Using RE-AIM to Assess a Medication Safety Intervention for Generalizability and Potential for Translation to Clinical Practice. David Magid, MD, MPH
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1 Using RE-AIM to Assess a Medication Safety Intervention for Generalizability and Potential for Translation to Clinical Practice David Magid, MD, MPH
2 Medication Errors Common medical error! 19% of injuries in hospitalized patients were due to medication errors IOM priority area for transforming health care
3 KPCO Medication Safety Project Goals Improve the detection of medication prescribing errors in the ambulatory setting Develop new uses of this information to reduce errors and improve care
4 KPCO Pharmacy-based Interventions Designed in partnership with clinical and operational pharmacy leaders Supported by KPCO leadership Implemented with regular pharmacy staff
5 Pharmacy-based Intervention Objective To determine whether an automated tool that alerts pharmacists of potentially unsafe medication orders and prevents these medications from being dispensed is effective in reducing medication errors
6 Stages of Pharmaceutical Care Prescribing Dispensing Administering Monitoring
7 Drug-Drug Interaction Intervention Electronically screen prescriptions for errors Alert pharmacist of a potential error Prevent printing of prescription label Provide pharmacist with an intervention guide (decision support) Pharmacist resolves with prescriber
8 Pharmacy-based Intervention An Example Warn against dispensing drugs with known interactions when there is a good alternative! phenytoin and cimetidine
9 Intervention Guide Phenytoin and Cimetidine Confirm patient is taking both drugs Inform provider that the drug combination may increase phenytoin blood levels and thereby the risk of neurologic toxicity Recommend ranitidine or famotidine as alternatives which are less likely to interact significantly with phenytoin
10 Oh Dr. Magid, You ve done it again!!!
11 Critical Drug Interactions Macrolides carbamazepine digoxin theophylline cyclosporine Phenytoin cimetidine fluconazole Theophylline cimetidine ciprofloxacin
12 RE-AIM Outcome Measures Reach! Participation rate of KPCO members! Representativeness of participants Adoption! Participation rate of pharmacies and pharmacists! Representativeness of pharmacies and pharmacists Effectiveness! Medication Dispensing Errors
13 Evaluation of Effectiveness Critical-Drug Interactions Before-After Study Design Compare occurrence of co-dispensing of interacting drugs in the pre (before) and post (after) intervention periods
14 Critical Drug Interactions Number Before Intervention Time After
15 Statistical Analysis Time Series Model Poisson Distribution! outcome - number of occurrences of co-prescribing! predictor - before versus after intervention periods Adjusted for total patients and number of prescriptions of the interacting drugs
16 RE-AIM Outcome Measures Implementation! Validity of Alerts! System Reliability! Census Note Documentation! Adherence to Recommendations Maintenance! Sustainability of intervention for 6 months after study completion
17 RESULTS
18 REACH 97% of the 350,000 KPCO Health Plan members Participants were representative of the Health Plan as a whole
19 ADOPTION All 19 pharmacies adopted the program All 240 dispensing pharmacists participated in the program
20 30 EFFECTIVENESS Critical Drug Interactions Occurrences Months Before After P< 0.01
21 Occurrences Critical Drug Interactions Macrolides Theophylline Phenytoin Interaction Class Before After
22 IMPLEMENTATION Validity of alerts > 95% System reliability > 95% Census note documentation > 85% Adherence to recommendations > 75%
23 MAINTENANCE Critical Drug Interactions 30 Occurrences Months Before After P< 0.01
24 Limitations Single Intervention Before-After Study Design Single Health Plan
25 Summary Automated Pharmacy Tool Reduced co-dispensing of interacting drugs
26 Intervention Demonstrated Good Potential for Translation Reached almost all members Adopted in all pharmacies by all pharmacists and physicians Implemented reliably Improvements maintained for a 6 month follow-up period
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