Detection of Elevated Risk for Drug-Related Problems in the Hospital

The AMTS² Risk Score

Drug-related problems (DRP) are an important cause of mortality, prolonged inpatient stays, and increased costs (1). The medication safety stewardship project (AMTS² project), funded by Germany’s Federal Ministry of Health as part of the ‘Action Plan for Medication Therapy Safety,’ addresses this issue: an interdisciplinary team was established at Klinikum Fürth [a hospital providing specialist care and an academic teaching hospital of the Friedrich-Alexander-Universität Erlangen-Nürnberg], which was tasked with supporting the wards in the sustainable optimization of medication therapy safety. Medication reviews were carried out as a fundamental instrument in order to prevent DRP or detect them early on and ameliorate their consequences. Since in many places not all patients will receive a detailed medication review because of limited specialist personnel resources (2), particular attention was given in the context of the AMTS² project to identifying and prioritizing patients at high risk for DRP. Internationally, several scoring tools have been published to help identify high-risk patients. But it needs to be borne in mind that many such tools are specialized for particular patient populations or specialties and/or their performance is merely moderate (3). Therefore, the main objective of the AMTS² project consisted in developing and validating a simple and broadly applicable risk score for identifying and prioritizing high-risk patients.

Methods

By means of a literature search and local risk analysis and on the basis of expert consensus (6 medication therapy safety experts from the specialties of clinical pharmacology, [clinical] pharmacy, internal medicine, and emergency medicine), nine risk factors for the occurrence of DRP were selected, with each factor contributing equally to the AMTS² risk score (Table 1). The risk scores of all patients who had reached the third day after being newly admitted were determined daily in five wards for internal medicine and surgery. The AMTS² risk score was evaluated in a prospective controlled trial (DRKS00017534). In accordance with the case number calculation, between April 2021 to July 2022, 150 patients with increased risk (a priori defined as ≥2 risk factors) and 150 patients without increased risk (defined as 0–1 risk factors) for DRP were consecutively included in the study. Subsequently to determining the score and independently of the actual score value, standardized extended medication reviews (type 2b according to the Pharmaceutical Care Network Europe [PCNE] classification) were carried out for all 300 participants, all current DRP were documented, and recommendations for solving identified DRP were communicated to the treating doctors by way of consultation. The primary endpoint of the study was the identification of clinically relevant DRP, which were defined as follows:

• Adverse drug reactions of severity category 2 and above in the Common Terminology Criteria for Adverse Events (CTCAE) (for example, oropharyngeal candidiasis in patients using inhaled budesonide)
• Absolutely contraindicated prescriptions (for example, moxonidine in heart failure)
• Dosing errors (for example, excessively high dose of metoclopramide in severely impaired renal function).

Table 1

AMTS² risk score

Approval from the ethics committee of the Friedrich-Alexander-Universität Erlangen-Nürnberg and written consent from all participants had been obtained.

Results

The 300 patients’ mean age was 67.1±14.7 years; 64% were female; 52% were treated in wards for internal medicine; and 48% were treated in surgical wards. Patients took an average of 9.7±4.5 medications and had 9.1±5.8 diagnoses.

The high-risk patients identified by applying the AMTS² risk score had clinically relevant DRP significantly more often than patients with a lower risk score (OR 10.5 [95% confidence interval: 6.1; 18.0]; p < 0.0001). Table 2 shows the number of patients in both groups with at least one clinically relevant DRP, as well as the sensitivity, specificity, and performance of the score. The area under the receiver operating characteristic (ROC) curve showed for the AMTS² risk score a good predictive validity in predicting DRP (0.79 [0.74; 0.84]).

Table 2

Fourfold/2x2 table evaluating the performance of the risk score

Discussion

The present study shows that patients with an increased risk for DRP can be identified by applying the AMTS² risk score. Prioritizing at-risk patients in medication reviews enables a more targeted allocation of the few available medication safety experts. For the selected threshold of two risk factors, the score shows adequate sensitivity and specificity; it is characterized by good predictive validity in the ROC analysis. The score’s factors can be easily and quickly assessed by assisting personnel. Furthermore, the score can be applied even without technical integration into the hospital information systems, which is an advantage in Germany’s healthcare reality with its often limited IT infrastructure.

A multitude of the published scoring tools specialize in certain patient populations (for example, older persons) or specialties (for example, emergency departments) or were validated in a restricted clinical setting. The consequently questionable generalizability to other clinical settings can be interpreted as an obstacle to broader use of the tools (3). To guarantee wide applicability, the AMTS² risk score was therefore intentionally evaluated in a non-specialized multidisciplinary patient population.

A recommended next step would be to measure the effect of risk scoring on hard endpoints. The present study is intended to provide motivation and form a justification basis for relevant follow-on projects.

Conclusions

The AMTS² risk score enables the identification of patients at increased risk for DRP by means of simple pre-screening. It is easily adaptable without any great IT effort and can be used for the targeted identification of DRP and to manage limited specialist personnel resources more efficiently.

Lea Jung-Poppe, Barbara Pfistermeister, Hagen Fabian Nicolaus, Anna Roggenhofer, Anna Altenbuchner, Wahram Andrikyan, Armin Ströbel, Christine Schnitzer, Harald Dormann, Renke Maas

Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany (Jung-Poppe, Nicolaus, Roggenhofer, Altenbuchner, Andrikyan, Maas) [e-mail]; Universitätsklinikum Erlangen (Jung-Poppe, Nicolaus); Center for Clinical Studies, Universitätsklinikum Erlangen (Ströbel); Department of Emergency Medicine, Hospital Fürth (Pfistermeister, Dormann); Pharmacy, Hospital Fürth (Pfistermeister, Schnitzer)

Lea Jung-Poppe performed the present work in (partial) fulfillment of the requirements for obtaining the degree ‘Dr. rer. biol. hum.’ at the Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU).

Funding

The AMTS stewardship project received funding from Germany’s Federal Ministry of Health (project code: ZMVI1–2519ATS004Z).

Conflict of interest statement
HD is a board member of DGINA [the German Society for Emergency Medicine], director of the Institut für Notfallmedizinische Bildung (INOB—German Institute for Education in Emergency Medicine), and a member of the Drug Commission of the German Medical Association (AkdÄ). RM is actively involved in the DGKliPha (the German Society for Clinical Pharmacology and Therapy). The remaining authors declare that no conflict of interest exists.

Manuscript received on 24 January 2024, revised version accepted on 20 May 2024.

Cite this as
Jung-Poppe L, Pfistermeister B, Nicolaus HF, Roggenhofer A, Altenbuchner A, Andrikyan W, Ströbel A, Schnitzer C, Dormann H, Maas R: Detection of elevated risk for drug-related problems in the hospital—the AMTS² Risk Score. Dtsch Arztebl Int 2024; 121: 639–40.
DOI: 10.3238/arztebl.m2024.0115

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