Person: Borus, Joshua
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Borus
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Borus, Joshua
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Publication Adverse Drug Events in Ambulatory Care(Massachusetts Medical Society, 2003-04-17) Gandhi, Tejal; Weingart, Saul N.; Borus, Joshua; Seger, Andrew; Peterson, Josh; Burdick, Elisabeth; Seger, Diane L.; Small, Kirstin; Federico, Frank; Leape, Lucian; Bates, DavidBackground: Adverse events related to drugs occur frequently among inpatients, and many of these events are preventable. However, few data are available on adverse drug events among outpatients. We conducted a study to determine the rates, types, severity, and preventability of such events among outpatients and to identify preventive strategies. Methods: We performed a prospective cohort study, including a survey of patients and a chart review, at four adult primary care practices in Boston (two hospital-based and two community-based), involving a total of 1202 outpatients who received at least one prescription during a four-week period. Prescriptions were computerized at two of the practices and handwritten at the other two. Results: Of the 661 patients who responded to the survey (response rate, 55 percent), 162 had adverse drug events (25 percent; 95 percent confidence interval, 20 to 29 percent), with a total of 181 events (27 per 100 patients). Twenty-four of the events (13 percent) were serious, 51 (28 percent) were ameliorable, and 20 (11 percent) were preventable. Of the 51 ameliorable events, 32 (63 percent) were attributed to the physician's failure to respond to medication-related symptoms and 19 (37 percent) to the patient's failure to inform the physician of the symptoms. The medication classes most frequently involved in adverse drug events were selective serotonin-reuptake inhibitors (10 percent), beta-blockers (9 percent), angiotensin-converting-enzyme inhibitors (8 percent), and nonsteroidal antiinflammatory agents (8 percent). On multivariate analysis, only the number of medications taken was significantly associated with adverse events. Conclusions: Adverse events related to drugs are common in primary care, and many are preventable or ameliorable. Monitoring for and acting on symptoms are important. Improving communication between outpatients and providers may help prevent adverse events related to drugs.Publication Adverse Drug Events in Ambulatory Care(Massachusetts Medical Society, 2003-04-17) Gandhi, Tejal; Weingart, Saul N.; Borus, Joshua; Seger, Andrew C.; Peterson, Josh; Burdick, Elisabeth; Seger, Diane L.; Small, Kirstin; Federico, Frank; Leape, Lucian; Bates, DavidBACKGROUND Adverse events related to drugs occur frequently among inpatients, and many of these events are preventable. However, few data are available on adverse drug events among outpatients. We conducted a study to determine the rates, types, severity, and preventability of such events among outpatients and to identify preventive strategies. METHODS We performed a prospective cohort study, including a survey of patients and a chart review, at four adult primary care practices in Boston (two hospital-based and two community-based), involving a total of 1202 outpatients who received at least one prescription during a four-week period. Prescriptions were computerized at two of the practices and handwritten at the other two. RESULTS Of the 661 patients who responded to the survey (response rate, 55 percent), 162 had adverse drug events (25 percent; 95 percent confidence interval, 20 to 29 percent), with a total of 181 events (27 per 100 patients). Twenty-four of the events (13 percent) were serious, 51 (28 percent) were ameliorable, and 20 (11 percent) were preventable. Of the 51 ameliorable events, 32 (63 percent) were attributed to the physician's failure to respond to medication-related symptoms and 19 (37 percent) to the patient's failure to inform the physician of the symptoms. The medication classes most frequently involved in adverse drug events were selective serotonin-reuptake inhibitors (10 percent), beta-blockers (9 percent), angiotensin-converting–enzyme inhibitors (8 percent), and nonsteroidal antiinflammatory agents (8 percent). On multivariate analysis, only the number of medications taken was significantly associated with adverse events. CONCLUSIONS Adverse events related to drugs are common in primary care, and many are preventable or ameliorable. Monitoring for and acting on symptoms are important. Improving communication between outpatients and providers may help prevent adverse events related to drugs.Publication Patient-Reported Medication Symptoms in Primary Care(American Medical Association (AMA), 2005-01-24) Weingart, Saul N.; Gandhi, Tejal; Seger, Andrew; Seger, Diane L.; Borus, Joshua; Burdick, Elizabeth; Leape, Lucian; Bates, DavidBackground Little is known about the prevalence and character of medication-related symptoms in primary care and their relationship to adverse drug events (ADEs) or about factors that affect patient-physician communication regarding medication symptoms. Methods The study included 661 patients who received prescriptions from physicians at 4 adult primary care practices. We interviewed patients 2 weeks and 3 months after the index visit, reviewed patients’ medical records, and surveyed physicians whose patients identified medication-related symptoms. Physician reviewers determined whether medication symptoms constituted true ADEs. We used multivariable regression to examine factors associated with patients’ decision to discuss symptoms with a physician and with physicians’ decision to alter therapy. Results A total of 179 patients identified 286 medication-related symptoms but discussed only 196 (69%) with their physicians. Physicians changed therapy in response to 76% of reported symptoms. Patients’ failure to discuss 90 medication symptoms resulted in 19 (21%) ameliorable and 2 (2%) preventable ADEs. Physicians’ failure to change therapy in 48 cases resulted in 31 (65%) ameliorable ADEs. In multivariable analyses, patients who took more medications (odds ratio [OR] = 1.06; 95% confidence interval [CI] = 1.04-1.08; P<.001) and had multiple medication allergies (OR = 1.07; 95% CI = 1.03-1.11; P = .001) were more likely to discuss symptoms. Male physicians (OR = 1.20, 95% CI = 1.09-1.26; P = .002) and physicians at 2 practices were more likely to change therapy (OR = 1.24; 95% CI = 1.17-1.28; P<.001; and OR = 1.17; 95% CI = 1.08-1.24; P = .002). Conclusion Primary care physicians may be able to reduce the duration and/or the severity of many ADEs by eliciting and addressing patients’ medication symptoms. Patients’ experiences of medical care offer insights into health care quality. Patient reports have been used to evaluate dimensions of inpatient and ambulatory care, such as communication, coordination, family involvement, and respect for patient preferences.1,2 Recognizing patients’ ability to judge quality, several groups have recommended that patients play a role in reducing medical errors and injuries.3-5 In favor of this view is the observation that patients and their families are motivated and attentive observers.6 They may, for example, notice discrepancies between the dosage of an antihypertensive drug prescribed by a patient’s internist and that prescribed by his or her cardiologist or the inadvertent prescription of an antibiotic to which a patient is allergic. However, there is little empirical evidence regarding the role of patients in identifying and preventing medical harm.7 For hospitalized patients, the technical complexity of medical care and the acute nature of their illnesses undermine their ability to recognize problems. In ambulatory patients, several studies document poor understanding of treatment recommendations or medication regimens.8-10 Two recent reports address patients’ ability to identify medication-related errors and injuries in primary care. In the Ambulatory Quality Improvement Project, 18% of patients in 11 primary care practices reported a problem due to medications in the previous year, but only 3% of patients’ charts recorded this finding.11 A limitation of the study was the lack of corroboration by physicians of patient-reported medication symptoms. To further characterize adverse drug events (ADEs, defined as injuries due to medications) in ambulatory care, we used chart review and patient interviews in a multifaceted study of 4 primary care practices in Boston, Mass. In our first study, which focused on the epidemiology of ADEs, we found that 25% of 661 patients experienced an ADE. Consistent with the results of the Ambulatory Quality Improvement Project, we found that 92% of ADEs confirmed by physician reviewers were identified from patient surveys, 28% by chart review, and 19% by both methods.12 Importantly, 28% of ADEs could have been mitigated with better patient-physician communication. The goal of the present study was to understand the medication-related symptoms experienced by members of this patient cohort as well as the contribution of poor patient-physician communication to ADEs. We theorized that if patients and physicians communicated more effectively about medication-related symptoms, then the intensity or duration of symptoms could be mitigated. Specifically, we sought to answer the following questions: (1) What are the frequency, type, and severity of patient-identified medication symptoms? (2) How often do clinicians agree with patients’ attribution of symptoms to their medications? (3) What factors are associated with patients’ decisions to tell physicians about symptoms? (4) What factors are associated with physicians’ decisions to address patient-reported medication symptoms?