Clinical rules de nieuwe generatie medicatiebewaking

Hugo van der Kuy

Erasmus MC

Voorheen Zuyderland

Week 1 Case 1 Case 2 Case 3 Maximum score (expert panel) 24 20 34

Mean score (participants) -0.82* 0.76* 2.39*

SD 2.41 2.39 3.07

% -3.40% 3.82% 7.04%

Week 2 Case 1 Case 2 Case 3 Maximum score (expert panel) 24 20 34

Mean score (participants) 3.50* 3.66* 6.97*

SD 3.87 3.55 4.96

% 14.58% 18.29% 20.51%

Week 3 Case 1 Case 2 Case 3 Maximum score (expert panel) 24 20 34

Mean score (participants) 6.89* 7.18* 14.63*

SD 4.91 3.94 6.80

% 28.73% 35.92% 43.03%

CLEAR study

* Statistically significant p <0.001

CLEAR study Clinical and Laboratory data Evaluation for an Appropriate medication Review

Week 1 Week 2 Week 3

Medication list Medication list Medication list Lab data Lab data Medical history

What is the score of the reviewer compared to the expert panel?

The expert panel had all the information from week 3!

CLEAR study Week 1 Case 1 Case 2 Case 3 Maximum score (expert panel) 24 20 34

Mean score (participants) -0.82* 0.76* 2.39*

SD 2.41 2.39 3.07

% -3.40% 3.82% 7.04%

Week 2 Case 1 Case 2 Case 3 Maximum score (expert panel) 24 20 34

Mean score (participants) 3.50* 3.66* 6.97*

SD 3.87 3.55 4.96

% 14.58% 18.29% 20.51%

Week 3 Case 1 Case 2 Case 3 Maximum score (expert panel) 24 20 34

Mean score (participants) 6.89* 7.18* 14.63*

SD 4.91 3.94 6.80

% 28.73% 35.92% 43.03%

* Statistically significant p <0.001

Business case • 800 patients in nursing homes

• Recommended at least 2 medication reviews/patient/year (reality is different)

• Average 1 hour per patient/review

• Total 1600 hours = 1 FTU

The solution? Automatic

Standardized/objective

Knowledge database

Less time consuming

More efficient (no or less unnecessary alerts) Efficiency current medicationsurveillance?

Around the clock surveillance

System independent

Available for more hospitals/Nursing Homes

CRR ● Clinical Rule Reporter

● Extracting 3 different files medication, patient characteristics, lab data

● Upload to CRE (A’dam)

● Daily evaluation 2000 patients

● Average time upload: 10-15 minutes

● Efficiency increase 15% 80%

● Feedback via email

Which rules? • Labdata (31 parameters) e.g. Renal function, K, Na, Leuco, INR, albumin

• Stopdata e.g. cytostatics, warfarin+LMWH • START/STOPP criteria e.g. Prolonged use of 1st generation antihistamines

• Indications NHG-standards (GP) e.g. myocard infarction, CHADS-2

• Possible medication errors e.g. MTX, bisphosphonates 1x per week

• Identification risk patients e.g. PPI-prophylaxis, opioids + laxatives

• Patient indexes e.g. risk of falling, risk of delirium, Drug Burden Index

Efficacy potassium

Efficacy potassium When potassium affecting medication is used and

potassium level is abnormal (<3.0 mmol/L or >5.0 mmol/L). 5%

Efficacy potassium When potassium affecting medication is used and

potassium level is abnormal (<3.0 mmol/L or >5.0 mmol/L).

The CR is divided in two separate rules: A hypopotassemia rule generating alerts if potassium

decreasing medication is used and the potassium level is decreased (<3.0 mmol/L).

A hyperpotassemia rule generating alerts if potassium increasing medication is used and the potassium level is increased (>5.5 mmol/L).

5%

+ 40%

Efficacy potassium When potassium affecting medication is used and

potassium level is abnormal (<3.0 mmol/L or >5.0 mmol/L).

The CR is divided in two separate rules: A hypopotassemia rule generating alerts if potassium

decreasing medication is used and the potassium level is decreased (<3.0 mmol/L).

A hyperpotassemia rule generating alerts if potassium increasing medication is used and the potassium level is increased (>5.5 mmol/L).

The clinical rules are further developed: The hypopotassemia rule generates alerts if potassium

decreasing medication is used, the potassium level is <3.0 mmol/L, and no potassium supplements are used.

The hyperpotassemia rule generates alerts if potassium increasing medication is used, the potassium level is >5.5 mmol/L, and no potassium binder is used.

5%

+ 40%

80%

Efficacy potassium When potassium affecting medication is used and potassium level

is abnormal (<3.0 mmol/L or >5.0 mmol/L).

The CR is divided in two separate rules: A hypopotassemia rule generating alerts if potassium

decreasing medication is used and the potassium level is decreased (<3.0 mmol/L).

A hyperpotassemia rule generating alerts if potassium increasing medication is used and the potassium level is increased (>5.5 mmol/L).

The clinical rules are further developed: The hypopotassemia rule generates alerts if potassium

decreasing medication is used, the potassium level is <3.0 mmol/L, and no potassium supplements are used.

The hyperpotassemia rule generates alerts if potassium increasing medication is used, the potassium level is >5.5 mmol/L, and no potassium binder is used.

The hypopotassemia CR is adjusted so that alerts are generated if the potassium levels are <2.0 mmol/L, despite the use of potassium supplements.

5%

+ 40%

80%

added

SCREAM

Supporting Clinical Rules Engine in the Adjustment of Medication

Hugo van der Kuy Clinical Pharmacologist The Netherlands Edvard Munch

SCREAM Primary endpoints:

death, fall, delirium, hospital admission: combined

>3000 patients (Orbis, Helmond, Envida, Novicare)

1 year

Randomisation: regular care versus regular care+CRR CRR is run on a weekly basis

Randomisation per nursing home physician

SCREAM (Interim analysis) Analysis for 1 nursing home

779 patients controle 420 PG 286 SOM 134 Intervention 359 PG 269 SOM 90

Number of signals Only clinically relevant signals

Intervention 1952 (5.4) PG 1403 (5.2) SOM 549 (6.1)

After 1 year!!!

Control 2492 (5.9) PG 1687 (5.9) SOM 805 (6.0)

Several parameters Control Intervention P

EQ-5D 0.35 (0.28) 0.35 (0.23) 0.72 Fall incidence 1.5 (3.07) 1.33 (2.64 0.48 Deceased 137 112 0.7 Days in hospital 0.14 (1.56) 0.03 (0.24) 0.77 Medication costs 913 663 0.01

Hospital costs 19.7 (215) 16.2 (169) 0.80 TTFE 240 (142) 231 (146) 0.45 Time for review 1600 h 156 h

Conclusions This is the first interim analysis.

No clear benefit is seen yet on clinically relevant endpoints

Time for medication review is clearly reduced

Twice a year a review means that a patient is exposed too long to “not optimal medication”.

Added Value of the CRR in the hospital

Methods During 4 months observation of the weekly grand

rounds

Internal medicine and orthopedia

Remarks physicians were compared with alerts of the CRR

CRR consisted of 469 rules of which 120 were specialised for the hospital setting

Relevance of th remarks/alerts was determined by two internists

Notifications divided in subgroups

Results

More prediction models

• Falls • Adverse events

DElier MOdel

Prediction readmissions

CHECkUP Control in the Hospital by

Extensive Clinical rules for Unplanned hospitalisations in elderly Patients ZonMw

Studie opzet Doel: Reductie heropnames van ouderen met ongeplande opnames

Inclusie

Ouderen met ongeplande opnames Regio Heerlen, Maastricht en Sittard

2400 patienten opgedeeld in twee groepen

Interventie Bij ontslag CRR draaien Adviezen naar HA/APO Wekelijks herhalen via LSP + adviezen Vragenlijsten naar patient

Controle Geen adviezen naar HA/APO

Start Januari 2018

Further research Contribution patients prefer quality of life or longer life

What if we inform the patients with alerts?

What is the role of the CRR in POS?

What is the role of the CRR for outpatient management?

Can we use the CRR for HSMR reduction

What is the role of the CRR in primary care?

Helaas ervaar ik het nu anders……

Take home Medicationsurveillance is changing rapidly

Medication review and medication surveillance

Medication optimisation

Watch out, others will take over…

Amen

E: h.vanderkuy@erasmusmc.nl

HSMR Een kwestie van verslaglegging?

HSMR

Twee aandachtspunten Lege voorgeschiedenis

De kwaliteit van de inhoud

Voorgeschiedenis wordt gebruikt om risico van patienten te classificeren

De lege voorgeschiednis

Actieplan 1 In September starten we met pilot lege

voorgeschiedenis

Gemandateerde krijgt overzicht met lege voorgeschiedenissen

Gaan we volgen gedurende 3 maanden

Daarna moet ieder specialisme onder de 10 per week zitten

In december evaluatie door MSB bestuur en terugkoppeling

Actieplan II Mbv CDSS van apotheek controle op voorgeschiedenis

Gaat in september lopen als pilot

(zaal) arts krijgt een mail met signaal

Via link afhandelen wat je er mee doet 0 ingevoerd in VG 0 Geneesmiddel is voor andere indicatie 0 Alert is ten onrechte afgegaan

Actieplan II Alleen opgenomen patienten worden gecontroleerd

Afhandeling per vakgroep kan gemonitord worden

Is in ontwikkeling actieve bijdrage verbeterd het systeem

Apotheek gaat voorlopig de mails versturen weten niet wat workload is

Evaluatie in december