A New Computer-Based Tool to Reduce Potentially Inappropriate Prescriptions in Hospitalized Geriatric Patients

Polypharmacy Management in Chronic Conditions: A Systematic Literature Review of Italian Interventions

Background: Potentially inappropriate polypharmacy (PIP) is among the major factors leading to adverse drug reactions, increased healthcare costs, reduced medication adherence, and worsened patient conditions. This study aims to identify existing interventions implemented to monitor and manage polypharmacy in the Italian setting. Methods: A systematic literature review (PROSPERO: CRD42023457049) was carried out according to the PRISMA statement guidelines. PubMed, Embase, ProQuest, and Web of Science were queried without temporal constraints, encompassing all published papers until October 2023. Inclusion criteria followed the PICO model: patients with polypharmacy; interventions to monitor/manage polypharmacy regimen versus no/any intervention; outcomes in terms of intervention effectiveness and cost variation. Results: After duplicate deletion, 153 potentially relevant publications were extracted. Following abstract and full-text screenings, nine articles met the inclusion criteria. Overall, 78% (n = 7) were observational studies, 11% (n = 1) were experimental studies, and 11% (n = 1) were two-phase studies. A total of 44% (n = 4) of the studies involved patients aged ≥ 65 years, while 56% (n = 5) were disease-specific. Monitoring was the most prevalent choice of intervention (67%; n = 6). Outcomes were mainly related to levels of polypharmacy (29%; n = 6) and comorbidities (29%; n = 6), effectiveness rates (14%; n = 3), and avoidable costs (9%; n = 2). Conclusions: This review outlines that Italy is still lacking in interventions to monitor/manage PIP, addressing an unmet need in developing patient-tailored strategies for reducing health-system burden.

A systematic review of data elements of computerized physician order entry (CPOE): mapping the data to FHIR

OBJECTIVE

Medication errors are the third leading cause of death. There are several methods to prevent prescription errors, one of which is to use a Computerized Physician Order Entry system (CPOE). In a CPOE system, necessary data needs to be collected so that making decisions about prescribing medications and treatment plans could be made. Although many CPOE systems have been developed worldwide, studies have yet to identify the necessary data and data elements of CPOE systems. This study aims to identify data elements of CPOE and standardize these data with Fast Healthcare Interoperability Resources (FHIR) to facilitate data sharing and integration with the electronic health record (EHR) system and reduce data diversity.

METHODS

PubMed, Web of Science, Embase, and Scopus databases for studies up to October 2019 were searched. Two reviewers independently assessed original articles to determine eligibility for inclusion in this review. All articles describing data elements of a COPE system were included. Data elements were obtained from the included articles' text, tables, and figures.Classification of the extracted data elements and mapping them to FHIR was done to facilitate data sharing and integration with the electronic health record (EHR) system and reduce data diversity. The final data elements of CPOE were categorized into five main categories of FHIR (foundation, base, clinical, financial, and specialized) and 146 resources, where possible. One of the researchers did mapping and checked and verified by the second researcher. If a data element could not be mapped to any FHIR resources, this data element was considered an extension to the most relevant resource.

RESULTS

We retrieved 5162 articles through database searches. After the full-text assessment, 21 articles were included. In total, 270 data elements were identified and mapped to the FHIR standard. These elements have been reported in 26 FHIR resources of 146 ones (18%). In total, 71 data elements were considered an extension.

CONCLUSIONS

The results of this study showed that the same data elements were not used in the CPOE systems, and the degree of homogeneity of these systems is limited. The mapping of extracted data with data elements used in the FHIR standard shows the extent to which these systems comply with existing standards. Considering the standards in these systems' design helps developers design more coherent systems that can share data with other systems.

How Safe are Outpatient Electronic Health Records? An Evaluation of Medication-Related Decision Support using the Ambulatory Electronic Health Record Evaluation Tool

BACKGROUND

The purpose of the Ambulatory Electronic Health Record (EHR) Evaluation Tool is to provide outpatient clinics with an assessment that they can use to measure the ability of the EHR system to detect and prevent common prescriber errors. The tool consists of a medication safety test and a medication reconciliation module.

OBJECTIVES

The goal of this study was to perform a broad evaluation of outpatient medication-related decision support using the Ambulatory EHR Evaluation Tool.

METHODS

We performed a cross-sectional study with 10 outpatient clinics using the Ambulatory EHR Evaluation Tool. For the medication safety test, clinics were provided test patients and associated medication test orders to enter in their EHR, where they recorded any advice or information they received. Once finished, clinics received an overall percentage score of unsafe orders detected and individual order category scores. For the medication reconciliation module, clinics were asked to electronically reconcile two medication lists, where modifications were made by adding and removing medications and changing the dosage of select medications.

RESULTS

For the medication safety test, the mean overall score was 57%, with the highest score being 70%, and the lowest score being 40%. Clinics performed well in the drug allergy (100%), drug dose daily (85%), and inappropriate medication combinations (74%) order categories. Order categories with the lowest performance were drug laboratory (10%) and drug monitoring (3%). Most clinics (90%) scored a 0% in at least one order category. For the medication reconciliation module, only one clinic (10%) could reconcile medication lists electronically; however, there was no clinical decision support available that checked for drug interactions.

CONCLUSION

We evaluated a sample of ambulatory practices around their medication-related decision support and found that advanced capabilities within these systems have yet to be widely implemented. The tool was practical to use and identified substantial opportunities for improvement in outpatient medication safety.

Optimizing pharmacotherapy on geriatric hospital units in Belgium - a national survey

OBJECTIVE

Inappropriate prescribing remains highly prevalent on geriatric units. The aim of this investigation, initiated by the Belgian College for Geriatrics, was to evaluate the implementation of strategies to optimize pharmacotherapy on geriatric units in Belgium.

METHODS

A literature search was performed to identify strategies to support the appropriate use of medications in very old inpatients. These strategies were subsequently validated based on Delphi consensus rounds and a national survey was developed. Experts were selected by the research team in collaboration with the Belgian College for Geriatrics. The survey was sent to the heads of the geriatric departments of all Belgian hospitals (n = 100).

RESULTS

After 3 months a response rate of 55% was achieved. Strategies that were implemented more frequently were the use of electronic prescribing (85%), performing a structured medication review (69%) and providing patient education (76%). In a minority (24%) of hospitals, a clinical pharmacist was directly involved in the multidisciplinary geriatric team. Implementation of clinical decisions support systems (CDSS) was reported by 36% of the hospitals. Educational strategies for healthcare professionals and strategies to optimize transitional care were variable.

CONCLUSION

Taking into account the current body of evidence, strategies that include transitional care components, CDSS or ward-based clinical pharmacy services should be further promoted on Belgian geriatric units.

STOPP/START interventions to improve medicines management for people aged 65 years and over: a realist synthesis

Background

Drug-related problems and potentially inappropriate prescribing impose a huge burden on patients and the health-care system. The most widely used tools for appropriate prescription in older adults in England and in other European countries are the Screening Tool of Older People’s Prescriptions (STOPP)/Screening Tool to Alert to the Right Treatment (START) tools. STOPP/START tools support medicines optimisation for older adults.

Objectives

To identify, test and refine the programme theories underlying how interventions based on the STOPP/START tools are intended to work, for whom, in what circumstances and why, as well as the resource use and cost requirements or impacts.

Design

A realist synthesis.

Setting

Primary care, hospital care and nursing homes.

Patients

Patients aged ≥ 65 years.

Interventions

Any intervention based on the use of the STOPP/START tools.

Review methods

Database and web-searching was carried out to retrieve relevant evidence to identify and test programme theories about how interventions based on the use of the STOPP/START tools work. A project reference group made up of health-care professionals, NHS decision-makers, older people, carers and members of the public was set up. In phase 1 we identified programme theories about STOPP/START interventions on how, for whom, in what contexts and why they are intended to work. We searched the peer-reviewed and grey literature to identify documents relevant to the research questions. We interviewed experts in the field in our reference group to gain input on our list of candidate context–mechanism–outcome configurations, to identify additional context–mechanism–outcome configurations and to identify additional literature and/or relevant concepts. In phase 2 we reviewed and synthesised relevant published and unpublished empirical evidence and tested the programme theories using evidence from a larger set of empirical studies.

Results

We developed a single logic model structured around three key mechanisms: (1) personalisation, (2) systematisation and (3) evidence implementation. Personalisation: STOPP/START-based interventions are based on shared decision-making, taking into account patient preferences, experiences and expectations (mechanisms), leading to increased patient awareness, adherence, satisfaction, empowerment and quality of life (outcomes). Systematisation: STOPP/START tools provide a standardised/systematic approach for medication reviews (mechanisms), leading to changes in professional and organisational culture and burden/costs (outcomes). Evidence implementation: delivery of STOPP/START-based interventions is based on the implementation of best evidence (mechanisms), reducing adverse outcomes through appropriate prescribing/deprescribing (outcomes). For theory testing, we identified 40 studies of the impact of STOPP/START-based interventions in hospital settings, nursing homes, primary care and community pharmacies. Most of the interventions used multiple mechanisms. We found support for the impact of the personalisation and evidence implementation mechanisms on selected outcome variables, but similar impact was achieved by interventions not relying on these mechanisms. We also observed that the impact of interventions was linked to the proximity of the selected outcomes to the intervention in the logic model, resulting in a clearer benefit for appropriateness of prescribing, adverse drug events and prescription costs.

Limitations

None of the available studies had been explicitly designed for evaluating underlying causal mechanisms, and qualitative information was sparse.

Conclusions

No particular configuration of the interventions is associated with a greater likelihood of improved outcomes in given settings.

Study registration

This study is registered as PROSPERO CRD42018110795.

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. 9, No. 23. See the NIHR Journals Library website for further project information.

Drug-Drug Interactions in Elderly Patients with Potentially Inappropriate Medications in Primary Care, Nursing Home and Hospital Settings: A Systematic Review and a Preliminary Study

Drug–drug interactions (DDI) occurring with potentially inappropriate medications (PIM) are additional risk factors that may increase the inappropriate character of PIM. The aim of this study was (1) to describe the prevalence and severity of DDI in patients with PIM and (2) to evaluate the DDI specifically regarding PIM. This systematic review is based on a search carried out on PubMed and Web-of-Science from inception to June 30, 2020. We extracted data of original studies that assessed the prevalence of both DDI and PIM in elderly patients in primary care, nursing home and hospital settings. Four hundred and forty unique studies were identified: 91 were included in the qualitative analysis and 66 were included in the quantitative analysis. The prevalence of PIM in primary care, nursing home and hospital were 19.1% (95% confidence intervals (CI): 15.1–23.0%), 29.7% (95% CI: 27.8–31.6%) and 44.6% (95% CI: 28.3–60.9%), respectively. Clinically significant severe risk-rated DDI averaged 28.9% (95% CI: 17.2–40.6), in a hospital setting; and were approximately 7-to-9 lower in primary care and nursing home, respectively. Surprisingly, only four of these studies investigated DDI involving specifically PIM. Hence, given the high prevalence of severe DDI in patients with PIM, further investigations should be carried out on DDI involving specifically PIM which may increase their inappropriate character, and the risk of adverse drug reactions.

Artificial intelligence-based conversational agent to support medication prescribing

Objective

This article describes the system architecture, training, initial use, and performance of Watson Assistant (WA), an artificial intelligence-based conversational agent, accessible within Micromedex^®.

Materials and methods

The number and frequency of intents (target of a user’s query) triggered in WA during its initial use were examined; intents triggered over 9 months were compared to the frequency of topics accessed via keyword search of Micromedex. Accuracy of WA intents assigned to 400 queries was compared to assignments by 2 independent subject matter experts (SMEs), with inter-rater reliability measured by Cohen’s kappa.

Results

In over 126 000 conversations with WA, intents most frequently triggered involved dosing (N = 30 239, 23.9%) and administration (N = 14 520, 11.5%). SMEs with substantial inter-rater agreement (kappa = 0.71) agreed with intent mapping in 247 of 400 queries (62%), including 16 queries related to content that WA and SMEs agreed was unavailable in WA. SMEs found 57 (14%) of 400 queries incorrectly mapped by WA; 112 (28%) queries unanswerable by WA included queries that were either ambiguous, contained unrecognized typographical errors, or addressed topics unavailable to WA. Of the queries answerable by WA (288), SMEs determined 231 (80%) were correctly linked to an intent.

Discussion

A conversational agent successfully linked most queries to intents in Micromedex. Ongoing system training seeks to widen the scope of WA and improve matching capabilities.

Conclusion

WA enabled Micromedex users to obtain answers to many medication-related questions using natural language, with the conversational agent facilitating mapping to a broader distribution of topics than standard keyword searches.

Can screening tools for potentially inappropriate prescriptions in older adults prevent serious adverse drug events?

PURPOSE

The purpose of the study is to identify and explore risk factors of serious adverse drug events (SADE) and SADE-related admissions in acutely hospitalized multimorbid older adults and assess whether these could have been prevented by adherence to the prescription tools Screening Tool of Older Persons' Prescriptions (STOPP) and The Norwegian General Practice (NORGEP) criteria.

METHODS

Cross-sectional study of acutely admitted patients to a medical department in a Norwegian regional hospital. Eligible patients were community-dwelling, receiving home care services, and aged 75+, with ≥ 3 chronic diseases. Medications and information regarding the admission were retrieved from the referral letter and medical records, while an expert panel identified SADE using the Common Terminology Criteria for Adverse Events and SADE-related admissions.

RESULTS

We included 232 patients. Mean (SD) age was 86 (5.7) years, 137 (59%) were female, 121 (52%) used 5-9 drugs whereas 65 (28%) used ≥ 10. We identified SADEs in 72 (31%) of the patients, and in 49 (68%) of these cases, the SADE was considered to cause the hospital admission. A low body mass index (BMI) and a high Cumulative Illness Rating Scale-Geriatrics (CIRS-G) score were independent risk factors for SADEs. Among the SADEs identified, 32 (44%) and 11 (15%) were preventable by adherence to STOPP and NORGEP, respectively.

CONCLUSIONS

We found a high prevalence of SADE leading to hospitalization. Risk factors for SADE were high CIRS-G and low BMI. STOPP identified more SADEs than NORGEP, but adherence to the prescription tools could only to a limited degree prevent SADEs in this patient group.

Development of a pharmaceutical care program in progressive stages in geriatric institutions

BACKGROUND

To introduce and manage a Pharmaceutical care programs in geriatric care institutions presents difficulties such as reduced pharmacy service staff, complexity of the patients or lack of integration of the pharmacist in the health care team. This work describes the evolution of the implementations of a program of pharmaceutical care centered in drug related problems (DRP) in a group of geriatric institutions of different levels of complexity.

METHODS

Setting: Long-term and subacute care hospitals (HSS) and Health care teams attending nursing homes (EARs).

PARTICIPANTS

Patients attended in HSS and EARs during different periods between 2010 and 2016.

INTERVENTIONS

The program was developed in different stages, in which pharmacists made interventions of increasing complexity.

RESULTS

Between 2010 and 2013, the approach was only to improve the prescription of non-appropriate drugs for the elderly, which was reduced from 19 to 14.5%. Subsequent steps included detection of drug-related problems (DRP), systematization of treatment revisions, recording of pharmacist interventions, improvements in the classification of interventions and the creation of a web-based database for recording in a more efficient way. During these years, there was an increase in the number of patients included in pharmaceutical care activities and thus the number of pharmacist interventions (3872 in 2014 vs 5903 in 2016). In 2016, mean age in 2016: 83.2 years old. Mean number of medicines/patient: 8.4 ± 3.3, and mean interventions/patient: 1.62. Degree of acceptance of the interventions by physicians improved (68.6% in 2016 vs 45.5% in 2012), even though there is still much work to do. The Medication Appropriateness Index (MAI) showed that when the interventions were accepted, there was an important improvement. HSS mean MAI values pre-intervention: 2.52, post-intervention 0.80. In EARs: 5 pre and 1.39 post. In both cases p < 0.0001.

CONCLUSIONS

Approaching the deployment of activities in a progressive way has made us more efficient and able to confront and solve the problems that have arisen. Even though there has been a very restricted increase in the staff and budget, we are able to implement a DRP detection programme with guaranties of quality.

Reduction in targeted potentially inappropriate medication use in elderly inpatients: a pragmatic randomized controlled trial

PURPOSE

The use of potentially inappropriate medications (PIMs) in hospitalized older adults is a complex problem, but the use of computerized alert systems (CAS) has shown some potential. The study's objective is to assess the change in PIM use with a CAS-based pharmacist-physician intervention model compared to usual clinical care.

METHODS

Pragmatic single-site randomized controlled trial was conducted at a university teaching hospital. Hospitalizations identified with selected Beers or STOPP criteria were randomized to usual clinical care or to the CAS-based pharmacist-physician intervention. The primary outcome was PIM drug cessation or dosage decrease. Clinical relevance of the CAS alerts was assessed.

RESULTS

Analyses included 231 patients who had 128 and 126 hospitalizations in the control and intervention groups, respectively. Patients had a mean age of 81, and 60% were female. In the intervention compared to the control group, drug cessation or dosage decrease were more frequent at 48 h post-alert (45.8 vs 15.9%; absolute difference 30.0%; 95%CI 13.8 to 46.1%) and at discharge from the hospital (48.1 vs 27.3%; absolute difference 20.8%; 95%CI 4.6 to 37.0%). In a post hoc analysis of all alerts, regardless of their clinical relevance, the absolute difference in drug cessation or dosage decrease between the intervention and control groups was 16.2% (95%CI 2.9 to 29.6%) at 48 h and 8.0% (95%CI -4.0 to 20.0%) at discharge from the hospital.

CONCLUSIONS

In hospitalized older adults, a CAS-based pharmacist-physician intervention, compared to usual clinical care, resulted in significant higher number of drug cessation and dosage reductions for targeted PIMs.