ATRIAL FIBRILLATION And Digoxin

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ATRIAL FIBRILLATIONAnd Digoxin

• BY
• ROD BEARD
• PRINCIPAL PHARMACIST
• SUNDERLAND ROYAL HOSPTIAL

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Ernest Rutherford

• A good scientific theory should be explicable to
  a barmaid.

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MOTIVATION FOR WORK

• NICE guidance on AF produced in 2006
• Digoxin included in guidance
• No specific reference to target digoxin levels
• Discussion with NICE. They stated poor evidence
  base therefore not included.
• Because of this we decided to look into it.

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• This work forms part of PhD thesis.
• Thesis is based on Does Electronic Prescribing
  contribute to Clinical Governance?
• Focus in literature on EP on medication errors,
  but there area many more benefits
• This piece of work is one of a series in
  different areas that illustrate power of
  integrated EP systems.
• EP also brings corporate efficiencies that make
  a good case from a Trust business perspective

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SRH context

• SRH has around 990 beds
• SRH is a first wave Foundation Trust.
• Early AfC implementer
• Fully integrated EP system since 2002
• This means Medical records, HIS, prescribing,
  pathology, radiology, pharmacy, nurse
  administration all interlinked

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• Theme of thesis is that EP is more than a means
  to reduce medication errors, but has substantial
  other benefits.
• One of these is powerful audit capability.
• The study is one of several that has been used
  this approach to look at lithium, statins and
  cholesterol levels, osteoporosis, phosphate
  binders and haemodialysis

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Method

• Records for 2002 to 2006 were used
• Patients were selected on basis of those coded
  with diagnosis of A/F
• As part of system, patient demographics (age,
  gender etc) recorded.
• Any items prescribed at hospital also recorded
  ( not community)
• Any blood level measurements recorded

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• This study looked represents one of the larger
  ones done with regard to digoxin monitoring.
• Previously, most studies have looked at around
  20 to 30 patients, and not over the time
  frames we have considered

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• For this study, serum digoxin level of more use
  than prescription, so this information was
  downloaded for each patient.
• 6166 patients identified as having A/F on file (
  clinical coding)
• 2631 digoxin blood assays done in study period
• 651 ( 10 ) of patients were on dead file
• Patients were profiled for age and gender and
  multiple assays

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A/F no of patients by age with Digoxin level
measured
Fig. 14

• Fig. 14
• Pilot study warfarin not included.

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Results
        recommended maximum serum concentration.

Fig. 7

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Age distribution in sub-therapeutic group

• Age 40-49 50-59 60-69 70-79 gt80
• No. 1 3 5
  11 4

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• Why did we look at those with 5 digoxin
  results?
• 5 levels represents some degree of concern about
  patients digoxin status, and consistency in
  treatment approach.
• It is accepted that the study could not account
  for time of sampling, but the range of values
  might indicate significant variation.

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Conclusions

• Where monitoring is done, our studies indicate
  around 25 do not achieve serum target levels
• The study represents one of the larger ones of
  its type done. No reason to believe that the
  practice in Sunderland differs from elsewhere in
  the UK.
• The fact that it could be done illustrates the
  power of using EP as an audit tool.

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Conclusions

• As we might have expected, there was a
  correlation between higher mortality and above
  therapeutic digoxin levels, reflecting
  compromised renal function ( looked at case
  notes)
• The comparison is simplistic, and other factors
  may be operating. At this point more qualitative
  data is required as this represents the limit
  of this type of audit . The method can say how
  many, but not why.

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Conclusions

• The method does however suggest the NICE guidance
  may not be in-appropriate with regard to
  digoxin monitoring
• It puts some evidence in the public domain where
  NICE themselves concurred there was a paucity of
  data.