Abstract
Purpose
To enable the use of automatic clinical decision support for pharmacotherapy in patients with bariatric surgery, it is necessary to register the contraindication “bariatric surgery” in the hospital, general practitioner (GP), and community pharmacy electronic health record systems. The aim of this research was to quantify the correct registration of this contraindication in hospital, GP, and community pharmacy records. Furthermore, we investigated whether the registration status in primary care was dependent on the registration status in the hospital.
Methods
From patients who underwent bariatric procedures performed in the Albert Schweitzer Hospital (Dordrecht, the Netherlands) between 2018 and 2021, the percentage of registered contraindications in hospital medical records was assessed. Due to feasibility reasons, a subset of the patients’ data was created for assessing the percentage of registered contraindications in GP and community pharmacy records.
Results
Out of 664 patients who underwent bariatric surgery, the contraindication bariatric surgery was registered in 69.1% of the cases. Out of 552 patients, 28.3% and 25.1% were correctly registered in GP and community pharmacy records, respectively. There was no correlation between registration status in the hospital EHR and registration status in GP practices or community pharmacies.
Conclusions
The percentage of correct registration of bariatric surgery in hospital, GP, and community pharmacies is low. To avoid doctors prescribing and pharmacists dispensing drugs to post-bariatric patients without knowing that they have undergone this procedure, better registration of the contraindication is required to enable optimal use of clinical decision support systems for the pharmacotherapy of patients after bariatric surgery.
Keywords: Medication error, Bariatric surgery, Electronic health records, Clinical decision support systems, Care transition
Background
The number of bariatric surgical procedures performed has increased globally in the last decade. Of these procedures, Roux-en-Y gastric bypass and gastric sleeve are most frequently performed [1, 2]. In recent years, there has been increased awareness of the correct use of medication after bariatric surgery. Several reviews illustrate that the pharmacokinetics of drugs can change as a consequence of bariatric surgery [3–6], leading to adjusted drug dosing advice. A recent report also described pharmacovigilance signals showing changes in drug efficacy and adverse drug reactions after bariatric surgery [7].
A contraindication is defined as a patient’s feature based on which a drug should be avoided or the dose of the drug adjusted accordingly. It is coded in an unambiguous and comprehensive way as structured data into the electronic health record systems (EHRs) used by physicians and pharmacists. After correct registration of this contraindication, e.g., bariatric surgery, healthcare professionals can exchange the contraindication. In case a drug is prescribed or dispensed to a patient with bariatric surgery, relevant drug-specific recommendations will appear automatically, if available. However, when the contraindication is not entered as structured data, e.g., only described as nonstructured text in the medical history, recommendations will not be automatically triggered when a relevant drug is prescribed or dispensed. Unstructured data are difficult to extract. To date, it is challenging to analyze free-text clinical notes in EHRs [8].
In the Netherlands, recommendations are available for the dose and choice of drugs with respect to the contraindication “bariatric surgery,” proposed by guidelines of the Working Group of the Royal Dutch Association for the Advancement of Pharmacy (KNMP). The recommendations are incorporated into the Dutch computerized medication surveillance systems for all prescribers, including general practitioners (GPs), bariatric surgeons, and pharmacists. These recommendations are frequently updated, forming a major step forward in the implementation of medication safety and optimizing dosing advice in daily clinical practice. However, to use these recommendations via a clinical decision support system, it is essential that bariatric surgery be registered as a contraindication in EHRs.
The Albert Schweitzer Hospital in Dordrecht is one of 19 hospitals in the Netherlands in which bariatric surgery is performed. In this hospital, approximately 200 procedures are conducted annually. Normally, bariatric surgeons inform GPs about the treatment in the hospital. Relevant patient-specific structured information can be shared via a national network (“Landelijk Schakelpunt”) to which the majority of community and outpatient pharmacies, GP practices, and hospitals in the Netherlands are connected.
Clinical decision support for patients with bariatric surgical procedures can be enabled, provided that bariatric surgery is entered as a contraindication in a structured way. Given the potential lifetime benefits of a correctly documented contraindication in all prescribing and pharmacy systems, it is important to ensure that contraindications are properly registered and exchanged with other healthcare providers. Clinical decision support systems have been implemented in multiple countries, such as the USA, Canada, the UK, Denmark, and Australia [9].
The primary aim of this research was to study the percentage of bariatric surgical procedures currently registered by healthcare professionals treating these patients, including hospitals, GPs, and community pharmacists. As a secondary aim, we assessed whether the registrations in GP and pharmacy systems were dependent on the registration status in the hospital.
Methods
Study design, population, and data collection
This cross-sectional study was conducted in the Albert Schweitzer Hospital, a teaching hospital situated in Dordrecht (the Netherlands). The patients who underwent bariatric surgical procedures between 2018 and 2021 and all registrations of the contraindication “bariatric surgery” were extracted from the EHR system HiX 6.1 (Chipsoft, Amsterdam, the Netherlands). In the Netherlands, patients are eligible for bariatric surgery if they are 18 years old or older. The starting date of 2018 was chosen because therapeutic recommendations about dose adjustments after bariatric surgery were implemented in Dutch healthcare systems since then. Moreover, bariatric surgeons in our clinic have implemented the registration of contraindications since 2018.
This study was an evaluation of the process of registering bariatric surgery as a contraindication among patients who underwent bariatric surgery. Due to the nature of this study being an evaluation of healthcare procedures, the local review committee approved this study and declared that it was waived for informed consent from patients.
The percentage of bariatric surgery registered as a contraindication was assessed in both the hospital and primary care settings. For the evaluation in primary care, the researchers contacted the GPs and community pharmacists of patients to check whether the contraindication had been already registered correctly. If no registration was present, the researchers advised them to register the contraindication to enable future benefit. In some cases, GPs and community pharmacies share information about contraindications via a linked electronic patient system. Therefore, the contraindication could have been registered during the research period, which could potentially lead to an overestimation of the registration. Hence, the date of registration was included to prevent incorrect interpretation of the data.
The GPs and community pharmacists were contacted in order from most to least number of patients registered per GP practice or pharmacy. For feasibility reasons, we intended to retrieve data from a subset that consisted of at least 80% of the patients to evaluate registration of the contraindication in a primary care setting.
Statistical analyses
Data were entered into an Access (Microsoft Access; IBM Corp.; version 2016) spreadsheet on a password-protected network. Descriptive statistical analyses were conducted with Access. Medians (ranges) were reported when continuous data were not normally distributed, tested by means of a Q-Q plot. Since a subset was used for the evaluation in primary care, the patient characteristics of the subset and complete dataset were compared with either a two-sample T-test or Chi-square test (two-sided, α = 0.05).
Results
Characteristics of the study sample
From the hospital EHRs, 686 bariatric surgical procedures were extracted between 2018 and 2021. Twenty-two patients underwent multiple bariatric surgical procedures. The first records of these duplicates were excluded, leaving 664 unique patients for assessment of registration in hospital EHRs. Of these, a subset of 552 (83%) was created to retrieve pharmacy and GP data. The subset was based on the pharmacies and GPs that had the most patients per GP practice or pharmacy, as described in the “Methods” section. Figure 1 shows the flowchart for patient eligibility and inclusion. There were no statistically significant differences in the patients’ characteristics between the subset and complete dataset (Table 1).
Fig. 1.
Flowchart of patient eligibility and study inclusion
Table 1.
Overview of patient characteristics
| Characteristic | Dataset registration in hospital (n = 664) | Dataset registration in GP and community pharmacies (n = 549) |
|---|---|---|
| Sex: female, n (%) | 524 (78.9%) | 432 (78.7%) |
| Age when undergoing bariatric surgery (sd) | 44.0 (12.1) | 44.0 (12.0) |
| Year of bariatric surgery, n (%) | ||
| 2018 | 220 (33.1%) | 174 (31.7%) |
| 2019 | 196 (29.5%) | 161 (29.3%) |
| 2020 | 105 (15.8%) | 89 (16.2%) |
| 2021 | 143 (21.5%) | 125 (22.8%) |
| Type of bariatric surgery, n (%) | ||
| Roux-en-Y gastric bypass | 440 (66.3%) | 359 (65.4%) |
| Gastric sleeve | 221 (33.3%) | 188 (34.2%) |
| Other | 3 (0.5%) | 2 (0.4%) |
In our dataset, 78.9% of the patients who underwent bariatric surgery were female. The numbers of surgical procedures performed in 2020 and 2021 were lower due to the coronavirus disease 2019 (COVID-19) pandemic. The most commonly performed type of surgery in our clinic was Roux-en-Y gastric bypass.
Registration within the hospital electronic patient record
Out of 664 bariatric patients, bariatric surgery was registered in the primary hospital for a total of 459 cases overall (69.1%). Although the registration percentage tended to increase between 2018 and 2020, this was not the case in 2021 (Fig. 2).
Fig. 2.
Overview of correctly registered contraindications in the hospital medical record over time
Registration in the primary care setting
In the GP and pharmacy systems, 153 (27.9%) and 133 (24.2%) were registered correctly, respectively. The registrations in the order of hospital, GP, and pharmacy system are visualized in a Sankey diagram in Fig. 3. Green bars indicate correct registration, while red bars indicate incorrect registration. Complete registrations with the contraindication registered in both the GP and pharmacy systems occurred 49 out of 549 times (8.9%), as indicated in the bottom right corner of Fig. 3. In 312/549 (56.8%) cases, neither the GP nor the pharmacy had a registration of the contraindication.
Fig. 3.
Sankey diagram of bariatric surgery registered as contraindication in hospital and primary care. Red: not registered, green: registered. GP: general practitioner, pharmacy: community pharmacy, surgeries: bariatric surgical procedures performed in Albert Schweitzer Hospital between 2018 and 2021
Based on discussions with GPs and pharmacists, we identified several barriers to having the contraindication registered. First, pharmacies were rarely informed about the contraindication bariatric surgery by either the hospital or GP. Second, pharmacists remarked that patients do not inform them either, possibly due to a lack of awareness of the importance of adequate medication surveillance by pharmacists. Furthermore, although most GPs registered bariatric surgery in the patient records as nonstructured data, some of them were not aware of the need to separately enter the contraindication as structured data.
Furthermore, we did not find a correlation between registration status in the hospital EHR and registration status in GP practices or community pharmacies (Table 2). The number of registered contraindications in the primary care system was slightly higher when the contraindication was registered in the hospital EHR. However, the differences between the groups of registered and unregistered contraindications in the hospital EHR were not statistically significant. Therefore, registration in the hospital did not lead to an improved registration in primary care.
Table 2.
Registration status in the hospital vs. registration status at GP clinics and community pharmacies. Values were tested with chi-square tests (α = 0.05). GP: general practitioner
| Registered in the hospital (n = 395) | Not registered in the hospital (n = 154) | Difference | |
|---|---|---|---|
| Registration status GP | |||
| Registered | 118 (29.9%) | 35 (22.7%) | n.s |
| Unregistered | 277 (70.1%) | 119 (77.3%) | |
| Registration status community pharmacies | |||
| Registered | 98 (24.8%) | 35 (22.7%) | n.s |
| Unregistered | 297 (75.2%) | 119 (77.3%) | |
Discussion
To enable optimal clinical decision support in both hospital and outpatient settings, it is essential to register the contraindication “bariatric surgery” in a structured way in all EHRs. To our knowledge, this is the first study that investigated the extent to which the contraindication bariatric surgery was registered. The contraindication was registered in the hospital EHR for less than 70% of the patients, but the percentages were strikingly lower for GPs and community pharmacies.
The results of our study indicated that a substantial portion of patients who have undergone a bariatric surgical procedure are at risk of being prescribed and dispensed new drugs, which should be better avoided or dosed alternatively. This could be overcome by a better registration in both hospital and primary care settings.
In this research, we did not find an association between registration status in the hospital and in primary care. Thus, registration in hospitals does not guarantee registration in other healthcare institutes. This is probably due to the lack of an automatic integrated medication record system between the inpatient EHR, GP EHR, and community pharmacy system. Therefore, it would be preferred if all healthcare professionals had access to a nationally accessible system of shared contraindications and allergies (nationwide medication record system) [10], without the need for manual registrations. Health information exchange is an evolving concept in multiple countries, including the USA, UK, Australia, Scandinavian countries, Germany, and the Netherlands [11]. In the future, we strongly recommend the registration of contraindications in hospitals to be automatically shared in such a nationwide medication record system.
Patients who underwent bariatric surgery in our hospital before 2018 or who underwent surgery elsewhere were not included in this study. A possibility to identify these patients is by medication reconciliation by a pharmacy technician. Even when the registration did not take place correctly at the time of the surgery, we believe that registration afterward can still be beneficial to patients for future use of medication.
As a limitation of our study setup, we retrieved 83% of the data in the primary care setting. The patient characteristics of the subset were not different from those of the complete dataset. Therefore, there are no reasons to believe that the results of this present research would be different if all data had been retrieved. Although the data were collected from a single bariatric center in the Netherlands, we believe that the results can to some extent be extrapolated to other centers in the Netherlands and perhaps to other countries with similar healthcare systems with clinical decision support systems. Similar barriers for registration will be encountered in other regions, as long as manual registrations are needed in a nationwide system of shared contraindications.
Registration of bariatric surgery as a contraindication can be improved through additional education of healthcare providers and patients. It is essential that hospitals, GPs, and pharmacies cooperate to facilitate proper transfer of relevant patient-specific medical information, including the contraindication bariatric surgery. Moreover, we encourage advising patients to actively share their medical history of bariatric surgery to ensure correct registration in pharmacy and prescribing systems.
Our study focused on the registration itself and not on the number of medication errors that could have been prevented. Further research could be conducted on the medication-related harm that was caused by incorrect registration to further increase awareness among healthcare professionals.
Conclusions
We demonstrate that registration and exchange of the contraindication bariatric surgery in prescribing and community pharmacy systems needs improvement. Better registration of the contraindication enables automatic clinical decision support and thus improves pharmacotherapy for bariatric patients.
Author contribution
All authors contributed to the study conception and design. Data collection and analyses were performed by Ouarda Sbaa and Cedric Lau. The first draft of the manuscript was written by Cedric Lau, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Availability of data and materials
The datasets generated and analyzed during the current study are not publicly available due to individual privacy concerns, but are available from the corresponding author upon reasonable request.
Declarations
Ethical approval
This study was an evaluation of the process of registering bariatric surgery as a contraindication for patients who underwent bariatric surgery. The local committee of the Albert Schweitzer Hospital approved the protocol and declared that no informed consent from patients was required.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and analyzed during the current study are not publicly available due to individual privacy concerns, but are available from the corresponding author upon reasonable request.