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Summary adherence estimates do not portray the true incongruity between drug intake, nurse documentation and physicians' orders.

Cohen-Glickman I, Haviv YS, Cohen MJ - BMC Nephrol (2014)

Bottom Line: Drug practices were abstracted from their records and compared to electronic pharmacy data.We found a high rate of physician order turbulence for active vitamin D and calcium.Summary estimates do not divulge the extent of these disparities.

View Article: PubMed Central - PubMed

Affiliation: Dialysis unit, Nephrology and Hypertension services, Hadassah-Hebrew University Medical Center, POB 12000, En Kerem campus, Jerusalem 91120, Israel. yhaviv@hadassah.org.il.

ABSTRACT

Background: Hemodialysis patients (HD) need to adhere to a complex medication regimen. Because their daily pill burden is one of the highest reported, poor compliance is a major cause of therapeutic failure. The primary aim of this study was to define patterns of medication prescription, intake and documentation among HD patients.

Methods: HD patients treated between 2007 and 2009 and assigned to the largest health service provider in Israel were randomly selected. Drug practices were abstracted from their records and compared to electronic pharmacy data. The discrepancy between drug intake reports and the actual purchase was measured to estimate adherence. Drug purchase, intake report and physician order were plotted in complementing diagrams to appreciate consistency and discrepancy patterns.

Results: The study included full analysis of 75 patients. The mean overall drug adherence was 56.7% (95% CI 53.6-59.9%), varying among drug families and over time. Often, there was a systematic disengagement between the nurses' documentation and the actual patient purchase. Specifically, we observed either different quantities of medication use, improper documentation of a non-purchased drug, drug purchase without nurse documentation and futile physician attempts to modify prescriptions of unpurchased medication. We found a high rate of physician order turbulence for active vitamin D and calcium.

Conclusions: Drug prescription, documentation and adherence are incongruent and their mismatches are diverse. Summary estimates do not divulge the extent of these disparities. These system-wide communication failures compromise patient care. Strategies to promote system reconciliation and reasonable medication prescription are in need.

Show MeSH
Differences between nurse reports and actual drug purchase. Error bars indicate 95% confidence interval. A positive value indicates the nurses documented medication use than actually purchased, A negative value indicate more drugs purchased than reported by nurses. *Calcium carbonate and alfacalcidol.
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Fig3: Differences between nurse reports and actual drug purchase. Error bars indicate 95% confidence interval. A positive value indicates the nurses documented medication use than actually purchased, A negative value indicate more drugs purchased than reported by nurses. *Calcium carbonate and alfacalcidol.

Mentions: During a follow up period of 25 months, the average (SD) time span of drug purchase was 11.2 (7.8) months and the nurse documented patient intake for each drug was on average (SD) 14.5 (8.0) months (Table 2). Thus, for most medications, documentation by the nurse exceeded patient purchases (Figure 3). This difference was primarily evident for alfacalcidol and calcium carbonate but could also be observed for aspirin, statins and beta-blockers. For furosemide, calcium channel blockers and antiarrhythmics, nitrates and doxazosin, the rates of patient purchase and nurse reporting were similar. The mean patient-nurse concordant months (months in which the nurse reported exactly what the patient purchased) was 5.7 months (95% CI 5.2-6.4), which comprised 50.9% of the purchase months and 39.3% of the reported intake months were matched. After excluding calcium carbonate and alfacalcidol, the mean number of concordant months was 7.1 (95% CI 6.4-7.8). For example, patient # 2 did not purchase beta blockers at all throughout the entire follow-up period, while it was “documented” by the nurse (Additional file 1: Figures S2-A to S2-D); patient # 54 purchased a higher dose of statins than documented by the nurse for most of our study period (Additional file 1: Figure S3-D). Thus, nurses’ reports and actual patient purchase were often incompatible, sometimes over long periods.Figure 3


Summary adherence estimates do not portray the true incongruity between drug intake, nurse documentation and physicians' orders.

Cohen-Glickman I, Haviv YS, Cohen MJ - BMC Nephrol (2014)

Differences between nurse reports and actual drug purchase. Error bars indicate 95% confidence interval. A positive value indicates the nurses documented medication use than actually purchased, A negative value indicate more drugs purchased than reported by nurses. *Calcium carbonate and alfacalcidol.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4230519&req=5

Fig3: Differences between nurse reports and actual drug purchase. Error bars indicate 95% confidence interval. A positive value indicates the nurses documented medication use than actually purchased, A negative value indicate more drugs purchased than reported by nurses. *Calcium carbonate and alfacalcidol.
Mentions: During a follow up period of 25 months, the average (SD) time span of drug purchase was 11.2 (7.8) months and the nurse documented patient intake for each drug was on average (SD) 14.5 (8.0) months (Table 2). Thus, for most medications, documentation by the nurse exceeded patient purchases (Figure 3). This difference was primarily evident for alfacalcidol and calcium carbonate but could also be observed for aspirin, statins and beta-blockers. For furosemide, calcium channel blockers and antiarrhythmics, nitrates and doxazosin, the rates of patient purchase and nurse reporting were similar. The mean patient-nurse concordant months (months in which the nurse reported exactly what the patient purchased) was 5.7 months (95% CI 5.2-6.4), which comprised 50.9% of the purchase months and 39.3% of the reported intake months were matched. After excluding calcium carbonate and alfacalcidol, the mean number of concordant months was 7.1 (95% CI 6.4-7.8). For example, patient # 2 did not purchase beta blockers at all throughout the entire follow-up period, while it was “documented” by the nurse (Additional file 1: Figures S2-A to S2-D); patient # 54 purchased a higher dose of statins than documented by the nurse for most of our study period (Additional file 1: Figure S3-D). Thus, nurses’ reports and actual patient purchase were often incompatible, sometimes over long periods.Figure 3

Bottom Line: Drug practices were abstracted from their records and compared to electronic pharmacy data.We found a high rate of physician order turbulence for active vitamin D and calcium.Summary estimates do not divulge the extent of these disparities.

View Article: PubMed Central - PubMed

Affiliation: Dialysis unit, Nephrology and Hypertension services, Hadassah-Hebrew University Medical Center, POB 12000, En Kerem campus, Jerusalem 91120, Israel. yhaviv@hadassah.org.il.

ABSTRACT

Background: Hemodialysis patients (HD) need to adhere to a complex medication regimen. Because their daily pill burden is one of the highest reported, poor compliance is a major cause of therapeutic failure. The primary aim of this study was to define patterns of medication prescription, intake and documentation among HD patients.

Methods: HD patients treated between 2007 and 2009 and assigned to the largest health service provider in Israel were randomly selected. Drug practices were abstracted from their records and compared to electronic pharmacy data. The discrepancy between drug intake reports and the actual purchase was measured to estimate adherence. Drug purchase, intake report and physician order were plotted in complementing diagrams to appreciate consistency and discrepancy patterns.

Results: The study included full analysis of 75 patients. The mean overall drug adherence was 56.7% (95% CI 53.6-59.9%), varying among drug families and over time. Often, there was a systematic disengagement between the nurses' documentation and the actual patient purchase. Specifically, we observed either different quantities of medication use, improper documentation of a non-purchased drug, drug purchase without nurse documentation and futile physician attempts to modify prescriptions of unpurchased medication. We found a high rate of physician order turbulence for active vitamin D and calcium.

Conclusions: Drug prescription, documentation and adherence are incongruent and their mismatches are diverse. Summary estimates do not divulge the extent of these disparities. These system-wide communication failures compromise patient care. Strategies to promote system reconciliation and reasonable medication prescription are in need.

Show MeSH