Got the time? Pharmacists excel at adverse drug detection on chart review
But with time constraints auto systems more practical
When they have time to do the work, pharmacists perform better than non-pharmacists in manually reviewing charts to determine inpatient adverse drug events (ADEs). That's the conclusion of a systematic review and meta-analysis conducted by researchers at the University of Utah, Salt Lake Informatics, Decision Enhancement, and Surveillance Center, and Department of Veterans Affairs Medical Center in Salt Lake City.1
The research was conducted to determine if studies that included pharmacists as chart reviewers detected higher rates of adverse drug events than studies that included other healthcare professionals or hospital personnel as chart reviewers. Lead author Shobha Phansklar, MS, at the University of Utah Department of Biomedical Informatics, tells Drug Formulary Review the study did not address the cost-effectiveness of using pharmacists as chart reviewers and she conceded it may be difficult for them to find time for chart reviews. While pharmacists' training in therapeutics and comprehensive drug knowledge makes them an obvious choice for ADE surveillance, chart review is a resource-intensive process that takes pharmacists' time away from patient care activities. The allocation of pharmacists' time in chart review can be justified by determining whether pharmacists are capable of detecting a greater number of ADEs than other healthcare professionals such as nurses and physicians, or non-clinical personnel who are engaged in ADE surveillance.
Many clinical organizations have recognized the importance of establishing mechanisms for adverse drug event surveillance. Hospitals are mandated to have ongoing drug surveillance programs in place to detect and evaluate drugs' effects and to propagate safe, appropriate, and effective drug therapies. Phansklar says several surveillance methods are used in clinical settings to detect ADEs. Voluntary spontaneous reporting systems are commonly used, she says, but reporting has been said to be as low as 1.5%. Computer-assisted techniques are used in some hospitals, but they require sophisticated clinical information systems and often lack the ability to search through progress notes for textual signals, thus not exploring a considerable amount of data. Manual chart review has resulted in high detection rates with the ability to identify a greater number of ADEs than other methods. That technique also offers the potential to extract implicit clinical information from free-text documents such as progress notes, nursing notes, and discharge summaries. "Manual chart review is therefore considered the gold standard in ADE detection," Phansklar says. "Despite these advantages, chart review requires relatively large resource use and expense, thus limiting its use to research studies."
Dearth of data
A total of 661 abstracts were identified in a literature search, and 46 studies potentially met the inclusion criteria. Some 13 studies meeting the inclusion criteria and including either pharmacists or non- pharmacists as chart reviewers were included in the final analysis. Meta-analysis of the 13 studies comparing chart reviews performed by pharmacists with those performed by other healthcare professionals or hospital personnel revealed that pharmacists detected higher ADEs per admission as compared with non-pharmacists. Phansklar cautions there is not much scientific literature reporting high-quality studies using chart review for detecting inpatient ADEs. Despite searching a broad range of databases, the researchers found only a small number of studies meeting all inclusion criteria. Most of the excluded studies looked at outpatient ADEs, medication-related admissions, or evaluation of ADEs related to specific drug classes or specific ADE types.
The researchers said they made every effort to determine the profession of the reviewers from the data reported in the studies. They recommended that future studies make an effort to describe in greater detail not just the clinical background of chart reviewers but also other relevant characteristics that can give rise to heterogeneity, such as the pieces of information reviewed in patients' medical records. Another factor identified as contributing to heterogeneity was the criteria used for assessment of ADE characteristics. "In our review we found a staggering number of disparate criteria used to assess various characteristics of an ADE," they reported. "The World Health Organization definition and its related terminology are used in many studies to determine the likelihood of an event being an adverse drug reaction, but standards for deriving conclusions about the causality, severity, and preventability are absent. The lack of such standards limits the validity of case identification across ADE studies." Phansklar says that despite overwhelming evidence of statistical heterogeneity, the numbers pertaining to ADE rates detected by the two groups were large enough to indicate significant differences. "However," she says, "it is difficult to state that actual differences exist in light of the heterogeneity that exists among the studies. Nevertheless, despite the heterogeneity, there is strong evidence that pharmacist-led interventions based on chart review report a higher ADE rate among inpatients. Our data suggest that pharmacists are the most thorough chart reviewers. Pharmacists' knowledge of drugs and clinical therapeutics may give them an advantage over other clinicians for the purpose of inpatient ADE detection. As awareness of patient safety issues increases, pharmacists find themselves more engaged in ADE surveillance activities. However, dedicating full-time clinical pharmacist positions to ADE chart review is expensive and difficult to justify, in part because of the expanded clinical role pharmacists play in the inpatient setting. Our data support allocation of clinical pharmacists' time for ADE surveillance studies that are aimed at detecting higher sensitivities of ADE frequency among inpatients. Owing to the disparity in the criteria used for ADE detection, we could not derive a conclusion about the specificity of attributing ADEs."
Automation may be a solution
The researchers suggest that chart review automation may provide a potential solution for making ADE surveillance less expensive and more efficient for pharmacists. To work, Phansklar tells DFR, such systems need to incorporate the cognitive reasoning used by pharmacists when conducting automated chart reviews. "It is important to note that in the studies that we reviewed," she says, "pharmacists were not limited to only medication orders or laboratory values, but also took into account any textual signals that existed in the medical record, such as progress notes, shift assessments, and pharmacist notes. This is significant for developing automated ADE surveillance systems to aid pharmacists in the chart-review process. Researchers should focus on capturing the pharmacists' cognitive framework, not just for being able to reason about the appropriateness of medications, but also for reasoning about additional textual signals that pharmacists routinely take into consideration when deliberating about an ADE."
Phansklar and colleagues are working on developing an automated chart review system and trying to identify the items that pharmacists find to be important when they review a chart. Focus groups are used to identify the triggers that pharmacists use. Phansklar has received a number of e-mails from people wanting to learn more about the study. "People want to see pharmacists involved in ADE studies," she concludes, "but need a scientific basis."
- Phansklar S, Hoffman J, Nebeker J, et al. Pharmacists versus Nonpharmacists in Adverse Drug Event Detection: A Meta-analysis and Systematic Review, Am Jrl Health-System Phar. 2007;64(8):842-849.