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Large-Scale, Community-Based Trial of a Personalized Drug-Related Problem Rectification System

A controlled trial of a system for rectifying and preventing drug-related problems was conducted to evaluate improvement in the efficiency of resource utilization.

Published Online: May 10,2017
Natan R. Kahan, PhD, RPh, MHA; Dan-Andrei Waitman, MD, MPH; Matityahu Berkovitch, MD; Shimona Yosselson Superstine, PharmD, MPH; Jacob Glazer, PhD; Abraham Weizman, MD; and Roni Shiloh, MD
Objectives: The risk of clinically significant drug-related problems is a major concern, particularly among elderly, polypharmacy-treated patients. Previous efforts to develop computerized alert systems have shown limited effectiveness. The purpose of this study was to evaluate the efficacy of a novel technology, the Drug-Drug Interaction Plus (DDI+) decision support system, used in a real-world ambulatory health maintenance organization (HMO) setting and developed to overcome the limitations of currently available programs.
Study Design: Controlled trial.
Methods: We conducted a controlled trial of the DDI+ system in Leumit Health Services (LHS), an HMO in Israel that provides coverage to approximately 700,000 members with approximately 2000 physicians nationally. All LHS physicians were geographically allocated by region to a study or control arm. Physician access rates, alert resolution rates, and resource utilization of their patients were evaluated and compared between the intervention and control arms.
Results: There were 5.6% (P = .001) fewer mean episodes of hospitalization, 1.5% (P = .01) fewer mean drugs dispensed, and 2.1% (P = .055) fewer mean episodes of imaging in
the intervention population versus controls. Drug-related problems that were re-encountered were often rectified without
re-accessing the system. 
Conclusions: Comparing the acceptance by physicians of the DDI+ system to reports of acceptance of similar systems, DDI+ was observed to be better accepted. This will possibly initiate improvements in resource utilization patterns. We surmise that improved physician willingness to access the system can be attributed to the novel graphic presentation, specificity, and integration of DDI+ into the work flow of routine clinical practice.

Am J Pharm Benefits. 2017;9(2):-0

Drug prescribing is among the most powerful and ubiquitous tools employed by physicians for treating patients. Over the decades, thousands of safe and effective drugs have been added to the armamentarium at physicians’ disposal, empowering them to treat most of the acute and chronic conditions encountered in the community setting. 
These developments, however, while generally positive, have not emerged without adding concomitant risks of harm to the patient. Administration of multiple drugs, and of herbal preparations, vitamins, and food supplements, directly increases the risk of avoidable medication error–induced sequelae, which include adverse effects, pharmacokinetic interactions, decreased efficacy, morbidity, mortality, and unnecessary resource use.
Furthermore, the degree of risk is exacerbated when multiple physicians practicing various subspecialties independently prescribe medications for a patient in the absence of a case manager whose job would be to actively coordinate a cohesive care plan. 
The risk of clinically significant drug-related problems (CSDRPs) is of major concern, particularly among elderly, polypharmacy-treated patients in whom the incidence of major iatrogenic events is estimated at more than 25%.1-5 Overall, CSDRPs are responsible for approximately 2% to 5% of all hospital admissions.6,7 Unfortunately, the growing use of electronic health record (EHR)-based modules for addressing CSDRPs has not dramatically changed the occurrences of such outcomes, given that more than 90% of physicians override or do not use these modules.8-11

Accordingly, the development and implementation of intervention strategies, such as the requirement for pharmacists to assess drug-related problems prior to dispensing and improved uptake of existing technologies to prevent CSDRPs, is a well-established practice in managed care systems. 
Although significant progress has been made in developing new technologies, the applications currently available provide suboptimal prevention of CSDRPs. Their many shortcomings include lack of systematic assessment of pharmacokinetic/pharmacogenetic data,12 long and difficult-to-comprehend textual outputs,13-15 lack of suggestions for alternative drug options, an inability to evaluate drug combinations involving more than 2 concomitantly prescribed drugs, and limitation of use to the prescribing phase of the visit.
Additionally, because these systems are seldom evaluated in robust controlled trials, few data are generally available to clinicians and medical managers to evaluate the potential value of these technologies in a real-life clinical setting.