The use of a clinical decision support tool to assess the risk of QT drug–drug interactions in community pharmacies

Abstract

Introduction: The handling of drug–drug interactions regarding QTc-prolongation (QT-DDIs) is not well defined. A clinical decision support (CDS) tool will support risk management of QT-DDIs. Therefore, we studied the effect of a CDS tool on the proportion of QT-DDIs for which an intervention was considered by pharmacists. Methods: An intervention study was performed using a pre- and post-design in 20 community pharmacies in The Netherlands. All QT-DDIs that occurred during a before- and after-period of three months were included. The impact of the use of a CDS tool to support the handling of QT-DDIs was studied. For each QT-DDI, handling of the QT-DDI and patient characteristics were extracted from the pharmacy information system. Primary outcome was the proportion of QT-DDIs with an intervention. Secondary outcomes were the type of interventions and the time associated with handling QT-DDIs. Logistic regression analysis was used to analyse the primary outcome. Results: Two hundred and forty-four QT-DDIs pre-CDS tool and 157 QT-DDIs post-CDS tool were included. Pharmacists intervened in 43.0% and 35.7% of the QT-DDIs pre- and post-CDS tool respectively (odds ratio 0.74; 95% confidence interval 0.49–1.11). Substitution of interacting agents was the most frequent intervention. Pharmacists spent 20.8 ± 3.5 min (mean ± SD) on handling QT-DDIs pre-CDS tool, which was reduced to 14.9 ± 2.4 min (mean ± SD) post-CDS tool. Of these, 4.5 ± 0.7 min (mean ± SD) were spent on the CDS tool. Conclusion: The CDS tool might be a first step to developing a tool to manage QT-DDIs via a structured approach. Improvement of the tool is needed in order to increase its diagnostic value and reduce redundant QT-DDI alerts. Plain Language Summary The use of a tool to support the handling of QTc-prolonging drug interactions in community pharmacies Introduction: Several drugs have the ability to cause heart rhythm disturbances as a rare side effect. This rhythm disturbance is called QTc-interval prolongation. It may result in cardiac arrest. For health care professionals, such as physicians and pharmacists, it is difficult to decide whether or not it is safe to proceed treating a patient with combinations of two or more of these QT-prolonging drugs. Recently, a tool was developed that supports the risk management of these QT drug–drug interactions (QT-DDIs). Methods: In this study, we studied the effect of this tool on the proportion of QT-DDIs for which an intervention was considered by pharmacists. An intervention study was performed using a pre- and post-design in 20 community pharmacies in The Netherlands. All QT-DDIs that occurred during a before- and after-period of 3 months were included. Results: Two hundred and forty-four QT-DDIs pre-implementation of the tool and 157 QT-DDIs post-implementation of the tool were included. Pharmacists intervened in 43.0% of the QT-DDIs before the tool was implemented and in 35.7% after implementation of the tool. Substitution of one of the interacting agents was the most frequent intervention. Pharmacists spent less time on handling QT-DDIs when the tool was used. Conclusion: The clinical decision support tool might be a first step to developing a tool to manage QT-DDIs via a structured approach.

Risk assessment tools for QT prolonging pharmacotherapy in older adults: a systematic review

“…In total, 21 studies were included in the systematic review in which 11 different RATs for prolonged QT were used [ 12 , 14 , 19 – 24 , 31 – 33 , 36 , 40 , 43 , 44 ]. Most commonly used tools were risk scores ( n = 9) [ 12 , 14 , 21 – 27 ], computerized physician order entry systems ( n = 3) [ 31 – 33 ], and clinical decision support systems ( n = 6) [ 19 , 20 , 36 – 39 ]. Of the studies, eight were conducted in the USA [ 12 , 21 , 22 , 32 , 33 , 36 , 38 , 44 ], four in Belgium [ 14 , 23 , 24 , 27 ], two in Australia [ 25 , 40 , 43 ], one in Germany [ 20 ], four in the Netherlands [ 26 , 31 , 37 , 39 ], and one in Sweden [ 19 ].…”

“…The included RATs could be further developed to fit different health information systems. There is potential for the RATs to be adapted to outpatient settings and furthermore assist other healthcare providers other than physicians, e.g., community pharmacists [19,39]. However, no guidelines for managing risks of QT prolongation in primary care or community pharmacies exist and more training on the topic is needed to adopt the tools in clinical practice [48,50].…”

“…Most commonly used tools were risk scores (n = 9) [12,14,[21][22][23][24][25][26][27], computerized physician order entry systems (n = 3) [31][32][33], and clinical decision support systems (n = 6) [19,20,[36][37][38][39]. Of the studies, eight were conducted in the USA [12,21,22,32,33,36,38,44], four in Belgium [14,23,24,27], two in Australia [25,40,43], one in Germany [20], four in the Netherlands [26,31,37,39], and one in Sweden [19]. The RATs were developed mainly for physicians and pharmacists.…”

“…Clinical decision support systems (CDSS) were studied in six studies [19,20,[36][37][38][39] (Table 3; Supplementary Table S2). The interventional study by Bertsche et al [20] investigated drug-drug interactions (DDIs) and DDI-related adverse drug events in intensive care patients with a CDSS (Table 3).…”

“…Berger et al [39] Intervention study using a pre-and post-design in 20 community pharmacies in the Netherlands All QT-DDIs including QTc-prolonging drugs with a known risk of TdP that occurred in the community pharmacies (n = 20) during a study period of 3 months before and 3 months after CDS tool implementation…”