens at discharge from the general medicine departments at six hospitals in Norway. These changes were altered doses, discontinuation of drugs or start of new drugs. Clinical pharmacists visited the patients' GPs 4-5 months after patient discharge and recorded any additional drug regimen changes. RESULTS: In total, 105 patients (mean age 76.1 years, 54.3% women) completed the study. On average, they used 5.6 drugs at admission (range 0-16) and 7.6 drugs at discharge (range 1-17). On average, 4.4 drug changes per patient (SD 2.7, range 1-16) were made at the hospital, and 3.4 drug changes per patient (SD 2.9, range 0-14) within 4-5 months of discharge. Of the 465 drug changes made in hospital, 153 were changed again after discharge (mean 1.5 per patient, SD 1.8, range 0-13). The drug regimens of 90 of these 105 patients were changed after discharge. The OR for extensive drug changes after discharge (≥ 4 changes) increased significantly with the number of drugs used at discharge from hospital (OR=1.29, 95% CI 1.04 to 1.59). Only 68 of 105 discharge notes contained complete drug lists, and only 24 of the discharge notes were received by the GPs within 7 days. CONCLUSIONS: In addition to the extensive changes in drug regimens during hospitalisation, almost equally extensive changes were made in the initial months after discharge. Surveillance of drug regimens is particularly necessary in the period immediately after hospital discharge.

Handling drug-related problems in rehabilitation patients: a randomized study.

BACKGROUND: Drug-related problems (DRPs) have been found to be associated with increased morbidity, mortality, and health costs. OBJECTIVE: To investigate whether the inclusion of pharmacists in a rehabilitation team influences the handling of DRPs in the ward and whether an intervention in hospital affects drug use after discharge. SETTING: The rehabilitation ward of a general hospital in Oslo, Norway. METHODS: Patients were randomized into an intervention group (IG) or a usual care group (CG). The IG patients were followed prospectively by a pharmacist, who reviewed the patients' drug therapies using information from their medical records and patient interviews. The pharmacist identified DRPs and suggested solutions during multidisciplinary team meetings. The IG patients received targeted drug counselling from the pharmacist before discharge. The drug therapy in the CG, for the period from study randomization to discharge, was assessed retrospectively by the pharmacist, who identified DRPs and recorded how they were acted upon. Three months after discharge, pharmacists who were blinded to the patient randomization, visited the patients at home and interviewed them about their medication. MAIN OUTCOME MEASURES: Types and frequencies of DRPs in the IG and CG were compared at hospital admission, at discharge, and 3 months after discharge. RESULTS: Of the 77 patients included, 40 belonged to the IG and 37 to the CG. Patient characteristics (IG vs CG) were as follows: age 73.5 versus 76.8 years; female 58 versus 68%; mean number of drugs at admission 8.3 versus 7.8; and mean number of drugs at discharge 8.5 versus 7.7. At admission, 4.4 DRPs per patient were recorded in the IG and 4.2 in the CG. Significantly more DRPs were acted upon and resolved in the IG; at discharge, the IG had 1.2 DRPs per patient and the CG had 4.0 (P < 0.01). At the home visit, a significant difference between the groups was found: 1.63 versus 2.62 DRPs (P = 0.02) for the IG and the CG, respectively. CONCLUSION: Involvement of a pharmacist in drug-therapy management, including participation in multidisciplinary team discussions, markedly improved the identification and resolution of DRPs during a hospital stay. The benefit persisted after discharge.

Mortality after myocardial infarction: impact of gender and smoking status.

We have shown previously that smoking causes a first myocardial infarction (MI) to occur significantly more prematurely in women than in men. The aim of the study was to investigate mortality after MI with special emphasis on the impact of smoking and gender. The study included 2,281 consecutive patients (36.8% women) who died or were discharged from a central hospital with a diagnosis of MI from 1998 to 2005; the median follow-up of survivors was 7 years. Death after MI was adjusted for confounders. Mean age for women was 5.8 years older than for men (76.0 vs. 70.2 years) and women were less likely to have been smokers. In-hospital mortality for the first MI was 8.9% for men and 13.3% for women, and total mortality rates for all indexed MI after 7 years were 47% for men and 61% for women. Using Cox regression analysis, with all indexed MIs included, the after-discharge mortality for women was significantly lower than for men (hazard ratio 0.82; 95% confidence interval 0.70-0.96; P = 0.015). Compared with non-smokers, patients who were smokers on admission had significantly increased seven-year mortality after discharge (hazard ratio 1.30; 95% confidence interval 1.03-1.63; P = 0.002). In conclusion, current smoking at the time of the indexed MI was associated with increased mortality after 7 years follow-up. The smoking effect was independent of gender. Female gender was associated with a moderately lower risk of death during the same follow-up period.

Drugs with narrow therapeutic index as indicators in the risk management of hospitalised patients / Medicamentos de margen terapéutico estrecho como indicadores de gestión de riesgo en pacientes hospitalizados

Drugs with narrow therapeutic index (NTI-drugs) are drugs with small differences between therapeutic and toxic doses. The pattern of drug-related problems (DRPs) associated with these drugs has not been explored. Objective: To investigate how, and to what extent drugs, with a narrow therapeutic index (NTI-drugs), as compared with other drugs, relate to different types of drug-related problems (DRPs) in hospitalised patients. Methods: Patients from internal medicine and rheumatology departments in five Norwegian hospitals were prospectively included in 2002. Clinical pharmacists recorded demographic data, drugs used, medical history and laboratory data. Patients who used NTI-drugs (aminoglycosides, ciclosporin, carbamazepine, digoxin, digitoxin, flecainide, lithium, phenytoin, phenobarbital, rifampicin, theophylline, warfarin) were compared with patients not using NTI-drugs. Occurrences of eight different types of DRPs were registered after reviews of medical records and assessment by multidisciplinary hospital teams. The drug risk ratio, defined as number of DRPs divided by number of times the drug was used, was calculated for the various drugs. Results: Of the 827 patients included, 292 patients (35%) used NTI-drugs. The NTI-drugs were significantly more often associated with DRPs than the non-NTI-drugs, 40% versus 19% of the times they were used. The drug risk ratio was 0.50 for NTI-drugs and 0.20 for non-NTI-drugs. Three categories of DRPs were significantly more frequently found for NTI-drugs: non-optimal dose, drug interaction, and need for monitoring. Conclusion: DRPs were more frequently associated with NTI-drugs than with non-NTI-drugs, but the excess occurrence was solely related to three of the eight DRP categories recorded. The drug risk ratio is a well-suited tool for characterising the risk attributed to various drugs (AU)

Los medicamentos con estrecho margen terapéutico (NTI) son medicamentos con pequeñas diferencias entre las dosis terapéuticas y tóxicas. No se han explorado los problemas relacionados con medicamentos (DRPs) de estos medicamentos. Objetivo: Investigar cómo y cuanto se relacionan los tipos de problemas relacionados con medicamentos de estrecho margen terapéutico con los de otros medicamentos en pacientes hospitalizados. Métodos: Se incluyeron prospectivamente en 2002 los pacientes de medicina interna y reumatología de 5 hospitales noruegos. Farmacéuticos clínicos registraron los datos demográficos, medicamentos utilizados, historial médico y datos de laboratorio. Los pacientes que usaban NTI (aminoglucósidos, ciclosporina, carbamazepina, digoxina, digitoxina, flecainamida, litio, fenitoina, fenobarbital, rifampicina, teofilina, warfarina) se compararon con pacientes que no usaban NTI. Se registraron las apariciones de los 8 tipos de DRPs después de revisiones de los registros médicos y evaluación del equipo multidisciplinario del hospital. Se calculó para los varios medicamentos el ratio de riesgo de medicamento, definido como el número de DRP dividido por el número de veces que se uso el medicamento. Resultados: De los 827 pacientes incluidos, 292 (35%) utilizaron NTI. Los NTI estaban significativamente más asociados a DRP que los no NTI, 40% contra 19% de las veces que se utilizaron. El ratio de riesgo de medicamento fue de 0,50 para los NTI y de 0,20 para los no-NTI. Tres categorías de DRP que se encontraron más significativamente en los NTI: dosis no-óptima, interacción medicamentosa, y necesidad de monitorización. Conclusión: Los DRP estaban más frecuentemente asociados a medicamentos NTI que a los no-NTI, pero el exceso de aparición de DRP estaba relacionado solamente con tres de las ocho categorías de DRP. El ratio de riesgo de medicamento es una herramienta apropiada para caracterizar el riesgo atribuido a diversos medicamentos (AU)

Drugs with narrow therapeutic index as indicators in the risk management of hospitalised patients.

UNLABELLED: Drugs with narrow therapeutic index (NTI-drugs) are drugs with small differences between therapeutic and toxic doses. The pattern of drug-related problems (DRPs) associated with these drugs has not been explored. OBJECTIVE: To investigate how, and to what extent drugs, with a narrow therapeutic index (NTI-drugs), as compared with other drugs, relate to different types of drug-related problems (DRPs) in hospitalised patients. METHODS: Patients from internal medicine and rheumatology departments in five Norwegian hospitals were prospectively included in 2002. Clinical pharmacists recorded demographic data, drugs used, medical history and laboratory data. Patients who used NTI-drugs (aminoglycosides, ciclosporin, carbamazepine, digoxin, digitoxin, flecainide, lithium, phenytoin, phenobarbital, rifampicin, theophylline, warfarin) were compared with patients not using NTI-drugs. Occurrences of eight different types of DRPs were registered after reviews of medical records and assessment by multidisciplinary hospital teams. The drug risk ratio, defined as number of DRPs divided by number of times the drug was used, was calculated for the various drugs. RESULTS: Of the 827 patients included, 292 patients (35%) used NTI-drugs. The NTI-drugs were significantly more often associated with DRPs than the non-NTI-drugs, 40% versus 19% of the times they were used. The drug risk ratio was 0.50 for NTI-drugs and 0.20 for non-NTI-drugs. Three categories of DRPs were significantly more frequently found for NTI-drugs: non-optimal dose, drug interaction, and need for monitoring. CONCLUSION: DRPs were more frequently associated with NTI-drugs than with non-NTI-drugs, but the excess occurrence was solely related to three of the eight DRP categories recorded. The drug risk ratio is a well-suited tool for characterising the risk attributed to various drugs.

Health-related quality of life after myocardial infarction is associated with level of left ventricular ejection fraction.

BACKGROUND: The objective was to explore the relationship between left ventricular ejection fraction (LVEF) assessed during hospitalization for acute myocardial infarction (MI) and later health-related quality of life (HRQoL). METHODS: We used multivariable linear regression to assess the relationship between LVEF and HRQoL in 256 MI patients who responded to the Kansas City Cardiomyopathy Questionnaire (KCCQ), the EQ-5D Index, and the EuroQol Visual Analogue Scale (EQ-VAS) 2.5 years after the index MI. RESULTS: 167 patients had normal LVEF (>50%), 56 intermediate (40%-50%), and 33 reduced (<40%). The mean (SD) KCCQ clinical summary scores were 85 (18), 75 (22), and 68 (21) (p <0.001) in the three groups, respectively. The corresponding EQ-5D Index scores were 0.83 (0.18), 0.72 (0.27), and 0.76 (0.14) (p = 0.005) and EQ-VAS scores were 72 (18), 65 (21), and 57 (20) (p = 0.001). In multivariable linear regression analysis age > or = 70 years, known chronic obstructive pulmonary disease (COPD), subsequent MI, intermediate LVEF, and reduced LVEF were independent determinants for reduced KCCQ clinical summary score. Female sex, medication for angina pectoris at discharge, and intermediate LVEF were independent determinants for reduced EQ-5D Index score. Age > or = 70 years, COPD, and reduced LVEF were associated with reduced EQ-VAS score. CONCLUSION: LVEF measured during hospitalization for MI was a determinant for HRQoL 2.5 years later.

Risk of drug-related problems for various antibiotics in hospital: assessment by use of a novel method.

PURPOSE: To investigate the use of antibiotics in hospitals, to explore drug-related problems (DRPs) linked to antibiotics and to introduce a novel way of expressing the risks accompanying use of various antibiotics. METHODS: Patients from internal medicine departments in four Norwegian hospitals were prospectively included in 2002. Demographics, drugs used, medical history, laboratory data and clinical/pharmacological risk factors were recorded. DRPs were identified by clinical pharmacists and assessed in multidisciplinary hospital teams. A new term, the drug risk ratio, was established and defined as the number of times the antibiotic was associated with DRPs in relation to the number of times it was used. RESULTS: Out of the 668 patients included, 283 patients (42%) used antibiotics (AB users). AB users were older (76.2 vs. 73.9), used more drugs on admission (5.1 vs. 4.4) and had more DRPs (3.0 vs. 2.2) than non-users. The DRP categories no further need for drug, non-optimal drug and non-optimal dose were most frequently observed. The drug risk ratio, calculated for 12 antibiotic groups, was highest for aminoglycosides (0.77), beta-lactamase-resistant penicillins (0.56), macrolides (0.54) and quinolones (0.48) and lowest for first- and third-generation cephalosporins, 0.17 and 0.13, respectively. CONCLUSIONS: Nearly half of the hospitalised patients were prescribed antibiotics and antibiotic associated DRPs occurred frequently. The drug risk ratio for the different antibiotic groups varied with a factor of six from the lowest to the highest. A high drug risk ratio would alert of antibiotics which require heightened awareness when going to be used in clinical practice.

Understanding sex differences in health-related quality of life following myocardial infarction.

BACKGROUND: The role of sex differences in health-related quality of life (HRQoL) after myocardial infarction (MI) remains controversial. METHODS: In total 408 Norwegian patients completed the Short Form 36 (SF-36) questionnaire 2.5 years after MI. We compared HRQoL between sexes and with national norms. Multiple linear regression analysis was used to explore the association of scores on the Physical (PCS) and Mental (MCS) component summary scales with clinical and sociodemographic variables. RESULTS: Women scored lower than norms on the Physical functioning, Role functioning-physical, General health, and Role functioning-emotional scales. Men scored higher on Bodily pain, and lower on the other 7 scales compared to norms. Women <70 years scored lower than men on 3 out of 8 scales and on PCS. Women >/=70 scored lower than men on 5 out of 8 scales and on PCS. Relative to sex- and age-specific norms, there were no sex-differences in SF-36 scores. Age, time since the index MI, chronic obstructive pulmonary disease (COPD), previous MI, and stroke predicted PCS scores in women. Education, COPD, infarct localization, number of indications for cardiovascular medication at discharge, medication for heart failure, and subsequent MI predicted PCS scores in men. Smoking status, education, and Q-wave MI were determinants for MCS scores in men. CONCLUSION: Patients had impaired HRQoL compared to sex- and age-specific norms 2.5 years after MI. Women had lower HRQoL scores than men, but relative to norms HRQoL was equally affected in both sexes. Men and women had different determinants of HRQoL.

High mortality in diabetic patients with acute myocardial infarction: cardiovascular co-morbidities contribute most to the high risk.

BACKGROUND: High mortality rates have been reported in diabetic patients after acute myocardial infarction (AMI). The excess mortality has been attributed to the diabetic state itself. We aimed to investigate how other risk factors along with diabetes per se may predict mortality in an unselected AMI population. METHODS: A representative sample of an unselected AMI population was collected over a three-month period. Data on patients' histories, co-morbidity, presenting features and treatment were collected from medical records. The data sets included outcome variables at discharge, after 6 months and after 2.5 years. Patients with confirmed diabetes on admission to hospital were registered as diabetic patients. RESULTS: Of the 901 patients admitted to hospital with AMI, 121 (14%) were diabetic patients. Compared with the nondiabetic patients significantly fewer of the diabetic patients were alive at discharge (78% vs 86%), after 6 months (64% vs 78%) and after 2.5 years (42% vs 65%). In multiple logistic regression analyses adjusted for age, sex and smoking status, the most important predictor of death at 2.5 years was heart failure, followed by previous MI, diabetes, and angina pectoris. The population attributable risk (PAR) of death after 2.5 years was 7% for diabetes, 17% for previous MI, 13% for heart failure and 12% for angina pectoris. CONCLUSION: Among patients with diabetes suffering an AMI the already established cardiovascular co-morbidities, which previously partly or fully might have been caused by diabetes, contributed more than diabetes per se to high mortality in-hospital and in the follow-up period.

Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems.

AIM: To investigate whether polypharmacy defined as a definite number of drugs is a suitable indicator for describing the risk of occurrence of drug-related problems (DRPs) in a hospital setting. METHODS: Patients admitted to six internal medicine and two rheumatology departments in five hospitals were consecutively included and followed during the hospital stay, with particular attention to medication and DRPs. Comparisons were made between patients admitted with five or more drugs and with less than five drugs. Clinical pharmacists assessed DRPs by reviewing medical records and by participating in multidisciplinary team discussions. RESULTS: Of a total of 827 patients, 391 (47%) used five or more drugs on admission. Patients admitted with five or more and less than five drugs were prescribed the same number of drugs after admission: 4.1 vs. 3.9 drugs [P = 0.4, 95% confidence interval (CI) - 0.57, 0.23], respectively. The proportion of drugs used on admission which was associated with DRPs was similar in the patient group admitted with five or more drugs and in those admitted with less than five drugs. The number of DRPs per patient increased approximately linearly with the increase in number of drugs used; one unit increase in number of drugs yielded a 8.6% increase in the number of DRPs (95% CI 1.07, 1.10). CONCLUSION: The number of DRPs per patient was linearly related to the number of drugs used on admission. To set a strict cut-off to identify polypharmacy and declare that using more than this number of drugs represents a potential risk for occurrence of DRPs, is of limited value when assessing DRPs in a clinical setting.

Use of renal risk drugs in hospitalized patients with impaired renal function--an underestimated problem?

BACKGROUND: Inappropriate use of drugs in patients with renal impairment (RI) may be harmful and may have deleterious effects. We aimed to investigate the use of renal risk drugs in such patients in general hospitals and to analyse the relationship to demographic factors, risk factors and occurrence of drug-related problems (DRPs). METHODS: Patients admitted to departments of internal medicine and rheumatology in five general hospitals were included. We recorded demographic data, drugs used, drugs described to be a risk in RI (renal risk drugs), relevant medical history, laboratory data and clinical/pharmacological risk factors. We used levels of glomerular filtration rates, calculated by the Modification of Diet in Renal Disease formula to classify patients into five stages of renal function. DRPs were recorded and assessed in multidisciplinary hospital team discussions. RESULTS: Of the 808 included patients, 293 (36%) had normal renal function (stage 1), 314 (39%) had mild RI (stage 2), 160 (20%) had moderate RI (stage 3), 35 (4%) had severe RI (stage 4) and six (0.7%) had kidney failure (stage 5). Mean number of drugs used per patient in patients with RI (stages 3, 4 and 5) and patients evaluated to have adequate renal function relative to drug therapy (stages 1 and 2): on admission 6.2 vs 4.1; started in hospital 4.3 vs 3.9 and total number of renal risk drugs 6.1 vs 4.5. All but six patients with RI stages 3, 4 and 5 used two or more renal risk drugs. 124 (62%) of the patients with RI stages 3, 4 and 5 had DRPs linked to the renal risk drugs, and 26% of the renal risk drugs were associated with DRPs. The most common drug classes associated with DRPs were antibacterials, antithrombotic agents, angiotensin-converting enzyme (ACE) inhibitors, opioids and non-steroidal anti-inflammatory drugs (NSAIDs). CONCLUSIONS: Among patients admitted to general hospitals, a considerable proportion had renal impairment. In patients with reduced renal function, renal risk drugs were widely used and often in combination. DRPs were frequently associated with the use of renal risk drugs.

Interview of patients by pharmacists contributes significantly to the identification of drug-related problems (DRPs).

PURPOSE: To investigate whether pharmacist interviews of hospitalised patients about their medication would result in identification of more drug-related problems (DRPs) than those found by usual care procedures and further to characterise the DRPs revealed at the interviews. METHODS: Patients from five internal medicine and two rheumatology departments in four hospitals in Norway were prospectively included in the study. Clinical pharmacists assessed DRPs by reviewing medical records and by participating in multidisciplinary team discussions. Drugs used, medical history, laboratory data and clinical/pharmacological risk factors were recorded (usual care procedure). A proportion of patients were randomly selected for interview with pharmacists. A quality team assessed the clinical significance of the DRPs. RESULTS: Seven hundred and twenty seven patients were included. Significantly more DRPs were found in the interview group (96 patients), an average of 4.4 DRPs per patient as compared to 2.4 DRPs in the non-interview group (631 patients) (p < 0.01). Of a total of 431 DRPs recorded in the interview group, 168 DRPs (39.9%) were disclosed through interviews. 'Need for additional drug', 'medical chart error', 'patient adherence' and 'need for patient education' were significantly more often recorded in this group. The quality team assessed 63% of the DRPs revealed in the interviews to be of major clinical significance. CONCLUSION: Significantly more DRPs were identified among the patients who were interviewed compared to those patients having only usual care examination. A high proportion of the DRPs identified in the interviews were of major clinical significance. The clinical pharmacists, with their way of interviewing, seem to fill a gap, ensuring that significant DRPs do not escape detection.

Reliability and validity of the Norwegian translation of the Seattle Angina Questionnaire following myocardial infarction.

The aim of this study was to validate the Norwegian version of the Seattle Angina Questionnaire (SAQ), a self-administered 19-item questionnaire designed to assess health-related quality of life in patients with chest pain or coronary artery disease. In 885 patients with prior myocardial infarction (MI), we abstracted clinical data from the patients' medical records. Two to three years after the MI, we mailed a self-administered questionnaire including the SAQ, the Short Form 36 (SF-36), and questions about current medication, to the 548 patients still alive. The response rate was 74%. Internal consistency reliability of the SAQ, assessed with Cronbach's alpha, ranged 0.75-0.92. Test-retest reliability, tested with an intraclass correlation coefficient, ranged 0.29-0.84. The pattern of association between similar and dissimilar scales of the SAQ and SF-36 mainly supported the construct validity of the SAQ. Four of the five SAQ scales discriminated between patients with different medication regimens as a proxy for severity of angina pectoris. We conclude that the Norwegian version of the SAQ showed acceptable reliability and cross-sectional validity following MI, with properties in line with the original US version.

Reliability and validity of the Kansas City cardiomyopathy questionnaire in patients with previous myocardial infarction.

BACKGROUND: The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a recently developed disease-specific instrument for measuring health-related quality of life (HRQoL) in patients with chronic heart failure (CHF) regardless of aetiology. AIM: To assess the reliability and validity of the KCCQ in patients with previous myocardial infarction (MI). METHODS AND RESULTS: In 754 myocardial infarction patients who were discharged alive, we collected clinical data from the patients' medical records. Two and a half years after the acute myocardial infarction, we mailed a self-administered questionnaire to the 548 patients still alive. The response rate was 74%. Internal consistency reliability, assessed with Cronbach's alpha, ranged 0.66-0.95. Test-retest reliability, tested with an intraclass correlation coefficient (ICC), ranged 0.41-0.83. The pattern of association between similar and dissimilar scales of the KCCQ and Short Form 36 (SF-36) supported the convergent/divergent validity of the KCCQ. Four of the KCCQ scales and the two summary scores discriminated between patients with and without medication for heart failure, and between different levels of left ventricular ejection fraction (LVEF) supporting different groups validity. CONCLUSIONS: The Norwegian version of the KCCQ showed acceptable reliability and cross-sectional validity, which support the use of this questionnaire to measure health-related quality of life after myocardial infarction.

Comparison of drug-related problems in different patient groups.

BACKGROUND: There is a lack of knowledge concerning how drug-related problems (DRPs) vary in different patient groups. Possible dissimilarities need to be taken into consideration when guidelines for detecting and preventing DRPs are compiled. OBJECTIVE: To characterize and compare the frequency and categories of DRPs in different groups of hospitalized patients. METHODS: Patients admitted to 4 different types of departments at 5 hospitals in Norway were included consecutively. Medical records and information acquired at multidisciplinary morning meetings were sources for assessing the patients' DRPs. RESULTS: A total of 827 patients were included. Mean age was 70.8 years, 58.6% were female, and 81% had at least one DRP. An average of 1.9, 2.0, 2.1, and 2.3 DRPs per patient were found in the departments of cardiology, geriatrics, respiratory medicine, and rheumatology, respectively. Significant differences in the type of DRPs between the patient groups were found. The most frequent DRPs and the patient group in which they most often occurred were nonoptimal dose (cardiology, respiratory, geriatric) and need for additional drug (rheumatology). CONCLUSIONS: DRPs occurred in the majority of the patients in all departments. The type of DRP differed markedly between the patient groups. Knowledge of these differences is clinically valuable by enabling us to guide efforts toward prevention of DRPs. Antithrombotic agents, loop diuretics, angiotensin-converting enzyme inhibitors, penicillins, antiinflammatory drugs, and opioid analgesics commonly caused DRPs, even in departments where knowledge of these drugs is assumed to be extensive.

The problem of underdosing of angiotensin-converting enzyme inhibitors is markedly overrated: results from a study of patients discharged from hospital after an acute myocardial infarction.

OBJECTIVE: The use of angiotensin-converting enzyme (ACE) inhibitors has increased markedly during the last decade. It has been claimed that doses of ACE inhibitors prescribed in clinical practice are considerably lower than the target doses used in randomized clinical trials. The aim of the study was to investigate dosing of ACE inhibitors in patients discharged from the hospital after an acute myocardial infarction (AMI) and, furthermore, to compare these doses with the doses actually reached in clinical trials. METHODS: From 16 hospitals, we drew a sample of patients who were discharged alive with the diagnosis of AMI during a 3-month period in 1999/2000. From medical records, physicians in each hospital obtained the observed rate of cardiovascular drugs at discharge, including type and doses of ACE inhibitors. The clinicians' main indication for ACE inhibitor use was also reported. Outcome variables, including deaths and drug utilization with dosing after 6 months, were collected. RESULTS: Of a total of 767 patients discharged alive, 274 patients received an ACE inhibitor. The daily mean doses of the four ACE inhibitors used in the study were as follows: captopril 69.8+/-36.9 mg (n=44), enalapril 13.6+/-8.1 mg (n=75), lisinopril 11.0+/-7.2 mg (n=114), and ramipril 8.4+/-4.5 mg (n=38). The doses were unchanged after 6 months except for captopril, which showed a rise in mean daily dose to 84.4+/-36.7 mg. Ramipril compared most favorably with clinical trial medications, while captopril deviated most. The indication of hypertension was associated with slightly higher doses than the indication of secondary prevention. CONCLUSION: AMI patients were discharged from the hospital with ACE inhibitor doses fairly close to the ones achieved in clinical trials showing survival benefits for ACE inhibitors. A distinction should be made between target doses and doses actually obtained in clinical trials.

Angiotensin-converting enzyme (ACE) inhibitor therapy after myocardial infarction in relation to left ventricular function.

OBJECTIVE: To investigate to what extent and by what methods clinicians assess left ventricular (LV) function after an acute myocardial infarction (AMI) and how the results of the assessments relate to the use of angiotensin-converting enzyme (ACE) inhibitors; furthermore, to explore which main indications caused the clinicians to initiate ACE inhibitor therapy. DESIGN: From 16 hospitals we drew a sample of patients who were discharged with the diagnosis of AMI during a 3-month period in 1999/2000. Physicians in each hospital obtained the observed rate of use of cardiovascular drugs at discharge and also information on ejection fraction (EF) measurements. The results of the EF recordings were classified into three categories: >0.50, 0.40-0.50 and <0.40. The clinicians' main indications for drug use were reported. RESULTS: Among 767 patients discharged alive, EF was measured in 409 (53%), by echocardiography in 53% and by radionuclide ventriculography in 47%. Of the 409 patients 227 (55%) had EF >0.50, 95 (24%) EF 0.40-0.50 and 87 (21%) EF <0.40. Adjusted odds ratio for ACE inhibitor therapy being initiated during the AMI was 13.5 for those with EF <0.40 compared with those with EF >0.50. The main indication for starting ACE inhibitor therapy was heart failure (50%) followed by secondary prevention (42%). CONCLUSION: Measuring EF appears to be an important tool in the evaluation of AMI patients prior to discharge from hospital. Initiation of ACE inhibitor therapy related strongly to the results of the assessments.