An automated phone calling system that asks patients about the prescriptions their doctors ordered, with follow-up calls from pharmacists, can mitigate adverse drug events (ADEs) and prescription non-compliance that might otherwise go unnoticed.
"Most patients do ask [about their medications if they have questions] when given the opportunity," says Alan Foster, MD, general internist and Scientific Director of Performance Measurement at the Ottawa Hospital in Canada. But that's an opportunity they don't easily get, he says.
"We need to increase opportunities to ask questions—hence our intervention."
The results of his experiment with the phone system is published in the current issue of JAMA Internal Medicine.
Foster was prompted to see if the automated system and pharmacists' follow-up calls could avoid or identify adverse drug events, which he defined as poor health outcomes caused by prescription medications.
Such ADEs, as well as medication non-adherence, occur in 25% of new prescriptions taken by ambulatory patients. They can also result in poor patient outcomes and even increased hospital admissions in some cases.
So he and co-worker Claudine Auger of Montreal, designed what they call the ISTOP-ADE System. ISTOP ADE automatically called patients on the third day, and again on the 17th day after they were given a new prescription.
Data flow through ISTOP Click to view full image |
Calls were placed to 628 patients of 76 physician practices and the system reached four out of five, or 465 and 475 during the third day and 17th day attempts. Patients were asked if they had
- Had a problem obtaining their medication
- Had problem taking their medication
- Encountered new symptoms
- Wanted to discuss a drug's impact with a pharmacist
Then, 21 days after the patients first received their prescription, they contacted all patients and conducted interviews to learn about their medication use, symptoms, health status and health care visits, and collated that with their electronic health record and the results of their automated calls.
The researchers identified 125 adverse drug events experienced by 125 patients, 58 of which were caught by the ISTOP-ADE system.
A pharmacist was able to modify the drug regimen for 23 of the 58 patients to prevent the adverse event or adverse symptoms.
Forster says that when the pharmacist intervenes, symptoms can be reduced or obliterated by reducing the dose or changing the class of drug, "although sometimes they go away on their own."
For those patients whose adverse reactions were identified by the automated system, 20 had symptoms that had lasted at least seven days, and for patients whose symptoms were not identified by the automated system, 33 of 67 had symptoms that lasted at least seven days.
Of those patients who were reached, "one-third required follow-up with the pharmacist," the researchers wrote. "On the day-3 contact, the most common reason for pharmacist assistance was the patient not starting to take the medication; at day 17, the most common reason was new problems starting since the patient started taking the medication."
In an editorial in the same issue of the journal, Michael Steinman, MD, of the Department of Medicine at the University of California San Francisco, gave praise to Forster's and Auger's report, saying their "ISTOP-ADE" system "is exciting and highly promising."
But he tempered his remarks with caution, saying the system is not yet 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 non-adherence in patients—and would likely have done worse outside the controlled environment of a research setting."
Steinman wrote that one-fourth of adverse drug reactions can be prevented by catching errors or problems at the time of prescribing. And that most of the rest "are not the result of prescriber error but simply represent the known adverse effects of drugs," and physicians "cannot predict who will develop an adverse drug reaction and who will not."
The problem is, he says, that "physicians do not do a good job of identifying and appropriately managing adverse reactions when they occur," in part because many patients don't tell their physicians when they're experiencing one.
Sometimes, he added, doctors "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."
What is needed, Steinman wrote, are proven coaching methods that help patients "be engaged participants in their own care," monitoring their own adverse reactions and non-adherence.
"The solution to the problems of adverse drug reactions and non-adherence cannot solely rest on bringing the healthcare system closer to the patient," he wrote. "We need to empower our patients to come closer to us."