Patient Safety and Quality

Physician, patient, and pharmacy outreach reminders can improve recommended laboratory monitoring for certain medications

Specific laboratory tests are recommended when doctors start patients on certain medications. For example, baseline liver enzyme testing is recommended before patients begin taking thiazolidinediones for diabetes because these drugs have been associated with liver toxicity. Later laboratory monitoring can uncover changes from baseline enzymes that indicate liver toxicity, so that the drug dose can be lowered or the drug discontinued. Yet some studies have shown that only 61 percent of patients receive recommended therapeutic monitoring. Failure to monitor drug therapy is a frequent cause of preventable adverse drug events. Physician reminders, patient reminders, and pharmacy outreach using nurses can improve laboratory monitoring when patients begin new medications, according to a new study.

The study was conducted by researchers at the HMO Research Network Center for Education and Research in Therapeutics, which is supported by the Agency for Healthcare Research and Quality (HS10391). Researchers studied 10 medications prescribed to 961 patients in 15 primary care clinics. The goal was to measure the impact of 3 interventions on patients receiving the recommended laboratory monitoring for the 10 medications by comparing the interventions with usual care.

The 15 clinics were randomized into 4 groups that received either an intervention—an electronic medical reminder to the prescribing clinician to order the test(s) or contact the patient to obtain the test(s), an automated voice message to the patient to obtain the test(s), or a pharmacy team outreach to the patient—or usual care. At 25 days after a study medication was prescribed, nearly half (48.5 percent) of the 196 patients in the electronic medical record reminder group, 66 percent of the 267 patients in the automated voice message group, and 82 percent of the 261 patients in the pharmacy team outreach group had completed all recommended baseline laboratory monitoring, compared with only 22 percent in the usual care group. These findings indicate that routine linkage of pharmacy and laboratory data to identify and correct lapses in therapeutic monitoring holds great promise for reducing medication errors and adverse events.

See "Improved therapeutic monitoring with several interventions," by Adrianne C. Feldstein, M.D., M.S., David H. Smith, R.Ph., M.H.A., Ph.D., Nancy Perrin, Ph.D., and others, in the September 25, 2006, Archives of Internal Medicine 166, pp. 1848-1854.

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