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Safety Alerts as Drivers for the Pharmaceutical Opinion Program
A pilot study to reduce potential hospitalizations due to preventable drug-drug interactions
Drug-drug interactions (DDIs) represent a potentially serious problem that can result in adverse drug events (ADEs). Pharmacists are uniquely positioned to prevent ADEs by intervening in DDIs. Unfortunately, tertiary drug information resources may be limited in their ability to capture novel, up-to-date, and evidence-based DDIs associated with an increased risk of harm; additionally, these drug information resources often contribute to alert fatigue and desensitization among practising pharmacists due to an overload of DDI alerts, many of which may be clinically insignificant and not rooted in robust evidence.
Clinically significant drug interactions have been documented over the years, and studies demonstrate that DDIs can contribute to hospitalizations. Table 1 outlines the risk of adverse events for patients concurrently taking a certain set of interacting medications (i.e. the adjusted odds ratio and estimated risk of hospitalization within one to two weeks of exposure to a specific antibiotic while taking a specific chronic medication).
Clinically significant outcomes from this pilot study, such as hospitalizations, can therefore be derived or extrapolated based on this pharmacoepidemiologic data (Table 1). The DDIs that were selected for this study were based on pharmacoepidemiologic data obtained through the Ontario Drug Benefits (ODB) claims database. Each DDI pair was associated with evidence from primary literature to substantiate their association with hospitalizations in the elderly. The implications of the data and their findings are two-fold:
- There is sufficient external validity of the study to real-life practice (i.e. Ontarians over the age of 65 years represent a high proportion of medication users)
- The knowledge of clinically significant evidence-based DDIs in the elderly provides eligibility and an opportunity to utilize the Pharmaceutical Opinion Program (POP) in Ontario to make clinical interventions (http://www.health.gov.on.ca/en/pro/programs/drugs/pharmaopinion/).
Table 2 outlines information available regarding these DDIs in tertiary literature and drug information resources that many pharmacies depend on for point-of-care clinical decision-making.
Between Sept 2013 to Dec 2014, the Institute for Safe Medication Practices Canada (ISMP Canada) conducted a research project titled, “Safety Alerts as Drivers for the Pharmaceutical Opinion Program: A pilot study to reduce potential hospitalizations due to preventable drug-drug interactions”. This study integrated a subset of evidence-based DDIs involving an antibiotic and a chronic medication into pharmacy practice to raise awareness about these clinically significant DDIs.
Notably, prior to the initiation of the research project, the targeted DDIs in Table 1 were not consistently flagged in tertiary drug information references (i.e. within clinical decision support systems built into community pharmacy dispensing software systems) that are commonly relied upon by community pharmacists in Ontario, and across Canada (Table 2). This knowledge and systems gap formed the basis of an ISMP Canada Safety Alert, which can be accessed here.
This safety alert was then disseminated to pharmacists and served as an education and continuing professional development opportunity to pharmacists to supplement those tertiary resources.
The information from the safety alert was translated into practice through this pilot study, which ultimately served as a catalyst for change and encouraged pharmacists to be more proactive in identifying opportunities for clinical interventions to optimize patient care. This research project by ISMP Canada offered an innovative strategy to the pharmacy profession through the integration of:
- Medication safety (via the ISMP Canada Safety Alert to educate pharmacists and increase their awareness of DDIs with an increased risk of hospitalization);
- Cognitive services (via clinical interventions based on the identification and prevention of DDIs); and
- Business opportunity (through recognition and reimbursement of cognitive services via the POP).
The above research project wrapped up in December 2014, and has been completed. To learn more about the research project and the findings, we welcome interested individuals to visit the following webpages:
Drug-Drug Interactions - Safety Alerts as Drivers for Pharmaceutical Opinion Program
A Pilot Study to Reduce Potential Hospitalizations Due to Preventable Drug-Drug Interactions
In addition, one of the outputs of this study was the development of a Drug-Drug Interactions Treatment Algorithm Handbook; this handbook serves as a guide that outlines alternative antibiotic therapies to assist pharmacists when one or more of the problematic DDI pairs that were evaluated in this study is identified in practice; it also outlines algorithms to quickly formulate recommendations for prescribers.
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About the Institute for Safe Medication Practices Canada (ISMP Canada):
The Institute for Safe Medication Practices Canada is an independent, national, not-for-profit organization committed to the advancement of medication safety in all healthcare settings. ISMP Canada works collaboratively with the healthcare community, regulatory agencies and policy makers, provincial, national and international patient safety organizations, the pharmaceutical industry and the public to promote safe medication practices. ISMP Canada's mandate includes analyzing medication incidents, making recommendations for the prevention of harmful medication incidents, and facilitating quality improvement initiatives. Information about ISMP Canada's work with Canadians to prevent medication incidents is available at: www.ismp-canada.org; and also at www.SafeMedicationUse.ca, a website designed for consumers.
Lindsay Yoo, BSc, BScPhm, RPh, CDE, CGP, PharmD
Medication Safety Analyst
Lindsay has a diverse range of experiences as a pharmacist, with experience in direct patient care in both ambulatory and outpatient pharmacy settings, research, academia, and knowledge dissemination. She currently practices as a front-line pharmacist at an independent community pharmacy and as a medication safety analyst at ISMP Canada. Since joining ISMP Canada in 2009, Lindsay has been involved in a variety of medication safety initiatives related to the analysis of medication incidents, research projects, as well as medication safety initiatives and continuous quality assurance in community pharmacy. In addition to medication safety, Lindsay has a special interest in chronic disease management such as diabetes and pharmacotherapy in the elderly.
- Guest Post, adverse drug reaction