Recent Research

Medication safety assessment, international gout guidelines, statins and intracerebral hemorrhage, and more.

Medication safety assessment shows progress, challenges

Hospitals have increased medication safety in the past decade, but further improvement is still necessary, a recent study found.

The Institute for Safe Medication Practices (IMSP) Medication Safety Self-Assessment was first launched in 2000 in partnership with the American Hospital Association and the Health Research Educational Trust. The goal of the assessment was to help hospitals assess medication safety practices and identify areas of improvement. Hospitals submitted their findings anonymously and confidentially to ISMP for analysis. The assessment was repeated in 2004 and again in 2011. Researchers from the partnership organizations compared findings from the 2011 assessment with findings from 2000 and identified key areas of greatest improvement and greatest need. The results of this comparison were published in the February Joint Commission Journal on Quality and Patient Safety.

A total of 1,310 hospitals submitted data from the 2011 assessment to ISMP, representing a response rate of 23% of all hospitals registered in the U.S. (n=5,786). The response rate in the 2000 study was also 23% (1,435 of 6,180 hospitals). Hospitals that submitted data in both 2000 and 2011 were more likely than those that did not to be larger and nonprofit, to have a physician training program, to be part of a larger health system and to provide more medical and surgical services. Overall scores on the assessment improved significantly from 2000 to 2011, from a mean of 56% to a mean of 71% (P<0.001).

The researchers found that hospitals in the 2011 assessment made the greatest improvements in communication of drug orders and other drug information, patient education, and quality processes and risk management. The key elements with the lowest scores in 2011 were management of patient information (e.g., linking inpatient and outpatient computer order entry systems), staff competency and education (e.g., orientation and education and safety education) and drug information (e.g., medication reconciliation). The researchers analyzed factors affecting 2011 scores and found that hospitals with a strong safety culture were more likely to have better medication safety and that safety measures were more likely to be implemented if they were inexpensive and uncomplicated. In addition, hospitals that employed a medication safety officer were more likely to have higher scores on all key elements in the assessment that those that did not.

The authors acknowledged that their study relied on self-reported data and that the study sample may not have been representative of all U.S. hospitals, among other limitations. However, based on the assessment results, they compiled a list of recommended national priorities for improvement in medication safety in the areas of technology enhancements (e.g., improving order entry systems), clinical improvement (e.g., improving care of patients receiving opioids), expanded pharmacy role (e.g., expanded outpatient services), increased patient education, increased staff education (e.g., teaching risk identification and prevention strategies), and management of risk and safety (e.g., measuring medication safety).

“Our study demonstrates that medication safety improvements have been substantial in the last decade, lending support to a more optimistic viewpoint that patients are clearly safer today than a decade ago,” the researchers wrote. “Yet, our task is far from completed. Although we should take pride in the progress we have made thus far, much still remains to be done.”

Internationally developed gout guidelines seek to improve clinical practice

Ten recommendations for the diagnosis and management of patients with gout have been developed by a multinational group with the aim of improving daily clinical practice.

The 10 recommendations appeared in the February Annals of the Rheumatic Diseases:

  1. 1. Identification of monosodium urate crystals should be performed to definitively diagnose gout; if not possible, a diagnosis of gout can be supported by classical clinical features (such as podagra, tophi, rapid response to colchicine) and/or characteristic imaging findings.
  2. 2. In patients with gout, measure renal function and assess cardiovascular risk factors.
  3. 3. Treat acute gout with low-dose colchicine (up to 2 mg daily), NSAIDs and/or intra-articular, oral or intramuscular glucocorticoids.
  4. 4. Patients should reduce excess body weight, exercise, stop smoking, and avoid excess alcohol and sugar-sweetened drinks.
  5. 5. Allopurinol should be the first-line urate-lowering therapy, followed by uricosurics or febuxostat. Uricase as monotherapy should only be considered in patients with severe gout after all other therapies have failed or are contraindicated. Urate-lowering therapy, except uricase, should be started as a low dose and then increased to achieve a target serum urate level.
  6. 6. Patient education on flare is essential and prophylaxis, of colchicine up to 1.2 mg daily, should be considered. NSAIDs or low-dose glucocorticoids can be used if colchicine is contraindicated or not tolerated.
  7. 7. Patients with mild-moderate renal impairment can consider allopurinol, with close monitoring for adverse events, starting at a daily dose of 50 to 100 mg that can be titrated up to achieve a target serum for uric acid. Febuxostat and benzbromarone can be used as alternative drugs without dose adjustment.
  8. 8. Treat to target serum urate level below 0.36 mmol/L (6 mg/dL) and the eventual absence of gout attacks and resolution of tophi. Monitor serum urate level, frequency of gout attacks and tophi size.
  9. 9. Tophi should be treated medically by achieving a sustained reduction in serum uric acid, preferably below 0.30 mmol/L (5 mg/dL). Surgery is only indicated in cases such as nerve compression, mechanical impingement or infection.
  10. 10. Pharmacological treatment of asymptomatic hyperuricemia is not recommended.

“Even though gout is a potentially curable disease, its management is far from optimal in both primary care and rheumatology clinics,” the authors wrote. “The quality of care provided to gout patients needs to improve.”

The higher the statin dose, the more likely an intracerebral hemorrhage after IV thrombolysis

Patients taking higher doses of statins are more likely to have a symptomatic intracerebral hemorrhage after IV thrombolysis for ischemic stroke than those taking lower doses, a study found.

In a retrospective study, researchers combined data on 1,446 stroke patients from 2 European IV thrombolysis (IVT) registries. To compare different types of statins, they stratified groups based on the attainable lowering of LDL cholesterol associated with each dose of a given statin. “Low dose” meant attainable reduction <35%, “medium dose” meant 35% to 44% attainable reduction, and “high dose” meant ≤45% attainable reduction. Main outcomes were occurrence of symptomatic intracerebral hemorrhage (sICH) and functional outcome at 3 months, defined as either a favorable outcome (modified Rankin Scale score of 0-2) or an unfavorable one (score >2).

Fifty-three (3.7%) patients had sICH, with occurrence differing significantly in patients by statin dose before IVT (P<0.01). Frequency of sICH was 1.7% for those taking low-dose statins, 6.0% for those taking medium-dose statins, and 12.7% for those taking high-dose statins (P<0.01 for dose-response trend). Compared with non-statin users, patients with medium- and high-dose statin use had about 2.5 times and 5 times higher odds ratios, respectively. Results were published in the February Stroke.

Functional outcome data at 3 months were available for 1,425 patients; 52.4% of these had favorable outcomes. Overall, patients who used statins prior to their stroke were more likely to have a favorable outcome than those who didn't (58% vs. 51%; odds ratio, 1.80; P=0.03), and this association didn't differ across dose groups. There was no significant association between statin type and outcome. In a subgroup of patients who didn't have sICH, favorable outcomes were 56.8% for low-dose, 62.9% for medium-dose, and 61.8% for high-dose statin users, compared to 52.2% for patients who didn't use statins.

While the risk of sICH in stroke patients appears to rise with higher statin doses, patients who use statins still have better functional outcomes than non-statin users, the authors concluded. The association was similar across doses “although it was attenuated and not significant in the high-dose group,” they noted. It's possible that the baseline traits of statin users may contribute to prestroke morbidity and thus lead to a greater chance of having sICH after IVT, with the traits most prominent in high-dose statin users, they wrote. Also, since pre-existing statin treatment has been associated with greater reperfusion after acute stroke, the authors suggested this mechanism may increase the risk of sICH, but may also result in improved clinical outcome.

Adverse event rates decline for heart attack, heart failure inpatients between 2005 and 2011

Adverse events for heart attack and heart failure patients declined from 2005-2011, but didn't decline for pneumonia patients or those recovering from surgery, a recent analysis found.

Researchers used Medicare data abstracted from patient records to compare the rate of 21 adverse events that occurred in 2005-2006 with events in 2010-2011. The 61,523 patients in the analysis were hospitalized for acute myocardial infarction (19%), congestive heart failure (25%), pneumonia (30%) or conditions necessitating surgery (27%). The adverse events included drug reactions, hospital-acquired pressure ulcers, falls and several health care-associated infections. The analysis was funded by the Agency for Healthcare Research and Quality (AHRQ) and published in the Jan. 23 New England Journal of Medicine.

Among patients with acute myocardial infarction (AMI), the adverse event rate fell from 5% to 3.7%, the proportion of patients with 1 or more adverse events fell from 26% to 19.4%, and the number of adverse events per 1,000 hospitalizations fell from 402 to 262. In patients with congestive heart failure, the adverse event rate fell from 3.7% to 2.7%, the proportion of patients with 1 or more adverse events fell from 18% to 14%, and the number of events per 1,000 hospitalizations fell from 235 to 167.

Adverse event rates and numbers didn't change significantly for patients with pneumonia or conditions requiring surgery. When all 4 conditions were combined, the adjusted yearly decline in adverse events per 1,000 hospitalizations was 4.7%. Among patients in each of the four groups, having one or more adverse events was correlated with a longer length of stay and an increased chance of dying in the hospital, although this association “may simply reflect the greater opportunity for adverse events to develop during a longer stay,” the authors wrote.

The lack of reductions in adverse events across the board is “disappointing,” the authors wrote, though they added that the data suggest “national efforts focused on patient safety have made some inroads.”

These summaries come from ACP HospitalistWeekly an e-newsletter provided every Wednesday by ACP Hospitalist. To receive it, call Customer Service at 800-543-1546, ext. 2600, or direct at 215-351-2600 (M-F, 9 a.m. to 5 p.m. EST); send an email; or subscribe online.