Spacial Application of Pharmaco-epidemiology

1. HOSPITAL
PHARMACOEPIDEMIOLOGY

2. What is the necessity of hospital
pharmacoepidemiology?
• Tracking the drug administered to the patient during the
entire stay in the hospital
• Systematical recording of ADR
• Creation of databases has enabled the storage of large
number of patient data over longer period of time (Claim
database & medical record databases)

3. CLINICALPROBLEMSIN
PHARMACOEPIDEMIOLOGICRESEARCH
1. Volume and characteristics of hospital admission.
1. Patients discharge
2. Discharge rate
3. LOS
2. Characteristics of hospitalized patients and hospitalized drug
use.
1. Age
2. Comorbidities
3. LOS
4. Polypharmacy-DDI
5. Time of onset AE

4. Volume and characteristicsof hospital
admission
• Heart disease is the most common cause of hospital
discharge diagnosis -154.8 per 10000 population
• Respiratory disease ranking the next.
• Older people with high risk of cardio vascular diseases
and cancer surgeries are more likely to survive in
hospitals.

5. CHRACTERISTICS OF HOSPITALIZED PATIENTS
HOSPITALDRUG USE
Hospitalized patients receive multiple drugs because of :
• Older age
• Sickness
• Multiple concurrent diseases
• Older patients are more likely to suffer from
complications during hospital stay.

6. • Patients with polypharmacy during hospital stay has greater
risk of:
• drug interaction.
• Eg:concurrent use of Trimethoprim Sufamethoxasole with
Warfarin
• Prescribing suboptimal drug regimens.
• Eg:insufficient aggressive dose of heparin in patients with
pulmonary embolism.
• Inadequate laboratory monitoring .
• Eg:lack of monitoring of Amino glycoside level.
• Pharmacoepidemiology says that most drug reactions occurs
on the first 5 days on a drug therefore surveillance during this
period helps to detect ADR .

7. Methodologicalproblemsinpharmacoepidemiology
research
• LOGISTIC ISSUES
• METHODOLOGIC ISSUES
Logistical issues:
• total drug exposure during a hospital stay is a major challenge for
pharmacoepidemiologic research in the hospital setting
• Admission in Different department during the treatment. Eg Emergency, GM etc.
• Drugs are also administered by multiple types of personnel, e.g., nurses, physicians,
radiology technicians
without complete information about inpatient drug exposure, inferences
about adverse drug reactions associated with particular exposures are
impossible to make credibly.
• Computerized Prescriber Order Entry (CPOE): linked, automated inpatient
data systems, the capture of complete inpatient drug exposure will be
addressed.

8. • CPOE data can be incomplete due to omitted high-risk
populations, such as
• neonates or patients receiving chemotherapy;
• inability to handle selected complex clinical situations,
e.g., patient-controlled analgesia and operating room
medications;
• CPOE systems that are not fully integrated with other
medication system components, e.g., barcode point-
of-care systems.

9. Methodological Issues:
• Issue of uncertain validity of the drug information in the hospital
medical record.
• Issue of uncertain validity of diagnosis information in hospital
medical record.
• Issue of absence of inpatient information in the absence of
outpatient information.
• Issue of uniqueness of drug exposure in hospital settings.
• Hospitalized patients tend to be more severely ill than non
hospitalized patients.
• Tendency to record only the most extreme or dramatic events.
• Referral bias will be present.
• Appropriate denominator for calculation of adverse drug reaction
depends on the question of interest.
• Problems from hospital staff participation.
• Medical records are not meant for research purposes.

10. Currently Available Solution
• Intensive Hospital-Based Surveillance:
Disease Medical Progress: “Survey of Disease and Syndromes
Unintentionally Induced as a Result of Properly Indicated,
Widely Accepted Therapeutic Procedures”
• Hôspital based cohort study for AE
• Boston Collaborative Drug Surveillance Program (BCDSP)
• Journal publications
• Intensive drug monitoring programme was developed-
converted to electronic data entry and to computer analysis.

11. Inpatient database
Multisite Database:
• Provide support on rare drug events.
TYPES:
Commercial:
Noncommercial:
Eg:the Health Evaluation through Logical Processing
System(HELP)
Brigham and Women’s Hospital(BWH): Brigham Integrated
Computing System (BICS)
Beth Israel Hospital(BIH)
The Regentrief Automated Medical Record System

12. Advantages and Limitation
Advantages
• integrated automated data systems for enhancing the
• quality of patient care,
• reducing medical errors and
• adverse reactions to treatment,
• and supporting research.
Limitation
• inpatient data systems are freestanding instead of integrated across
institutions.
• The size and composition of patient populations in individual hospitals
are likely to limit the ability detect events of low incidence and produce
generalizable results.

13. New Hospital – Based Adverse Drug
Monitoring and Drug Use Evaluation
Programme:
Goal:
• To improve the quality of patient care.
• To improving the clinical use of medications and minimizing ADR.
• To decrease the hospital cost .
• To decrease the liability associated with inappropriate use of high
risk drugs.
For achieving these goals :
• Maintain sponteneous reports of ADE.
• Maintain screen computerised discharge diagnosis of ADE
• Maintain all critical lab results reported in the hospitals

14. preventive measures: blocking a prescription incase of potential
drug interaction
Cost avoidance measures: suggesting a lower cost substitute drug.
 Also identify the exposed patients
Performed medical chart review
Organize and analyse the collected data
Report the results to a review committee
Design and implement interventions to address any problems
identified
Cost Containment Programme was developed to identify potential
problem
Monitors the monthly compilations of the list of drug and vaccine
shortage sin the hospital pharmacy.
The DUEC review monthly reports of
pharmacists interventions.
This involves

15. The findings from DUE analysis
triggered several recommendation
from DUEC including:
1. Develop policy concerning which health care professional should
be responsible collecting and disseminating height, weight and
allergy information
2. Incorporating height,weight,allergic information into pharmacist
medication histories
3. Instituting data entry prompt for missing height, weight and
allergy information into both computerized physician order entry
system and the pharmacy computer system
4. Educating healthcare professionals on the importance of
recording allergic reactions
5. Making patient allergy on a mandatory field prior to adding
medication orders.

16. • The findings from DUE leads to several recommendation:
1. Educating the staff
2. Entering patient weight into the computerized physician
order entry system
3. Aiding appropriate prescribing through alerts and reminders.

17. Reference
• David Lee, Sumit R. Majumdar, Helene Levens Lipton et al.
Special Applications of Pharmacoepidemiology, 2006 John
Wiley & Sons, Ltd,
• Editors B.L. Strom and S.E. Kimmel