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Elouafkaoui P, Young L, Newlands R, Duncan EM, Elders A, Clarkson JE, Ramsay CR. An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice: The RAPiD Cluster Randomised Controlled Trial. PLoS Med 2016; 13:e1002115. [PMID: 27575599 PMCID: PMC5004857 DOI: 10.1371/journal.pmed.1002115] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 07/22/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Dentists prescribe approximately 10% of antibiotics dispensed in UK community pharmacies. Despite clear clinical guidance, dentists often prescribe antibiotics inappropriately. This cluster-randomised controlled trial used routinely collected National Health Service (NHS) dental prescribing and treatment claim data to compare the impact of individualised audit and feedback (A&F) interventions on dentists' antibiotic prescribing rates. METHODS AND FINDINGS All 795 antibiotic prescribing NHS general dental practices in Scotland were included. Practices were randomised to the control (practices = 163; dentists = 567) or A&F intervention group (practices = 632; dentists = 1,999). A&F intervention practices were allocated to one of two A&F groups: (1) individualised graphical A&F comprising a line graph plotting an individual dentist's monthly antibiotic prescribing rate (practices = 316; dentists = 1,001); or (2) individualised graphical A&F plus a written behaviour change message synthesising and reiterating national guidance recommendations for dental antibiotic prescribing (practices = 316; dentists = 998). Intervention practices were also simultaneously randomised to receive A&F: (i) with or without a health board comparator comprising the addition of a line to the graphical A&F plotting the monthly antibiotic prescribing rate of all dentists in the health board; and (ii) delivered at 0 and 6 mo or at 0, 6, and 9 mo, giving a total of eight intervention groups. The primary outcome, measured by the trial statistician who was blinded to allocation, was the total number of antibiotic items dispensed per 100 NHS treatment claims over the 12 mo post-delivery of the baseline A&F. Primary outcome data was available for 152 control practices (dentists = 438) and 609 intervention practices (dentists = 1,550). At baseline, the number of antibiotic items prescribed per 100 NHS treatment claims was 8.3 in the control group and 8.5 in the intervention group. At follow-up, antibiotic prescribing had decreased by 0.4 antibiotic items per 100 NHS treatment claims in control practices and by 1.0 in intervention practices. This represents a significant reduction (-5.7%; 95% CI -10.2% to -1.1%; p = 0.01) in dentists' prescribing rate in the intervention group relative to the control group. Intervention subgroup analyses found a 6.1% reduction in the antibiotic prescribing rate of dentists who had received the written behaviour change message relative to dentists who had not (95% CI -10.4% to -1.9%; p = 0.01). There was no significant between-group difference in the prescribing rate of dentists who received a health board comparator relative to those who did not (-4.3%; 95% CI -8.6% to 0.1%; p = 0.06), nor between dentists who received A&F at 0 and 6 mo relative to those who received A&F at 0, 6, and 9 mo (0.02%; 95% CI -4.2% to 4.2%; p = 0.99). The key limitations relate to the use of routinely collected datasets which did not allow evaluation of any effects on inappropriate prescribing. CONCLUSIONS A&F derived from routinely collected datasets led to a significant reduction in the antibiotic prescribing rate of dentists. TRIAL REGISTRATION Current Controlled Trials ISRCTN49204710.
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Affiliation(s)
- Paula Elouafkaoui
- NHS Education for Scotland (NES), Dundee Dental Education Centre, Frankland Building, Dundee, United Kingdom
- Dental Health Services Research Unit (DHSRU), University of Dundee, Park Place, Dundee, United Kingdom
| | - Linda Young
- NHS Education for Scotland (NES), Dundee Dental Education Centre, Frankland Building, Dundee, United Kingdom
- * E-mail:
| | - Rumana Newlands
- Health Services Research Unit (HSRU), University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, United Kingdom
| | - Eilidh M. Duncan
- Health Services Research Unit (HSRU), University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, United Kingdom
| | - Andrew Elders
- NMAHP Research Unit, Glasgow Caledonian University, Cowcaddens Road, Glasgow, United Kingdom
| | - Jan E. Clarkson
- NHS Education for Scotland (NES), Dundee Dental Education Centre, Frankland Building, Dundee, United Kingdom
- Dental Health Services Research Unit (DHSRU), University of Dundee, Park Place, Dundee, United Kingdom
| | - Craig R. Ramsay
- Health Services Research Unit (HSRU), University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, United Kingdom
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Ajemigbitse AA, Omole MK, Erhun WO. Effect of providing feedback and prescribing education on prescription writing: An intervention study. Ann Afr Med 2016; 15:1-6. [PMID: 26857930 PMCID: PMC5452687 DOI: 10.4103/1596-3519.161722] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background/Objective: Accurate medication prescribing important to avoid errors and ensure best possible outcomes. This is a report of assessment of the impact of providing feedback and educational intervention on prescribing error types and rates in routine practice. Methods: Doctors’ prescriptions from selected wards in two tertiary hospitals in central Nigeria were prospectively reviewed for a 6-month period and assessed for errors; grouped into six categories. Intervention was by providing feedback and educational outreach on the specialty/departmental level at one hospital while the other acted as the control. Chi-squared statistics was used to compare prescribing characteristics pre- and post-intervention. Results: At baseline, error rate was higher at the control site. At the intervention site, statistically significant reductions were obtained for errors involving omission of route of administration (P < 0.001), under dose (P = 0.012), dose adjustment in renal impairment (P = 0.019), ambiguous orders (P < 0.001) and drug/drug interaction (P < 0.001) post intervention though there was no change in mean error rate post intervention (P = 0.984). Though House Officers and Registrars wrote most prescriptions, highest reduction in prescribing error rates post intervention was by the registrars (0.93% to 0.29%, P < 0.001). Conclusion: Writing prescriptions that lacked essential details was common. Intervention resulted in modest changes. Routinely providing feedback and continuing prescriber education will likely sustain error reduction.
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Systematic Review of Factors Associated with Antibiotic Prescribing for Respiratory Tract Infections. Antimicrob Agents Chemother 2016; 60:4106-18. [PMID: 27139474 DOI: 10.1128/aac.00209-16] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 04/20/2016] [Indexed: 01/21/2023] Open
Abstract
Antibiotic use is a modifiable driver of antibiotic resistance. In many circumstances, antibiotic use is overly broad or unnecessary. We systematically assessed factors associated with antibiotic prescribing for respiratory tract infections (RTI). Studies were included if they used actual (not self-reported or intended) prescribing data, assessed factors associated with antibiotic prescribing for RTIs, and performed multivariable analysis of associations. We searched Medline, Embase, and International Pharmaceutical Abstracts using keyword and MeSH (medical subject headings) search terms. Two authors reviewed each abstract and independently appraised all included texts. Data on factors affecting antibiotic prescribing were extracted. Our searches retrieved a total of 2,848 abstracts, with 97 included in full-text review and 28 meeting full inclusion criteria. Compared to other factors, diagnosis of acute bronchitis was associated with increased antibiotic prescribing (range of adjusted odds ratios [aOR], 1.56 to 15.9). Features on physical exam, such as fever, purulent sputum, abnormal respiratory exam, and tonsillar exudate, were also associated with higher odds of antibiotic prescribing. Patient desire for an antibiotic was not associated or was modestly associated with prescription (range of aORs, 0.61 to 9.87), in contrast to physician perception of patient desire for antibiotics, which showed a stronger association (range of aORs, 2.11 to 23.3). Physician's perception of patient desire for antibiotics was strongly associated with antibiotic prescribing. Antimicrobial stewardship programs should continue to expand in the outpatient setting and should emphasize clear and direct communication between patients and physicians, as well as signs and symptoms that do and do not predict bacterial etiology of upper respiratory tract infections.
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Lloyd M, Watmough S, O'Brien S, Furlong N, Hardy K. Exploring attitudes and opinions of pharmacists toward delivering prescribing error feedback: A qualitative case study using focus group interviews. Res Social Adm Pharm 2016; 12:461-74. [DOI: 10.1016/j.sapharm.2015.08.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 08/26/2015] [Accepted: 08/26/2015] [Indexed: 10/23/2022]
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García-Molina Sáez C, Urbieta Sanz E, Madrigal de Torres M, Vicente Vera T, Pérez Cárceles MD. Computerized pharmaceutical intervention to reduce reconciliation errors at hospital discharge in Spain: an interrupted time-series study. J Clin Pharm Ther 2016; 41:203-8. [PMID: 26916590 DOI: 10.1111/jcpt.12365] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 01/25/2016] [Indexed: 01/01/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE It is well known that medication reconciliation at discharge is a key strategy to ensure proper drug prescription and the effectiveness and safety of any treatment. Different types of interventions to reduce reconciliation errors at discharge have been tested, many of which are based on the use of electronic tools as they are useful to optimize the medication reconciliation process. However, not all countries are progressing at the same speed in this task and not all tools are equally effective. So it is important to collate updated country-specific data in order to identify possible strategies for improvement in each particular region. Our aim therefore was to analyse the effectiveness of a computerized pharmaceutical intervention to reduce reconciliation errors at discharge in Spain. METHODS A quasi-experimental interrupted time-series study was carried out in the cardio-pneumology unit of a general hospital from February to April 2013. The study consisted of three phases: pre-intervention, intervention and post-intervention, each involving 23 days of observations. At the intervention period, a pharmacist was included in the medical team and entered the patient's pre-admission medication in a computerized tool integrated into the electronic clinical history of the patient. The effectiveness was evaluated by the differences between the mean percentages of reconciliation errors in each period using a Mann-Whitney U test accompanied by Bonferroni correction, eliminating autocorrelation of the data by first using an ARIMA analysis. In addition, the types of error identified and their potential seriousness were analysed. RESULTS AND DISCUSSION A total of 321 patients (119, 105 and 97 in each phase, respectively) were included in the study. For the 3966 medicaments recorded, 1087 reconciliation errors were identified in 77·9% of the patients. The mean percentage of reconciliation errors per patient in the first period of the study was 42·18%, falling to 19·82% during the intervention period (P = 0·000). When the intervention was withdrawn, the mean percentage of reconciliation errors increased again to 27·72% (P = 0·008). The difference between the percentages of pre- and post-intervention periods was statistically significant (P = 0·000). Most reconciliation errors were due to omission (46·7%) or incomplete prescription (43·8%), and 35·3% of which could have caused harm to the patient. WHAT IS NEW AND CONCLUSION A computerized pharmaceutical intervention is shown to reduce reconciliation errors in the context of a high incidence of such errors.
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Affiliation(s)
| | - E Urbieta Sanz
- Department of Hospital Pharmacy, Queen Sofia Hospital, Murcia, Spain
| | | | - T Vicente Vera
- Department of Cardiology, Queen Sofia Hospital, Murcia, Spain
| | - M D Pérez Cárceles
- Department of Legal Medicine, Regional Campus of International Excellence 'Campus Mare Nostrum', School of Medicine, University of Murcia, Murcia, Spain
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Alldred DP, Kennedy M, Hughes C, Chen TF, Miller P. Interventions to optimise prescribing for older people in care homes. Cochrane Database Syst Rev 2016; 2:CD009095. [PMID: 26866421 PMCID: PMC7111425 DOI: 10.1002/14651858.cd009095.pub3] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND There is a substantial body of evidence that prescribing for care home residents is suboptimal and requires improvement. Consequently, there is a need to identify effective interventions to optimise prescribing and resident outcomes in this context. This is an update of a previously published review (Alldred 2013). OBJECTIVES The objective of the review was to determine the effect of interventions to optimise overall prescribing for older people living in care homes. SEARCH METHODS For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (including the Cochrane Effective Practice and Organisation of Care (EPOC) Specialised Register), MEDLINE, EMBASE and CINAHL to May 2015. We also searched clinical trial registries for relevant studies. SELECTION CRITERIA We included randomised controlled trials evaluating interventions aimed at optimising prescribing for older people (aged 65 years or older) living in institutionalised care facilities. Studies were included if they measured one or more of the following primary outcomes: adverse drug events; hospital admissions; mortality; or secondary outcomes, quality of life (using validated instrument); medication-related problems; medication appropriateness (using validated instrument); medicine costs. DATA COLLECTION AND ANALYSIS Two authors independently screened titles and abstracts, assessed studies for eligibility, assessed risk of bias and extracted data. We presented a narrative summary of results. MAIN RESULTS The 12 included studies involved 10,953 residents in 355 (range 1 to 85) care homes in ten countries. Nine studies were cluster-randomised controlled trials and three studies were patient-randomised controlled trials. The interventions evaluated were diverse and often multifaceted. Medication review was a component of ten studies. Four studies involved multidisciplinary case-conferencing, five studies involved an educational element for health and care professionals and one study evaluated the use of clinical decision support technology. We did not combine the results in a meta-analysis due to heterogeneity across studies. Interventions to optimise prescribing may lead to fewer days in hospital (one study out of eight; low certainty evidence), a slower decline in health-related quality of life (one study out of two; low certainty evidence), the identification and resolution of medication-related problems (seven studies; low certainty evidence), and may lead to improved medication appropriateness (five studies out of five studies; low certainty evidence). We are uncertain whether the intervention improves/reduces medicine costs (five studies; very low certainty evidence) and it may make little or no difference on adverse drug events (two studies; low certainty evidence) or mortality (six studies; low certainty evidence). The risk of bias across studies was heterogeneous. AUTHORS' CONCLUSIONS We could not draw robust conclusions from the evidence due to variability in design, interventions, outcomes and results. The interventions implemented in the studies in this review led to the identification and resolution of medication-related problems and improvements in medication appropriateness, however evidence of a consistent effect on resident-related outcomes was not found. There is a need for high-quality cluster-randomised controlled trials testing clinical decision support systems and multidisciplinary interventions that measure well-defined, important resident-related outcomes.
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Affiliation(s)
- David P Alldred
- University of LeedsSchool of HealthcareLeedsWest YorkshireUKLS2 9JT
| | | | - Carmel Hughes
- Queen's University BelfastSchool of Pharmacy97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
| | - Timothy F Chen
- The University of SydneyFaculty of PharmacyScience RoadCamperdownNSWAustralia2006
| | - Paul Miller
- University of OxfordNuffield Department of Population HealthOxfordUK
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Winder MB, Johnson JL, Planas LG, Crosby KM, Gildon BL, Oberst-Walsh LA. Pharmacist-led educational and error notification interventions on prescribing errors in family medicine clinic. J Am Pharm Assoc (2003) 2015; 55:238-45. [PMID: 26003154 DOI: 10.1331/japha.2015.14130] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine the rate of prescribing errors in a family medicine clinic and the subsequent impact of pharmacist-led educational and error notification interventions on prescribing errors. DESIGN Single site, pre-post study design. SETTING An outpatient academic family medicine clinic serving pediatric and adult populations in Oklahoma from March 1, 2011, through April 30, 2012. PARTICIPANTS 24 resident physicians who prescribed medications during routine outpatient visits. INTERVENTION A prescribing educational program, audit and feedback methods, and weekly newsletter. MAIN OUTCOMES MEASURE Percentage of prescription errors and physician error rate before and after intervention among pediatric and adult populations. RESULTS During the two assessment periods, 24 resident physicians wrote 2,753 prescriptions for 394 pediatric and 899 adult patients. The overall percentage of prescription errors decreased from 18.6% during March 2011 to 14.5% during April 2012 (P = 0.004). Errors were more commonly seen with prescriptions written for pediatric patients (24.9%) than for adult patients (13.9%) (P = 0.001). Individual physician error rates ranged from 5% to 36% (mean ± SD 16.5% ± 8.1). Physicians committed significantly fewer prescribing errors during the postintervention assessment period (14.9%) than during the preintervention assessment period (20.9%) (P = 0.002). Controlling for time, pediatric prescription error rates among physicians who participated in the educational intervention were 36% lower than the error rates among physicians who did not participate (rate ratio 0.64 [95% CI 0.45, 0.91], P = 0.01). CONCLUSION The pharmacist-led educational program was effective in reducing pediatric prescribing errors among resident physicians in a family medicine clinic.
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Barozzi N, Peeters GMEEG, Tett SE. Actions following adverse drug events - how do these influence uptake and utilisation of newer and/or similar medications? BMC Health Serv Res 2015; 15:498. [PMID: 26545734 PMCID: PMC4635584 DOI: 10.1186/s12913-015-1165-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 11/03/2015] [Indexed: 11/10/2022] Open
Abstract
Background Over the last decade, actions following some adverse drug events received major publicity. This study investigated changes in usage patterns of medications in Australia following two examples - rofecoxib market withdrawal (2004) and warnings about jaw necrosis following bisphosphonates (2007). Methods Dispensing data for COX-2 inhibitors (2000–2008) and anti-osteoporosis medications (2003–2012) were obtained from the Australian Pharmaceutical Benefits Scheme database. For bisphosphonates, data on Australian marketing expenditures were purchased from CegedimR. Results For COX-2 inhibitors, celecoxib dispensing halved after rofecoxib withdrawal, but meloxicam dispensing increased by 60 %. When lumiracoxib was introduced (2006) there was uptake of prescribing at a faster rate than meloxicam in 2002, its first year of use. For bisphosphonates, alendronate had highest use at the time of the warnings (8.3 DDD/1000/day), dropping to 4.9 DDD/1000/day by 2012. In contrast, risedronate use rose 2007–2012 from 4.1 to 4.9 DDD/1000/day. There was 49 % increase in reported annual expenditure on detailing for risedronate from 2007 to 2008 (to AUD$7.3 million) and only 29 % increase for alendronate (to AUD$3.1 million). Conclusions The rapid uptake of prescribing of lumiracoxib and increased use of meloxicam flagged a concern, especially after rofecoxib withdrawal due to safety issues. Bisphosphonates are useful drugs, however the dramatic rise in expenditure on detailing, followed by a rise in utilisation of risedronate could suggest that adverse publicity triggered a marketing response. These examples highlight the importance of tracking utilisation of medication classes in real time, using different data as needed, to ensure that due caution is exercised (and quick intervention provided if needed) for medications in the same class. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1165-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadia Barozzi
- School of Pharmacy, The University of Queensland, Brisbane, QLD, 4072, Australia. .,Healthy 4Life, PO Box 41, 4009, Basel, Switzerland.
| | - G M E E Geeske Peeters
- Schools of Population Health and Human Movement Studies, The University of Queensland, Brisbane, QLD, 4072, Australia.
| | - Susan E Tett
- School of Pharmacy, The University of Queensland, Brisbane, QLD, 4072, Australia.
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Rashidian A, Omidvari A, Vali Y, Sturm H, Oxman AD. Pharmaceutical policies: effects of financial incentives for prescribers. Cochrane Database Syst Rev 2015; 2015:CD006731. [PMID: 26239041 PMCID: PMC7390265 DOI: 10.1002/14651858.cd006731.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The proportion of total healthcare expenditures spent on drugs has continued to grow in countries of all income categories. Policy-makers are under pressure to control pharmaceutical expenditures without adversely affecting quality of care. Financial incentives seeking to influence prescribers' behaviour include budgetary arrangements at primary care and hospital settings (pharmaceutical budget caps or targets), financial rewards for target behaviours or outcomes (pay for performance interventions) and reduced benefit margin for prescribers based on medicine sales and prescriptions (pharmaceutical reimbursement rate reduction policies). This is the first update of the original version of this review. OBJECTIVES To determine the effects of pharmaceutical policies using financial incentives to influence prescribers' practices on drug use, healthcare utilisation, health outcomes and costs (expenditures). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (searched 29/01/2015); MEDLINE, Ovid SP (searched 29/01/2015); EMBASE, Ovid SP (searched 29/01/2015); International Network for Rational Use of Drugs (INRUD) Bibliography (searched 29/01/2015); National Health Service (NHS) Economic Evaluation Database (searched 29/01/2015); EconLit - ProQuest (searched 02/02/2015); and Science Citation Index and Social Sciences Citation Index, Institute for Scientific Information (ISI) Web of Knowledge (citation search for included studies searched 10/02/2015). We screened the reference lists of relevant reports and contacted study authors and organisations to identify additional studies. SELECTION CRITERIA We included policies that intend to affect prescribing by means of financial incentives for prescribers. Included in this category are pharmaceutical budget caps or targets, pay for performance and drug reimbursement rate reductions and other financial policies, if they were specifically targeted at prescribing or drug utilisation. Policies in this review were defined as laws, rules, regulations and financial and administrative orders made or implemented by payers such as national or local governments, non-government organisations, private or social insurers and insurance-like organisations. One of the following outcomes had to be reported: drug use, healthcare utilisation, health outcomes or costs. The study had to be a randomised or non-randomised trial, an interrupted time series (ITS) analysis, a repeated measures study or a controlled before-after (CBA) study. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed eligibility for inclusion of studies and risks of bias using Cochrane Effective Practice and Organisation of Care (EPOC) criteria and extracted data from the included studies. For CBA studies, we reported relative effects (e.g. adjusted relative change). The review team re-analysed all ITS results. When possible, the review team also re-analysed CBA data as ITS data. MAIN RESULTS Eighteen evaluations (six new studies) of pharmaceutical policies from six high-income countries met our inclusion criteria. Fourteen studies evaluated pharmaceutical budget policies in the UK (nine studies), two in Germany and Ireland and one each in Sweden and Taiwan. Three studies assessed pay for performance policies in the UK (two) and the Netherlands (one). One study from Taiwan assessed a reimbursement rate reduction policy. ITS analyses had some limitations. All CBA studies had serious limitations. No study from low-income or middle-income countries met the inclusion criteria.Pharmaceutical budgets may lead to a modest reduction in drug use (median relative change -2.8%; low-certainty evidence). We are uncertain of the effects of the policy on drug costs or healthcare utilisation, as the certainty of such evidence has been assessed as very low. Effects of this policy on health outcomes were not reported. Effects of pay for performance policies on drug use and health outcomes are uncertain, as the certainty of such evidence has been assessed as very low. Effects of this policy on drug costs and healthcare utilisation have not been measured. Effects of the reimbursement rate reduction policy on drug use and drug costs are uncertain, as the certainty of such evidence has been assessed as very low. No included study assessed the effects of this policy on healthcare utilisation or health outcomes. Administration costs of the policies were not reported in any of the included studies. AUTHORS' CONCLUSIONS Although financial incentives are considered an important element in strategies to change prescribing patterns, limited evidence of their effects can be found. Effects of policies, including pay for performance policies, in improving quality of care and health outcomes remain uncertain. Because pharmaceutical policies have uncertain effects, and because they might cause harm as well as benefit, proper evaluation of these policies is needed. Future studies should consider the impact of these policies on health outcomes, drug use and overall healthcare expenditures, as well as on drug expenditures.
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Affiliation(s)
- Arash Rashidian
- Tehran University of Medical SciencesDepartment of Health Management and Economics, School of Public HealthPoursina AveTehranIran1417613191
| | - Amir‐Houshang Omidvari
- Tehran University of Medical SciencesKnowledge Utilization Research Center (KURC)16 AzarTehranTehranIran
| | - Yasaman Vali
- Tehran University of Medical SciencesSchool of MedicineTehranIran
| | - Heidrun Sturm
- University Medical Center TübingenComprehensive Cancer CenterHerrenberger Str. 23TübingenGermanyD 72070
| | - Andrew D Oxman
- Norwegian Knowledge Centre for the Health ServicesGlobal Health UnitP.O. Box 7004, St. Olavs plassOsloNorwayN‐0130
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Pechlivanoglou P, Wieringa JE, de Jager T, Postma MJ. The effect of financial and educational incentives on rational prescribing. A state-space approach. HEALTH ECONOMICS 2015; 24:439-453. [PMID: 24519732 DOI: 10.1002/hec.3030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 09/16/2013] [Accepted: 12/06/2013] [Indexed: 06/03/2023]
Abstract
In 2005, a Dutch health insurer introduced a financial incentive directed to general practitioners to promote rational prescribing of statins and proton pump inhibitors (PPIs). Concomitantly, a regional institution that develops pharmacotherapeutic guidelines implemented two educational interventions also aiming at promoting rational statin and PPI prescribing. Utilizing a prescription database, we estimated the effect of the interventions on drug utilization and cost of statins and PPIs over time. We measured the effect of the interventions within an implementation and a control region. The implementation region included prescriptions from the province of Groningen where the educational intervention was implemented and where the health insurer is most active. The control region comprised all other provinces covered by the database. We modelled the effect of the intervention using a state-space approach. Significant differences in prescribing and cost patterns between regions were observed for statins and PPIs. These differences however were mostly related to the concurrent interventions of Proeftuin Farmacie Groningen. We found no evidence indicating a significant effect of the rational prescribing intervention on the prescription patterns of statins and PPIs. Our estimates on the economic impact of the Proeftuin Farmacie Groningen interventions indicate that educational activities as such can achieve significant cost savings.
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Affiliation(s)
- Petros Pechlivanoglou
- Unit of PharmacoEpidemiology and PharmacoEconomics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands; Toronto Health Economics and Technology Assessment collaborative, Department of Pharmacy, University of Toronto, Toronto, Canada
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Charpiat B, Bedouch P, Dode X, Klegou S, Bosson JL, Allenet B. Quantifying the amount of information available in order to prescribe, dispense and administer drugs. Br J Clin Pharmacol 2015; 77:908-9. [PMID: 23879403 DOI: 10.1111/bcp.12212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 07/11/2013] [Indexed: 11/28/2022] Open
Affiliation(s)
- Bruno Charpiat
- Université Joseph Fourier-Grenoble 1/CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble, France; Pharmacy Department, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
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Löffler C, Drewelow E, Paschka SD, Frankenstein M, Eger J, Jatsch L, Reisinger EC, Hallauer JF, Drewelow B, Heidorn K, Schröder H, Wollny A, Kundt G, Schmidt C, Altiner A. Optimizing polypharmacy among elderly hospital patients with chronic diseases--study protocol of the cluster randomized controlled POLITE-RCT trial. Implement Sci 2014; 9:151. [PMID: 25287853 PMCID: PMC4192341 DOI: 10.1186/s13012-014-0151-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 09/23/2014] [Indexed: 01/10/2023] Open
Abstract
Background Treatment of patients with multimorbidity is challenging. A rational reduction of long-term drugs can lead to decreased mortality, less acute hospital treatment, and a reduction of costs. Simplification of drug treatment schemes is also related to higher levels of patient satisfaction and adherence. The POLITE-RCT trial will test the effectiveness of an intervention aiming at reducing the number of prescribed long-term drugs among multimorbid and chronically ill patients. The intervention focuses on the interface between primary and secondary health care and includes a pharmacist-based, patient-centered medication review prior to the patient’s discharge from hospital. Methods The POLITE-RCT trial is a cluster randomized controlled trial. Two major secondary health care providers of Mecklenburg-Western Pomerania, Germany, take part in the study. Clusters are wards of both medical centers. All wards where patients with chronic diseases and multimorbidity are regularly treated will be included. Patients aged 65+ years who take five or more prescribed long-term drugs and who are likely to spend at least 5 days in the participating hospitals will be recruited and included consecutively. Cluster-randomization takes place after a six-month baseline data collection period. Patients of the control group receive care as usual. The independent two main primary outcomes are (1) health-related quality of life (EQ-5D) and (2) the difference in the number of prescribed long-term pharmaceutical agents between intervention and control group. The secondary outcomes are appropriateness of prescribed medication (PRISCUS list, Beers Criteria, MAI), patient satisfaction (TSQM), patient empowerment (PEF-FB-9), patient autonomy (IADL), falls, re-hospitalization, and death. The points of measurement are at admission to (T0) and discharge from hospital (T1) as well as 6 and 12 months after discharge from the hospital (T2 and T3). In 42 wards, 1,626 patients will be recruited. Discussion In case of positive evaluation, the proposed study will provide evidence for a sustainable reduction of polypharmacy by enhancing patient-centeredness and patient autonomy. Trial registration Current Controlled Trials ISRCTN42003273
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Affiliation(s)
- Christin Löffler
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany.
| | - Eva Drewelow
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany.
| | - Susanne D Paschka
- Hospital Pharmacy, Rostock University Medical Center, Rostock, Germany.
| | | | - Julia Eger
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany.
| | - Lisa Jatsch
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany.
| | - Emil C Reisinger
- Department of Internal Medicine II, Rostock University Medical Center, Rostock, Germany.
| | | | - Bernd Drewelow
- Institute of Pharmacology, Rostock University Medical Center, Rostock, Germany.
| | - Karen Heidorn
- Hospital Pharmacy, Rostock University Medical Center, Rostock, Germany.
| | | | - Anja Wollny
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany.
| | - Günther Kundt
- Institute for Biostatistics and Informatics in Medicine and Ageing Research, Rostock University Medical Center, Rostock, Germany.
| | | | - Attila Altiner
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany.
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Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging 2014; 30:793-807. [PMID: 23912674 DOI: 10.1007/s40266-013-0106-8] [Citation(s) in RCA: 338] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Inappropriate medication use is common in the elderly and the risks associated with their use are well known. The term deprescribing has been utilised to describe the complex process that is required for the safe and effective cessation of inappropriate medications. Given the primacy of the consumer in health care, their views must be central in the development of any deprescribing process. OBJECTIVES The aim of this study was to identify barriers and enablers that may influence a patient's decision to cease a medication. DATA SOURCES A systematic search of MEDLINE, International Pharmaceutical Abstracts, EMBASE, CINAHL, Informit and Scopus was conducted and augmented with a manual search. Numerous search terms relating to withdrawal of medications and consumers' beliefs were utilised. STUDY ELIGIBILITY CRITERIA Articles were included if the barriers or enablers were directly patient/carer reported and related to long-term medication(s) that they were currently taking or had recently ceased. STUDY APPRAISAL AND SYNTHESIS METHODS Determination of relevance and data extraction was performed independently by two reviewers. Content analysis with coding was utilised for synthesis of results. RESULTS Twenty-one articles met the criteria and were included in the review. Three themes, disagreement/agreement with 'appropriateness' of cessation, absence/presence of a 'process' for cessation, and negative/positive 'influences' to cease medication, were identified as both potential barriers and enablers, with 'fear' of cessation and 'dislike' of medications as a fourth barrier and enabler, respectively. The most common barrier/enabler identified was 'appropriateness' of cessation, with 15 studies identifying this as a barrier and 18 as an enabler. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS The decision to stop a medication by an individual is influenced by multiple competing barriers and enablers. Knowledge of these will aid in the development of a deprescribing process, particularly in approaching the topic of cessation with the patient and what process should be utilised. However, further research is required to determine if the proposed patient-centred deprescribing process will result in improved patient outcomes.
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Affiliation(s)
- Emily Reeve
- Sansom Institute, University of South Australia, Adelaide, SA, Australia,
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Consider the factors that influence patients’ decisions to stop taking potentially inappropriate medications when developing a deprescribing plan. DRUGS & THERAPY PERSPECTIVES 2014. [DOI: 10.1007/s40267-014-0113-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Expectations for consultations and antibiotics for respiratory tract infection in primary care: the RTI clinical iceberg. Br J Gen Pract 2014; 63:e429-36. [PMID: 23834879 DOI: 10.3399/bjgp13x669149] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Respiratory tract infection (RTI) is the commonest indication for community antibiotic prescriptions. Prescribing is rising and is influenced by patients' consulting behaviour and beliefs. AIM To build up a profile of the 'RTI clinical iceberg' by exploring how the general public manage RTI, visit GPs and why. DESIGN AND SETTING Two-phase qualitative and quantitative study in England. METHOD Qualitative interviews with 17 participants with acute RTI visiting pharmacies in England, and face-to-face questionnaire survey of 1767 adults ≥15 years in households in England during January 2011. RESULTS Qualitative interviews: interviewees with RTI visited GPs if they considered their symptoms were prolonged, or severe enough to cause pain, or interfered with daily activities or sleep. Questionnaire: 58% reported having had an RTI in the previous 6 months, and 19.7% (95% CI = 16.8 to 22.9%) of these contacted or visited their GP surgery for this, most commonly because 'the symptoms were severe'; or 'after several days the symptoms hadn't improved'; 10.3% of those experiencing an RTI (or 53.1% of those contacting their GP about it) expected an antibiotic prescription. Responders were more likely to believe antibiotics would be effective for a cough with green rather than clear phlegm. Perceptions of side effects of antibiotics did not influence expectations for antibiotics. Almost all who reported asking for an antibiotic were prescribed one, but 25% did not finish them. CONCLUSION One-fifth of those with an RTI contact their GP and most who ask for antibiotics are prescribed them. A better public understanding about the lack of benefit of antibiotics for most RTIs and addressing concerns about illness duration and severity, could reduce GP consultations and antibiotic prescriptions for RTI.
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Dylst P, Vulto A, Simoens S. Demand-side policies to encourage the use of generic medicines: an overview. Expert Rev Pharmacoecon Outcomes Res 2014; 13:59-72. [DOI: 10.1586/erp.12.83] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Godman B, Shrank W, Andersen M, Berg C, Bishop I, Burkhardt T, Garuoliene K, Herholz H, Joppi R, Kalaba M, Laius O, McGinn D, Samaluk V, Sermet C, Schwabe U, Teixeira I, Tilson L, Tulunay FC, Vlahović-Palčevski V, Wendykowska K, Wettermark B, Zara C, Gustafsson LL. Comparing policies to enhance prescribing efficiency in Europe through increasing generic utilization: changes seen and global implications. Expert Rev Pharmacoecon Outcomes Res 2014; 10:707-22. [DOI: 10.1586/erp.10.72] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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The effect of interventions to reduce potentially inappropriate antibiotic prescribing in long-term care facilities: a systematic review of randomised controlled trials. Drugs Aging 2013; 30:401-8. [PMID: 23444263 DOI: 10.1007/s40266-013-0066-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The prevalence of antibiotic use in long-term care facilities (LTCF) is high and in many cases it may not be in accordance with local guidelines. It is important to review interventions that aim to improve the quality of antibiotic prescribing in this setting. OBJECTIVE The objective of this systematic review was to collect and interpret the results of studies of interventions to improve the quality of, or appropriateness of antibiotic prescribing in LTCF in order to determine the key components for a successful intervention. DATA SOURCES A search of The Cochrane Library, PubMed, EMBASE, ISI Web of Knowledge, International Pharmaceutical Abstracts, the Database of Abstracts of Review of Effects (DARE), the Health Technology Assessments (HTA) at the Centres for Reviews and Dissemination (CRD) and Google Scholar was conducted from their inception to August 2012. A manual search of the grey literature and relevant journals was also conducted. STUDY SELECTION Studies were selected that were randomised controlled trials of an intervention to improve the quality of antibiotic prescribing, or increase adherence to a prescribing guideline or reduce the amount of antibiotic prescribing. All studies were conducted in the long-term care setting. The search strategy found four randomised controlled trials that met the inclusion criteria, from an initial 1,904 titles. STUDY APPRAISAL AND SYNTHESIS METHODS The risk of bias assessment of the included studies was conducted using the Cochrane Risk of Bias Table. Due to the heterogeneity of the interventions, study designs and outcome measures, a meta-analysis was not conducted. RESULTS Four studies met the inclusion criteria for this review. Three studies directed educational material and sessions at physicians and nurses, with one of the three studies providing prescribing feedback as well. The fourth study provided educational material and prescribing feedback for physicians only. Due to the mixed and modest effects of the interventions and the variety of interventions implemented, it is difficult to attribute the success of any intervention to just one component alone. It seems that a multifaceted intervention involving small group educational sessions and the provision of educational materials is generally acceptable to nurses and physicians in LTCF. The involvement of local consensus procedures when developing guidelines and interventions may improve the success of the intervention. LIMITATIONS A limitation of this systematic review is the small number of studies that met the inclusion criteria. CONCLUSION Interventions in the long-term care setting involving local consensus procedures, educational strategies, and locally developed guidelines may improve the quality of antibiotic prescribing, but the quality of the evidence is low. Due to the poor quality of evidence and mixed results, no definitive conclusion can be reached about the effect of the interventions. Future research in this area needs to include process evaluation research in order to define the characteristics contributing to the success or failure of any intervention. The contribution of a multidisciplinary antibiotic management team, which could include a pharmacist, a nurse and specialists in microbiology and infectious diseases and geriatrics, needs further investigation in order to improve antibiotic prescribing practices in LTCF.
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Miguel Cisneros J, Cobo J, San Juan R, Montejo M, Carmen Fariñas M. Education on antibiotic use. Education systems and activities that work. Enferm Infecc Microbiol Clin 2013; 31 Suppl 4:31-7. [DOI: 10.1016/s0213-005x(13)70130-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kamarudin G, Penm J, Chaar B, Moles R. Educational interventions to improve prescribing competency: a systematic review. BMJ Open 2013; 3:e003291. [PMID: 23996821 PMCID: PMC3758972 DOI: 10.1136/bmjopen-2013-003291] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/20/2013] [Accepted: 07/24/2013] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To review the literature on educational interventions to improve prescribing and identify educational methods that improve prescribing competency in both medical and non-medical prescribers. DESIGN A systematic review was conducted. The databases Medline, International Pharmaceutical Abstracts (IPA), EMBASE and CINAHL were searched for articles in English published between January 1990 and July 2013. SETTING Primary and secondary care. PARTICIPANTS Medical and non-medical prescribers. INTERVENTION Education-based interventions to aid improvement in prescribing competency. PRIMARY OUTCOME Improvements in prescribing competency (knows how) or performance (shows how) as defined by Miller's competency model. This was primarily demonstrated through prescribing examinations, changes in prescribing habits or adherence to guidelines. RESULTS A total of 47 studies met the inclusion criteria and were included in the systematic review. Studies were categorised by their method of assessment, with 20 studies assessing prescribing competence and 27 assessing prescribing performance. A wide variety of educational interventions were employed, with different outcome measures and methods of assessments. In particular, six studies demonstrated that specific prescribing training using the WHO Guide to Good Prescribing increased prescribing competency in a wide variety of settings. Continuing medical education in the form of academic detailing and personalised prescriber feedback also yielded positive results. Only four studies evaluated educational interventions targeted at non-medical prescribers, highlighting that further research is needed in this area. CONCLUSIONS A broad range of educational interventions have been conducted to improve prescribing competency. The WHO Guide to Good Prescribing has the largest body of evidence to support its use and is a promising model for the design of targeted prescribing courses. There is a need for further development and evaluation of educational methods for non-medical prescribers.
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Affiliation(s)
- Gritta Kamarudin
- Faculty of Pharmacy, World Hospital Pharmacy Research Consortium, The University of Sydney, New South Wales, Australia
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Clyne B, Bradley MC, Hughes CM, Clear D, McDonnell R, Williams D, Fahey T, Smith SM. Addressing potentially inappropriate prescribing in older patients: development and pilot study of an intervention in primary care (the OPTI-SCRIPT study). BMC Health Serv Res 2013; 13:307. [PMID: 23941110 PMCID: PMC3751793 DOI: 10.1186/1472-6963-13-307] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 08/12/2013] [Indexed: 11/17/2022] Open
Abstract
Background Potentially inappropriate prescribing (PIP) in older people is common in primary care and can result in increased morbidity, adverse drug events, hospitalizations and mortality. The prevalence of PIP in Ireland is estimated at 36% with an associated expenditure of over €45 million in 2007. The aim of this paper is to describe the application of the Medical Research Council (MRC) framework to the development of an intervention to decrease PIP in Irish primary care. Methods The MRC framework for the design and evaluation of complex interventions guided the development of the study intervention. In the development stage, literature was reviewed and combined with information obtained from experts in the field using a consensus based methodology and patient cases to define the main components of the intervention. In the pilot stage, five GPs tested the proposed intervention. Qualitative interviews were conducted with the GPs to inform the development and implementation of the intervention for the main randomised controlled trial. Results The literature review identified PIP criteria for inclusion in the study and two initial intervention components - academic detailing and medicines review supported by therapeutic treatment algorithms. Through patient case studies and a focus group with a group of 8 GPs, these components were refined and a third component of the intervention identified - patient information leaflets. The intervention was tested in a pilot study. In total, eight medicine reviews were conducted across five GP practices. These reviews addressed ten instances of PIP, nine of which were addressed in the form of either a dose reduction or a discontinuation of a targeted medication. Qualitative interviews highlighted that GPs were receptive to the intervention but patient preference and time needed both to prepare for and conduct the medicines review, emerged as potential barriers. Findings from the pilot study allowed further refinement to produce the finalised intervention of academic detailing with a pharmacist, medicines review with web-based therapeutic treatment algorithms and tailored patient information leaflets. Conclusions The MRC framework was used in the development of the OPTI-SCRIPT intervention to decrease the level of PIP in primary care in Ireland. Its application ensured that the intervention was developed using the best available evidence, was acceptable to GPs and feasible to deliver in the clinical setting. The effectiveness of this intervention is currently being tested in a pragmatic cluster randomised controlled trial. Trial registration Current controlled trials ISRCTN41694007
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Affiliation(s)
- Barbara Clyne
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland.
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Pichetti S, Sermet C, Godman B, Campbell SM, Gustafsson LL. Multilevel analysis of the influence of patients' and general practitioners' characteristics on patented versus multiple-sourced statin prescribing in France. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2013; 11:205-218. [PMID: 23609765 DOI: 10.1007/s40258-013-0014-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND The French National Health Insurance and the Ministry of Health have introduced multiple reforms in recent years to increase prescribing efficiency. These include guidelines, academic detailing, financial incentives for the prescribing and dispensing of generics drugs as well as a voluntary pay-for-performance programme. However, the quality and efficiency of prescribing could be enhanced potentially if there was better understanding of the dynamics of prescribing behaviour in France. OBJECTIVE To analyse the patient and general practitioner characteristics that influence patented versus multiple-sourced statin prescribing in France. METHODOLOGY Statistical analysis was performed on the statin prescribing habits from 341 general practitioners (GPs) that were included in the IMS-Health Permanent Survey on Medical Prescription in France, which was conducted between 2009 and 2010 and involved 14,360 patients. Patient characteristics included their age and gender as well as five medical profiles that were constructed from the diagnoses obtained during consultations. These were (1) disorders of lipoprotein metabolism, (2) heart disease, (3) diabetes, (4) complex profiles and (5) profiles based on other diagnoses. Physician characteristics included their age, gender, solo or group practice, weekly workload and payment scheme. RESULTS Patient age had a statistically significant impact on statin prescribing for patients in profile 1 (disorders of lipoprotein metabolism) and profile 3 (complex profiles) with a greater number of patented statins being prescribed for the youngest patients. For instance, patients older than 76 years with a complex profile were prescribed fewer patented statins than patients aged 68-76 years old with the same medical profile (coefficient: -0.225; p = 0.0008). By contrast, regardless of the patient's age, the medical profile did not affect the probability of prescribing a patented statin except in young patients with heart diseases who were prescribed a greater number of patented statins (coefficient: 0.3992; p = 0.0007). Prescribing was also statistically influenced by physician features, e.g., older male physicians were more likely to prescribe patented statins (coefficient: 0.245; p = 0.0417) and GPs practicing in groups were more likely to prescribe multiple sourced statins (coefficient: -0.178; p = 0.0338), which is an important finding of the study. GPs with a lower workload prescribed a greater number of patented statins. CONCLUSION There is significant variability in the prescribing of different statins among patient and physician profiles as well as between solo and group practices. Consequently, there are opportunities to target demand-side measures to enhance the prescribing of multiple-sourced statins. Further studies are warranted, in particular in other therapeutic classes, to provide a counter-balance to the considerable marketing activities of pharmaceutical companies.
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Larson EL, Patel SJ, Evans D, Saiman L. Feedback as a strategy to change behaviour: the devil is in the details. J Eval Clin Pract 2013; 19:230-4. [PMID: 22128773 PMCID: PMC3303967 DOI: 10.1111/j.1365-2753.2011.01801.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Performance feedback is one of a number of strategies used to improve clinical practice among students and clinicians. OBJECTIVES The aims of this paper were to examine conceptual underpinnings and essential components for audit and feedback strategies, to assess the extent to which recently published audit and feedback interventions include these components and to recommend future directions for feedback to improve its educational and behavioural impact. METHODS Based on the actionable feedback model, we examined the presence of four theoretical constructs--timeliness, individualization, lack of punitiveness and customizability--in studies published during 2009-2010 which included a feedback intervention. RESULTS There was wide variation in the definition, implementation and outcomes of 'feedback' interventions, making it difficult to compare across studies. None of the studies we reviewed included all of the components of the actionable feedback model. CONCLUSIONS Feedback interventions reported to date, even when results are positive, often fail to include concepts of behaviour change. This may partially explain the large variation in approaches and in results of such interventions and presents major challenges for replicating any given intervention. If feedback processes are to be successfully used and disseminated and implemented widely, some standardization and certainly more clarity is needed in the specific action steps taken to apply behavioural theory to practice.
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Affiliation(s)
- Elaine L Larson
- School of Nursing, Columbia University, New York, NY 10032, USA.
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Clyne B, Bradley MC, Smith SM, Hughes CM, Motterlini N, Clear D, McDonnell R, Williams D, Fahey T. Effectiveness of medicines review with web-based pharmaceutical treatment algorithms in reducing potentially inappropriate prescribing in older people in primary care: a cluster randomized trial (OPTI-SCRIPT study protocol). Trials 2013; 14:72. [PMID: 23497575 PMCID: PMC3621288 DOI: 10.1186/1745-6215-14-72] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 02/27/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Potentially inappropriate prescribing in older people is common in primary care and can result in increased morbidity, adverse drug events, hospitalizations and mortality. In Ireland, 36% of those aged 70 years or over received at least one potentially inappropriate medication, with an associated expenditure of over €45 million.The main objective of this study is to determine the effectiveness and acceptability of a complex, multifaceted intervention in reducing the level of potentially inappropriate prescribing in primary care. METHODS/DESIGN This study is a pragmatic cluster randomized controlled trial, conducted in primary care (OPTI-SCRIPT trial), involving 22 practices (clusters) and 220 patients. Practices will be allocated to intervention or control arms using minimization, with intervention participants receiving a complex multifaceted intervention incorporating academic detailing, medicines review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options, and tailored patient information leaflets. Control practices will deliver usual care and receive simple patient-level feedback on potentially inappropriate prescribing. Routinely collected national prescribing data will also be analyzed for nonparticipating practices, acting as a contemporary national control. The primary outcomes are the proportion of participant patients with potentially inappropriate prescribing and the mean number of potentially inappropriate prescriptions per patient. In addition, economic and qualitative evaluations will be conducted. DISCUSSION This study will establish the effectiveness of a multifaceted intervention in reducing potentially inappropriate prescribing in older people in Irish primary care that is generalizable to countries with similar prescribing challenges. TRIAL REGISTRATION Current controlled trials ISRCTN41694007.
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Affiliation(s)
- Barbara Clyne
- Health Research Board (HRB) Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland
| | - Marie C Bradley
- School of Pharmacy, Queen’s University Belfast (QUB), University Road, Belfast Northern BT7 1NN, Ireland
| | - Susan M Smith
- Health Research Board (HRB) Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland
| | - Carmel M Hughes
- School of Pharmacy, Queen’s University Belfast (QUB), University Road, Belfast Northern BT7 1NN, Ireland
| | - Nicola Motterlini
- Health Research Board (HRB) Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland
| | - Daniel Clear
- Health Research Board (HRB) Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland
| | - Ronan McDonnell
- Health Research Board (HRB) Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland
| | - David Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland (RCSI), Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Tom Fahey
- Health Research Board (HRB) Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland
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Alldred DP, Raynor DK, Hughes C, Barber N, Chen TF, Spoor P. Interventions to optimise prescribing for older people in care homes. Cochrane Database Syst Rev 2013:CD009095. [PMID: 23450597 DOI: 10.1002/14651858.cd009095.pub2] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is a substantial body of evidence that prescribing for care home residents is suboptimal and requires improvement. Consequently, there is a need to identify effective interventions to optimise prescribing and resident outcomes in this context. OBJECTIVES The objective of the review was to determine the effect of interventions to optimise prescribing for older people living in care homes. SEARCH METHODS We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library (Issue 11, 2012); Cochrane Database of Systematic Reviews, The Cochrane Library (Issue 11, 2012); MEDLINE OvidSP (1980 on); EMBASE, OvidSP (1980 on); Ageline, EBSCO (1966 on); CINAHL, EBSCO (1980 on); International Pharmaceutical Abstracts, OvidSP (1980 on); PsycINFO, OvidSP (1980 on); conference proceedings in Web of Science, Conference Proceedings Citation Index - SSH & Science, ISI Web of Knowledge (1990 on); grey literature sources and trial registries; and contacted authors of relevant studies. We also reviewed the references lists of included studies and related reviews (search period November 2012). SELECTION CRITERIA We included randomised controlled trials evaluating interventions aimed at optimising prescribing for older people (aged 65 years or older) living in institutionalised care facilities. Studies were included if they measured one or more of the following primary outcomes, adverse drug events; hospital admissions;mortality; or secondary outcomes, quality of life (using validated instrument); medication-related problems; medication appropriateness (using validated instrument); medicine costs. DATA COLLECTION AND ANALYSIS Two authors independently screened titles and abstracts, assessed studies for eligibility, assessed risk of bias and extracted data. A narrative summary of results was presented. MAIN RESULTS The eight included studies involved 7653 residents in 262 (range 1 to 85) care homes in six countries. Six studies were cluster-randomised controlled trials and two studies were patient-randomised controlled trials. The interventions evaluated were diverse and often multifaceted. Medication review was a component of seven studies, three studies involved multidisciplinary case-conferencing, two studies involved an educational element for care home staff and one study evaluated the use of clinical decision support technology. Due to heterogeneity, results were not combined in a meta-analysis. There was no evidence of an effect of the interventions on any of the primary outcomes of the review (adverse drug events, hospital admissions and mortality). No studies measured quality of life. There was evidence that the interventions led to the identification and resolution of medication-related problems. There was evidence from two studies that medication appropriateness was improved. The evidence for an effect on medicine costs was equivocal. AUTHORS' CONCLUSIONS Robust conclusions could not be drawn from the evidence due to variability in design, interventions, outcomes and results. The interventions implemented in the studies in this review led to the identification and resolution of medication-related problems, however evidence of an effect on resident-related outcomes was not found. There is a need for high-quality cluster-randomised controlled trials testing clinical decision support systems and multidisciplinary interventions that measure well-defined, important resident-related outcomes.
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Molina López T, Domínguez Camacho JC, Palma Morgado D, Caraballo Camacho MDLO, Morales Serna JC, López Rubio S. [A review of the medication in polymedicated elderly with vascular risk: a randomised controlled trial]. Aten Primaria 2012; 44:453-60. [PMID: 22341703 PMCID: PMC7025269 DOI: 10.1016/j.aprim.2011.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 09/04/2011] [Accepted: 09/19/2011] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To analyse the effectiveness of a medication review based on intervention directed at improving the appropriateness of drug treatments according to the established guidelines, as well as blood pressure, serum lipid and blood glucose control in elderly patients on multiple medication, and cardiovascular disease or high risk of cardiovascular disease. DESIGN A randomised controlled trial with blind evaluation. SETTING Fourteen Primary Health Care centres in Andalusia PARTICIPANTS A total of 323 patients older than 65 on polypharmacy and cardiovascular disease or high risk of cardiovascular disease. INTERVENTION A pharmacist interviewed the patient, reviewed the appropriateness of the drug treatment, taking in account health record data, proposed modifications and communicated them to the general practitioner or nurse. The control group received usual health care. MAIN MEASUREMENTS Percentage of patients with appropriate use of low doses of acetylsalicylic acid, blood pressure, LDL-cholesterol, HbA(1c), and quality of life scores. RESULTS A total of 41% of patients (average age 74, 61% women) had cardiovascular disease. Ten months after the intervention (18.3% withdrawals), more patients in the intervention group used low dose acetylsalicylic acid than in the control group (52.3% vs 38.6%; P=.024). There were no differences between groups in intermediate clinic outcomes. Quality of life scores improve in intervention group by 6.1 points (100 points scale), but was not statistically significant (P=.051). CONCLUSION Clinical medication review improves the appropriateness of antiplatelet treatment in the elderly on polypharmacy and with high risk of cardiovascular disease. No improvement in biochemistry measurements was found.
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Affiliation(s)
- Teresa Molina López
- Servicio de Promoción del Uso Racional del Medicamento, Subdirección de Farmacia, Dirección General de Asistencia Sanitaria, Servicio Andaluz de Salud, Consejería de Salud, Junta de Andalucía, Spain.
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Wessell AM, Ornstein SM, Jenkins RG, Nemeth LS, Litvin CB, Nietert PJ. Medication Safety in Primary Care Practice. Am J Med Qual 2012; 28:16-24. [DOI: 10.1177/1062860612445070] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Gazarian M, Graudins LV. Long-term reduction in adverse drug events: an evidence-based improvement model. Pediatrics 2012; 129:e1334-42. [PMID: 22473370 DOI: 10.1542/peds.2011-1902] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To develop and test an evidence-based model for reducing medication errors and harm in hospitalized children. METHODS Prospective interrupted time series study evaluating the effectiveness of a multifaceted, staged intervention over 4 years in a major urban pediatric referral hospital. Guidelines for safe pediatric prescribing were implemented by using an evidence-based model. Key components included early clinician engagement and improved multidisciplinary communication, consensus development, interactive education, and timely data feedback by using iterative Plan-Do-Study-Act cycles. Impact on medication error and harm (adverse drug events, [ADEs]) was measured by using standard definitions and a multimethod approach. Prospective data from voluntary reports by nursing, medical, and pharmacy staff and intensive chart review were combined. All data were reviewed by a multidisciplinary panel, including causality assessments for ADEs. RESULTS Reviewed over 3 time periods were 1011 patients with 6651 medication orders. Total ADEs decreased by > 50% in the first year and this was maintained at 4 years. Greatest improvements were in potential ADEs, which decreased from 12.26 per 100 patients at baseline to 4.60 per 100 patients at 4 years (P < .05). Total medication errors decreased from 4.51 per 100 orders at baseline to 2.78 per 100 orders at 4 years (P < .05). Prescribing errors decreased by 65%, from 4.07 per 100 orders at baseline to 2.05 orders at 4 years (P < .05). CONCLUSIONS A multifaceted, evidence-based model for safe prescribing guideline implementation, engaging multidisciplinary clinicians, was effective in reducing medication error and harm in hospitalized children, resulting in sustained long-term improvement.
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Affiliation(s)
- Madlen Gazarian
- Paediatric Therapeutics Program, School of Women’s and Children’s Health, University of New South Wales, New South Wales, Australia.
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A long-term care center interdisciplinary education program for antipsychotic use in dementia: program update five years later. Int Psychogeriatr 2012; 24:599-605. [PMID: 22126992 DOI: 10.1017/s1041610211002225] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND While antipsychotic (AP) medications are frequently used in long-term care, current evidence suggests that the risks may offset the benefits, necessitating periodic reassessment of their use. The aims of this present study were: (1) to assess rates of AP use five years after our first intervention to determine the long-term impact; and (2) to implement an updated AP reduction educational intervention program at the same center five years later in order to determine whether AP use could be further reduced. METHODS Participants were residents with dementia receiving AP medication. The educational program component included separate lectures on pharmacologic and non-pharmacologic treatment of behavioral and psychological symptoms of dementia (BPSD). Completion of the Nursing Home Behavior Problems Scale (NHBPS), physician interviews concerning AP treatment plans for subjects with dementia, and AP administration and dose assessment occurred both at baseline and again between four to five months after the educational program. RESULTS Of 308 long-term residents with dementia, 53 (17.2%) were receiving regular APs, primarily for agitation, aggressivity, other behavioral problems and psychosis. Of these, six died and one was transferred, leaving 46 participants. At five months, ten (21.7%) residents were no longer receiving APs and seven (15.2%) were on a lower dose; thus, 17 (37.0%) were either discontinued or on a lower dose. There was no worsening of NHBPS scores. CONCLUSION Despite the low prevalence (17.2%) of AP users at the beginning of the current study compared to that observed five years prior (30.5%), it is still possible to further decrease the proportion of users.
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Butler CC, Simpson SA, Dunstan F, Rollnick S, Cohen D, Gillespie D, Evans MR, Alam MF, Bekkers MJ, Evans J, Moore L, Howe R, Hayes J, Hare M, Hood K. Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial. BMJ 2012; 344:d8173. [PMID: 22302780 PMCID: PMC3270575 DOI: 10.1136/bmj.d8173] [Citation(s) in RCA: 194] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and costs of a multifaceted flexible educational programme aimed at reducing antibiotic dispensing at the practice level in primary care. DESIGN Randomised controlled trial with general practices as the unit of randomisation and analysis. Clinicians and researchers were blinded to group allocation until after randomisation. SETTING 68 general practices with about 480,000 patients in Wales, United Kingdom. PARTICIPANTS 34 practices were randomised to receive the educational programme and 34 practices to be controls. 139 clinicians from the intervention practices and 124 from control practices had agreed to participate before randomisation. Practice level data covering all the clinicians in the 68 practices were analysed. INTERVENTIONS Intervention practices followed the Stemming the Tide of Antibiotic Resistance (STAR) educational programme, which included a practice based seminar reflecting on the practices' own dispensing and resistance data, online educational elements, and practising consulting skills in routine care. Control practices provided usual care. MAIN OUTCOME MEASURES Total numbers of oral antibiotic items dispensed for all causes per 1000 practice patients in the year after the intervention, adjusted for the previous year's dispensing. Secondary outcomes included reconsultations, admissions to hospital for selected causes, and costs. RESULTS The rate of oral antibiotic dispensing (items per 1000 registered patients) decreased by 14.1 in the intervention group but increased by 12.1 in the control group, a net difference of 26.1. After adjustment for baseline dispensing rate, this amounted to a 4.2% (95% confidence interval 0.6% to 7.7%) reduction in total oral antibiotic dispensing for the year in the intervention group relative to the control group (P=0.02). Reductions were found for all classes of antibiotics other than penicillinase-resistant penicillins but were largest and significant individually for phenoxymethylpenicillins (penicillin V) (7.3%, 0.4% to 13.7%) and macrolides (7.7%, 1.1% to 13.8%). There were no significant differences between intervention and control practices in the number of admissions to hospital or in reconsultations for a respiratory tract infection within seven days of an index consultation. The mean cost of the programme was £2923 (€3491, $4572) per practice (SD £1187). There was a 5.5% reduction in the cost of dispensed antibiotics in the intervention group compared with the control group (-0.4% to 11.4%), equivalent to a reduction of about £830 a year for an average intervention practice. CONCLUSION The STAR educational programme led to reductions in all cause oral antibiotic dispensing over the subsequent year with no significant change in admissions to hospital, reconsultations, or costs. Trial registration ISRCT No 63355948.
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Affiliation(s)
- Christopher C Butler
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff CF14 4XN, UK.
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Pettersson B, Hoffmann M, Wändell P, Levin LÅ. Utilization and costs of lipid modifying therapies following health technology assessment for the new reimbursement scheme in Sweden. Health Policy 2012; 104:84-91. [DOI: 10.1016/j.healthpol.2011.10.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 09/29/2011] [Accepted: 10/15/2011] [Indexed: 10/15/2022]
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van Niekerk AC, Venter DJL, Boschmans SA. Implementation of intravenous to oral antibiotic switch therapy guidelines in the general medical wards of a tertiary-level hospital in South Africa. J Antimicrob Chemother 2011; 67:756-62. [DOI: 10.1093/jac/dkr526] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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Rosich I, Allepuz A, Alba G, Benages N, Arranz T. [The efficiency of drug prescription: impact of a therapeutic exchange program]. GACETA SANITARIA 2011; 26:58-64. [PMID: 21993073 DOI: 10.1016/j.gaceta.2011.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 06/08/2011] [Accepted: 06/15/2011] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To assess the impact of substituting proton pump inhibitors (PPI) for omeprazole. METHOD We performed a community trial of the impact of a therapeutic exchange program in the primary care teams of a region compared with non-implementation in a control region. The study included patients prescribed a PPI between May 2008 and June 2009. The intervention consisted of providing educational sessions to physicians (n=68), as well as a list of patients receiving a PPI who were suitable for therapeutic exchange. Information was gathered from medical records (PPI prescribed, primary care team) and the pharmacy database (cost of defined daily doses of the PPI). The percentage of therapeutic exchange in each region before and after the intervention was compared through relative risk (RR). The percentage of omeprazole at the end of each study period and changes in PPI costs were also calculated. RESULTS Therapeutic exchange was higher in the intervention group (RR: 4.2; 95%CI: 3.1-5.8) than in the control group (RR: 1.8; 95%CI: 1.2-2.6). The percentage of patients prescribed omeprazole increased from 86.2% to 89.3% in the intervention region and from 84.3% to 84.7% in the control region. The total cost of the PPI group decreased by 7.6% in the intervention region and increased by 2.0% in the control group. CONCLUSIONS This study demonstrates the effectiveness of the therapeutic exchange program. This is a simple intervention that is able to modify prescription and reduce its costs.
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Affiliation(s)
- Isabel Rosich
- Servicio de Atención Primaria Alt Penedès-Garraf, Insituto Catalán de la Salud, Vilanova i la Geltrú, Barcelona, España.
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Ruiz San Pedro A, Prado Prieto M. La influencia de la entrevista del farmacéutico de Atención Primaria sobre el bolígrafo del médico. Aten Primaria 2011; 43:326-7. [DOI: 10.1016/j.aprim.2010.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 05/27/2010] [Accepted: 05/28/2010] [Indexed: 11/28/2022] Open
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Sladek RM, Jones T, Phillips PA, Luszcz M, Rowett D, Eckermann S, Woodman RJ, Frith P. Health, economic, psychological and social impact of educating carers of patients with advanced pulmonary disease (protocol). Contemp Clin Trials 2011; 32:717-23. [PMID: 21616171 DOI: 10.1016/j.cct.2011.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 04/01/2011] [Accepted: 05/11/2011] [Indexed: 11/19/2022]
Abstract
People with advanced pulmonary disease (APD), such as those with chronic obstructive pulmonary disease, have markedly impaired quality of life. Home Oxygen Therapy (HOT) itself is burdensome, although it often improves survival duration and quality of life in these patients. The exact burdens on informal caregivers of these patients are unknown. The central purpose of the pragmatic randomized controlled study described in this protocol is to determine the effectiveness of improving the skills and knowledge of carers of patients with APD who use HOT. Specifically we aimed to estimate the incremental impact of this carer intervention above usual care on health, economic, psychological and social domains for patient and carer dyads relative to the level of current burden. Eligible patients and their carers were recruited through three major hospitals, and randomized to an intervention or control group. The carers in the intervention group received two home-delivered education sessions based on the principles of academic detailing. Participants are currently being followed over 12 months. The primary outcome will be the proportion of patients surviving without a chronic obstructive pulmonary disease-related readmission / residential (non respite) care over 12 months. Carer secondary outcomes include perceived caregiver burden, level of expected and received social support, perceived level of mastery, self esteem, health related quality of life and disability, and ability to conduct domestic chores and household maintenance, social activities and provide service to others, and fatigue. Secondary patient outcomes include health related quality of life and disability, and current respiratory health status.
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Affiliation(s)
- R M Sladek
- Flinders University, Sturt Drive, Bedford Park, South Australia 5042, Australia.
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Lee SJ, Boscardin WJ, Stijacic Cenzer I, Huang ES, Rice-Trumble K, Eng C. The risks and benefits of implementing glycemic control guidelines in frail older adults with diabetes mellitus. J Am Geriatr Soc 2011; 59:666-72. [PMID: 21480838 DOI: 10.1111/j.1532-5415.2011.03362.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine the hypo- and hyperglycemic outcomes associated with implementing the American Geriatrics Society (AGS) guideline for a glycosylated hemoglobin (HbA1c) level of less than 8% in frail older adults with diabetes mellitus (DM). DESIGN Guideline implementation. SETTING Program of All-Inclusive Care for the Elderly. PARTICIPANTS All participants in the before (October 2002-December 2004, n=338), early (January 2005-June 2006, n=289) and late (July 2006-December 2008, n=385) periods of guideline implementation with a diagnosis of DM and at least one HbA1c measurement. INTERVENTION Clinician education in 2005 with annual monitoring of the proportion of each clinician's patients with DM with HbA1c less than 8%. MEASUREMENTS Hypoglycemia (blood glucose<50 mg/dL), hyperglycemia (blood glucose>400 mg/dL), and severe hypoglycemia (emergency department (ED) visit for hypoglycemia). RESULTS Participants in the before, early, and late periods were similar in age, race and ethnicity, comorbidities, and functional dependence. Antihyperglycemic medication use was greater in the late period, with more participants using metformin (28% before, 42% late, P<.001) and insulin (23% before, 34% late, P<.001) and achieving the AGS glycemic target of HbA1c of less than 8% (74% before, 84% late, P<.001). Episodes of hyperglycemia (per 100 person-years) were dramatically lower in the late period (159 before, 46 late, P<.001), and episodes of hypoglycemia were similar (10.1 before, 9.3 late, P=.50). There were more episodes of severe hypoglycemia in the early period (1.1 before, 2.9 early, P=.03). CONCLUSION Implementing the AGS glycemic control guideline for frail older adults led to fewer hyperglycemic episodes but more severe hypoglycemic episodes requiring ED visits in the early implementation period. Future glycemic control guideline implementation efforts should be coupled with close monitoring for severe hypoglycemia in the early guideline implementation period.
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Affiliation(s)
- Sei J Lee
- Division of Geriatrics, San Francisco Veterans Affairs Medical Center and University of California at San Francisco, San Francisco, California, USA.
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Patel UB, Ni Q, Clayton C, Lam P, Parks J. An attempt to improve antipsychotic medication adherence by feedback of medication possession ratio scores to prescribers. Popul Health Manag 2011; 13:269-74. [PMID: 20879908 DOI: 10.1089/pop.2009.0053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Poor medication adherence is well documented for patients with severe and persistent mental illness. The State of Missouri implemented an early alert system to notify caregivers when patients fail to refill essential prescriptions in a timely manner and as an educational resource for providers on best practices for improving treatment adherence. Missouri Medicaid patients who were prescribed at least 1 of 9 orally-administered antipsychotic medications and who had at least 1 medication possession ratio (MPR) score below 0.8 were included in the adherence intervention group. Their prescribing clinicians and case managers were messaged electronically 2 times per week at the point that failure to refill the targeted prescription was identified. Notification occurred when the prescription had lapsed at 7 days, 30 days, and 45 days, and occurred in real time. In addition, MPR scores were provided monthly for the most recent 6-month period. Change in MPR scores was measured for the intervention group and for a matched control group. Trends in MPR scores were analyzed for both groups pre, during, and post intervention. In both the intervention and postintervention periods, there was a significant difference in the MPR scores between the two groups. The intervention group had a significantly greater increase in MPR score between preintervention and intervention periods. After the conclusion of the intervention, the MPR score decreased somewhat but was still higher than during the preintervention period. Results suggest that clinicians and patients need specific data about adherence in order to address the issue.
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Affiliation(s)
- Urvashi B Patel
- Outcomes Research Division, Caremanagement Technologies , White Plains, NY 10605, USA.
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Intervention to Decrease Glyburide Use in Elderly Patients With Renal Insufficiency. ACTA ACUST UNITED AC 2011; 9:58-68. [DOI: 10.1016/j.amjopharm.2011.02.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2011] [Indexed: 11/17/2022]
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Faden L, Vialle-Valentin C, Ross-Degnan D, Wagner A. Active pharmaceutical management strategies of health insurance systems to improve cost-effective use of medicines in low- and middle-income countries: a systematic review of current evidence. Health Policy 2010; 100:134-43. [PMID: 21185616 DOI: 10.1016/j.healthpol.2010.10.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 10/29/2010] [Accepted: 10/31/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Health insurance systems have great potential to improve the cost-effective use of medicines by leveraging better provider prescribing, more cost-effective use by consumers, and lower prices from industry. Despite ample evidence from high-income countries, little is known about insurance system strategies targeting medicines in low- and middle-income countries (LMIC). This paper provides a critical review of the literature on these strategies and their impacts in LMIC. METHODS We conducted a systematic review of published peer-reviewed and grey literature and organized the insurance system strategies into four categories: medicines selection, purchasing, contracting and utilization management. RESULTS In n=63 reviewed publications we found reasonable evidence supporting the use of insurance as an overall strategy to improve access to pharmaceuticals and outcomes in LMIC. Beyond this, most of the literature focused on provider contracting strategies to influence prescribing. There was very little evidence on medicines selection, purchasing, or utilization management strategies. CONCLUSIONS There is a paucity of published evidence on the impact of insurance system strategies on improving the use of medicines in LMIC. The existing evidence is questionable since the majority of the published studies utilize weak study designs. This review highlights the need for well-designed studies to build an evidence base on the impact of medicines management strategies deployed by LMIC insurance programs.
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Affiliation(s)
- Laura Faden
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, USA.
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Ajjawi R, Thistlethwaite JE, Aslani P, Cooling NB. What are the perceived learning needs of Australian general practice registrars for quality prescribing? BMC MEDICAL EDUCATION 2010; 10:92. [PMID: 21143939 PMCID: PMC3017526 DOI: 10.1186/1472-6920-10-92] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Accepted: 12/09/2010] [Indexed: 05/30/2023]
Abstract
BACKGROUND Little is known about the perceived learning needs of Australian general practice (GP) registrars in relation to the quality use of medicines (QUM) or the difficulties experienced when learning to prescribe. This study aimed to address this gap. METHODS GP registrars' perceived learning needs were investigated through an online national survey, interviews and focus groups. Medical educators' perceptions were canvassed in semi-structured interviews in order to gain a broader perspective of the registrars' needs. Qualitative data analysis was informed by a systematic framework method involving a number of stages. Survey data were analysed descriptively. RESULTS The two most commonly attended QUM educational activities took place in the workplace and through regional training providers. Outside of these structured educational activities, registrars learned to prescribe mainly through social and situated means. Difficulties encountered by GP registrars included the transition from hospital prescribing to prescribing in the GP context, judging how well they were prescribing and identifying appropriate and efficient sources of information at the point of care. CONCLUSIONS GP registrars learn to prescribe primarily and opportunistically in the workplace. Despite many resources being expended on the provision of guidelines, decision-support systems and training, GP registrars expressed difficulties related to QUM. Ways of easing the transition into GP and of managing the information 'overload' related to medicines (and prescribing) in an evidence-guided, efficient and timely manner are needed. GP registrars should be provided with explicit feedback about the process and outcomes of prescribing decisions, including the use of audits, in order to improve their ability to judge their own prescribing.
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Affiliation(s)
- Rola Ajjawi
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Notting Hill, VIC 3168, Australia
| | - Jill E Thistlethwaite
- Institute of Clinical Education, The University of Warwick, Coventry, UK CV4 7AL, UK
| | - Parisa Aslani
- Faculty of Pharmacy, The University of Sydney, NSW 2006 Australia
| | - Nick B Cooling
- GP Training Tasmania, New Town, Tasmania 7008, Australia
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Improving the use of benzodiazepines--is it possible? A non-systematic review of interventions tried in the last 20 years. BMC Health Serv Res 2010; 10:321. [PMID: 21118575 PMCID: PMC3019200 DOI: 10.1186/1472-6963-10-321] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Accepted: 11/30/2010] [Indexed: 01/09/2023] Open
Abstract
Background Benzodiazepines are often used on a long term basis in the elderly to treat various psychological disorders including sleep disorders, some neurological disorders and anxiety. This is despite the risk of dependence, cognitive impairment, and falls and fractures. Guidelines, campaigns and prescribing restrictions have been used to raise awareness of potentially inappropriate use, however long term use of benzodiazepine and related compounds is currently increasing in Australia and worldwide. The objective of this paper is to explore interventions aimed at improving the prescribing and use of benzodiazepines in the last 20 years. Methods Medline, EMBASE, PsychINFO, IPA were searched for the period 1987 to June 2007. Results Thirty-two articles met the study eligibility criteria (interventions solely focusing on increasing appropriate prescribing and reducing long term use of benzodiazepines) and were appraised. Insufficient data were presented in these studies for systematic data aggregation and synthesis, hence critical appraisal was used to tabulate the studies and draw empirical conclusions. Three major intervention approaches were identified; education, audit and feedback, and alerts. Conclusions Studies which used a multi-faceted approach had the largest and most sustained reductions in benzodiazepines use. It appears that support groups for patients, non-voluntary recruitment of GPs, and oral delivery of alerts or feedback may all improve the outcomes of interventions. The choice of outcome measures, delivery style of educational messages, and requests by GPs to stop benzodiazepines, either in a letter or face to face, showed no differences on the success rates of the intervention.
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Communicating pharmacogenetic research results to breastfeeding mothers taking codeine: a pilot study of perceptions and benefits. Clin Pharmacol Ther 2010; 88:792-5. [PMID: 20739920 DOI: 10.1038/clpt.2010.125] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Sixty-two codeine-prescribed breastfeeding mothers from a pharmacogenetic study were interviewed regarding the communication of individual CYP2D6 genotype results and overall research findings. All participants wanted to receive the results of their individual genetic tests; however, individuals placed different values on the usefulness of this information toward future medical decisions. Receiving one's pharmacogenetic test results was not associated with a negative psychosocial impact. Thirty-three percent of the participants wished to withhold these results from their physicians. Participants' expectations seem to dictate the extent of transparency of pharmacogenetic research results.
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Marcum ZA, Handler SM, Wright R, Hanlon JT. Interventions to improve suboptimal prescribing in nursing homes: A narrative review. ACTA ACUST UNITED AC 2010; 8:183-200. [PMID: 20624609 DOI: 10.1016/j.amjopharm.2010.05.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2010] [Indexed: 11/15/2022]
Abstract
BACKGROUND Appropriate medication prescribing for nursing home residents remains a challenge. OBJECTIVE The purpose of this study was to conduct a narrative review of the published literature describing randomized controlled trials that used interventions to improve suboptimal prescribing in nursing homes. METHODS The PubMed, International Pharmaceutical Abstracts, and EMBASE databases were searched for articles published in the English language between January 1975 and December 2009, using the terms drug utilization, pharmaceutical services, aged, long-term care, nursing homes, prescribing, geriatrics, and randomized controlled trial. A manual search of the reference lists of identified articles and the authors' files, book chapters, and recent review articles was also conducted. Abstracts and posters from meetings were not included in the search. Studies were included if they: (1) had a randomized controlled design; (2) had a process measure outcome for quality of prescribing or a distal outcome measure for medication-related adverse patient events; and (3) involved nursing home residents. RESULTS Eighteen studies met the inclusion criteria for this review. Seven of those studies described educational approaches using various interventions (eg, outreach visits) and measured suboptimal prescribing in different manners (eg, adherence to guidelines). Two studies described computerized decision-support systems to measure the intervention's impact on adverse drug events (ADEs) and appropriate drug orders. Five studies described clinical pharmacist activities, most commonly involving a medication review, and used various measures of suboptimal prescribing, including a measure of medication appropriateness and the total number of medications prescribed. Two studies each described multidisciplinary and multifaceted approaches that included heterogeneous interventions and measures of prescribing. Most (15/18; 83.3%) of these studies reported statistically significant improvements in >or=1 aspect of suboptimal prescribing. Only 3 of the studies reported significant improvements in distal health outcomes, and only 3 measured ADEs or adverse drug reactions. CONCLUSIONS Mixed results were reported for a variety of approaches used to improve suboptimal prescribing. However, the heterogeneity of the study interventions and the various measures of suboptimal prescribing used in these studies does not allow for an authoritative conclusion based on the currently available literature.
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Affiliation(s)
- Zachary A Marcum
- Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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López-Montenegro Soria MA, Climente Martí M, Jiménez Torres NV. Doctors' acceptance of recommendations for patients with the opportunity for pharmacotherapy improvement. FARMACIA HOSPITALARIA 2010; 35:51-7. [PMID: 20615738 DOI: 10.1016/j.farma.2010.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 04/20/2010] [Accepted: 04/22/2010] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To identify and quantify the influence of different variables on the implementation of pharmacotherapy optimisation measures in hospitalised patients. METHOD Descriptive transversal study. PERIOD 2000-2007. ENVIRONMENT public university general hospital (25,000 patients admitted/year). The Programme implemented to improve pharmacotherapy quality and patient safety covers 30% of all patients. Using records from the Atefarm(®) Farmis application, we analysed pharmacotherapy recommendations (PRs) made by pharmacists to doctors. The selected variables were the following: Risk of the medication for ADE (1-high, 0-low), ADE category, (0-indication, 1-effectiveness, 2-safety), potential severity (scale of 1 to 5), impact of the PR (0-effectiveness, 1-safety, 2-efficiency) and implementation of the PR (yes/no). We calculated the frequency (%) and 95% CI for the categorical variables and performed a multivariate logistical regression analysis to identify the variables' degree of influence on implementing the PRs. RESULTS We identified 7,920 ADEs in 4,680 patients. A PR was issued in 85% of the cases (6,762), and it was implemented in 83% (95% CI 74.2-89.8). Potential severity of the ADE ≥2 (OR 1.57; 95% CI 1.27-1.94), and ADE category for effectiveness and safety (OR 1.19; 95% CI 1.02-1.39) were shown to be determining factors for implementing the PR for the patient. CONCLUSIONS The probability that a PR will be implemented for a patient is related to the potential severity and the category of the identified ADE. Therefore, recommendations intended to improve effectiveness of pharmacotherapy or patient safety, and those with potential clinical consequences have a greater chance of being applied to a patient.
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95
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Hope NH, Ray SM, Franks AS, Heidel E. Impact of an educational intervention on steroid prescribing and dosing effect on patient outcomes in COPD exacerbations. Pharm Pract (Granada) 2010; 8:162-6. [PMID: 25126135 PMCID: PMC4127050 DOI: 10.4321/s1886-36552010000300002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Accepted: 06/10/2010] [Indexed: 11/11/2022] Open
Abstract
UNLABELLED The increasing number of patients affected by chronic obstructive pulmonary disease (COPD) and associated exacerbations has led to both rising hospital admissions and significant economic impact. Evidence-based guidelines have been formulated for COPD management recommending the use of low dose, oral corticosteroid therapy in the treatment of exacerbations. However, fewer than 50% of physicians' prescribing practices appropriately reflect the published clinical guidelines on the use of systemic corticosteroids in these patients. OBJECTIVE The purpose of this study was to evaluate the impact of a pharmacist-led educational intervention on prescribing practices and patient outcomes when using systemic corticosteroids in patients with COPD exacerbations. METHODS This retrospective case-control study included patients admitted to an inpatient family medicine service with a COPD exacerbation who received systemic corticosteroids. Two pharmacist-led educational interventions were delivered to prescribers to review current guidelines for managing COPD exacerbations with systemic corticosteroids. Patients were retrospectively identified over a three month span prior to and following the educational intervention. Data was collected via chart review to evaluate prescribing practices prior to and following the educational sessions. In addition, data was collected to evaluate the effects of an educational intervention on length of stay, adverse events, and cost of treatment. RESULTS A total of 23 pre-intervention patients and 18 post-intervention patients met inclusion criteria. After pharmacist-led interventions, guidelines were not more likely to be adhered to by prescribers when compared to guideline adherence in the pre-intervention patients. Because no statistically significant change in guideline adherence was observed, there was no impact on secondary outcomes. CONCLUSION Pharmacist-led didactic educational interventions and guideline dissemination do not improve guideline adherence and prescribing practices with respect to systemic corticosteroids in COPD exacerbations.
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Affiliation(s)
- Nancy H Hope
- Assistant Professor of Pharmacy Practice Presbyterian College School of Pharmacy Clinton, South Carolina; At the time of writing this manuscript Dr. Hope was a PGY-2 Internal Medicine Resident at University of Tennessee Medical Center . Knoxville, TN ( United States )
| | - Shaunta' M Ray
- Assistant Professor. Department of Clinical Pharmacy: University of Tennessee College of Pharmacy and Department of Family Medicine. University of Tennessee Graduate School of Medicine. Knoxville, TN ( United States )
| | - Andrea S Franks
- Associate Professor. Department of Clinical Pharmacy, University of Tennessee College of Pharmacy and Department of Family Medicine, University of Tennessee Graduate School of Medicine. Knoxville, TN ( United States )
| | - Eric Heidel
- Dean's Office, University of Tennessee Graduate School of Medicine. Knoxville, TN ( United States )
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Niquille A, Ruggli M, Buchmann M, Jordan D, Bugnon O. The nine-year sustained cost-containment impact of swiss pilot physicians-pharmacists quality circles. Ann Pharmacother 2010; 44:650-7. [PMID: 20215496 DOI: 10.1345/aph.1m537] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Six pioneer physicians-pharmacists quality circles (PPQCs) located in the Swiss canton of Fribourg (administratively corresponding to a state in the US) were under the responsibility of 6 trained community pharmacists moderating the prescribing process of 24 general practitioners (GPs). PPQCs are based on a multifaceted collaborative process mediated by community pharmacists for improving compliance with clinical guidelines within GPs' prescribing practices. OBJECTIVE To assess, over a 9-year period (1999-2007), the cost-containment impact of the PPQCs. METHODS The key elements of PPQCs are a structured continuous quality improvement and education process; local networking; feedback of comparative and detailed data regarding costs, drug choice, and frequency of prescribed drugs; and structured independent literature review for interdisciplinary continuing education. The data are issued from the community pharmacy invoices to the health insurance companies. The study analyzed the cost-containment impact of the PPQCs in comparison with GPs working in similar conditions of care without particular collaboration with pharmacists, the percentage of generic prescriptions for specific cardiovascular drug classes, and the percentage of drug costs or units prescribed for specific cardiovascular drugs. RESULTS For the 9-year period, there was a 42% decrease in the drug costs in the PPQC group as compared to the control group, representing a $225,000 (USD) savings per GP only in 2007. These results are explained by better compliance with clinical and pharmacovigilance guidelines, larger distribution of generic drugs, a more balanced attitude toward marketing strategies, and interdisciplinary continuing education on the rational use of drugs. CONCLUSIONS The PPQC work process has yielded sustainable results, such as significant cost savings, higher penetration of generics and reflection on patient safety, and the place of "new" drugs in therapy. The PPQCs may also constitute a solid basis for implementing more comprehensive collaborative programs, such as medication reviews, adherence-enhancing interventions, or disease management approaches.
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Sterling JA. Recent Publications on Medications and Pharmacy. Hosp Pharm 2009. [DOI: 10.1310/hpj4405-439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly. Suggestions or comments may be addressed to Jacyntha Sterling, Drug Information Specialist at Saint Francis Hospital, 6161 S Yale Ave, Tulsa, OK 74136 or e-mail: jasterling@saintfrancis.com .
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