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Improved Therapeutic Monitoring With Several Interventions
A Randomized Trial
Adrianne C. Feldstein, MD, MS;
David H. Smith, RPh, MHA, PhD;
Nancy Perrin, PhD;
Xiuhai Yang, MS;
Mary Rix, RN, BS;
Marsha A. Raebel, PharmD;
David J. Magid, MD, MPH;
Steven R. Simon, MD, MPH;
Stephen B. Soumerai, ScD
Arch Intern Med. 2006;166:1848-1854.
Background Medication errors are frequently related to failure to appropriately select medications or adjust for laboratory parameters. Differences between guideline recommendations and actual frequency of therapeutic laboratory monitoring are substantial. This study evaluated interventions to improve laboratory monitoring at initiation of medication therapy.
Methods This cluster-randomized trial compared 3 interventions to usual care for 10 medications in 15 primary care clinics in a health maintenance organization with an electronic medical record system. Eligible patients, identified from electronic databases, had not received recommended laboratory monitoring within 5 days after new dispensing of a study medication. Interventions were an electronic medical record reminder to the prescribing health care professional, an automated voice message to the patient, and a pharmacy team outreach to the patient. Primary outcome was completion of all recommended baseline laboratory monitoring.
Results A total of 961 patients participated in the study. At 25 days, 95 (48.5%) of 196 patients in the electronic medical record reminder group, 177 (66.3%) of 267 in the automated voice message group, 214 (82.0%) of 261 in the pharmacy team outreach group, and 53 (22.4%) of 237 in the usual care group had completed all recommended baseline laboratory monitoring (P<.001). After adjustments, the hazard ratios for completing laboratory monitoring compared with usual care were 2.5 (95% confidence interval, 1.8-3.5) for electronic medical record reminder, 4.1 (95% confidence interval, 3.0-5.6) for automated voice message, and 6.7 (95% confidence interval, 4.9-9.0) for pharmacy team outreach.
Conclusions All 3 interventions were effective in increasing laboratory monitoring when initiating new medications in primary care. Further work is necessary to determine if these interventions improve patient outcomes.
Trial Registration clinicaltrials.gov Identifier: NCT00256386
Author Affiliations: Center for Health Research, Kaiser Permanente (Drs Feldstein, Smith, and Perrin and Mss Yang and Rix), and Northwest Permanente (Dr Feldstein), Portland, Ore; Kaiser Permanente Colorado Clinical Research Unit, Aurora (Drs Raebel and Magid); and Harvard Medical School and Harvard Pilgrim Health Care, Boston, Mass (Drs Simon and Soumerai).
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