Computerized advice on drug dosage to improve prescribing practice

Examining nursing processes in primary care settings using the Chronic Care Model: an umbrella review

BACKGROUND

While there is clear evidence that nurses can play a significant role in responding to the needs of populations with chronic conditions, there is a lack of consistency between and within primary care settings in the implementation of nursing processes for chronic disease management. Previous reviews have focused either on a specific model of care, populations with a single health condition, or a specific type of nurses. Since primary care nurses are involved in a wide range of services, a comprehensive perspective of effective nursing processes across primary care settings and chronic health conditions could allow for a better understanding of how to support them in a broader way across the primary care continuum. This systematic overview aims to provide a picture of the nursing processes and their characteristics in chronic disease management as reported in empirical studies, using the Chronic Care Model (CCM) conceptual approach.

METHODS

We conducted an umbrella review of systematic reviews published between 2005 and 2021 based on the recommendations of the Joanna Briggs Institute. The methodological quality was assessed independently by two reviewers using the AMSTAR 2 tool.

RESULTS

Twenty-six systematic reviews and meta-analyses were included, covering 394 primary studies. The methodological quality of most reviews was moderate. Self-care support processes show the most consistent positive outcomes across different conditions and primary care settings. Case management and nurse-led care show inconsistent outcomes. Most reviews report on the clinical components of the Chronic Care Model, with little mention of the decision support and clinical information systems components.

CONCLUSIONS

Placing greater emphasis on decision support and clinical information systems could improve the implementation of nursing processes. While the need for an interdisciplinary approach to primary care is widely promoted, it is important that this approach not be viewed solely from a clinical perspective. The organization of care and resources need to be designed to support contributions from all providers to optimize the full range of services available to patients with chronic conditions.

PROSPERO REGISTRATION

CRD42021220004.

Interventions to Reduce Hospital Length of Stay in High-risk Populations: A Systematic Review

IMPORTANCE

Many strategies to reduce hospital length of stay (LOS) have been implemented, but few studies have evaluated hospital-led interventions focused on high-risk populations. The Agency for Healthcare Research and Quality (AHRQ) Learning Health System panel commissioned this study to further evaluate system-level interventions for LOS reduction.

OBJECTIVE

To identify and synthesize evidence regarding potential systems-level strategies to reduce LOS for patients at high risk for prolonged LOS.

EVIDENCE REVIEW

Multiple databases, including MEDLINE and Embase, were searched for English-language systematic reviews from January 1, 2010, through September 30, 2020, with updated searches through January 19, 2021. The scope of the protocol was determined with input from AHRQ Key Informants. Systematic reviews were included if they reported on hospital-led interventions intended to decrease LOS for high-risk populations, defined as those with high-risk medical conditions or socioeconomically vulnerable populations (eg, patients with high levels of socioeconomic risk, who are medically uninsured or underinsured, with limited English proficiency, or who are hospitalized at a safety-net, tertiary, or quaternary care institution). Exclusion criteria included interventions that were conducted outside of the hospital setting, including community health programs. Data extraction was conducted independently, with extraction of strength of evidence (SOE) ratings provided by systematic reviews; if unavailable, SOE was assessed using the AHRQ Evidence-Based Practice Center methods guide.

FINDINGS

Our searches yielded 4432 potential studies. We included 19 systematic reviews reported in 20 articles. The reviews described 8 strategies for reducing LOS in high-risk populations: discharge planning, geriatric assessment, medication management, clinical pathways, interdisciplinary or multidisciplinary care, case management, hospitalist services, and telehealth. Interventions were most frequently designed for older patients, often those who were frail (9 studies), or patients with heart failure. There were notable evidence gaps, as there were no systematic reviews studying interventions for patients with socioeconomic risk. For patients with medically complex conditions, discharge planning, medication management, and interdisciplinary care teams were associated with inconsistent outcomes (LOS, readmissions, mortality) across populations. For patients with heart failure, clinical pathways and case management were associated with reduced length of stay (clinical pathways: mean difference reduction, 1.89 [95% CI, 1.33 to 2.44] days; case management: mean difference reduction, 1.28 [95% CI, 0.52 to 2.04] days).

CONCLUSIONS AND RELEVANCE

This systematic review found inconsistent results across all high-risk populations on the effectiveness associated with interventions, such as discharge planning, that are often widely used by health systems. This systematic review highlights important evidence gaps, such as the lack of existing systematic reviews focused on patients with socioeconomic risk factors, and the need for further research.

Clinical and healthcare improvement through My Health Record usage and education in general practice (CHIME-GP): a study protocol for a cluster-randomised controlled trial

BACKGROUND

There is an international interest in whether improved primary care can lead to a more rational use of health resources. There is evidence that educational interventions can lead to improvements in the quality of rational prescribing and test ordering. A new national platform for shared medical records in Australia, My Health Record (MHR), poses new opportunities and challenges for system-wide implementation. This trial (CHIME-GP) will investigate whether components of a multifaceted education intervention in an Australian general practice setting on rational prescribing and investigation ordering leads to reductions in health-service utilisation and costs in the context of the use of a national digital health record system.

METHODS

The trial will be undertaken in Australian general practices. The aim of the research is to evaluate the effectiveness of components of a web-based educational intervention for general practitioners, regarding rational use of medicines, pathology and imaging in the context of the use of the MHR system. Our target is to recruit 120 general practitioners from urban and regional regions across Australia. We will use a mixed methods approach incorporating a three-arm pragmatic cluster randomised parallel trial and a prospective qualitative inquiry. The effect of each education component in each arm will be assessed, using the other two arms as controls. The evaluation will synthesise the results embedding qualitative pre/post interviews in the quantitative results to investigate implementation of the intervention, clinical behaviour change and mechanisms such as attitudes, that may influence change. The primary outcome will be an economic analysis of the cost per 100 consultations of selected prescriptions, pathology and radiology test ordering in the 6 months following the intervention compared with 6 months prior to the intervention. Secondary outcome measures include the rates per 100 consultations of selected prescriptions, pathology and radiology test ordering 6 months pre- and post-intervention, and comparison of knowledge assessment tests pre- and post-intervention.

DISCUSSION

The trial will produce robust health economic analyses on the evidence on educational intervention in reducing unnecessary prescribing, pathology and imaging ordering, in the context of MHR. In addition, the study will contribute to the evidence-base concerning the implementation of interventions to improve the quality of care in primary care practice.

TRIAL REGISTRATION

ClinicalTrials.gov ACTRN12620000010998 . Registered on 09 January 2020 with the Australian New Zealand Clinical Trials Registry.

Deprescribing in the Older Patient: A Narrative Review of Challenges and Solutions

Polypharmacy is a major challenge in healthcare for older people, and is associated with increased risks of adverse outcomes, such as delirium, falls, frailty, cognitive impairment and hospitalization. There is significant public and professional interest in the role of deprescribing in reducing medication-related harms in older people. We aim to provide a narrative review of 1) the safety and efficacy of deprescribing interventions, 2) the challenges and solutions of deprescribing research and implementation in clinical practice, and 3) the benefits of using Computerized Clinical Decision Support Systems (CCDSS) and Quality Indicators (QIs) in deprescribing research and practice. Deprescribing is an established management strategy to minimize polypharmacy and potentially inappropriate medications. There is limited clinical evidence for its efficacy on global and geriatric outcomes. Various challenges at patient, healthcare professional and healthcare system levels may impact on the success of deprescribing interventions in research and practice. Management strategies that target all levels of the healthcare system are required to overcome these challenges. Future studies may consider large multicenter prospective designs to establish the effects and sustainability of deprescribing interventions on clinical outcomes.

Medication safety knowledge, attitude, and practice among hospital pharmacists in tertiary care hospitals in Saudi Arabia: a multi-center study

BACKGROUND

Pharmacovigilance (PV) demarcates all actions involving the detection and prevention of adverse drug reactions (ADR) for marketed drugs. However, ADRs are considerably underreported worldwide and continue to be a major concern to health care systems. This study aims to assess the knowledge, attitude, and perception of hospital pharmacists regarding medication safety concerning PV and ADRs across multiple tertiary care centers around Saudi Arabia.

METHODS

This cross-sectional study was conducted between July 2019 and January 2020. Pharmacists working in the tertiary care centers of Riyadh City, Saudi Arabia were asked to participate in the study. A self-administered questionnaire was used to conduct this study, it consisted of: 63 questions out of which 19 questions were knowledge-based, 15 were attitude-based, and 29 were practice-based questions.

RESULTS

A total of 350 pharmacists were distributed and 289 agreed to participate, giving a response rate of 82.6%. Most pharmacists were aware of the concept of VP and its functions (96.5%) and (87.2%), respectively. Moreover, 90% said that ADR can be preventable and non-preventable. However, the findings revealed inadequate knowledge about the overall PV field, where the majority of the pharmacists failed to correctly answer questions related to independent ADRs treatment, Augmented drug reaction, the international location of ADR, and the World Health Organization "online database" for reporting ADRs. Moreover, incomplete and/or wrong answers were recorded for questions that included single or multiple correct answers. Regarding the participants" attitude, 96.9% were interested in ADR reporting, agreeing that ADR is important to enable safe drug usage. Although a general positive attitude was recorded, pharmacists have stated that the three main barriers that hinder reporting ADRs are: unavailability of information about ADRs, lack of awareness about the need to report ADRs, and lack of time. Concerning practice, 69.2% said they received training in ADRs reporting, and 70% have reported ADRs more than once a week.

CONCLUSION

Surveyed pharmacists from Riyadh hospitals showed narrow knowledge of the PV field. However, a positive attitude and satisfactory practice was observed among pharmacists. These findings warrant the need for educational programs and an encouraging environment for ADR reporting to increase ADR reporting rates and support PV activities in Saudi Arabia.

Clinical decision support systems-based interventions to improve medication outcomes: A systematic literature review on features and effects

Background: Clinical decision support systems (CDSSs) interventions were used to improve the life quality and safety in patients and also to improve practitioner performance, especially in the field of medication. Therefore, the aim of the paper was to summarize the available evidence on the impact, outcomes and significant factors on the implementation of CDSS in the field of medicine. Methods: This study is a systematic literature review. PubMed, Cochrane Library, Web of Science, Scopus, EMBASE, and ProQuest were investigated by 15 February 2017. The inclusion requirements were met by 98 papers, from which 13 had described important factors in the implementation of CDSS, and 86 were medicated-related. We categorized the system in terms of its correlation with medication in which a system was implemented, and our intended results were examined. In this study, the process outcomes (such as; prescription, drug-drug interaction, drug adherence, etc.), patient outcomes, and significant factors affecting the implementation of CDSS were reviewed. Results: We found evidence that the use of medication-related CDSS improves clinical outcomes. Also, significant results were obtained regarding the reduction of prescription errors, and the improvement in quality and safety of medication prescribed. Conclusion: The results of this study show that, although computer systems such as CDSS may cause errors, in most cases, it has helped to improve prescribing, reduce side effects and drug interactions, and improve patient safety. Although these systems have improved the performance of practitioners and processes, there has not been much research on the impact of these systems on patient outcomes.

Development and external validation of an admission risk prediction model after treatment from early intervention in psychosis services

Early Intervention in psychosis (EIP) teams are the gold standard treatment for first-episode psychosis (FEP). EIP is time-limited and clinicians are required to make difficult aftercare decisions that require weighing up individuals' wishes for treatment, risk of relapse, and health service capacity. Reliable decision-making tools could assist with appropriate resource allocation and better care. We aimed to develop and externally validate a readmission risk tool for application at the point of EIP discharge. All persons from EIP caseloads in two NHS Trusts were eligible for the study. We excluded those who moved out of the area or were only seen for assessment. We developed a model to predict the risk of hospital admission within a year of ending EIP treatment in one Trust and externally validated it in another. There were n = 831 participants in the development dataset and n = 1393 in the external validation dataset, with 79 (9.5%) and 162 (11.6%) admissions to inpatient hospital, respectively. Discrimination was AUC = 0.76 (95% CI 0.75; 0.77) in the development dataset and AUC = 0.70 (95% CI 0.66; 0.75) in the external dataset. Calibration plots in external validation suggested an underestimation of risk in the lower predicted probabilities and slight overestimation at predicted probabilities in the 0.1-0.2 range (calibration slope = 0.86, 95% CI 0.68; 1.05). Recalibration improved performance at lower predicted probabilities but underestimated risk at the highest range of predicted probabilities (calibration slope = 1.00, 95% CI 0.79; 1.21). We showed that a tool for predicting admission risk using routine data has good performance and could assist clinical decision-making. Refinement of the model, testing its implementation and further external validation are needed.

Inpatient and Outpatient Technologies to Assist in the Management of Insulin Dosing

Several new technologies use computer algorithms to analyze a person's blood glucose response to insulin treatment, calculate the person's next recommended insulin dose, advise the person regarding when to check blood glucose next, and provide alerts regarding glucose control for the individual patient or across a hospital system. This article reviews U.S. Food and Drug Administration (FDA)-approved products designed to help manage insulin dosing for inpatients, as well as those available to provide people with insulin-requiring diabetes support in making adjustments to their basal and/or mealtime insulin doses. Many of these products have a provider interface that allows for remote monitoring of patients' glucose readings and insulin doses. By alleviating some of the burdens of insulin initiation and dose adjustment, these products may facilitate improved glycemic management and patient outcomes.

Publication and related bias in quantitative health services and delivery research: a multimethod study

Background

Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.

Objectives

To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.

Methods

The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).

Results

We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.

Conclusions

This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.

Study registration

This study is registered as PROSPERO CRD42016052333 and CRD42016052366.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.

Reduction in the Doses of Direct Oral Anticoagulants and Risk of Ischemic Stroke Events: A Hospital Survey

Inappropriately reduced doses (IRDs) of direct oral anticoagulants (DOACs) are common in clinical practice. We performed a retrospective review using electronic medical records of St. Marianna University School of Medicine Hospital (a 1200-bed teaching hospital in Japan) to address the prevalence of IRDs and patient-related factors that result in IRDs. We also surveyed DOAC-treated patients who were hospitalized due to a stroke during the 5-year study period to analyze the association between stroke events and IRDs. We found that one in five patients who were newly prescribed a DOAC was treated with IRDs. Patients treated with edoxaban received the most IRDs (64%, 7/11), followed by those treated with dabigatran (50%, 1/2), apixaban (32%, 19/61), and rivaroxaban (27%, 12/44). Our analysis showed that the renal function (measured as serum creatinine and creatinine clearance values) and age are possible factors influencing dose reduction. The HAS-BLED score and antiplatelet use were not associated with IRD prescription. An analysis of the 5-year hospital records revealed 20 stroke cases despite ongoing treatments with DOACs, and IRDs were noted in three of these cases. In all three cases, the patients had been on an IRD of rivaroxaban. To prevent IRDs of DOACs, we suggest that a clinical protocol be incorporated into formularies to support the prescription process.

Assessment of publication bias and outcome reporting bias in systematic reviews of health services and delivery research: A meta-epidemiological study

Strategies to identify and mitigate publication bias and outcome reporting bias are frequently adopted in systematic reviews of clinical interventions but it is not clear how often these are applied in systematic reviews relating to quantitative health services and delivery research (HSDR). We examined whether these biases are mentioned and/or otherwise assessed in HSDR systematic reviews, and evaluated associating factors to inform future practice. We randomly selected 200 quantitative HSDR systematic reviews published in the English language from 2007-2017 from the Health Systems Evidence database (www.healthsystemsevidence.org). We extracted data on factors that may influence whether or not authors mention and/or assess publication bias or outcome reporting bias. We found that 43% (n = 85) of the reviews mentioned publication bias and 10% (n = 19) formally assessed it. Outcome reporting bias was mentioned and assessed in 17% (n = 34) of all the systematic reviews. Insufficient number of studies, heterogeneity and lack of pre-registered protocols were the most commonly reported impediments to assessing the biases. In multivariable logistic regression models, both mentioning and formal assessment of publication bias were associated with: inclusion of a meta-analysis; being a review of intervention rather than association studies; higher journal impact factor, and; reporting the use of systematic review guidelines. Assessment of outcome reporting bias was associated with: being an intervention review; authors reporting the use of Grading of Recommendations, Assessment, Development and Evaluations (GRADE), and; inclusion of only controlled trials. Publication bias and outcome reporting bias are infrequently assessed in HSDR systematic reviews. This may reflect the inherent heterogeneity of HSDR evidence and different methodological approaches to synthesising the evidence, lack of awareness of such biases, limits of current tools and lack of pre-registered study protocols for assessing such biases. Strategies to help raise awareness of the biases, and methods to minimise their occurrence and mitigate their impacts on HSDR systematic reviews, are needed.

Computerized clinical decision support system for diabetes in primary care does not improve quality of care: a cluster-randomized controlled trial

Background

The EBMeDS system is the computerized clinical decision support (CCDS) system of EBPNet, a national computerized point-of-care information service in Belgium. There is no clear evidence of more complex CCDS systems to manage chronic diseases in primary care practices (PCPs). The objective of this study was to assess the effectiveness of EBMeDS use in improving diabetes care.

Methods

A cluster-randomized trial with before-and-after measurements was performed in Belgian PCPs over 1 year, from May 2017 to May 2018. We randomly assigned 51 practices to either the intervention group (IG), to receive the EBMeDS system, or to the control group (CG), to receive usual care. Primary and secondary outcomes were the 1-year pre- to post-implementation change in HbA1c, LDL cholesterol, and systolic and diastolic blood pressure. Composite patient and process scores were calculated. A process evaluation was added to the analysis. Results were analyzed at 6 and 12 months. Linear mixed models and logistic regression models based on generalized estimating equations were used where appropriate.

Results

Of the 51 PCPs that were enrolled and randomly assigned (26 PCPs in the CG and 25 in the IG), 29 practices (3815 patients) were analyzed in the study: 2464 patients in the CG and 1351 patients in the IG. No change differences existed between groups in primary or secondary outcomes. Change difference between CG and IG after 1-year follow-up was − 0.09 (95% CI − 0.18; 0.01, p-value = 0.06) for HbA1c; 1.76 (95% CI − 0.46; 3.98, p-value = 0.12) for LDL cholesterol; and 0.13 (95% CI − 0.91; 1.16, p-value = 0.81) and 0.12 (95% CI − 1.25;1.49, p-value = 0.86) for systolic and diastolic blood pressure respectively. The odds ratio of the IG versus the CG for the probability of no worsening and improvement was 1.09 (95% CI 0.73; 1.63, p-value = 0.67) for the process composite score and 0.74 (95% CI 0.49; 1.12, p-value = 0.16) for the composite patient score. All but one physician was satisfied with the EBMeDS system.

Conclusions

The CCDS system EBMeDS did not improve diabetes care in Belgian primary care. The lack of improvement was mainly caused by imperfections in the organizational context of Belgian primary care for chronic disease management and shortcomings in the system requirements for the correct use of the EBMeDS system (e.g., complete structured records). These shortcomings probably caused low-use rates of the system.

Trial registration

ClinicalTrials.gov, NCT01830569, Registered 12 April 2013.

Effect of Electronic Prescribing Strategies on Medication Error and Harm in Hospital: a Systematic Review and Meta-analysis

BACKGROUND

Computerized physician order entry and clinical decision support systems are electronic prescribing strategies that are increasingly used to improve patient safety. Previous reviews show limited effect on patient outcomes. Our objective was to assess the impact of electronic prescribing strategies on medication errors and patient harm in hospitalized patients.

METHODS

MEDLINE, EMBASE, CENTRAL, and CINAHL were searched from January 2007 to January 2018. We included prospective studies that compared hospital-based electronic prescribing strategies with control, and reported on medication error or patient harm. Data were abstracted by two reviewers and pooled using random effects model. Study quality was assessed using the Effective Practice and Organisation of Care and evidence quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Thirty-eight studies were included; comprised of 11 randomized control trials and 27 non-randomized interventional studies. Electronic prescribing strategies reduced medication errors (RR 0.24 (95% CI 0.13, 0.46), I² 98%, n = 11) and dosing errors (RR 0.17 (95% CI 0.08, 0.38), I² 96%, n = 9), with both risk ratios significantly affected by advancing year of publication. There was a significant effect of electronic prescribing strategies on adverse drug events (ADEs) (RR 0.52 (95% CI 0.40, 0.68), I² 0%, n = 2), but not on preventable ADEs (RR 0.55 (95% CI 0.30, 1.01), I² 78%, n = 3), hypoglycemia (RR 1.03 (95% CI 0.62-1.70), I² 28%, n = 7), length of stay (MD - 0.18 (95% - 1.42, 1.05), I² 94%, n = 7), or mortality (RR 0.97 (95% CI 0.79, 1.19), I² 74%, n = 9). The quality of evidence was rated very low.

DISCUSSION

Electronic prescribing strategies decrease medication errors and adverse drug events, but had no effect on other patient outcomes. Conservative interpretations of these findings are supported by significant heterogeneity and the preponderance of low-quality studies.

Quality of prescribing in older people from a broad family physician perspective: a descriptive pilot study

OBJECTIVES

To investigate the quality of drug treatment in older people from a broad family physician perspective, and to provide evidence for power calculations in full-scale studies on prescribing quality.

DESIGN

Descriptive, retrospective pilot study.

SETTING

A primary healthcare centre in Sweden.

PARTICIPANTS

123 consecutive patients, ≥65 years, with a non-urgent physician consultation in January 2016.

MEASURES

The drug treatment was assessed by a physician as either appropriate or suboptimal, taking individual factors like morbidity, life expectancy and concurrent drug treatment into account, and preceded by the application of 493 criteria from three screening tools for Potentially Inappropriate Medications (PIMs) and Potential Prescribing Omissions (PPOs). Suboptimal drug treatment was further categorised regarding priority: (1) immediate change suggested or (2) actions suggested in the longer term. Prevalence of the procedure code 'medication review' and the results thereof were also recorded.

RESULTS

Median age: 76 years; 48% women. When a family physician perspective was applied, and 593 PIMs/PPOs identified in 117 (95%) patients considered, 45 (37%) patients had suboptimal drug treatment. Immediate handling was suggested in 13 (11%) patients, most often concerning withdrawals of drugs for anxiety and insomnia. Handling in the longer term was suggested in 32 (26%) patients, most often concerning overuse of proton pump inhibitors. Over the last year, the procedure code 'medication review' was recorded for 65 (53%) patients. In medication reviews recorded during January 2016 (n=45), 23 (7%) drugs out of 309 were acted on, most often a dosage adjustment.

CONCLUSIONS

This pilot study shows that when a broad family physician perspective is applied, taking individual factors and medical priorities in the complex clinical situation into account, drug treatment in primary care is appropriate for the majority of older patients. The results may be useful in sample size considerations for future studies on prescribing practices.

Handling interoccasion variability in model-based dose individualization using therapeutic drug monitoring data

AIMS

This study aims to assess approaches to handle interoccasion variability (IOV) in a model-based therapeutic drug monitoring (TDM) context, using a population pharmacokinetic model of coagulation factor VIII as example.

METHODS

We assessed 5 model-based TDM approaches: empirical Bayes estimates (EBEs) from a model including IOV, with individualized doses calculated based on individual parameters either (i) including or (ii) excluding variability related to IOV; and EBEs from a model excluding IOV by (iii) setting IOV to zero, (iv) summing variances of interindividual variability (IIV) and IOV into a single IIV term, or (v) re-estimating the model without IOV. The impact of varying IOV magnitudes (0-50%) and number of occasions/observations was explored. The approaches were compared with conventional weight-based dosing. Predictive performance was assessed with the prediction error percentiles.

RESULTS

When IOV was lower than IIV, the accuracy was good for all approaches (50^th percentile of the prediction error [P50] <7.4%), but the precision varied substantially between IOV magnitudes (P97.5 61-528%). Approach (ii) was the most precise forecasting method across a wide range of scenarios, particularly in case of sparse sampling or high magnitudes of IOV. Weight-based dosing led to less precise predictions than the model-based TDM approaches in most scenarios.

CONCLUSIONS

Based on the studied scenarios and theoretical expectations, the best approach to handle IOV in model-based dose individualization is to include IOV in the generation of the EBEs but exclude the portion of unexplained variability related to IOV in the individual parameters used to calculate the future dose.

Impact of Complex Quality-Interventions on Patient Outcome: A Systematic Overview of Systematic Reviews

Quality of care and the increasing strategies to its promotion, especially in inpatient settings, led to the question which quality-interventions work best and which do not. The aim was to summarize and critically appraise the evidence on the effects of structure- and/or process-related quality-interventions on patient outcome in predominantly controlled and inpatient settings. A systematic overview of systematic reviews after electronic searches in Medline, Embase, Cinahl, and PsycINFO, supplemented by hand search and expert survey, was conducted. From a total of 1559 identified records, 37 reviews fulfilled the inclusion criteria. 26 reviews assessed process-related quality-interventions, 6 structure-related quality-interventions, and 5 combined structure- and process-related quality-interventions. In all, 19 reviews reported pooled effect estimates (meta-analysis). Based on the evidence of this systematic overview, stroke units and pathways can be recommended. Although patient-relevant improvements for interprofessional approaches and discharge planning have been reported, pooled effect estimated evidence are currently missing for these and other quality-interventions.

Interventions targeting the prescribing and monitoring of vancomycin for hospitalized patients: a systematic review with meta-analysis

Purpose

Vancomycin prescribing requires individualized dosing and monitoring to ensure efficacy, limit toxicity, and minimize resistance. Although there are nationally endorsed guidelines from several countries addressing the complexities of vancomycin dosing and monitoring, there is limited consideration of how to implement these recommendations effectively.

Methods

We conducted a systematic search of multiple databases to identify relevant comparative studies describing the impact of interventions of educational meetings, implementation of guidelines, and dissemination of educational material on vancomycin dosing, monitoring, and nephrotoxicity. Effect size was assessed using ORs and pooled data analyzed using forest plots to provide overall effect measures.

Results

Six studies were included. All studies included educational meetings. Two studies used implementation of guidance, educational meetings, and dissemination of educational materials, one used guidance and educational meetings, one educational meetings and dissemination of educational materials, and two used educational meetings solely. Effect sizes for individual studies were more likely to be significant for multifaceted interventions. In meta-analysis, the overall effect of interventions on outcome measures of vancomycin dosing was OR 2.50 (95% CI 1.29–4.84); P< 0.01. A higher proportion of sampling at steady-state concentration was seen following intervention (OR 1.95, 95% CI 1.26–3.02; P<0.01). Interventions had no effect on appropriate timing of trough sample (OR 2.02, 95% CI 0.72–5.72; P=0.18), attaining target concentration in patients (OR 1.50, 95% CI 0.49–4.63; P=0.48, or nephrotoxicity (OR 0.75, 95% CI 0.42–1.34; P=0.33).

Conclusion

Multifaceted interventions are effective overall in improving the complex task of dosing vancomycin, as well as some vancomycin-monitoring outcome measures. However, the resulting impact of these interventions on efficacy and toxicity requires further investigation. These findings may be helpful to those charged with designing implementation strategies for vancomycin guidelines or complex prescribing processes in hospitals.

Model-Informed Precision Dosing at the Bedside: Scientific Challenges and Opportunities

The development of model-informed precision dosing (MIPD) tools, especially in the form of native or web-based applications to be used at the bedside, has garnered marked attention in recent years. Their potential clinical benefit can be large, but it should be ensured that such tools make optimal use of available clinical data and have adequate predictive ability. Unique scientific challenges specific to MIPD remain, which may require adaptation of commonly used diagnostics in pharmacometrics.

Developing a new clinical governance framework for chronic diseases in primary care: an umbrella review

OBJECTIVES

Our goal is to conceptualise a clinical governance framework for the effective management of chronic diseases in the primary care setting, which will facilitate a reorganisation of healthcare services that systematically improves their performance.

SETTING

Primary care.

PARTICIPANTS

Chronic Care Model by Wagner et aland Clinical Governance statement by Scally et alwere taken for reference. Each was reviewed, including their various components. We then conceptualised a new framework, merging the relevant aspects of both.

INTERVENTIONS

We conducted an umbrella review of all systematic reviews published by the Cochrane Effective Practice and Organisation of Care Group to identify organisational interventions in primary care with demonstrated evidence of efficacy.

RESULTS

All primary healthcare systems should be patient-centred. Interventions for patients and their families should focus on their values; on clinical, professional and institutional integration and finally on accountability to patients, peers and society at large. These interventions should be shaped by an approach to their clinical management that achieves the best clinical governance, which includes quality assurance, risk management, technology assessment, management of patient satisfaction and patient empowerment and engagement. This approach demands the implementation of a system of organisational, functional and professional management based on a population health needs assessment, resource management, evidence-based and patient-oriented research, professional education, team building and information and communication technologies that support the delivery system. All primary care should be embedded in and founded on an active partnership with the society it serves.

CONCLUSIONS

A framework for clinical governance will promote an integrated effort to bring together all related activities, melding environmental, administrative, support and clinical elements to ensure a coordinated and integrated approach that sustains the provision of better care for chronic conditions in primary care setting.

The GUIDES checklist: development of a tool to improve the successful use of guideline-based computerised clinical decision support

Background

Computerised decision support (CDS) based on trustworthy clinical guidelines is a key component of a learning healthcare system. Research shows that the effectiveness of CDS is mixed.

Multifaceted context, system, recommendation and implementation factors may potentially affect the success of CDS interventions. This paper describes the development of a checklist that is intended to support professionals to implement CDS successfully.

Methods

We developed the checklist through an iterative process that involved a systematic review of evidence and frameworks, a synthesis of the success factors identified in the review, feedback from an international expert panel that evaluated the checklist in relation to a list of desirable framework attributes, consultations with patients and healthcare consumers and pilot testing of the checklist.

Results

We screened 5347 papers and selected 71 papers with relevant information on success factors for guideline-based CDS. From the selected papers, we developed a 16-factor checklist that is divided in four domains, i.e. the CDS context, content, system and implementation domains. The panel of experts evaluated the checklist positively as an instrument that could support people implementing guideline-based CDS across a wide range of settings globally. Patients and healthcare consumers identified guideline-based CDS as an important quality improvement intervention and perceived the GUIDES checklist as a suitable and useful strategy.

Conclusions

The GUIDES checklist can support professionals in considering the factors that affect the success of CDS interventions. It may facilitate a deeper and more accurate understanding of the factors shaping CDS effectiveness. Relying on a structured approach may prevent that important factors are missed.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0772-3) contains supplementary material, which is available to authorized users.

Development of a Tailored Intervention With Computerized Clinical Decision Support to Improve Quality of Care for Patients With Knee Osteoarthritis: Multi-Method Study

BACKGROUND

Clinical practice patterns greatly diverge from evidence-based recommendations to manage knee osteoarthritis conservatively before resorting to surgery.

OBJECTIVE

This study aimed to tailor a guideline-based computerized decision support (CDS) intervention that facilitates the conservative management of knee osteoarthritis.

METHODS

Experts with backgrounds in clinical medicine, research, implementation, or health informatics suggested the most important recommendations for implementation, how to develop an implementation strategy, and how to form the CDS algorithms. In 6 focus group sessions, 8 general practitioners and 22 patients from Norway, Belgium, and Finland discussed the suggested CDS intervention and identified factors that would be most critical for the success of the intervention. The focus group moderators used the GUideline Implementation with DEcision Support checklist, which we developed to support consideration of CDS success factors.

RESULTS

The experts prioritized 9 out of 22 recommendations for implementation. We formed the concept for 6 CDS algorithms to support implementation of these recommendations. The focus group suggested 59 unique factors that could affect the success of the presented CDS intervention. Five factors (out of the 59) were prioritized by focus group participants in every country, including the perceived potential to address the information needs of both patients and general practitioners; the credibility of CDS information; the timing of CDS for patients; and the need for personal dialogue about CDS between the general practitioner and the patient.

CONCLUSIONS

The focus group participants supported the CDS intervention as a tool to improve the quality of care for patients with knee osteoarthritis through shared, evidence-based decision making. We aim to develop and implement the CDS based on these study results. Future research should address optimal ways to (1) provide patient-directed CDS, (2) enable more patient-specific CDS within the context of patient complexity, and (3) maintain user engagement with CDS over time.

Effectiveness of a standardized electronic admission order set for acute exacerbation of chronic obstructive pulmonary disease

Background

Variation in hospital management of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may prolong length of stay, increasing the risk of hospital-acquired complications and worsening quality of life. We sought to determine whether an evidence-based computerized AECOPD admission order set could improve quality and reduce length of stay.

Methods

The order set was designed by a provincial COPD working group and implemented voluntarily among three physician groups in a Canadian tertiary-care teaching hospital. The primary outcome was length of stay for patients admitted during order set implementation period, compared to the previous 12 months. Secondary outcomes included length of stay of patients admitted with and without order set after implementation, all-cause readmissions, and emergency department visits.

Results

There were 556 admissions prior to and 857 admissions after order set implementation, for which the order set was used in 47%. There was no difference in overall length of stay after implementation (median 6.37 days (95% confidence interval 5.94, 6.81) pre-implementation vs. 6.02 days (95% confidence interval 5.59, 6.46) post-implementation, p = 0.26). In the post-implementation period, order set use was associated with a 1.15-day reduction in length of stay (95% confidence interval − 0.5, − 1.81, p = 0.001) compared to patients admitted without the order set. There was no difference in readmissions.

Conclusions

Use of a computerized guidelines-based admission order set for COPD exacerbations reduced hospital length of stay without increasing readmissions. Interventions to increase order set use could lead to greater improvements in length of stay and quality of care.

Electronic supplementary material

The online version of this article (10.1186/s12890-018-0657-x) contains supplementary material, which is available to authorized users.

Impact on process results of clinical decision support systems (CDSSs) applied to medication use: overview of systematic reviews

Objective

The purpose of this overview (systematic review of systematic reviews) is to evaluate the impact of clinical decision support systems (CDSS) applied to medication use in the care process.

Methods

A search for systematic reviews that address CDSS was performed on Medline following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane recommendations. Terms related to CDSS and systematic reviews were used in combination with Boolean operators and search field tags to build the electronic search strategy. There was no limitation of date or language for inclusion. We included revisions that investigated, as a main or secondary objective, changes in process outcomes. The Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) score was used to evaluate the quality of the studies.

Results

The search retrieved 954 articles. Five articles were added through manual search, totaling an initial sample of 959 articles. After screening and reading in full, 44 systematic reviews met the inclusion criteria. In the medication-use processes where CDSS was used, the most common stages were prescribing (n=38 (86.36%) and administering (n=12 (27.27%)). Most of the systematic reviews demonstrated improvement in the health care process (30/44 - 68.2%). The main positive results were related to improvement of the quality of prescription by the physicians (14/30 - 46.6%) and reduction of errors in prescribing (5/30 - 16.6%). However, the quality of the studies was poor, according to the score used.

Conclusion

CDSSs represent a promising technology to optimize the medication-use process, especially related to improvement in the quality of prescriptions and reduction of prescribing errors, although higher quality studies are needed to establish the predictors of success in these systems.

A web-based clinical decision tool to support treatment decision-making in psychiatry: a pilot focus group study with clinicians, patients and carers

BACKGROUND

Treatment decision tools have been developed in many fields of medicine, including psychiatry, however benefits for patients have not been sustained once the support is withdrawn. We have developed a web-based computerised clinical decision support tool (CDST), which can provide patients and clinicians with continuous, up-to-date, personalised information about the efficacy and tolerability of competing interventions. To test the feasibility and acceptability of the CDST we conducted a focus group study, aimed to explore the views of clinicians, patients and carers.

METHODS

The CDST was developed in Oxford. To tailor treatments at an individual level, the CDST combines the best available evidence from the scientific literature with patient preferences and values, and with patient medical profile to generate personalised clinical recommendations. We conducted three focus groups comprising of three different participant types: consultant psychiatrists, participants with a mental health diagnosis and/or experience of caring for someone with a mental health diagnosis, and primary care practitioners and nurses. Each 1-h focus group started with a short visual demonstration of the CDST. To standardise the discussion during the focus groups, we used the same topic guide that covered themes relating to the acceptability and usability of the CDST. Focus groups were recorded and any identifying participant details were anonymised. Data were analysed thematically and managed using the Framework method and the constant comparative method.

RESULTS

The focus groups took place in Oxford between October 2016 and January 2017. Overall 31 participants attended (12 consultants, 11 primary care practitioners and 8 patients or carers). The main themes that emerged related to CDST applications in clinical practice, communication, conflicting priorities, record keeping and data management. CDST was considered a useful clinical decision support, with recognised value in promoting clinician-patient collaboration and contributing to the development of personalised medicine. One major benefit of the CDST was perceived to be the open discussion about the possible side-effects of medications. Participants from all the three groups, however, universally commented that the terminology and language presented on the CDST were too medicalised, potentially leading to ethical issues around consent to treatment.

CONCLUSIONS

The CDST can improve communication pathways between patients, carers and clinicians, identifying care priorities and providing an up-to-date platform for implementing evidence-based practice, with regard to prescribing practices.

Reassessment of antibiotic therapy in hospitals

INTRODUCTION

French national guidelines state that antibiotic therapies should be reassessed between 48 and 72hours after treatment initiation and that reassessment of antibiotic therapy (RA) must be recorded in patients' files.

OBJECTIVE

To determine whether RA is performed and recorded in patients' files in hospitals in a region of France.

METHODS

Setting: hospitals participating in the National nosocomial infection point- prevalence survey (NPS) in Upper-Normandy, France. Patients included those receiving antibiotic therapy (excluding antibiotic prophylaxis) on NPS day, started in the hospital in which the survey was conducted and ongoing for more than 72hours. Data collected included characteristics of participating hospitals and, for each included patient, characteristics of ward, infection and antibiotic therapy, and mention in the patients' files of explicit or implicit RA. The rate of explicit and implicit RA was calculated and factors associated with explicit or implicit RA were evaluated using a univariate analysis.

RESULTS

Thirty-three hospitals representing 87% of hospital beds region-wide were included in the study. In addition, 933 prescriptions were assessed for 724 infections in 676 patients. The overall rate of RA was 67.6% (49.3% of explicit RA and 18.3% of implicit RA). The rate of RA differed significantly according to infection and antibiotic class but not according to hospital or ward characteristics.

CONCLUSION

Our study provides new and reassuring results regarding reassessment of antibiotic therapy.

Definition of variables required for comprehensive description of drug dosage and clinical pharmacokinetics

PURPOSE

Electronic clinical decision support systems (CDSS) require drug information that can be processed by computers. The goal of this project was to determine and evaluate a compilation of variables that comprehensively capture the information contained in the summary of product characteristic (SmPC) and unequivocally describe the drug, its dosage options, and clinical pharmacokinetics.

METHODS

An expert panel defined and structured a set of variables and drafted a guideline to extract and enter information on dosage and clinical pharmacokinetics from textual SmPCs as published by the European Medicines Agency (EMA). The set of variables was iteratively revised and evaluated by data extraction and variable allocation of roughly 7% of all centrally approved drugs.

RESULTS

The information contained in the SmPC was allocated to three information clusters consisting of 260 variables. The cluster "drug characterization" specifies the nature of the drug. The cluster "dosage" provides information on approved drug dosages and defines corresponding specific conditions. The cluster "clinical pharmacokinetics" includes pharmacokinetic parameters of relevance for dosing in clinical practice. A first evaluation demonstrated that, despite the complexity of the current free text SmPCs, dosage and pharmacokinetic information can be reliably extracted from the SmPCs and comprehensively described by a limited set of variables.

CONCLUSION

By proposing a compilation of variables well describing drug dosage and clinical pharmacokinetics, the project represents a step forward towards the development of a comprehensive database system serving as information source for sophisticated CDSS.

Clinical relevance of the STOPP/START criteria in hip fracture patients

Purpose

The aim of this study was to investigate the clinical relevance of potentially inappropriate medications (PIMs), identified by the STOPP criteria, and potential prescribing omissions (PPOs), identified by the START criteria, and to identify predictors for clinically relevant PIMs and PPOs.

Methods

The STOPP and START criteria were applied on the medication lists of 200 older hip fracture patients, consecutively recruited to a randomized controlled study in 2009. For each identified PIM and/or PPO, the clinical relevance was assessed at the individual level, using medical records from both hospital and primary care as well as data collected in the original study.

Results

A total of 555 PIMs/PPOs were identified in 170 (85%) patients (median age: 85 years, 67% female), 298 (54%) of which, in 141 (71%) patients, were assessed as clinically relevant. A greater proportion of PIMs than PPOs were clinically relevant: 71% (95% CI: 66%; 76%) vs. 32% (27%; 38%). A greater proportion of PPOs than PIMs could not be assessed with available information: 38% (32%; 44%) vs. 22% (17%; 27%). Number of drugs and multidose drug dispensing, but not age, sex, cognition, or nursing home residence, were associated with ≥1 clinically relevant PIMs/PPOs.

Conclusions

The present study illustrates that one in two PIMs/PPOs identified by the STOPP/START criteria is clearly clinically relevant, PIMs being clinically relevant to a greater extent than PPOs. Based on available information, the clinical relevance could not be determined in a non-negligible proportion of PIMs/PPOs. Number of drugs and multidose drug dispensing were associated with ≥1 clinically relevant PIMs/PPOs.

Access to fracture risk assessment by FRAX and linked National Osteoporosis Guideline Group (NOGG) guidance in the UK-an analysis of anonymous website activity

In the UK, fracture risk guidance is provided by the National Osteoporosis Guideline Group (NOGG). NOGG usage showed widespread access through direct web-based linkage to FRAX. The facilitated interaction between fracture risk assessment and clinical guidelines could usefully be adopted in other countries.

INTRODUCTION

In the UK, guidance on assessment of osteoporosis and fracture risk is provided by the National Osteoporosis Guideline Group ( www.shef.ac.uk/NOGG ). We wished to determine access to this guidance by exploring website activity.

METHODS

We undertook an analysis of FRAX and NOGG website usage for the year between 1^st July 2013 and 30^th June 2014 using Google Analytics software.

RESULTS

During this period, there was a total of 1,774,812 sessions (a user interaction with the website) on the FRAX website with 348,964 of these from UK-based users; 253,530 sessions were recorded on the NOGG website. Of the latter, two-thirds were returning visitors, with the vast majority (208,766; 82 %) arising from sites within the UK. The remainder of sessions were from other countries demonstrating that some users of FRAX in other countries make use of the NOGG guidance. Of the UK-sourced sessions, the majority was from England, but the session rate (adjusted for population) was the highest for Scotland. Almost all (95.7 %) of the UK sessions arose from calculations being passed through from the FRAX tool ( www.shef.ac.uk/FRAX ) to the NOGG website, comprising FRAX calculations in patients without a bone mineral density (BMD) measurement (74.5 %) or FRAX calculations with a BMD result (21.2 %). National Health Service (NHS) sites were identified as the major source of visits to the NOGG website, comprising 79.9 % of the identifiable visiting locations, but this is an underestimate as many sites from within the NHS are not classified as such.

CONCLUSION

The study shows that the facilitated interaction between web-based fracture risk assessment and clinical guidelines is widely used in the UK. The approach could usefully be adopted in other countries for which a FRAX model is available.

The Effects of Clinical Decision Support Systems on Medication Safety: An Overview

BACKGROUND

The clinical decision support system(CDSS) has potential to improving medication safety. However, the effects of the intervention were conflicting and uncertain. Meanwhile, the reporting and methodological quality of this field were unknown.

OBJECTIVE

The aim of this overview is to evaluate the effects of CDSS on medication safety and to examine the methodological and reporting quality.

METHODS

PubMed, Embase and Cochrane Library were searched to August 2015. Systematic reviews (SRs) investigating the effects of CDSS on medication safety were included. Outcomes were determined in advance and assessed separately for process of care and patient outcomes. The methodological quality was assessed by Assessment of Multiple Systematic Reviews (AMSTAR) and the reporting quality was examined by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

Twenty systematic reviews, consisting of 237 unique randomized controlled trials(RCTs) and 176 non-RCTs were included. Evidence that CDSS significantly impacted process of care was found in 108 out of 143 unique studies of the 16 SRs examining this effect (75%). Only 18 out of 90 unique studies of the 13 SRs reported significantly evidence that CDSS positively impacted patient outcomes (20%). Ratings for the overall scores of AMSTAR resulted in a mean score of 8.3 with a range of scores from 7.5 to 10.5. The reporting quality was varied. Some contents were particularly strong. However, some contents were poor.

CONCLUSIONS

CDSS reduces medication error by obviously improving process of care and inconsistently improving patient outcomes. Larger samples and longer-term studies are required to ensure more reliable evidence base on the effects of CDSS on patient outcomes. The methodological and reporting quality were varied and some realms need to be improved.

Inpatient Diabetes Management in the Twenty-First Century

In hospitalized patients, both hyperglycemia and hypoglycemia have been associated with poor outcomes. During the inpatient period, hyperglycemia has been associated with increased risk of infection, cardiovascular events, and mortality. It is also associated with longer length of hospital stay. Hypoglycemia has also been associated with an increased risk of mortality. Therefore, current evidence supports avoidance of both conditions among hospitalized patients whether they are admitted to critical care units or noncritical care units.

Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews

OBJECTIVE

To provide an overview of effective interventions aimed at reducing rates of adverse events in hospitals.

DESIGN

Systematic review of systematic reviews.

DATA SOURCES

PubMed, CINAHL, PsycINFO, the Cochrane Library and EMBASE were searched for systematic reviews published until October 2015.

STUDY SELECTION

English-language systematic reviews of interventions aimed at reducing adverse events in hospitals, including studies with an experimental design and reporting adverse event rates, were included. Two reviewers independently assessed each study's quality and extracted data on the study population, study design, intervention characteristics and adverse patient outcomes.

RESULTS

Sixty systematic reviews with moderate to high quality were included. Statistically significant pooled effect sizes were found for 14 types of interventions, including: (1) multicomponent interventions to prevent delirium; (2) rapid response teams to reduce cardiopulmonary arrest and mortality rates; (3) pharmacist interventions to reduce adverse drug events; (4) exercises and multicomponent interventions to prevent falls; and (5) care bundle interventions, checklists and reminders to reduce infections. Most (82%) of the significant effect sizes were based on 5 or fewer primary studies with an experimental study design.

CONCLUSIONS

The evidence for patient-safety interventions implemented in hospitals worldwide is weak. The findings address the need to invest in high-quality research standards in order to identify interventions that have a real impact on patient safety. Interventions to prevent delirium, cardiopulmonary arrest and mortality, adverse drug events, infections and falls are most effective and should therefore be prioritised by clinicians.

Perceptions and experiences of the implementation, management, use and optimisation of electronic prescribing systems in hospital settings: protocol for a systematic review of qualitative studies

INTRODUCTION

There is increasing evidence that electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of healthcare services. However, it has also become clear that their implementation is not straightforward and may create unintended or undesired consequences once in use. In this context, qualitative approaches have been particularly useful and their interpretative synthesis could make an important and timely contribution to the field. This review will aim to identify, appraise and synthesise qualitative studies on ePrescribing/CPOE in hospital settings, with or without clinical decision support.

METHODS AND ANALYSIS

Data sources will include the following bibliographic databases: MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, Social Policy and Practice via Ovid, CINAHL via EBSCO, The Cochrane Library (CDSR, DARE and CENTRAL databases), Nursing and Allied Health Sources, Applied Social Sciences Index and Abstracts via ProQuest and SCOPUS. In addition, other sources will be searched for ongoing studies (ClinicalTrials.gov) and grey literature: Healthcare Management Information Consortium, Conference Proceedings Citation Index (Web of Science) and Sociological abstracts. Studies will be independently screened for eligibility by 2 reviewers. Qualitative studies, either standalone or in the context of mixed-methods designs, reporting the perspectives of any actors involved in the implementation, management and use of ePrescribing/CPOE systems in hospital-based care settings will be included. Data extraction will be conducted by 2 reviewers using a piloted form. Quality appraisal will be based on criteria from the Critical Appraisal Skills Programme checklist and Standards for Reporting Qualitative Research. Studies will not be excluded based on quality assessment. A postsynthesis sensitivity analysis will be undertaken. Data analysis will follow the thematic synthesis method.

ETHICS AND DISSEMINATION

The study does not require ethical approval as primary data will not be collected. The results of the study will be published in a peer-reviewed journal and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

CRD42016035552.

Cluster Randomised Trials in Cochrane Reviews: Evaluation of Methodological and Reporting Practice

Objective

Systematic reviews can include cluster-randomised controlled trials (C-RCTs), which require different analysis compared with standard individual-randomised controlled trials. However, it is not known whether review authors follow the methodological and reporting guidance when including these trials. The aim of this study was to assess the methodological and reporting practice of Cochrane reviews that included C-RCTs against criteria developed from existing guidance.

Methods

Criteria were developed, based on methodological literature and personal experience supervising review production and quality. Criteria were grouped into four themes: identifying, reporting, assessing risk of bias, and analysing C-RCTs. The Cochrane Database of Systematic Reviews was searched (2^nd December 2013), and the 50 most recent reviews that included C-RCTs were retrieved. Each review was then assessed using the criteria.

Results

The 50 reviews we identified were published by 26 Cochrane Review Groups between June 2013 and November 2013. For identifying C-RCTs, only 56% identified that C-RCTs were eligible for inclusion in the review in the eligibility criteria. For reporting C-RCTs, only eight (24%) of the 33 reviews reported the method of cluster adjustment for their included C-RCTs. For assessing risk of bias, only one review assessed all five C-RCT-specific risk-of-bias criteria. For analysing C-RCTs, of the 27 reviews that presented unadjusted data, only nine (33%) provided a warning that confidence intervals may be artificially narrow. Of the 34 reviews that reported data from unadjusted C-RCTs, only 13 (38%) excluded the unadjusted results from the meta-analyses.

Conclusions

The methodological and reporting practices in Cochrane reviews incorporating C-RCTs could be greatly improved, particularly with regard to analyses. Criteria developed as part of the current study could be used by review authors or editors to identify errors and improve the quality of published systematic reviews incorporating C-RCTs.

Association between drug-specific indicators of prescribing quality and quality of drug treatment: a validation study

Purpose

To evaluate the concurrent validity of three European sets of drug‐specific indicators of prescribing quality

Methods

In 200 hip fracture patients (≥65 years), consecutively recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was assessed according to a gold standard as well as to three drug‐specific indicator sets (Swedish National Board of Health and Welfare, French consensus panel list, and German PRISCUS list). As gold standard, two specialist physicians independently assessed and then agreed on the quality for each patient, after initial screening with STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) and START (Screening Tool to Alert to Right Treatment).

Results

According to the Swedish, French, and German indicator sets, 82 (41%), 54 (27%), and 43 (22%) patients had potentially inappropriate drug treatment. A total of 141 (71%) patients had suboptimal drug treatment according to the gold standard. The sensitivity for the indicator sets was 0.51 (95% confidence interval: 0.43; 0.59), 0.33 (0.26; 0.41), and 0.29 (0.22; 0.37), respectively. The specificity was 0.83 (0.72; 0.91), 0.88 (0.77; 0.94), and 0.97 (0.88; 0.99). Suboptimal drug treatment was 2.0 (0.8; 5.3), 1.9 (0.7; 5.1), and 6.1 (1.3; 28.6) times as common in patients with potentially inappropriate drug treatment according to the indicator sets, after adjustments for age, sex, cognition, residence, multi‐dose drug dispensing, and number of drugs.

Conclusions

In this setting, the indicator sets had high specificity and low sensitivity. This needs to be considered upon use and interpretation. Copyright © 2015 The Authors Pharmacoepidemiology and Drug Safety Published by John Wiley & Sons, Ltd.

Impact of a warning CPOE system on the inappropriate pill splitting of prescribed medications in outpatients

Background

Prescribing inappropriate pill splitting is not rare in clinical practice. To reduce inappropriate pill splitting, we developed an automatic warning system linked to a computerized physician order entry (CPOE) system for special oral formulation drugs in outpatient settings. We examined the impact of the warning system on inappropriate prescribing of pill splitting and assess prescribers' responses to the warnings.

Methods

Drugs with extended-release or enteric-coated formulations that were not originally intended to be split were recognized as “special oral formulations”. A hard-stop system which could examine non-integer doses of drugs with special oral formulations, provide warnings to interrupt inappropriate prescriptions was integrated in CPOE in a medical center since June 2010. We designed an intervention study to compare the inappropriate splitting before and after the implementation of the warning system (baseline period 2010 January to May vs. intervention period 2010 June to 2011 August). During the intervention period, prescription changes in response to a warning were logged and analyzed.

Results

A total of 470,611 prescribed drug items with 34 different drugs with special oral formulations were prescribed in the study period. During the 15-month intervention period, 909 warnings for 26 different drugs were triggered among 354,523 prescribed drug items with special oral formulations. The warning rate of inappropriate splitting in the late intervention period was lower than those in baseline period (0.16% vs. 0.61%, incidence rate ratio 0.27, 95% CI 0.23–0.31, P<0.001). In respond to warnings, physicians had to make adjustments, of which the majority was changing to an unsplit pill (72.9%).

Conclusions

The interruptive warning system could avoid the prescriptions with inappropriate pill splitting. Accordingly, physicians changed their behavior of prescribing special oral formulations regarding inappropriate pill splitting. We suggest the establishment of such system to target special oral formulations with warnings to prevent inappropriate pill splitting.

Implementing clinical guidelines for chronic obstructive pulmonary disease: barriers and solutions

Chronic obstructive pulmonary disease (COPD) is a complex chronic lung disease characterised by progressive fixed airflow limitation and acute exacerbations that frequently require hospitalisation. Evidence-based clinical guidelines for the diagnosis and management of COPD are now widely available. However, the uptake of these COPD guidelines in clinical practice is highly variable, as is the case for many other chronic disease guidelines. Studies have identified many barriers to implementation of COPD and other guidelines, including factors such as lack of familiarity with guidelines amongst clinicians and inadequate implementation programs. Several methods for enhancing adherence to clinical practice guidelines have been evaluated, including distribution methods, professional education sessions, electronic health records (EHR), point of care reminders and computer decision support systems (CDSS). Results of these studies are mixed to date, and the most effective ways to implement clinical practice guidelines remain unclear. Given the significant resources dedicated to evidence-based medicine, effective dissemination and implementation of best practice at the patient level is an important final step in the process of guideline development. Future efforts should focus on identifying optimal methods for translating the evidence into everyday clinical practice to ensure that patients receive the best care.