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Parker G, Shahid N, Rappon T, Kastner M, Born K, Berta W. Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review. Implement Sci 2022; 17:6. [PMID: 35057832 PMCID: PMC8772067 DOI: 10.1186/s13012-021-01177-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 11/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is recognition that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and, in some circumstances, can cause unnecessary stress and harm for patients. Initiatives across dozens of countries have raised awareness about the harms of low-value care but have had mixed success and the levels of reductions realized have been modest. Similar to the complex drivers of implementation processes, there is a limited understanding of the individual and social behavioral aspects of de-implementation. While researchers have begun to use theory to elucidate the dynamics of de-implementation, the research remains largely atheoretical. The use of theory supports the understanding of how and why interventions succeed or fail and what key factors predict success. The purpose of this scoping review was to identify and characterize the use of theoretical approaches used to understand and/or explain what influences efforts to reduce low-value care. METHODS We conducted a review of MEDLINE, EMBASE, CINAHL, and Scopus databases from inception to June 2021. Building on previous research, 43 key terms were used to search the literature. The database searches identified 1998 unique articles for which titles and abstracts were screened for inclusion; 232 items were selected for full-text review. RESULTS Forty-eight studies met the inclusion criteria. Over half of the included articles were published in the last 2 years. The Theoretical Domains Framework (TDF) was the most commonly used determinant framework (n = 22). Of studies that used classic theories, the majority used the Theory of Planned Behavior (n = 6). For implementation theories, Normalization Process Theory and COM-B were used (n = 7). Theories or frameworks were used primarily to identify determinants (n = 37) and inform data analysis (n = 31). Eleven types of low-value care were examined in the included studies, with prescribing practices (e.g., overuse, polypharmacy, and appropriate prescribing) targeted most frequently. CONCLUSIONS This scoping review provides a rigorous, comprehensive, and extensive synthesis of theoretical approaches used to understand and/or explain what factors influence efforts to reduce low-value care. The results of this review can provide direction and insight for future primary research to support de-implementation and the reduction of low-value care.
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Affiliation(s)
- Gillian Parker
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Nida Shahid
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Tim Rappon
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Monika Kastner
- Centre for Research and Innovation, North York General Hospital, 4001, Leslie Street, Toronto, Ontario M2K 1E1 Canada
| | - Karen Born
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Whitney Berta
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
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Rantsi M, Hyttinen V, Jyrkkä J, Vartiainen AK, Kankaanpää E. Process evaluation of implementation strategies to reduce potentially inappropriate medication prescribing in older population: A scoping review. Res Social Adm Pharm 2021; 18:2367-2391. [PMID: 33926827 DOI: 10.1016/j.sapharm.2021.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/07/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Several implementation strategies can reduce potentially inappropriate medication (PIM) prescribing. Although use of PIMs has declined in recent years, it remains prevalent. Various strategies exist to improve the appropriateness of medication use. However, little is known about the processes of these different implementation strategies. This scoping review aims to investigate how the process evaluation of implementation strategies for reducing PIM prescribing in the older population has been studied. METHODS We searched for process evaluations of implementation strategies for reducing PIM prescribing in PUBMED, SCOPUS and Web of Science published between January 2000 and November 2019 in English. We applied the following inclusion criteria: patients aged ≥65 years, validated PIM criteria, and implementation process evaluated. The review focuses on decision support for health care professionals. We described the findings of the process evaluations, and compared the authors' concepts of process evaluation of the included publications to those of Proctor et al.( 2010). RESULT Of 9131 publications screened, 29 met our inclusion criteria. Different process evaluation conceptualizations were identified. Most process evaluations took place in the initial stages of the process (acceptability, adoption, appropriateness, and feasibility) and sustainability and implementation costs were seldom evaluated. None of the included publications evaluated fidelity. Multifaceted interventions were the most studied implementation strategies. Medication review was more common in acceptability evaluations, multidisciplinary interventions in adoption evaluations, and computerized systems and educational interventions in feasibility evaluations. Process evaluations were studied from the health care professionals' viewpoint in most of the included publications, but the management viewpoint was missing. DISCUSSION The conceptualization of process evaluation in the field of PIM prescribing is indeterminate. There is also a current gap in the knowledge of sustainability and implementation costs. Clarifying the conceptualization of implementation process evaluation is essential in order to effectively translate research knowledge into practice.
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Affiliation(s)
- Mervi Rantsi
- Department of Health and Social Management, University of Eastern Finland, Finland.
| | - Virva Hyttinen
- Department of Health and Social Management, University of Eastern Finland, Finland
| | - Johanna Jyrkkä
- Assessment of Pharmacotherapies, Finnish Medicines Agency, Finland
| | | | - Eila Kankaanpää
- Department of Health and Social Management, University of Eastern Finland, Finland
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Kempen TGH, Cam H, Kälvemark A, Lindner KJ, Melhus H, Nielsen EI, Sulku J, Gillespie U. Intervention fidelity and process outcomes of medication reviews including post-discharge follow-up in older hospitalized patients: Process evaluation of the MedBridge trial. J Clin Pharm Ther 2020; 45:1021-1029. [PMID: 32171028 DOI: 10.1111/jcpt.13128] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/13/2020] [Indexed: 12/14/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Drug-related problems (DRPs) are a growing healthcare burden worldwide. In an ongoing cluster-randomized controlled trial in Sweden (MedBridge), comprehensive medication reviews (CMRs) including post-discharge follow-up have been conducted in older hospitalized patients to prevent and solve DRPs. As part of a process evaluation of the MedBridge trial, this study aimed to assess the intervention fidelity and process outcomes of the trial's interventions. METHODS For intervention delivery, the percentage of patients that received intervention components was calculated per study group. Process outcomes, measured in about one-third of all intervention patients, included the following: the number of identified medication discrepancies, DRPs and recommendations to solve DRPs, correction rate of discrepancies, and implementation rate of recommendations. RESULTS AND DISCUSSION The MedBridge trial included 2637 patients (mean age: 81 years). The percentage of intervention patients (n = 1745) that received the intended intervention components was 94%-98% during admission, and 40%-81% upon and after discharge. The percentage of control patients (n = 892) that received at least one unintended intervention component was 15%. On average, 1.1 discrepancies and 2.0 DRPs were identified in 652 intervention patients. The correction and implementation rates were 79% and 73%, respectively. Stop medication was the most frequently implemented recommendation (n = 293) and 77% of the patients had at least one corrected discrepancy or implemented recommendation. WHAT IS NEW AND CONCLUSION The intervention fidelity within the MedBridge trial was high for CMRs during hospital stay and lower for intervention components upon and after discharge. The high prevalence of corrected discrepancies and implemented recommendations may explain potential effects of CMRs in the MedBridge trial.
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Affiliation(s)
- Thomas G H Kempen
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden.,Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Henrik Cam
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Amanda Kälvemark
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
| | | | - Håkan Melhus
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Elisabet I Nielsen
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Johanna Sulku
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden.,Pharmacy Department, Region Gävleborg, Gävle, Sweden
| | - Ulrika Gillespie
- Hospital Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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Amin MEK, Nørgaard LS, Cavaco AM, Witry MJ, Hillman L, Cernasev A, Desselle SP. Establishing trustworthiness and authenticity in qualitative pharmacy research. Res Social Adm Pharm 2020; 16:1472-1482. [PMID: 32067887 DOI: 10.1016/j.sapharm.2020.02.005] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 01/31/2020] [Accepted: 02/10/2020] [Indexed: 10/25/2022]
Abstract
Spurred by the value it can add, the use of qualitative research methods has been steadily growing by social pharmacy researchers around the globe, either separately or as part of mixed methods research projects. Given this increase, it is important to provide guidance to assist researchers in ensuring quality when employing such methods. This commentary addresses both theoretical fundamentals as well as practical aspects of establishing quality in qualitative social pharmacy research. More specifically, it provides an explanation of each of the criteria of trustworthiness proposed by Lincoln and Guba (credibility, transferability, dependability and confirmability) and different techniques used in establishing them. It also provides a brief overview of authenticity, a more recent and less widely used set of criteria that involve demonstrating fairness, ontological authenticity, educative authenticity, catalytic authenticity, and tactical authenticity. For each of these terms, the commentary provides a definition, how it applies to social pharmacy research, and guidance on when and how to use them. These are accompanied by examples from the pharmacy literature where the criteria have been used. The commentary ends by providing a summary of competing viewpoints of establishing quality in the published literature while inviting the reader to reflect on how the presented criteria would apply to different qualitative research projects.
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Affiliation(s)
| | - Lotte Stig Nørgaard
- Department of Pharmacy, University of Copenhagen, Universitetsparken 2, Building: 17-5-504, 2100, København Ø, Denmark.
| | - Afonso M Cavaco
- Faculty of Pharmacy, University of Lisbon, Av. Prof. Gama Pinto, 1649-003, Lisboa, Portugal.
| | - Matthew J Witry
- College of Pharmacy, University of Iowa, 115 S. Grand Avenue, Iowa City, IA, 52242, USA.
| | - Lisa Hillman
- College of Pharmacy, University of Minnesota, 7-159 Weaver-Densford Hall, 308, Harvard St. SE, Minneapolis, MN, 55455, USA.
| | - Alina Cernasev
- The University of Tennessee Health Science Center, College of Pharmacy, 301 S Perimeter Park Drive, Suite 220, Nashville, TN, 37211, USA.
| | - Shane P Desselle
- Touro University, California College of Pharmacy, Applied Pharmacy Solutions, 1310 Club Dr, Vallejo, CA, 94592, USA.
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