Effects of an Adverse-drug-event Alert System on Cost and Quality Outcomes in Community Hospitals

Frank Piontek; Rajiv Kohli; Paul Conlon; Jeffrey J. Ellis; Jason Jablonski; Narendra Kini

Am J Health Syst Pharm. 2010;67(8):613-620.

Conclusion

Implementation of an ADE alert system in seven community hospitals demonstrated significant decreases in pharmacy department costs, variable drug costs, and severity-adjusted mortality rates.

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Donald Crandall, M.D., and Lee Schwab, M.D., are acknowledged for their early contributions to the content of this article. Kevin Swain and Jennifer Helmen are acknowledged for providing technical and logistic support.

Presented in part at the American College of Clinical Pharmacology Annual Scientific Assembly, Phoenix, AZ, October 2004; American College of Chest Physicians Annual Scientific Assembly, Seattle, WA, October 2004; and American Society for Clinical Pharmacology and Therapeutics Annual Meeting, Anaheim, CA, March 2006.

The authors have declared no potential conflicts of interest.

Cite this: Effects of an Adverse-drug-event Alert System on Cost and Quality Outcomes in Community Hospitals - Medscape - Apr 01, 2010.

Table 1. Outcomes Before and After Adverse-Drug-Event Alert System Implementation
Outcome	p^a	Study Group			External Control Group
Outcome	p^a	Preimplementation (n = 71,975)	Postimplementation (n = 87,876)	p^b	Preimplementation (n = 29,535)	Postimplementation (n = 40,077)	p^b
Primary
Pharmacy costs per patient, $	≤0.001	867	826	≤0.001	734	797	0.029
Variable drug costs per patient, $	≤0.001	360	337	≤0.001	401	429	0.029
Mortality, %	≤0.001	3.86	3.87	0.999	2.99	2.88	0.963
Secondary
Total hospitalization costs per patient, $	≤0.001	7,302	7,731	≤0.001	7,633	7,933	0.030
Length of hospital stay, days	≤0.001	4.72	4.72	0.999	4.27	4.32	0.610
Readmissions, %	0.76	0.105	0.108	NS^c	0.108	0.108	NS^c
Case-mix index	≤0.001	1.49	1.54	≤0.001	1.47	1.47	0.998
Severity adjusted
Pharmacy costs per patient, $	≤0.001	861	807	≤0.001	737	780	0.031
Variable drug costs per patient, $	≤0.001	362	330	≤0.001	402	420	0.047
Mortality, %^d	≤0.001	1.049	0.975	≤0.001	0.87	0.81	0.289
Total hospitalization costs, $^d	≤0.001	0.961	0.989	≤0.001	0.99	1.01	0.032
Length of hospital stay^d	≤0.001	1.02	0.996	≤0.001	1.01	1.00	0.237

^aAnalysis of variance.
^bPost hoc Dunnett's repeated-measures test.
^cOmnibus F from analysis of variance not significant.
^dExpressed as ratio of observed to expected.

Appendix—Rules Used to Trigger Adverse-drug-event Alerts

Rule 1 (Digoxin, Magnesium, and Potassium Products)

Alert triggers when digoxin is ordered. One-time orders are excluded. Recent (past seven days) laboratory values are checked for low serum potassium (<3.4 meq/L) or low serum magnesium (<1.3 meq/L) concentrations or an elevated digoxin concentration (>2.2 ng/mL). If the electrolyte level is low, current orders are also checked for the absence of potassium or magnesium supplementation.

Rule 2 (Digoxin, Magnesium, and Potassium Products)

Alert triggers when a low potassium or magnesium level or a high digoxin level is posted (as in Rule 1). Current orders are checked for an active digoxin order and, in the case of a low electrolyte level, the absence of an order for potassium or magnesium supplementation.

Rule 3 (Potassium-containing or Potassium-sparing Drugs)

Alert triggers when drugs that may cause hyperkalemia are ordered. One-time orders are excluded. Recent (past seven days) laboratory values are checked for high serum potassium concentrations (>5.4 meq/L).

Rule 4 (Potassium-containing or Potassium-sparing Drugs)

Alert triggers when a high serum potassium concentration (>6.0 meq/L) is posted. Current orders are checked for any of the specified drugs that may cause hyperkalemia.

Rule 5 (Renally Excreted Drugs)

Alert triggers when drugs that are excreted renally are ordered. One-time orders are excluded. Recent (past seven days) laboratory results are checked for a high serum creatinine concentration (≥1.4 mg/dL [female, age of ≥70 years], ≥1.7 mg/dL [female, age of <70 years], ≥1.6 mg/dL [male, age of ≥70 years], ≥2.0 mg/dL [male, age of <70 years]).

Rule 6 (Renally Excreted Drugs)

Alert triggers when a high creatinine value is posted, indicating impaired renal function (as in Rule 5). Current orders are checked for specified renally excreted drugs. Alert will not print if the patient has had a previously elevated creatinine (past seven days) unless the value increases by >0.5 mg/dL. If the creatinine result is >4.0 mg/dL, the alert will not print if the patient has had a previously elevated creatinine (past seven days) regardless of the change from previous levels.

Rule 7 (Phenytoin)

When a low serum albumin concentration (≤2.6 g/dL) is posted, the record is checked for a recent (past seven days) recording of a serum phenytoin concentration (≥10 µg/mL); when a serum phenytoin concentration (≥10 µg/mL) is posted, the record is checked for a recent (past seven days) low serum albumin concentration (≤2.6 g/dL). A new total phenytoin level is calculated and printed in the pharmacy.

The following calculation is used:

Rule 8 (Ketorolac)

Alert triggers when an order for ketorolac is entered. The dose, frequency, and patient age are evaluated. The dose is adjusted for patients ≥65 years old as follows: >15 mg for scheduled doses and >30 mg for one-time or as-needed doses.

Rule 9 (Metformin)

Alert triggers when metformin is ordered. Recent (past seven days) laboratory results are checked for elevated serum creatinine (≥1.4 mg/dL for females, ≥1.5 mg/dL for males), elevated liver enzymes (alanine transaminase, >100 units/L; aspartate transaminase, >100 units/L; total bilirubin, >2.0 mg/dL), elevated serum lactate (>2.2 mmol/L), or low venous pH (<7.34).

Rule 10 (Metformin)

Alert triggers when a high serum lactate, a high liver enzyme, a low serum pH, or an elevated serum creatinine value is posted (as in Rule 9). The database is checked for an active metformin order.

Rule 11 (Haloperidol)

This alert is evoked when a new order for haloperidol is entered for a patient ≥65 years old as a flag for the possible onset of drug-induced delirium.

Rule 12 (Antidiarrheals and Antibiotics)

Alert triggers when an antidiarrheal is ordered. The database is checked for a current antibiotic order or recently discontinued order (within the past seven days).

Rule 13 (Drugs that may Cause Thrombocy-topenia)

Alert triggers when a patient has a new result of a low platelet count (<100 × 10³/µL). Current orders are checked for drugs that can cause thrombocytopenia. Alert will not print if it has printed in the past three days.

Rule 14 (Drugs that can Cause Neutropenia)

Alert triggers when a patient has a new result of a low absolute neutrophil count (≤0.5 × 10³/µL) or low white blood cell count (<2.0 × 10³/µL). Current orders are checked for drugs that can cause neutropenia. Alert will not print if it has printed in the past three days.

Rule 15 (Potentially Nephrotoxic Drugs)

Alert triggers when a new serum creatinine concentration is >1 mg/dL and indicates a 0.4-mg/dL increase (or greater) from a previous creatinine result (within the past seven days). Current orders are checked for potentially nephrotoxic drugs.

Rule 16 (Sedating Drugs)

Alert triggers when a medication that has major sedative properties is ordered for a patient ≥65 years old.

Rule 17 (Amitriptyline)

Alert triggers when a dose of amitriptyline ≥50 mg is ordered for a patient ≥65 years old.

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