| Assessment of the appropriateness of serum digoxin concentration measurement in a medical group setting. | |
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MedLine Citation:
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PMID: 22050394 Owner: NLM Status: In-Data-Review |
Abstract/OtherAbstract:
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BACKGROUND: Recent quality initiatives require that the routine annual therapeutic drug-monitoring (TDM) parameters for the high-risk medication digoxin include a measure of renal function and a serum potassium level but not a serum digoxin concentration (SDC) measurement. Several studies have shown that the majority of the SDCs obtained in hospital settings provide little clinically actionable information. OBJECTIVE: To evaluate the appropriateness and utility of SDCs ordered in a medical group practice setting by categorizing the reason the SDC was ordered and identifying action taken in response to the result. METHODS: The descriptive study was conducted as a retrospective, electronic medical record (EMR) review of 90 primary care patients with continuous prescriptions for digoxin current on their medication profile with no gaps in therapy for at least 2 years prior to an SDC result entered into the EMR between January 1, 2009, and September 30, 2009. The reason the SDC was ordered was abstracted independently by 2 reviewers, who then assigned it to 1 of 8 predefined indication categories based on previously published criteria and practice guidelines. A third reviewer resolved inter-reviewer discrepancy (n?=?1). RESULTS: A total of 90 patients with at least 1 SDC met inclusion criteria. Routine monitoring was the most frequent SDC order indication category with 35 patients (38.9%), 17 (48.6%) of whom did not have the recommended monitoring measures of potassium or renal function drawn concurrently. Patients were included in other categories as follows: confirmation of signs/symptoms of toxicity 30 (33.3%); assessment of factors altering pharmacokinetics 5 (5.6%); assessment of dosage change 5 (5.6%); assessment of drug interaction 3 (3.3%); assessment of clinical response 3 (3.3%); assessment of adherence 1 (1.1%); and other 2 (2.2%). Across all categories, a total of 19 (21.1%) of SDC results were outside the therapeutic range of 0.5 nanograms (ng) per mL and 2.0 ng per mL, 18 of which were below 0.5 ng per mL, with none of the subtherapeutic levels leading to a change in digoxin therapy. Only 1 patient (1.1%) had therapy changed in response to an elevated abnormal SDC result of 2.1 ng per mL and was in the routine monitoring category. CONCLUSIONS: The majority of SDC results obtained in our medical group setting did not lead to clinical action, such as dose adjustment or drug discontinuation. SDCs were commonly measured as part of routine monitoring, which is considered an inappropriate indication, and often without being accompanied by better markers for digoxin toxicity such as serum potassium levels and measures of renal function as recommended by drug-monitoring quality initiatives. Provider education is needed regarding the most indicative digoxin TDM parameters to obtain in order to satisfy quality initiatives. |
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Authors:
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Kathleen B Orrico; May Wu; Ariane R Wilson |
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Publication Detail:
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Type: Journal Article |
Journal Detail:
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Title: Journal of managed care pharmacy : JMCP Volume: 17 ISSN: 1944-706X ISO Abbreviation: J Manag Care Pharm Publication Date: 2011 Nov |
Date Detail:
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Created Date: 2011-11-04 Completed Date: - Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 9605854 Medline TA: J Manag Care Pharm Country: United States |
Other Details:
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Languages: eng Pagination: 695-700 Citation Subset: IM |
Affiliation:
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Palo Alto Medical Foundation, 765 El Camino Real Pharmacy Level A, Palo Alto, CA 94301. USA. orricok@pamf.org. |
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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