Differences in patient outcomes and chronic care management of oral anticoagulant therapy: an explorative study

Contains fulltext : 96817.pdf (publisher's version ) (Open Access)BACKGROUND: The oral anticoagulant therapy - provided to prevent thrombosis - is known to be associated with substantial avoidable hospitalization. Improving the quality of the oral anticoagulant therapy could avoid drug related hospitalizations. Therefore, this study compared the patient outcomes between Dutch anticoagulant clinic (AC) regions taking the variation in chronic care management into account in order to explore whether chronic care management elements could improve the quality of oral anticoagulant therapy. METHODS: Two data sources were combined. The first source was a questionnaire that was send to all ACs in the Netherlands in 2008 (response = 100%) to identify the application of chronic care management elements in the AC regions. The Chronic Care Model of Wagner was used to make the concept of chronic care management operational. The second source was the report of the Dutch National Network of ACs which contains patient outcomes of the ACs. RESULTS: Patient outcomes achieved by the ACs were good, yet differences existed; for instance the percentage of patients in the appropriate therapeutic ranges varied from 67 to 87% between AC regions. Moreover, differences existed in the use of chronic care management elements of the chronic care model, for example 12% of the ACs had multidisciplinary meetings and 58% of the ACs had formal agreements with at least one hospital within their region. Patient outcomes were significantly associated with patient orientation and the number of specialized nurses versus doctors (p-values < 0.05). Furthermore, the overall extent to which chronic care management elements were applied was positively associated with patient outcomes (p-values < 0.05). CONCLUSIONS: Substantial differences in the patient outcomes as well as chronic care management of oral anticoagulant therapy existed. Since our results showed a positive association between overall application of chronic care management and patient outcomes, additional research is needed to fully understand the working mechanism of chronic care management

Patient safety in Dutch primary care: a study protocol

<p>Abstract</p> <p>Background</p> <p>Insight into the frequency and seriousness of potentially unsafe situations may be the first step towards improving patient safety. Most patient safety attention has been paid to patient safety in hospitals. However, in many countries, patients receive most of their healthcare in primary care settings. There is little concrete information about patient safety in primary care in the Netherlands. The overall aim of this study was to provide insight into the current patient safety issues in Dutch general practices, out-of-hours primary care centres, general dental practices, midwifery practices, and allied healthcare practices. The objectives of this study are: to determine the frequency, type, impact, and causes of incidents found in the records of primary care patients; to determine the type, impact, and causes of incidents reported by Dutch healthcare professionals; and to provide insight into patient safety management in primary care practices.</p> <p>Design and methods</p> <p>The study consists of three parts: a retrospective patient record study of 1,000 records per practice type was conducted to determine the frequency, type, impact, and causes of incidents found in the records of primary care patients (objective one); a prospective component concerns an incident-reporting study in each of the participating practices, during two successive weeks, to determine the type, impact, and causes of incidents reported by Dutch healthcare professionals (objective two); to provide insight into patient safety management in Dutch primary care practices (objective three), we surveyed organizational and cultural items relating to patient safety. We analysed the incidents found in the retrospective patient record study and the prospective incident-reporting study by type of incident, causes (Eindhoven Classification Model), actual harm (severity-of-outcome domain of the International Taxonomy of Medical Errors in Primary Care), and probability of severe harm or death.</p> <p>Discussion</p> <p>To estimate the frequency of incidents was difficult. Much depended on the accuracy of the patient records and the professionals' consensus about which types of adverse events have to be recognized as incidents.</p

Adverse Drug Reactions in Hospital In-Patients: A Prospective Analysis of 3695 Patient-Episodes

Adverse drug reactions (ADRs) are a major cause of hospital admissions, but recent data on the incidence and clinical characteristics of ADRs which occur following hospital admission, are lacking. Patients admitted to twelve wards over a six-month period in 2005 were assessed for ADRs throughout their admission. Suspected ADRs were recorded and analysed for causality, severity and avoidability and whether they increased the length of stay. Multivariable analysis was undertaken to identify the risk factors for ADRs. The 5% significance level was used when assessing factors for inclusion in multivariable models. Out of the 3695 patient episodes assessed for ADRs, 545 (14.7%, 95% CI 13.6–15.9%) experienced one or more ADRs. Half of ADRs were definitely or possibly avoidable. The patients experiencing ADRs were more likely to be older, female, taking a larger number of medicines, and had a longer length of stay than those without ADRs. However, the only significant predictor of ADRs, from the multivariable analysis of a representative sample of patients, was the number of medicines taken by the patient with each additional medication multiplying the hazard of an ADR episode by 1.14 (95% CI 1.09, 1.20). ADRs directly increased length of stay in 147 (26.8%) patients. The drugs most frequently associated with ADRs were diuretics, opioid analgesics, and anticoagulants. In conclusion, approximately one in seven hospital in-patients experience an ADR, which is a significant cause of morbidity, increasing the length of stay of patients by an average of 0.25 days/patient admission episode. The overall burden of ADRs on hospitals is high, and effective intervention strategies are urgently needed to reduce this burden

The potential interaction between oral anticoagulants and acetaminophen in everyday practice

Objective: The drug-drug interaction between oral anticoagulants (especially warfarin) and acetaminophen has been described, but evidence is conflicting and evidence for a similar interaction between acenocoumarol or phenprocoumon and acetaminophen is limited. Therefore, a study was performed to determine the influence of acetaminophen on oral anticoagulation with acenocoumarol or phenprocoumon in everyday practice. Method: Included were patients from two Dutch anticoagulant clinics who had used oral anticoagulants for at least three months and who started with acetaminophen (case group) or benzodiazepines (control group). Results: Fifty-four patients were included who had a first prescription of acetaminophen in their pharmacy record (during oral anticoagulant use) and twenty patients with a first prescription of a benzodiazepine (during oral anticoagulant use). The INR (International Normalized Ratio) difference before and after acetaminophen use was not statistically significant between the two groups and showed no dose dependency. Conclusion: These data do not demonstrate that acetaminophen, in the dosages used in everyday practice, has a clinically relevant influence on the INR in patients using acenocoumarol or phenprocoumon

Initiation of oral anticoagulant therapy in orthopedic and surgical patients:an algorithm compared with routine dosing

Oral anticoagulant therapy is initiated in most hospitals in The Netherlands by clinicians who routinely dose oral anticoagulants (without using an algorithm). This may explain the low proportion of patients leaving the hospital stabilized. To test this hypothesis this study compared the dosing of acenocoumarol in orthopedic and surgical patients using an algorithm with routine dosing. Because of the routine administration of low molecular weight heparin for at least the first 5 days of acenocoumarol therapy, the study focused on supra-therapeutic INR-values during this period. The study included 103 patients and was performed on orthopedic surgery and general surgery wards of a Dutch hospital over 5 months. The patients received acenocoumarol as an oral anticoagulant to prevent venous thromboembolism after general of orthopedic surgery. Patients were randomized into a group routinely dosed by physicians (n = 54) and a group dosed using a dosing algorithm (n = 49). A patient was defined as stable if he had two consecutive INR values within the range of 2-3 during hospitalization with the first (of the two consecutive INR values within range) having been measured on day 5 or later. The groups did not differ significantly in proportion of patients stabilized, time to stabilization, or length of hospitalization. In the first period (days 1-5) the routine dosing group had significantly more INR values above therapeutic range than the algorithm group, while the algorithm group had more INR values below the therapeutic range. There were two bleeding episodes in the routine dosing group and none in the algorithm group. Despite the lack of differences in stabilization between the two groups, this study suggests an advantage of dosing acenocoumarol using an algorithm in a study population consisting of prophylactically treated, mostly elderly orthopedic patients. The algorithm provides a safe dosing schedule for elderly postoperative patients who use low molecular weight heparin and NSAIDs concomitantly and are thus at high risk for bleeding complications

[Puto Poseidoni kolmhargiga]

http://tartu.ester.ee/record=b2156638~S1*es

Characteristics of potential drug-related problems among oncology patients

<p>Background Oncology patients are more at risk for drug related problems because of treatment with (combinations of) anticancer drugs, as they have a higher risk for organ failure or altered metabolism with progression of their disease. Objective The aim of this study was to characterize and to evaluate the frequency of potential drug related problems (pDRPs) among oncology patients. Setting Outpatient- and day-care centres for Internal and Pulmonary Medicine at the Deventer Hospital, Deventer, The Netherlands. Method A prospective, descriptive, observational study was carried out from March 2010 to March 2011 at the Deventer Hospital, Deventer, The Netherlands. All patients older than 18 years receiving anticancer drugs prescribed by an internal medicineoncologist or pulmonologist-oncologist were included. Main outcome measure The primary outcome was the number and type of pDRPs according to Dutch guidelines. Results Among 546 patients with cancer, 952 pDRPs were identified, of which 474 were oncology-related. These were mainly drug interactions (IA) (246 IA in 157 patients) and potential contraindications (pCI) (201 pCI in 143 patients). Conclusion Most identified pDRPs in cancer patients were IAs and pCIs and involved corticosteroids. The most frequently occurring oncology-related IAs were classified as minor or moderate levels of severity.</p>