The Effect of Cardiovascular Credentialed Pharmacists on Process Measures and Outcomes in Myocardial Infarction and Heart Failure

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/108262/1/phar1444.pd

A Trial of Automated Safety Alerts for Inpatient Digoxin Use with Computerized Physician Order Entry

Objective: Automated clinical decision support (CDS) has shown promise in improving safe medication use. The authors performed a trial of CDS, given both during computerized physician order entry (CPOE) and in response to new laboratory results, comparing the time courses of clinician behaviors related to digoxin use before and after implementation of the alerts. Design: Alerts were implemented to notify of the potential risk from low electrolyte concentrations or unknown digoxin or electrolyte concentrations during CPOE. Alerts were also generated in response to newly reported hypokalemia and hypomagnesemia in patients given digoxin. Measurements: Clinician responses to the alerts for six months were compared with responses to similar situations for six months prior to implementation. Results: During CPOE, checking for unknown serum values increased after implementation compared with control at one hour: 19% vs. 6% for digoxin, 57% vs. 9% for potassium, and 40% vs. 12% for magnesium as well as at 24 hours (p < 0.01 for all comparisons). Electrolyte supplementation increased with newly reported hypokalemia and hypomagnesemia after implementation at one hour: 35% vs. 6% and 49% vs. 5% for potassium and magnesium, respectively, as well as at 24 hours (p < 0.01 for all comparisons). During CPOE, supplementation for hypokalemia was not improved, whereas supplementation for hypomagnesemia improved at one hour (p < 0.05). Conclusion: Overall, the alerts improved the safe use of digoxin. During CPOE, alerts associated with missing levels were effective. For hypokalemia and hypomagnesemia, the alerts given during CPOE were not as effective as those given at the time of newly reported low electrolytes

Frequency of “on-label” use of intravenous diltiazem for rate control in patients with acute-onset atrial fibrillation or atrial flutter

Background: Intravenous (IV) diltiazem is indicated for acute atrial fibrillation or flutter (AFF) but real-world dosing strategies often differ from labeling. Objective: To characterize “on-label” use of IV diltiazem in acute AFF. Methods: An IRB-approved, single-center, retrospective, observational design was utilized. Eligible patients had acute AFF with heart rate > 120 bpm and received IV diltiazem between June 2012 – June 2014. The primary outcome was frequency of on-label use of IV diltiazem, defined as use of at least one FDA-approved weight-based bolus dose followed by an infusion, if appropriate, in the absence of contraindications. Results: 300 patients were screened; 97 patients were included for analysis. IV diltiazem was used on-label in only 14 patients (14.4%). Of the 96 patients who received an initial diltiazem bolus, the median dose was significantly higher in patients for whom the diltiazem dose was on-label [17.5 mg (IQR 10-20 mg) vs. 10.0 mg (IQR 10-20 mg), p < 0.02). Twenty-nine patients (34.9%) in the off-label group had a therapeutic response to diltiazem alone compared to 8 patients (57.1%) in the on-label group (p = 0.11). More patients treated with off label diltiazem boluses required additional rate control medications (40.9% vs. 7.1%, p < 0.04). Conclusion: IV diltiazem was not used in accordance with FDA labeling in the majority of patients. For most patients, IV diltiazem doses were lower than recommended and many of these patients required additional rate control medications to achieve a therapeutic response. Patients with tachycardia due to acute AFF may benefit from improved IV diltiazem dosing strategies or the use of alternative rate-control agents (e.g. beta blockers)

Risk of cardiac events with azithromycin-A prediction model.

Previous studies have suggested an increased risk of cardiac events with azithromycin, but the predictors of such events are unknown. We sought to develop and validate two prediction models to identify such predictors. We used data from Truven Marketscan Database (01/2009 to 06/2015). Using a split-sample approach, we developed two prediction models, which included baseline demographics, clinical conditions (Model 1), concurrent use of any drug (Model 1) and therapeutic class (Model 2) with a risk of QT-prolongation (CQT-Rx). Patients enrolled in a health plan for 365 days before and five days after dispensing of azithromycin (episodes). Cardiac events included syncope, palpitations, ventricular arrhythmias, cardiac arrest as a primary diagnosis for hospitalization including death. For each model, a backward elimination of predictors using logistic regression was applied to identify predictors in 100 random samples of the training cohort. Predictors prevalent in >50% of the models were included in the final model. A score for the Assessment of Cardiac Risk with Azithromycin (ACRA) was generated using the training cohort then tested in the validation cohort. A cohort of 20,134,659 episodes with 0.03% cardiac events were included. Over 60% included females with mean age of 40.1±21.3 years. Age, sex, history of syncope, cardiac dysrhythmias, non-specific chest pain, and presence of a CQT-Rx were included as predictors for Model-1 (c-statistic = 0.68). For Model-2 (c-statistic = 0.64), predictors included age, sex, anti-arrhythmic agents, anti-emetics, antidepressants, loop diuretics, and ACE inhibitors. ACRA score is available online (bit.ly/ACRA_2020). The ACRA score may help identify patients who are at higher risk of cardiac events following treatment with azithromycin. Providers should assess the risk-benefit of using azithromycin and consider alternative antibiotics among high-risk patients

Comparison of Rate Control versus Rhythm Control for Management of Atrial Fibrillation in Patients with Coexisting Heart Failure: A Cost-Effectiveness Analysis

STUDY OBJECTIVE: To compare lifetime costs and health outcomes of rate control versus rhythm control for management of atrial fibrillation in patients with coexisting heart failure from the third-party payer perspective. DESIGN: A Markov decision analysis model constructed from costs, utility, and transition probability inputs obtained from randomized clinical trials and publically available databases. PATIENTS: A simulated cohort aged 65 years or older with persistent or paroxysmal atrial fibrillation and heart failure. MEASUREMENTS AND MAIN RESULTS: Markov states for rhythm control were cardioversion plus amiodarone and maintenance amiodarone, and those for rate control were β-blocker, digoxin, and calcium channel blocker. Transition states included treatment success, hospitalizations for atrial fibrillation and/or heart failure, and severe adverse effects. Economic inputs included cost for drugs, cost of hospitalizations for atrial fibrillation and/or heart failure, and cost of management of severe adverse effects. Costs were measured in 2009 U.S. dollars, and clinical outcomes in quality-adjusted life-years (QALYs). One-way and multivariable sensitivity analyses were conducted. Uncertainty intervals (UIs) were obtained from probabilistic sensitivity analyses. Rate control was found to be less costly and more effective than rhythm control. Base case and probabilistic sensitivity analyses cost and effectiveness values for rate control were $7231 (95$5517-9016) and 2.395 QALYs (95% UI 2.366-2.424 QALYs); whereas those for rhythm control were $16,291 (95$11,033-21,434) and 2.197 QALYs (95% UI 2.155-2.237 QALYs). No critical values were found for any model parameters in the one-way sensitivity analyses. The cost-effectiveness acceptability curves showed that rate control was considered cost-effective in 100% of cases at willingness-to-pay ratios between $0 and$200,000/QALY. CONCLUSION: Rate control is less costly and more effective than rhythm control and should be the initial treatment for atrial fibrillation among patients with coexisting heart failure