Medication Discrepancies in Transferring T2DM Patients
Medication Discrepancies in Transferring T2DM Patients
The study was conducted at a tertiary outpatient Diabetes Ambulatory Care Centre associated with a major teaching hospital in Sydney, Australia. T2DM patients are referred to the Centre by their GP. The Diabetes Ambulatory Care Centre promotes a shared-care model between the referring GP, the patient and the Centre. GPs provide a written referral, including a list of current medications, for all referred patients. All patients undergo a structured nurse–patient interview (SNPI), by a specialist diabetes nurse during their clinic visits. The SNPI involves a comprehensive drug history including all prescriptions, over the counter and complementary medicines currently taken by the patient with verification from all available sources of information including the GP referral, the patient's own medications list or actual medications when available.
A retrospective audit of outpatient clinical medical records for a random sample of 300 patients referred to the Centre for management of diabetes-related complications between 1 January 2010 and 31 December 2011 was conducted. From the medical records and an in-house database, information provided in the GP referral letter was compared with that collected during the SNPI in the RPAH diabetes clinic.
Patients were eligible for inclusion if they had T2DM, this was their first referral to the clinic for a complications review during the study period and a complete medical record was available. All patients referred for management of complications undergo a comprehensive clinical assessment necessitating accurate referral information. Patients were excluded if they were participating in a clinical trial or were from a non-metropolitan area as these patients may have non-standard referral procedures or attend specialized non-metropolitan ('outreach') clinic sessions.
Based on a 14% discrepancy rate per patient derived from the literature, 289 medical records were needed to achieve a 95% confidence interval within 4% of the point estimate. Using the Diabetes Centre database, 1218 current clinic patients were eligible for inclusion in the study. A random sample of 341 patients (28%) was subsequently selected, with this oversampling to account for missing data/medical records.
Data collected included (i) patient demographics—age, sex, family history, interpreter needed and language other than English (ii) clinical data—duration of diabetes, HbA1c, chronic care plan documenting current and past medical problems, therapeutic goals and management strategies, (iii) record of diabetes-related complications (including CVD, retinopathy, nephropathy and neuropathy) and (iv) GP characteristics—GP gender, type of referral, practice type, date of referral and interview. Medication data from the GP referral letter and the SNPI, including name and dose of each diabetes-related medication, were recorded. Any differences between these two documented medication data lists were considered medication discrepancies.
Medicines were classified according to the World Health Organisation's Anatomical Therapeutic Chemical classifications. Diabetes-related medicines were defined as blood glucose-lowering agents (A10B and A10X), insulins (A10A), anti-hypertensive agents (C02) and lipid-modifying agents (C10). Insulins were further categorized into type by duration of action: ultra-short acting, short acting, intermediate acting, biphasic combinations and long-acting analogues in accordance with the Australian Medicines Handbook.
For the purposes of this study, medication discrepancies were defined as any difference, intended or unintended, between the diabetes-related medication list in the patient's GP referral letter, and the diabetes-related medications reported by the patient during the SNPI. The classification of type, definition and example pertinent to each type of medication discrepancy is listed in Table 1. Discrepancy types were mutually exclusive.
Data manipulation and analyses were carried out using Microsoft Access 2012 and IBM SPSS Statistics Data Editor Version 20.
Univariate and multiple regression analyses were conducted to identify possible risk factors associated with medication discrepancies. The dependent variable was the total number of diabetes-related medication discrepancies, and the independent variables included patient characteristics: age, gender (male/female), interpreter needed (yes/no), duration of diabetes, total number of complications, total number of medications, allergies (yes/no), chronic care plan (yes/no) and type of diabetes regimen (oral only or oral plus insulin). GP characteristics tested included gender, GP referral letter (hand written/computer generated) and GP practice type (group or individual), and the time elapsed between the GP referral letter to the clinic visit. The Student's t-test was used to test for differences in means for normally distributed variables, the Mann–Whitney U-Test for non-normally distributed variables and Spearman's Rho test for associations between continuous variables. All variables showing significant (P < 0.05) associations with total number of diabetes-related medication discrepancies were entered into the multiple regression analysis. The study was approved by the Sydney Local Health District Ethics Review Committee (Protocol No X12-0206 & HREC/12/RPAH/327).
Methods
Study Setting
The study was conducted at a tertiary outpatient Diabetes Ambulatory Care Centre associated with a major teaching hospital in Sydney, Australia. T2DM patients are referred to the Centre by their GP. The Diabetes Ambulatory Care Centre promotes a shared-care model between the referring GP, the patient and the Centre. GPs provide a written referral, including a list of current medications, for all referred patients. All patients undergo a structured nurse–patient interview (SNPI), by a specialist diabetes nurse during their clinic visits. The SNPI involves a comprehensive drug history including all prescriptions, over the counter and complementary medicines currently taken by the patient with verification from all available sources of information including the GP referral, the patient's own medications list or actual medications when available.
Study Design
A retrospective audit of outpatient clinical medical records for a random sample of 300 patients referred to the Centre for management of diabetes-related complications between 1 January 2010 and 31 December 2011 was conducted. From the medical records and an in-house database, information provided in the GP referral letter was compared with that collected during the SNPI in the RPAH diabetes clinic.
Study Population
Patients were eligible for inclusion if they had T2DM, this was their first referral to the clinic for a complications review during the study period and a complete medical record was available. All patients referred for management of complications undergo a comprehensive clinical assessment necessitating accurate referral information. Patients were excluded if they were participating in a clinical trial or were from a non-metropolitan area as these patients may have non-standard referral procedures or attend specialized non-metropolitan ('outreach') clinic sessions.
Sample Size
Based on a 14% discrepancy rate per patient derived from the literature, 289 medical records were needed to achieve a 95% confidence interval within 4% of the point estimate. Using the Diabetes Centre database, 1218 current clinic patients were eligible for inclusion in the study. A random sample of 341 patients (28%) was subsequently selected, with this oversampling to account for missing data/medical records.
Data Collection and Comparison
Data collected included (i) patient demographics—age, sex, family history, interpreter needed and language other than English (ii) clinical data—duration of diabetes, HbA1c, chronic care plan documenting current and past medical problems, therapeutic goals and management strategies, (iii) record of diabetes-related complications (including CVD, retinopathy, nephropathy and neuropathy) and (iv) GP characteristics—GP gender, type of referral, practice type, date of referral and interview. Medication data from the GP referral letter and the SNPI, including name and dose of each diabetes-related medication, were recorded. Any differences between these two documented medication data lists were considered medication discrepancies.
Diabetes-Related Medicines
Medicines were classified according to the World Health Organisation's Anatomical Therapeutic Chemical classifications. Diabetes-related medicines were defined as blood glucose-lowering agents (A10B and A10X), insulins (A10A), anti-hypertensive agents (C02) and lipid-modifying agents (C10). Insulins were further categorized into type by duration of action: ultra-short acting, short acting, intermediate acting, biphasic combinations and long-acting analogues in accordance with the Australian Medicines Handbook.
Medication Discrepancies
For the purposes of this study, medication discrepancies were defined as any difference, intended or unintended, between the diabetes-related medication list in the patient's GP referral letter, and the diabetes-related medications reported by the patient during the SNPI. The classification of type, definition and example pertinent to each type of medication discrepancy is listed in Table 1. Discrepancy types were mutually exclusive.
Analysis
Data manipulation and analyses were carried out using Microsoft Access 2012 and IBM SPSS Statistics Data Editor Version 20.
Univariate and multiple regression analyses were conducted to identify possible risk factors associated with medication discrepancies. The dependent variable was the total number of diabetes-related medication discrepancies, and the independent variables included patient characteristics: age, gender (male/female), interpreter needed (yes/no), duration of diabetes, total number of complications, total number of medications, allergies (yes/no), chronic care plan (yes/no) and type of diabetes regimen (oral only or oral plus insulin). GP characteristics tested included gender, GP referral letter (hand written/computer generated) and GP practice type (group or individual), and the time elapsed between the GP referral letter to the clinic visit. The Student's t-test was used to test for differences in means for normally distributed variables, the Mann–Whitney U-Test for non-normally distributed variables and Spearman's Rho test for associations between continuous variables. All variables showing significant (P < 0.05) associations with total number of diabetes-related medication discrepancies were entered into the multiple regression analysis. The study was approved by the Sydney Local Health District Ethics Review Committee (Protocol No X12-0206 & HREC/12/RPAH/327).
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