RESUMEN
OBJECTIVE: This study aimed to reduce high-risk medication (HRM) prescribing by direct electronic medical record messaging to providers. SETTING: Lincoln Community Health Center is a federally qualified health center in the southeast United States. PRACTICE DESCRIPTION: This was a single-center, observational study performed with quality improvement methodology including define, measure, analyze, improve, and control phases. A total of 89 patients, aged 65 years or older, received 115 HRM prescriptions from August 2016 to August 2018. Project follow-up period included September 2018 to April 2019, with 19 additional patients receiving 23 HRM prescriptions. PRACTICE INNOVATION: Shared electronic medical records allowed pharmacists to electronically communicate indication of HRM, possible alternatives to HRM, and pharmacy of choice to providers to reduce HRM prescribing. Pharmacists' recommendations were timed to appear in providers' inboxes 3 to 5 days before the patient's clinic visit. Patients not returning to the clinic in a timely manner were telephoned by pharmacists with medical provider approved HRM alternative recommendations. EVALUATION: Discontinuation of HRMs were verified by chart review and insurance claims. The Cochran-Armitage trend test was used to examine significance of change related to national benchmark prescribing rates. Two-sided z test was used to analyze significance of change from implementation to follow-up period. RESULTS: Fifty-two provider communications sent by clinical pharmacists resulted in a therapy modification rate of 71.2%. National benchmark data that reflected a peak HRM prescribing rate of 10.7% was reduced to 1.9% within 18 months (P = 0.014). The national benchmark goal of less than 3% HRM prescribing was achieved and sustained from February 2019 to May 2019. CONCLUSION: Using interdisciplinary access to electronic medical records resulted in significant rates of HRM discontinuation. Timing messages before patient clinic visits promotes shared decision making.
Asunto(s)
Servicios Farmacéuticos , Farmacéuticos , Prescripciones de Medicamentos , Humanos , Errores de Medicación , Pacientes Ambulatorios , Estados UnidosRESUMEN
We describe the first successful case of posaconazole salvage therapy for mucormycosis with concomitant sirolimus (SRL) maintenance immunosuppression following liver transplantation, despite black box drug interaction following intolerance to first-line tacrolimus and amphotericin due to nephrotoxicity and neurotoxicity. This case describes a 55-year-old female who developed rhinocerebral mucormycosis 108 days after liver transplantation. After 3 months of posaconazole therapy, the patient remains free of disease at 3 years posttransplant. This case report illustrates successful resolution of mucormycosis without SRL toxicity to resolve nephrotoxicity of long-term amphotericin on top of already nephrotoxic immunosuppression. With higher bioavailability of recently FDA-approved posaconazole delayed release tablets, this azole may be a therapeutic option for transplant patients who need to remain on CYP3A4-metabolized immunosuppressive agents.