What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.
What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.
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药物协调的有效方法：MARQUIS2 研究的治疗中和现场分析。
DOI：
10.1136/bmjqs-2022-014806
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发表时间：
2023
影响因子：
5.4
通讯作者：
Labonville,Stephan
中科院分区：
文献类型：
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作者：
Schnipper,JeffreyL;ReyesNieva,Harry;Yoon,Catherine;Mallouk,Meghan;Mixon,AmandaS;Rennke,Stephanie;Chu,EugeneS;Mueller,StephanieK;SmithJr,GRandy;Williams,MarkV;Wetterneck,ToshaB;Stein,Jason;Dalal,AnujK;Labonville,Stephan
背景第二项多中心用药协调质量改进研究表明，每个患者的用药差异显著减少。当前分析的目的是确定患者暴露于每个系统级别干预以及接受每个患者级别干预对这些结果的关联。方法本研究在17家北美医院进行，每个站点的研究周期为18个月，这些站点通常在2-5个月的预干预数据收集之后采取干预措施。我们根据每个地点的实施地点线索的月度调查(应答率65%)，在类别层面和单个组成部分层面对系统层面的干预措施进行了治疗中的分析(即，基于患者暴露的结果评估)。然后，我们对患者水平的干预进行了类似的分析，这是通过研究药剂师对病历中记录的活动进行审查而确定的。我们基于每个站点每月最多22名患者的随机样本，使用混合效应泊松回归和医院站点作为随机效应，分析了每种干预措施与每个患者入院和出院顺序中调整后的用药差异数量的相关性。结果在4947名患者中，患者暴露在8个系统级别组件类别中的7个类别与差异发生率(调整后的比率(ARR)0.75-0.97)的适度但显著的降低有关，17个单独的系统级别干预组件中的15个组件也是如此，包括雇用、重新分配和培训人员以获得尽可能好的用药历史(BPMH)，以及培训人员执行出院药物调节和患者咨询。接受七项患者水平干预措施中的五项独立地与大幅降低不合格率有关，包括由训练有素的临床医生在急诊科(ED)接受BPMH(ARR 0.40，95%CI 0.37至0.43)，由训练有素的临床医生进行入院药物调节(ARR 0.57，95%CI 0.50至0.64)，以及由训练有素的临床医生进行出院药物调节(ARR 0.64，95%CI 0.57至0.73)。在GLMM决策树分析中，在急诊科接受BPMH和由训练有素的临床医生进行出院药物调节的患者的不符合率最低(每名患者每种药物0.08)。结论和相关性与减少差异最相关的患者水平干预措施是在急诊科接受BPMH的入院患者和由训练有素的临床医生进行入院和出院药物调节。系统水平的干预与普通患者的差异适度减少有关，但可能对支持患者水平的干预很重要，可能会接触到更多的患者。这些发现可以用来帮助医院和卫生系统在护理过渡期间优先采取干预措施，以提高用药安全性。
BackgroundThe second Multicenter Medication Reconciliation Quality Improvement Study demonstrated a marked reduction in medication discrepancies per patient. The aim of the current analysis was to determine the association of patient exposure to each system-level intervention and receipt of each patient-level intervention on these results.MethodsThis study was conducted at 17 North American Hospitals, the study period was 18 months per site, and sites typically adopted interventions after 2–5 months of preintervention data collection. We conducted an on-treatment analysis (ie, an evaluation of outcomes based on patient exposure) of system-level interventions, both at the category level and at the individual component level, based on monthly surveys of implementation site leads at each site (response rate 65%). We then conducted a similar analysis of patient-level interventions, as determined by study pharmacist review of documented activities in the medical record. We analysed the association of each intervention on the adjusted number of medication discrepancies per patient in admission and discharge orders, based on a random sample of up to 22 patients per month per site, using mixed-effects Poisson regression with hospital site as a random effect. We then used a generalised linear mixed-effects model (GLMM) decision tree to determine which patient-level interventions explained the most variance in discrepancy rates.ResultsAmong 4947 patients, patient exposure to seven of the eight system-level component categories was associated with modest but significant reductions in discrepancy rates (adjusted rate ratios (ARR) 0.75–0.97), as were 15 of the 17 individual system-level intervention components, including hiring, reallocating and training personnel to take a best possible medication history (BPMH) and training personnel to perform discharge medication reconciliation and patient counselling. Receipt of five of seven patient-level interventions was independently associated with large reductions in discrepancy rates, including receipt of a BPMH in the emergency department (ED) by a trained clinician (ARR 0.40, 95% CI 0.37 to 0.43), admission medication reconciliation by a trained clinician (ARR 0.57, 95% CI 0.50 to 0.64) and discharge medication reconciliation by a trained clinician (ARR 0.64, 95% CI 0.57 to 0.73). In GLMM decision tree analyses, patients who received both a BPMH in the ED and discharge medication reconciliation by a trained clinician experienced the lowest discrepancy rates (0.08 per medication per patient).Conclusion and relevancePatient-level interventions most associated with reductions in discrepancies were receipt of a BPMH of admitted patients in the ED and admission and discharge medication reconciliation by a trained clinician. System-level interventions were associated with modest reduction in discrepancies for the average patient but are likely important to support patient-level interventions and may reach more patients. These findings can be used to help hospitals and health systems prioritise interventions to improve medication safety during care transitions.