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JAAPA Letters to the Editor, August 2008

Special Article: Helping to ensure safer transitions in hospitals

To the Editor:

I want to commend the AAPA Quality Care Committee (QCC) for taking the time to address such an important topic as medication reconciliation (Special article, "Helping to ensure safer transitions in hospitals," which was published in the March 2008 issue). As we all are aware, adverse drug reactions can be dangerous for our patients and costly for the provider and hospitals alike. I hope that the Committee will continue to address important topics like this in the future.

I would like to make a few comments regarding the proposals the Committee made in the article. I believe that there are three areas to consider when looking at medication reconciliation. The first consideration is whether to choose a paper-based or an electronic process. Second, how the home meds list is compiled during the admission process (and how this list will be addressed during the transfer and discharge process). And third, what role clinical decision support tools play in a medication reconciliation process.

In the beginning, when hospitals were challenged with developing a medication reconciliation process, the obvious choice was a paper solution. A paper medication reconciliation form provided a recognizable list of the patient's home medications. This method is easy, does not require any additional training or equipment, and is inexpensive. Completion of this form could be carried out by any member of the patient care team (physician, PA, NP, nurse, pharmacist, or pharmacy technician) but still required an authorized provider to sign off on the list of medications, in order to meet the Joint Commission requirements. In most cases, this process worked best if the nurse, pharmacy tech, or pharmacist filled in the list of the patient's home medications and then the appropriate provider would designate to continue, stop, or modify what was on the list.

With the advances in electronic medical records and increased acceptance of these processes by clinicians, it is a natural progression for the paper-based medication reconciliation process to migrate to an electronic process. Just like in the paper-based process, a list of medications is compiled and then the appropriate provider signs off on the list to complete the reconciliation process. However, simply taking a paper system and converting it to an electronic format provides little extra value to the provider. In this format, the medication reconciliation process does not address the major problem associated with the patient's home medications list: Relying on the patient, a spouse, family member, or caregiver to be able to recall, in significant enough detail, the doses, routes, and frequency of all the medications the patient is currently taking. If the patient is capable to recall these details, he or she can contribute in this process. However, it is entirely possible and becoming more common that patients, because of a disease state or injury, are unable to recall their medications and/or may not understand why they are taking the medications. Importantly, a spouse, family member, or caregiver may not know this information, either. In many cases, the admitting hospital spends many hours calling primary care physicians and pharmacies or using other means to compile the patient's home medication list. Having an electronic process that can populate a list of the patient's home medications based on filled prescriptions from retail pharmacies, information from pharmacy benefits managers, and identification of disparate pills will help to more accurately compile this list on admission. One key factor that providers should remember is that any electronic solution does not absolve the provider from having verbal communications with the patient, spouse, or family member to compile the home medication list. We are all responsible for reviewing the medication list for accuracy. The fact that a prescription was filled by a retail pharmacy does not ensure that the patient is taking the medication, taking it regularly, or taking it at the prescribed dose. Over-the-counter medications may not show up automatically (in an electronic programs format), so it is still important for providers to ask the appropriate questions during a history and examination process.

The second advantage of an electronic solution is the ability to immediately receive warnings/alerts of drug interactions, drug allergies, drug-drug reactions, drug-food allergies/interactions, and drug duplications. These alerts can help providers identify potential adverse drug events prior to their occurrence so they can make necessary changes in medication selections. This alert checking does not automatically occur in a paper based system. Even though these alerts occur, it does not negate the contributions of or remove the pharmacist from ensuring the safe and efficacious management of a patient's medications.

A third advantage to an electronic solution is embedded pharmacology reference sources that allow providers to quickly reference a specific medication without having to go to a different resource. The rationale being that the provider could review indications, contraindications, dosages, pharmacokinetics, administration, and any potential black box warnings immediately for any medication. Again, in a paper system this process would have to be carried out via a thorough review of a paper text, electronic text source (PDA) requiring a change in the workflow.

Last, during the discharge medication reconciliation process, the provider needs to be able to give the patient a current medications list to take home. This list should be easily read and understood by the patient, list both brand and generic names, and provide the patient with a means to carry such a list on their person so that they, a spouse, or family member can reproduce the list should it be the needed. Patients should get language-specific written instructions regarding their injury/disease and similar information for each medication that they are taking after discharge. Finally this process should include informing the family physician and/or consultant physician of the medications this patient is currently taking. Last, e-prescribing should be available, if appropriate.

A paper-based medication reconciliation system can be an excellent source for compiling a patient's home medication list prior to and during the admission process. However, a paper-based medication reconciliation process has to rely on the patient's memory of what medications are being taken, is unable to immediately provide alerts/warnings of drug interactions and potential adverse effects, does not address illegible handwriting problems, cannot provide a disease or pharmacology reference source within the workflow, does not provide disease/pharmacology-specific patient discharge information, and does not allow for reliable communication of home/discharge med information to the next caregiver after the patient is discharged.

The medication reconciliation process is a complex problem that affects all members of the healthcare team. A method that enhances this process will ultimately improve the quality of care for our patients by reducing potential adverse drug effects.

Thank you for allowing me to express my views and, again, I commend the committee members for addressing such an important topic.

Author's response:

Thank you for adding some good points to medication reconciliation. The QCC agrees that the electronic version would probably be the better method. However, most areas of the country, especially the rural areas, are unable to use the electronic version because of its cost. The advantage of having a member of the pharmacy team included in the process is that they can call the local pharmacies and to get a complete list of medications. But I can tell you through personal experience that the mail-order pharmacies are not very helpful and contacting them is time consuming. The QCC and the AAPA are committed to reducing medication errors and adverse events. Medication reconciliation is one step towards that goal.

James M. Taft, Immediate Past Chair
AAPA Quality Care Committee

Dermatology Digest: The lesion on this patient's tongue really hurts

To the Editor:

I would like to comment on the Dermatology Digest article by Sara Elder, "The lesion on this patient's tongue really hurts," published in the June issue of JAAPA.

I would like to give sincere credit to Ms. Elder for her initiative in wanting to publish such an interesting case and to share it with her fellow students and soon-to-be colleagues. I only wish that more students were as interested in academics and publishing interesting cases. However, I have some concerns regarding this article.

First, while this is a very informative article, there are no medical references made. I feel this sets a bad example for this student and others who wish to pursue publishing in the future. It is improper to allow an article to present medical facts without providing the source(s) of that information. Should there not have been some oversight in this regard, whether from a faculty mentor, co-author, or even the department editor for the Journal?

Second, the image presented depicts more of an apthous ulceration than the classic presentation of lichen planus with a "lace-like pattern of white hyperkeratosis (Wickham's striae)."¹ While the patient may have had an unusual presentation of ulcerative lichen planus, she may also have had a common apthous stomatitis—a diagnosis this picture is much more consistent with—which affects nearly 20% of the population and in itself may not carry an increased risk for oral squamous cell carcinoma.² I think that the image may confuse many of your readers and can potentially lead to an inappropriate diagnosis of lichen planus in a patient who may, in fact, have a simple apthous ulcer. Interesting enough, apthous ulcer was not even a choice in the differential diagnosis presented.

In conclusion, I feel that this was a very informative and interesting topic but it could have been presented in a more thorough and professional manner. I would hope that some consideration is given in the future to articles being supported by credible medical literature and with proper oversight.

Jason C. Fowler, MPAS, PA-C, PA(ASCP)
Meadville, Pennsylvania

REFERENCES

1. Lichen planus. In: Wolf K, Johnson RA, Suurmond R, eds. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. 5th ed. New York, NY: McGraw-Hill Professional Publishing; 2005:1031.

2. Pathology of the oral cavity, oropharynx and odontogenic lesions. In: Fu YS, Wenig BM, Abemayor E, Wenig B, eds. Head and Neck Pathology: With Clinical Correlations. Oxford, England: Churchill-Livingstone; 2001:519-520.

Editor's response:

I agree with you regarding the value and necessity of references in medical articles generally. Most of JAAPA�\our CME articles, our review articles, and our longer department pieces�\is referenced, and we do our best to make the majority of our content as evidence-based as possible. However, we publish a handful of short (usually 1 page), clinical quiz-type departments�\such as Dermatology Digest and Case of the Month�\where we discourage references. The focus in these departments is on the quiz, where the reader is presented with a succinct case, asked to guess the diagnosis (usually with the help of a clinical image), and then provided with a deliberately brief explanation. Our feedback surveys indicate that PAs enjoy reading these departments and do so in large numbers.

Regarding the oversight for these clinical quiz departments, the department editors review manuscripts and work with the authors to ready their articles for publication. Although the manuscripts for these departments do not undergo the type of peer review that we provide for our longer articles, the department editors are expert clinicians in their topic areas, and we believe that they provide sufficient vetting to the articles they receive.

Tanya Gregory, PhD
Editor

Author's response:

I agree with some of Mr. Fowler's comments and, as the department editor, I have to accept the lion's share of the responsibility for the article's shortcomings.

The point of the article is that oral ulcers have a broad differential and biopsy is necessary to establish the correct diagnosis. Aphthous ulcers are far more common than lichen planus (LP) in the mouth; however, any given episode of aphthous ulcers are typically limited to about 2 weeks duration and are almost never referred to dermatology because there is no need for a specialist.

LP is something we see often in dermatology, probably because the more common causes have already been ruled out by primary care. Although not at all rare, this presentation is not common either.

The biopsy is the final arbiter in these cases, not the "classic presentation," because the findings in LP are pathognomonic. We could have cited any number of authors as references for our case, but the facts spoke for themselves.

Joe R. Monroe, MPAS
Department editor

Dermatology Digest: A serious condition or a benign masquerade?

To the Editor:

I am a PA currently practicing in blood and marrow transplant. I was interested in the article on mycosis fungoides (MF) in the July 2008 issue of JAAPA ("A serious condition or a benign masquerade?" Dermatology Digest.).

I would like to add to the information provided by the three authors. The article states that MF is not curable; this information is absolutely incorrect. Late stage MF is potentially curable with an allogeneic hematopoetic stem cell transplant (commonly referred to as a bone barrow transplant from a donor). However, long-term survival is not great—approximately 30%-50% at 5 years after transplant. A large percentage of the mortality is attributed to the risks inherent in the transplant procedure. At the H. Lee Moffitt Cancer and Research Center in Tampa, where I practice, we currently have two active patients with MF. One is about a year posttransplant, is in remission, and is doing well; the other has had several transplant-related complications but will be discharged from the hospital soon.

The authors of the article only cited one reference. They need to look in hematology and/or transplant-related publications to find the information I have just discussed.

Mark J Honor, PA-C
Tampa, Florida

Author's response:

We welcome Mr. Honor's comments. He brings up some interesting points.

As we state in our article, early detection of MF is important precisely because long-term survival is improved by early intervention. To our knowledge, however, early treatments control but do not eradicate the malignant lymphocytes. Moreover, as Mr. Honor correctly points out, most patients with advanced MF do not survive even after intervention, either because of the treatment itself or because of recurrence of the lymphoma.

The larger issue here is the gray area between hope and statistically sound long-term survival rates. We recognize that bone marrow transplants strengthen our efforts to battle MF, and we are optimistic that new therapeutic interventions will in the future extend survival. Still, we suggest caution in equating low 5-year survival rates with a cure. We do not want to offer false hope to patients or mislead the medical community.

By convention, references in Dermatology Digest are limited to one or two citations in the published version. Our experience and review of the literature, including published studies using bone marrow transplants, leads us to conclude that late-stage MF is, unfortunately, incurable at this time.

David Payton, MA, MMS, PA-C
Christopher Reardon, PhD, MD
Michel Statler, MLA, PA-C

When the Patient Asks: What's the best sun protection to use?

To the Editor:

I am writing in regard to my disappointment in the When the Patient Asks article in the July 2008 issue of JAAPA. The article was about sun protection and included outdated information. For the first time since 1972, new sunscreens were approved in Spring 2007 for use in the United States. I think the PA profession should know this. This information was on several national television programs, but the article in our journal offered information that dates back to 1972.

What about ecamsule (Mexoryl)? Mexoryl is a new broad-spectrum chemical sunscreen that has photostability for 5 to 6 hours. Neutrogena and Aveeno developed a stabilized form of avobenzone, which is also photostable so patients don't have to reapply the product every 2 hours. I think an explanation of the difference between a chemical and a physical sunscreen would have been nice because patients may ask that question. As practitioners, we know the public does not follow the reapplication guidelines. The newer sunscreens fit our busy lives and lazy habits. Furthermore, clothing designed for sun protection is bigger than ever. There are many stores that offer such; and the clothes are very stylish too.

All forms of skin cancer are on the rise, but melanoma occurs at a rate close to 1 in 75 persons and is completely preventable. As a PA practicing in dermatology, I don't tell my patients to avoid the sun, I tell them to be sensible, and I teach them the tricks to having fun in the sun safely.

I am disappointed that the author did not do more research to find the most up-to-date information that the dermatology world is buzzing about.

Wendy Meredith, PA-C

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