Hayward Kelly L, Valery Patricia C, Patel Preya J, Li Catherine, Horsfall Leigh U, Wright Penny L, Tallis Caroline J, Stuart Katherine A, David Michael, Irvine Katharine M, Cottrell Neil, Martin Jennifer H, Powell Elizabeth E
Centre for Liver Disease Research, Faculty of Medicine, Translational Research Institute, The University of Queensland, 37 Kent Street, Woolloongabba, Brisbane, QLD 4102, Australia.
Pharmacy Department, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, QLD 4102, Australia.
Pharmaceuticals (Basel). 2021 Nov 23;14(12):1207. doi: 10.3390/ph14121207.
Discrepancies between the medicines consumed by patients and those documented in the medical record can affect medication safety. We aimed to characterize medication discrepancies and medication regimen complexity over time in a cohort of outpatients with decompensated cirrhosis, and evaluate the impact of pharmacist-led intervention on discrepancies and patient outcomes. In a randomized-controlled trial ( = 57 intervention and = 57 usual care participants), medication reconciliation and patient-oriented education delivered over a six-month period was associated with a 45% reduction in the incidence rate of 'high' risk discrepancies (IRR = 0.55, 95%CI = 0.31-0.96) compared to usual care. For each additional 'high' risk discrepancy at baseline, the odds of having ≥ 1 unplanned medication-related admission during a 12-month follow-up period increased by 25% (adj-OR = 1.25, 95%CI = 0.97-1.63) independently of the Child-Pugh score and a history of variceal bleeding. Among participants with complete follow-up, intervention patients were 3-fold less likely to have an unplanned medication-related admission (adj-OR = 0.27, 95%CI = 0.07-0.97) compared to usual care. There was no association between medication discrepancies and mortality. Medication regimen complexity, frequent changes to the regimen and hepatic encephalopathy were associated with discrepancies. Medication reconciliation may improve medication safety by facilitating communication between patients and clinicians about 'current' therapies and identifying potentially inappropriate medicines that may lead to harm.
患者实际服用药物与病历记录之间的差异会影响用药安全。我们旨在描述失代偿期肝硬化门诊患者队列中用药差异和用药方案复杂性随时间的变化情况，并评估药剂师主导的干预措施对差异和患者结局的影响。在一项随机对照试验中（干预组 = 57例，常规治疗组 = 57例参与者），与常规治疗相比，在六个月期间进行的用药核对和以患者为导向的教育使“高”风险差异的发生率降低了45%（风险比 = 0.55，95%置信区间 = 0.31 - 0.96）。在基线时每增加一个“高”风险差异，在12个月随访期内发生≥1次计划外药物相关住院的几率独立于Child-Pugh评分和静脉曲张出血史增加25%（校正比值比 = 1.25，95%置信区间 = 0.97 - 1.63）。在完成随访的参与者中，与常规治疗相比，干预组患者发生计划外药物相关住院的可能性降低了3倍（校正比值比 = 0.27，95%置信区间 = 0.07 - 0.97）。用药差异与死亡率之间没有关联。用药方案复杂性、方案频繁变更和肝性脑病与差异有关。用药核对可通过促进患者与临床医生之间关于“当前”治疗的沟通以及识别可能导致伤害的潜在不适当药物来提高用药安全。
