Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Reaching Out to Patients to Identify Adverse Drug Reactions and Nonadherence: Necessary but Not Sufficient

Reaching Out to Patients to Identify Adverse Drug Reactions and Nonadherence: Necessary but Not... Many millions of dollars have been spent on preventing adverse drug reactions at the point of prescribing. Automated systems help identify drug-drug interactions and excessive drug doses. Computerized alerts warn prescribers about potentially inappropriate drugs in older adults. However, only one-quarter of adverse drug reactions can be prevented by catching errors or problems at the time of prescribing.1 The remainder of adverse drug reactions are not the result of prescriber error but simply represent the known adverse effects of drugs. Some patients who take calcium channel blockers will develop peripheral edema. Some patients who take selective serotonin reuptake inhibitors will experience marked sexual dysfunction. For some drugs, risk factors have been identified that place a patient at higher risk of developing an adverse event. However, in most cases, we cannot predict who will develop an adverse drug reaction and who will not. We prescribe and hope for the best. Unfortunately, physicians do not do a good job of identifying and appropriately managing adverse reactions when they occur. Many patients do not tell their physicians when they are experiencing an adverse event, and we often do not ask.2,3 Moreover, physicians often misattribute the symptoms of an adverse drug reaction to an underlying disease, leading to diagnostic workups and a prescribing cascade of new medications rather than treating the problem at its source by discontinuing the offending drug.4 On a broader level, only a small fraction of adverse drug reactions are reported to the US Food and Drug Administration Adverse Event Reporting System (http://www.fda.gov/Safety/MedWatch/), hindering efforts for postmarketing surveillance of drug safety. These problems with recognizing and managing adverse drug reactions occur not because physicians are incompetent, but because we lack the systems that would allow us to systematically identify and address medication-related problems. The research described by Forster and Auger5 in this issue of JAMA Internal Medicine shows a promising approach to bridge this quality gap. Building on past studies that have shown the benefits of reaching out to patients to identify adverse drug reactions, the authors developed a hybrid system. Three days after a drug was newly prescribed, the system generated a phone call to the patient. Using interactive voice response technology, the system asked the patient 4 simple questions about problems they may be having with their drugs and whether they wanted to talk to a pharmacist. The process was repeated 2 weeks later. One-third of contacted patients needed a follow-up call from the pharmacist. Overall, the system identified slightly under half of the 22% of patients who experienced an adverse drug reaction. In addition, it identified one-third of the 6% of patients who were nonadherent to their medications. This is exciting and highly promising. It is also not ready for widespread implementation. While the system detected a number of medication-related problems, it missed more than half of adverse drug reactions and two-thirds of episodes of nonadherence in patients—and would likely have done worse outside the controlled environment of a research setting. For most patients, the simple act of reaching out is necessary but not sufficient. People do not develop adverse drug reactions—they develop symptoms, which may be mistakenly attributed to causes other than drugs (including “getting old”), and which they may be hesitant to disclose. (Other adverse reactions may be completely asymptomatic but nonetheless serious, such as progressive hyperkalemia or anemia.) Outreach calls may also be asynchronous with when the patient develops a medication-related problem. These challenges bedevil the widespread practice of calling patients several days after hospital discharge to inquire on their well-being and to identify problems with their medications. While a wonderful idea, relatively little is known about how well these follow-up procedures actually identify problems, and although there is some evidence that these interventions are effective, the benefits are not as great as one might hope.6 What might be most helpful is a multifocal approach in which the surveillance strategies being developed by Forster and Auger5 and like-minded colleagues are coupled with efforts to educate and encourage patients to be active partners in monitoring adverse reactions and nonadherence to their medications.7 This latter approach is best exemplified by health-coach based approaches pioneered by Coleman et al8 and others in which impressive improvements in health resulted not from bringing services to patients but by helping patients be engaged participants in their own care. These interventions are complex, and their potential benefits do not diminish the substantial contribution of surveillance-based approaches. Nonetheless, the solution to the problems of adverse drug reactions and nonadherence cannot solely rest on bringing the health care system closer to the patient. We need to empower our patients to come closer to us. Back to top Article Information Correspondence: Dr Steinman, San Francisco Veterans Affairs Medical Center, PO Box 181G, 4150 Clement St, San Francisco, CA 94121 (mike.steinman@ucsf.edu). Published Online: February 4, 2013. doi:10.1001/jamainternmed.2013.2965 Conflict of Interest Disclosures: None reported. Funding/Support: This work was supported by National Institute on Aging and the American Federation for Aging Research grant 1K23-AG030999. References 1. Steinman MA, Handler SM, Gurwitz JH, Schiff GD, Covinsky KE. Beyond the prescription: medication monitoring and adverse drug events in older adults. J Am Geriatr Soc. 2011;59(8):1513-152021797831PubMedGoogle ScholarCrossref 2. Weingart SN, Gandhi TK, Seger AC, et al. Patient-reported medication symptoms in primary care. Arch Intern Med. 2005;165(2):234-24015668373PubMedGoogle ScholarCrossref 3. Sleath B, Roter D, Chewning B, Svarstad B. Asking questions about medication: analysis of physician-patient interactions and physician perceptions. Med Care. 1999;37(11):1169-117310549619PubMedGoogle ScholarCrossref 4. Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. BMJ. 1997;315(7115):1096-10999366745PubMedGoogle ScholarCrossref 5. Forster AJ, Auger C.ISTOP ADE Investigators. Using information technology to improve the monitoring of outpatient prescribing. JAMA Intern Med. 2013;173(5):382-384Google ScholarCrossref 6. Mistiaen P, Poot E. Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home. Cochrane Database Syst Rev. 2006;(4):CD00451017054207PubMedGoogle Scholar 7. Rennke S, Kesh S, Neeman N, Sehgal NL. Complementary telephone strategies to improve postdischarge communication. Am J Med. 2012;125(1):28-3021871596PubMedGoogle ScholarCrossref 8. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-182817000937PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Internal Medicine American Medical Association

Reaching Out to Patients to Identify Adverse Drug Reactions and Nonadherence: Necessary but Not Sufficient

JAMA Internal Medicine , Volume 173 (5) – Mar 11, 2013

Loading next page...
 
/lp/american-medical-association/reaching-out-to-patients-to-identify-adverse-drug-reactions-and-SoEuSHbjZ4
Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6106
eISSN
2168-6114
DOI
10.1001/jamainternmed.2013.2965
Publisher site
See Article on Publisher Site

Abstract

Many millions of dollars have been spent on preventing adverse drug reactions at the point of prescribing. Automated systems help identify drug-drug interactions and excessive drug doses. Computerized alerts warn prescribers about potentially inappropriate drugs in older adults. However, only one-quarter of adverse drug reactions can be prevented by catching errors or problems at the time of prescribing.1 The remainder of adverse drug reactions are not the result of prescriber error but simply represent the known adverse effects of drugs. Some patients who take calcium channel blockers will develop peripheral edema. Some patients who take selective serotonin reuptake inhibitors will experience marked sexual dysfunction. For some drugs, risk factors have been identified that place a patient at higher risk of developing an adverse event. However, in most cases, we cannot predict who will develop an adverse drug reaction and who will not. We prescribe and hope for the best. Unfortunately, physicians do not do a good job of identifying and appropriately managing adverse reactions when they occur. Many patients do not tell their physicians when they are experiencing an adverse event, and we often do not ask.2,3 Moreover, physicians often misattribute the symptoms of an adverse drug reaction to an underlying disease, leading to diagnostic workups and a prescribing cascade of new medications rather than treating the problem at its source by discontinuing the offending drug.4 On a broader level, only a small fraction of adverse drug reactions are reported to the US Food and Drug Administration Adverse Event Reporting System (http://www.fda.gov/Safety/MedWatch/), hindering efforts for postmarketing surveillance of drug safety. These problems with recognizing and managing adverse drug reactions occur not because physicians are incompetent, but because we lack the systems that would allow us to systematically identify and address medication-related problems. The research described by Forster and Auger5 in this issue of JAMA Internal Medicine shows a promising approach to bridge this quality gap. Building on past studies that have shown the benefits of reaching out to patients to identify adverse drug reactions, the authors developed a hybrid system. Three days after a drug was newly prescribed, the system generated a phone call to the patient. Using interactive voice response technology, the system asked the patient 4 simple questions about problems they may be having with their drugs and whether they wanted to talk to a pharmacist. The process was repeated 2 weeks later. One-third of contacted patients needed a follow-up call from the pharmacist. Overall, the system identified slightly under half of the 22% of patients who experienced an adverse drug reaction. In addition, it identified one-third of the 6% of patients who were nonadherent to their medications. This is exciting and highly promising. It is also not ready for widespread implementation. While the system detected a number of medication-related problems, it missed more than half of adverse drug reactions and two-thirds of episodes of nonadherence in patients—and would likely have done worse outside the controlled environment of a research setting. For most patients, the simple act of reaching out is necessary but not sufficient. People do not develop adverse drug reactions—they develop symptoms, which may be mistakenly attributed to causes other than drugs (including “getting old”), and which they may be hesitant to disclose. (Other adverse reactions may be completely asymptomatic but nonetheless serious, such as progressive hyperkalemia or anemia.) Outreach calls may also be asynchronous with when the patient develops a medication-related problem. These challenges bedevil the widespread practice of calling patients several days after hospital discharge to inquire on their well-being and to identify problems with their medications. While a wonderful idea, relatively little is known about how well these follow-up procedures actually identify problems, and although there is some evidence that these interventions are effective, the benefits are not as great as one might hope.6 What might be most helpful is a multifocal approach in which the surveillance strategies being developed by Forster and Auger5 and like-minded colleagues are coupled with efforts to educate and encourage patients to be active partners in monitoring adverse reactions and nonadherence to their medications.7 This latter approach is best exemplified by health-coach based approaches pioneered by Coleman et al8 and others in which impressive improvements in health resulted not from bringing services to patients but by helping patients be engaged participants in their own care. These interventions are complex, and their potential benefits do not diminish the substantial contribution of surveillance-based approaches. Nonetheless, the solution to the problems of adverse drug reactions and nonadherence cannot solely rest on bringing the health care system closer to the patient. We need to empower our patients to come closer to us. Back to top Article Information Correspondence: Dr Steinman, San Francisco Veterans Affairs Medical Center, PO Box 181G, 4150 Clement St, San Francisco, CA 94121 (mike.steinman@ucsf.edu). Published Online: February 4, 2013. doi:10.1001/jamainternmed.2013.2965 Conflict of Interest Disclosures: None reported. Funding/Support: This work was supported by National Institute on Aging and the American Federation for Aging Research grant 1K23-AG030999. References 1. Steinman MA, Handler SM, Gurwitz JH, Schiff GD, Covinsky KE. Beyond the prescription: medication monitoring and adverse drug events in older adults. J Am Geriatr Soc. 2011;59(8):1513-152021797831PubMedGoogle ScholarCrossref 2. Weingart SN, Gandhi TK, Seger AC, et al. Patient-reported medication symptoms in primary care. Arch Intern Med. 2005;165(2):234-24015668373PubMedGoogle ScholarCrossref 3. Sleath B, Roter D, Chewning B, Svarstad B. Asking questions about medication: analysis of physician-patient interactions and physician perceptions. Med Care. 1999;37(11):1169-117310549619PubMedGoogle ScholarCrossref 4. Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. BMJ. 1997;315(7115):1096-10999366745PubMedGoogle ScholarCrossref 5. Forster AJ, Auger C.ISTOP ADE Investigators. Using information technology to improve the monitoring of outpatient prescribing. JAMA Intern Med. 2013;173(5):382-384Google ScholarCrossref 6. Mistiaen P, Poot E. Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home. Cochrane Database Syst Rev. 2006;(4):CD00451017054207PubMedGoogle Scholar 7. Rennke S, Kesh S, Neeman N, Sehgal NL. Complementary telephone strategies to improve postdischarge communication. Am J Med. 2012;125(1):28-3021871596PubMedGoogle ScholarCrossref 8. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-182817000937PubMedGoogle ScholarCrossref

Journal

JAMA Internal MedicineAmerican Medical Association

Published: Mar 11, 2013

Keywords: information sciences,outpatients,communication and information technology,adverse effects of medication,prescribing behavior,outreach

References