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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
Doctors’ orders by drug type. The proportion of orders regarding each drug family, of all orders recorded in our study.
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Fig5: Doctors’ orders by drug type. The proportion of orders regarding each drug family, of all orders recorded in our study.

Mentions: We documented 632 nephrologists’ orders for changes in medication regimen (Table 3, Figure 5). Drug turbulence is a qualitative measure defined as a high rate of change in physician orders for a given drug. While calcium carbonate and Alfacalcidol together comprised 33.2% of the drugs in our study, 63.6% of physicians’ orders involved these two drugs, thereby positioning this class of mineral bone disease drugs as the major drug class occupying doctors’ time (Table 3). For comparison, aspirin, prescribed for long periods at a fixed dose, manifested a very low turbulence rate. However, to more carefully focus on turbulence associated with non-adherence, we hypothesized that of all possible physician orders (i.e. start a new drug or stop, reduce or increase dose, or switch to another drug within the same group), an order to increase drug dose would better reflect non-adherence. Alfacalcidol uniquely required more orders to increase drug dose than decrease dose (142/281 of alfacalcidol orders vs. 46/121 for calcium carbonate and 38/230 for all other medications, Table 3), thereby reflecting a very high level of non-adherence for this drug. This finding is further corroborated by the low (44.9%) calculated adherence rate for alfacalcidol (Figure 4) and by its low purchase rate relative to the nurses reports (Figure 3).Table 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)

Doctors’ orders by drug type. The proportion of orders regarding each drug family, of all orders recorded in our study.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Fig5: Doctors’ orders by drug type. The proportion of orders regarding each drug family, of all orders recorded in our study.
Mentions: We documented 632 nephrologists’ orders for changes in medication regimen (Table 3, Figure 5). Drug turbulence is a qualitative measure defined as a high rate of change in physician orders for a given drug. While calcium carbonate and Alfacalcidol together comprised 33.2% of the drugs in our study, 63.6% of physicians’ orders involved these two drugs, thereby positioning this class of mineral bone disease drugs as the major drug class occupying doctors’ time (Table 3). For comparison, aspirin, prescribed for long periods at a fixed dose, manifested a very low turbulence rate. However, to more carefully focus on turbulence associated with non-adherence, we hypothesized that of all possible physician orders (i.e. start a new drug or stop, reduce or increase dose, or switch to another drug within the same group), an order to increase drug dose would better reflect non-adherence. Alfacalcidol uniquely required more orders to increase drug dose than decrease dose (142/281 of alfacalcidol orders vs. 46/121 for calcium carbonate and 38/230 for all other medications, Table 3), thereby reflecting a very high level of non-adherence for this drug. This finding is further corroborated by the low (44.9%) calculated adherence rate for alfacalcidol (Figure 4) and by its low purchase rate relative to the nurses reports (Figure 3).Table 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