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Palos C, Ierano C, Santos MJD, Leitão I, Nogueira P, James R, Paiva JA, Thursky K, Sousa P. Cultivating global antimicrobial stewardship: linguistic and cultural validation of the Australian National Antimicrobial Prescribing Survey appropriateness assessment definitions for Portugal. J Antimicrob Chemother 2024:dkae226. [PMID: 39011836 DOI: 10.1093/jac/dkae226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 06/14/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Antimicrobial resistance is driven by inappropriate antimicrobial prescribing. The National Antimicrobial Prescribing Survey (NAPS) is an Australian-developed auditing platform to assist in the assessments of antimicrobial quality by antimicrobial stewardship programmes using consensus-based definitions. The NAPS has demonstrated to be transferable to other countries. Its adaptation to Portugal could improve knowledge about the quality of antimicrobial prescribing in the country. OBJECTIVES To translate, culturally adapt, and validate the Australian Hospital NAPS appropriateness assessment definitions of antimicrobial prescribing for Portugal. METHODS International recommendations on translation and adaptation of instruments were followed. Two panels of experts participated in the process, using Zoom® for discussions and interviews, and Google Forms® for assessing vignettes. A native English-speaking person proficient in Portuguese conducted the back-translation. SPSS v.28 and Excel® were used for validity calculation. RESULTS The Portuguese version was well accepted, its implementation being perceived as desirable and feasible by the experts. Validation process showed a Fleiss' κ score of 0.483 (95% CI, 0.415-0.551, P < 0.005) for appropriateness, and an average agreement with the Australian NAPS team of 0.8 and 0.9, respectively, for appropriateness and reasons for inappropriateness. CONCLUSIONS The Portuguese version of the Australian Hospital NAPS appropriateness assessment definitions of antimicrobial prescribing, the first to be translated from English, was deemed non-inferior to the original, was well accepted, considered to be desirable and feasible, and could inspire other countries, particularly other Portuguese-speaking countries, to adapt and validate them in their own contexts, reinforcing the possibility of transferring NAPS use beyond Australia.
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Affiliation(s)
- C Palos
- NOVA National School of Public Health, Public Health Research Centre; Comprehensive Health Research Center, CHRC, REAL, CCAL, NOVA University Lisbon, Lisbon, Portugal
- Grupo Luz Saúde, Lisbon, Portugal
| | - C Ierano
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital Guidance Group, Melbourne Health, Melbourne, Australia
| | - M J D Santos
- ISCTE-Instituto Universitário de Lisboa, Centro de Investigação e Estudos de Sociologia, Lisbon, Portugal
| | - I Leitão
- Unidade Local PPCIRA, Hospital Beatriz Ângelo, Clínica Universitária de Doenças Infeciosas e Parasitárias, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - P Nogueira
- NOVA National School of Public Health, Public Health Research Centre; Comprehensive Health Research Center, CHRC, REAL, CCAL, NOVA University Lisbon, Lisbon, Portugal
| | - R James
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital Guidance Group, Melbourne Health, Melbourne, Australia
| | - J A Paiva
- Intensive Care Department, Centro Hospitalar Universitário de São João, Medicine Department, Faculty of Medicine, University of Porto, Porto, Portugal
| | - K Thursky
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital Guidance Group, Melbourne Health, Melbourne, Australia
| | - P Sousa
- NOVA National School of Public Health, Public Health Research Centre; Comprehensive Health Research Center, CHRC, REAL, CCAL, NOVA University Lisbon, Lisbon, Portugal
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Aronson JK. When I use a word . . . .Devising bioscience definitions. BMJ 2023; 380:768. [PMID: 37001902 DOI: 10.1136/bmj.p768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Jeffrey K Aronson
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Casula M, Ardoino I, Franchi C. Appropriateness of the Prescription and Use of Medicines: An Old Concept but More Relevant than Ever. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2700. [PMID: 36768066 PMCID: PMC9915431 DOI: 10.3390/ijerph20032700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 06/18/2023]
Abstract
The availability of drugs to treat diseases, control symptoms, or prevent their onset is one of the most important resources for maintaining health [...].
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Affiliation(s)
- Manuela Casula
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, 20133 Milan, Italy
- IRCCS MultiMedica, Sesto S. Giovanni, 20099 Milan, Italy
| | - Ilaria Ardoino
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Carlotta Franchi
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
- Italian Institute for Planetary Health (IIPH), 20156 Milan, Italy
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Mucherino S, Casula M, Galimberti F, Guarino I, Olmastroni E, Tragni E, Orlando V, Menditto E. The Effectiveness of Interventions to Evaluate and Reduce Healthcare Costs of Potentially Inappropriate Prescriptions among the Older Adults: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116724. [PMID: 35682331 PMCID: PMC9180095 DOI: 10.3390/ijerph19116724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/21/2022] [Accepted: 05/27/2022] [Indexed: 11/16/2022]
Abstract
Potentially inappropriate prescribing (PIP) is associated with an increased risk of adverse drug reactions, recognized as a determinant of adherence and increased healthcare costs. The study's aim was to explore and compare the results of interventions to reduce PIP and its impact on avoidable healthcare costs. A systematic literature review was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement guidelines. PubMed and Embase were queried until February 2021. Inclusion criteria followed the PICO model: older patients receiving PIP; Interventions aimed at health professionals, structures, and patients; no/any intervention as a comparator; postintervention costs variations as outcomes. The search strategy produced 274 potentially relevant publications, of which 18 articles met inclusion criteria. Two subgroups were analyzed according to the study design: observational studies assessing PIP frequency and related-avoidable costs (n = 10) and trials, including specific intervention and related outcomes in terms of postintervention effectiveness and avoided costs (n = 8). PIP prevalence ranged from 21 to 79%. Few educational interventions carried out to reduce PIP prevalence and avoidable costs resulted in a slowly improving prescribing practice but not cost effective. Implementing cost-effective strategies for reducing PIP and clinical and economic implications is fundamental to reducing health systems' PIP burden.
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Affiliation(s)
- Sara Mucherino
- CIRFF—Center of Pharmacoeconomics and Drug Utilization, Department of Pharmacy, Federico II University of Naples, 80131 Naples, Italy; (S.M.); (I.G.); (V.O.)
| | - Manuela Casula
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, 20133 Milan, Italy; (M.C.); (E.O.); (E.T.)
- IRCCS MultiMedica Hospital, Sesto S. Giovanni, 20099 Milan, Italy;
| | | | - Ilaria Guarino
- CIRFF—Center of Pharmacoeconomics and Drug Utilization, Department of Pharmacy, Federico II University of Naples, 80131 Naples, Italy; (S.M.); (I.G.); (V.O.)
| | - Elena Olmastroni
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, 20133 Milan, Italy; (M.C.); (E.O.); (E.T.)
| | - Elena Tragni
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, 20133 Milan, Italy; (M.C.); (E.O.); (E.T.)
| | - Valentina Orlando
- CIRFF—Center of Pharmacoeconomics and Drug Utilization, Department of Pharmacy, Federico II University of Naples, 80131 Naples, Italy; (S.M.); (I.G.); (V.O.)
| | - Enrica Menditto
- CIRFF—Center of Pharmacoeconomics and Drug Utilization, Department of Pharmacy, Federico II University of Naples, 80131 Naples, Italy; (S.M.); (I.G.); (V.O.)
- Correspondence:
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Lessons from working across fields to develop a framework for informed choices. RESEARCH FOR ALL 2022. [DOI: 10.14324/rfa.06.1.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In late 2018, Iain Chalmers, Andy Oxman and others from the Informed Health Choices team convened a cross-field forum to develop a generic framework of key concepts for thinking critically about claims, research and choices about interventions, with the aim of supporting ‘informed choices’. We define an informed choice as one that is based on critical understanding of the relevant available evidence. This paper describes the process of that cross-field engagement, and reflects on how consensus was reached on the generic framework. Working in an alliance of 24 researchers from across fields to develop the Key Concepts for Informed Choices framework, we learned three lessons about cross-field working: (1) there was much agreement, despite diversity of views and experiences; (2) the applications of our work were broader than we could have imagined; and (3) we identified a wide range of problems that we have in common when making informed choices. Here we describe our experience of working together to develop the framework, and draw out lessons for others who may be involved in similar cross-field initiatives.
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Cappi V, Riboni S, Grana M, Pierotti E, Ravelli A, Sutti S, Testa S, Spacci A, Artioli G, Sarli L, Pellegatta F. Health professionals' perception of appropriateness of care: a qualitative study in Italian pediatric hospices. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020013. [PMID: 33263346 PMCID: PMC8023111 DOI: 10.23750/abm.v91i12-s.10859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 11/05/2020] [Indexed: 11/23/2022]
Abstract
Background: Appropriateness is particularly relevant in palliative care, an area in which it is essential to question the real need for treatments. Few studies explored the perception of appropriateness by professionals in pediatric palliative care, revealing the conflict sometimes faced when confronted with the uncertainty of prognosis and end-of-life decisions. Aims: The objective of this study is firstly to investigate the perception that doctors, nurses and psychologists, operating in Italian pediatric hospices, have of the appropriateness of the care they provide. Secondly, to understand what repercussions the perception of non-appropriateness has at individual and team level. Methods: A qualitative study was conducted between 2019 and 2020 through semi-structured interviews with a convenience sample of 17 professionals working it Italian pediatric hospices. Results: The interviewees do not refer to a common concept of appropriateness, but compare the latter to: the quality of life, the global care of the assisted person, the proportionality of care, the early recognition of the need for palliative care. The discussion within the team emerges as a privileged place to manage the discomfort of individual professionals in the face of treatment choices in conflict with their own values. Conclusion: the non-referring to a univocal conception of appropriateness deprives professionals of an objective criterion to resolve the most difficult decisions. However, it allows them to establish what from time to time seems to be the most appropriate care pathway for a given patient, at a given time and context, preserving the goal of personalized care. (www.actabiomedica.it)
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Affiliation(s)
| | - Serena Riboni
- Department of Medicine and Surgery, University of Parma.
| | - Marianna Grana
- Post-Graduate Specialization in Palliative Care and Pain Therapy for Health Professions, Department of Medicine and Surgery, University of Parma.
| | - Emanuela Pierotti
- Post-Graduate Specialization in Palliative Care and Pain Therapy for Health Professions, Department of Medicine and Surgery, University of Parma.
| | - Andrea Ravelli
- Post-Graduate Specialization in Palliative Care and Pain Therapy for Health Professions, Department of Medicine and Surgery, University of Parma.
| | - Stefania Sutti
- Post-Graduate Specialization in Palliative Care and Pain Therapy for Health Professions, Department of Medicine and Surgery, University of Parma.
| | - Sara Testa
- Post-Graduate Specialization in Palliative Care and Pain Therapy for Health Professions, Department of Medicine and Surgery, University of Parma.
| | - Alessio Spacci
- Casa Sollievo Bimbi, Pediatric Hospice, VIDAS Association, Milan.
| | | | - Leopoldo Sarli
- Department of Medicine and Surgery, University of Parma.
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Ayalew MB, Dieberg G, Quirk F, Spark MJ. Potentially inappropriate prescribing for adults with diabetes mellitus: a scoping review protocol. JBI Evid Synth 2020; 18:1557-1565. [PMID: 32813395 DOI: 10.11124/jbisrir-d-19-00136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE This scoping review aims to explore and map studies investigating potentially inappropriate prescribing (PIP) for adults with diabetes mellitus. INTRODUCTION Inappropriate prescribing for people with diabetes mellitus has been reported by various authors focusing on different aspects of inappropriateness. A preliminary search revealed no published reviews on PIP for adults with diabetes mellitus. As a result, it is difficult to obtain a comprehensive map of PIP in this patient group. INCLUSION CRITERIA This scoping review will consider all studies on PIP for adults with the diagnosis of type 1 or type 2 diabetes mellitus from any clinical setting. Studies conducted in pediatric populations or in adults with pre-diabetes or gestational diabetes will be excluded. METHODS A three-step search strategy (i.e. an initial limited search in PubMed and ProQuest Central databases, a main search of eight databases and gray literature, and manual searches of reference lists of included articles) will be utilized. No language restrictions will be applied. All retrieved articles will be screened against the inclusion/exclusion criteria at title, abstract, and full-text stages. Data to be extracted from each study will include, but not be limited to, country, objective, study population, study methodology, type of PIP studied, examples of PIP events, medications involved, and criteria used for PIP identification. Data will be extracted by study team members using an online application for conducting systematic synthesis of evidence.
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Affiliation(s)
- Mohammed B Ayalew
- 1Department of Pharmacy, School of Rural Medicine, University of New England, Armidale, Australia 2Department of Clinical Pharmacy, School of Pharmacy, University of Gondar, Gondar, Ethiopia 3Biomedical Science, School of Science and Technology, University of New England, Armidale, Australia 4New England Institute of Healthcare Research, Faculty of Medicine and Health, University of New England, Armidale, Australia
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A pragmatic controlled trial to improve the appropriate prescription of drugs in adult outpatients: design and rationale of the EDU.RE.DRUG study. Prim Health Care Res Dev 2020. [PMCID: PMC7372175 DOI: 10.1017/s1463423620000249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Introduction: Pharmacological intervention is an important component of patient care. However, drugs are often inappropriately used. It is necessary for countries to implement strategies to improve the rational use of drugs, including independent information for healthcare professionals and the public, which must be supported by well-trained staff. The primary objectives of the EDU.RE.DRUG (Effectiveness of informative and/or educational interventions aimed at improving the appropriate use of drugs designed for general practitioners and their patients) study are the retrospective evaluation of rates of appropriate prescribing indicators (APIs) and the assessment of the effectiveness of informative and/or educational interventions addressed to general practitioners (GPs) and their patients, aimed at improving prescribing quality and promoting proper drug use. Methods and analysis: This is a prospective, multicentre, open-label, parallel-arm, controlled, pragmatic trial directed to GPs and their patients in two Italian regions (Campania and Lombardy). The study data are retrieved from administrative databases (Demographic, Pharmacy-refill, and Hospitalization databases) containing healthcare information of all beneficiaries of the National Health Service in the Local Health Units (LHUs) involved. According to LHU, the GPs/patients will be assigned to one of the following four intervention arms: (1) intervention on GPs and patients; (2) intervention on GPs; (3) intervention on patients; and (4) no intervention (control). The intervention designed for GPs consists of reports regarding the status of their patients according to the APIs determined at baseline and in two on-line Continuous Medical Education (CME) courses. The intervention designed for patients consists in flyers and posters distributed in GPs ambulatories and community pharmacies, focusing on correct drug use. A set of indicators (such as potential drug–drug interactions, unnecessary duplicate prescriptions, and inappropriate prescriptions in the elderly), adapted to the Italian setting, has been defined to determine inappropriate prescription at baseline and after the intervention phase. The primary outcome was a composite API. Ethics and dissemination: The study was approved by the Ethics Committee of the University of Milan on 7th June 2017 (code 15/17). The investigators will communicate trial results to stakeholders, collaborators, and participants via appropriate presentations and publications. Registration details: NCT04030468. EudraCT number 2017-002622-21
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McKay J, Begley E, Kerlin P, O’Carolan D, Cleary G, McKenna G, Burnett K. An analysis of the clinical appropriateness of out-of-hours emergency dental prescribing of antibiotics in Northern Ireland. Br Dent J 2020; 228:598-603. [DOI: 10.1038/s41415-020-1435-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Amorim WW, Passos LC, Oliveira MG. Why deprescribing instead of not prescribing? GERIATRICS, GERONTOLOGY AND AGING 2020. [DOI: 10.5327/z2447-212320202000058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Prescribing medications involves complex cognitive processes, and mistakes in prescription can cause serious adverse events. Deprescribing is one of the last opportunities to prevent patient harm from the use of drugs that should be avoided, especially among older patients. This viewpoint article aims to discuss the prescription process and some essential concepts, such as polypharmacy, prescription of potentially inappropriate medications, and, particularly, the relevance of deprescribing and its relationship with the appropriate prescription of medications in older people.
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Abstract
The appropriate prescribing of nutritional supplements is coming under increasing scrutiny due to rising costs, workforce challenges, and a product pricing model that does not meet the needs of the healthcare economy. Data show that, whilst the number of items being prescribed is marginally decreasing, the cost of these items is increasing, and the assumption that all patients discharged on nutritional borderline substances from hospital have been assessed by a dietitian cannot be made. Standards of communication are highly variable but, with increasing knowledge about best practice and digitalisation, improvements are being made. There is a disparity between adequate knowledge of nutrition, prescribing, and best use of resources to effectively manage patient-centred care and costs. A number of strategies are being trialled to improve education and the utilisation of the right workforce. The need for a clear public health message on the importance of maintaining weight in older age is essential to ensure nutritional borderline substances are appropriately used.
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Affiliation(s)
- Rebecca Fisher
- Allied Health Professional Prescribing and Procurement Advisor, NHS London Procurrment Partnership
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Husnain SZ, Bukhari NI, Hussain K, Babar ZUD, Hashmi FK, Saleem Z, Salman M, Curley L. Cross verification of prescribing trends through loop evaluation of physicians, patients and medical store personnel. BMC Health Serv Res 2019; 19:328. [PMID: 31118096 PMCID: PMC6532124 DOI: 10.1186/s12913-019-4145-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prescription connects physician, patient and community pharmacy personnel who can help in understanding prescribing pattern. The present study was aimed to get an insight of viewpoints of all members involved in progression of events from prescription to drug purchase, i.e., physician, patient and medical-store personals regarding the prescription pattern in Pakistan. METHODS Therefore, a cross-sectional study was conducted in four provinces and capital territory (Islamabad) of Pakistan to evaluate the perception of physicians, patients and medical stores/pharmacy personnel of the prescribing trends in Pakistan. RESULTS Response rate was higher from Punjab and lower in Sindh. Responses of 981 walk-in patients with 393 physicians and 618 medical stores/pharmacies were received and statistically evaluated. The majority of physicians, patients and pharmacists/medical store personnel considered the medicines of multinational manufacturers as more effective. Physicians considered their prescribing cost-effective. However, majority of patients as well as pharmacists/medical store personnel strongly disagreed or disagreed with this notion that physicians prescribe cheap medicines. Furthermore, physicians and patients reported that medicines of local companies were not as effective as the medicines of multinational manufacturers, which were contrary to what pharmacists thought. Majority of physicians disagreed that their prescribing was under the influence of medical stores in their vicinity. The response of most of the patients (40.5%) was in line with that of physicians whereas 32% pharmacist/medical store personnel agreed. Nearly half of the physicians strongly agreed or agreed that patients demand medicines of multinational companies. Contrarily, a majority of patients and medical store personnel denied that patients demand for the medicines of multinational manufacturers. CONCLUSION The study highlighted that there was a need to develop policy guidelines at the level of Federal Government and Drug Regulatory Authority of Pakistan in connection with prescribing practices to reduce the variation in perception of key stakholders involved in drug use process.
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Affiliation(s)
- Syed Zia Husnain
- Punjab University College of Pharmacy, University of the Punjab, Allama Iqbal Campus, Lahore, 54000, Pakistan
| | - Nadeem Irfan Bukhari
- Punjab University College of Pharmacy, University of the Punjab, Allama Iqbal Campus, Lahore, 54000, Pakistan.
| | - Khalid Hussain
- Punjab University College of Pharmacy, University of the Punjab, Allama Iqbal Campus, Lahore, 54000, Pakistan
| | - Zaheer-Ud-Din Babar
- Department of Pharmacy, University of Huddersfield, Queensgate, Huddersfield, UK
| | - Furqan Khurshid Hashmi
- Punjab University College of Pharmacy, University of the Punjab, Allama Iqbal Campus, Lahore, 54000, Pakistan
| | - Zikria Saleem
- Punjab University College of Pharmacy, University of the Punjab, Allama Iqbal Campus, Lahore, 54000, Pakistan
| | - Muhammad Salman
- Punjab University College of Pharmacy, University of the Punjab, Allama Iqbal Campus, Lahore, 54000, Pakistan
| | - Louise Curley
- School of Pharmacy, Faculty of medical and health sciences, University of Auckland, Auckland, New Zealand
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Squires JE, Graham ID, Grinspun D, Lavis J, Légaré F, Bell R, Bornstein S, Brien SE, Dobrow M, Greenough M, Estabrooks CA, Hillmer M, Horsley T, Katz A, Krause C, Levinson W, Levy A, Mancuso M, Maybee A, Morgan S, Penno LN, Neuner A, Rader T, Roberts J, Teare G, Tepper J, Vandyk A, Widmeyer D, Wilson M, Grimshaw JM. Inappropriateness of health care in Canada: a systematic review protocol. Syst Rev 2019; 8:50. [PMID: 30744703 PMCID: PMC6371550 DOI: 10.1186/s13643-019-0948-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 01/14/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There is increasing recognition in Canada and globally that a substantial proportion of health care delivered is inappropriate as evidenced by (1) harmful and/or ineffective practices being overused, (2) effective clinical practices being underused, and (3) other clinical practices being misused. Inappropriate health care leads to negative patient experiences, poor health outcomes, and inefficient use of scarce health care resources. The purpose of this study is to conduct a systematic review of inappropriate health care in Canada. Our specific objectives are to (1) systematically search and critically review published and grey literature for studies on inappropriate health care in Canada; (2) estimate the nature and magnitude of inappropriate health care in Canada and its provincial and territorial jurisdictions. METHODS We will include all quantitative study designs reporting objective or subjective measurements of inappropriate health care in Canada over the last 10 years. We will search the following online databases: MEDLINE, Cochrane Central Register of Controlled Trials, EconLit, and ISI-Web of Knowledge, which contains Web of Science Core Collection-Citation Indexes, Science Citation Index Expanded, Conference Proceedings Citation Index-Science, and Conference Proceedings Citation Index-Social Science & Humanities. We will also search grey literature sources to identify provincial and national audits of inappropriate health care. Two authors will independently screen, assess data quality, and extract data for synthesis. Study findings will be synthesized narratively. We will organize our data into three care categorizations: preventive care, acute care, and chronic care. We will provide a compendium of inappropriate health care for each care category for Canada and each Canadian province and territory, where sufficient data exists, by calculating (1) overall medians of underuse, overuse, and misuse of clinical practices and (2) the range of medians of underuse, overuse, and misuse for each clinical practice investigated. DISCUSSION This review will result in the first-ever evidence-based compendium of inappropriate health care in Canada. We will also develop detailed reports of inappropriate health care for each Canadian province and territory. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018093495.
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Affiliation(s)
- Janet E. Squires
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, P.O. Box 201-B, Ottawa, Ontario K1H 8L6 Canada
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Canada
| | - Ian D. Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, P.O. Box 201-B, Ottawa, Ontario K1H 8L6 Canada
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Doris Grinspun
- Registered Nurses’ Association of Ontario, Toronto, Canada
| | - John Lavis
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - France Légaré
- Population Health and Practice Changing Research, Research Centre of the CHU de Québec, Québec City, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Canada
- Health and Social Services Systems, Knowledge Translation and Implementation Core, Quebec SPOR Support Unit, Montréal, Canada
| | - Robert Bell
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Stephen Bornstein
- Newfoundland & Labrador Centre for Applied Health Research, Memorial University, St. John’s, Canada
- Department of Political Science and Faculty of Medicine, Memorial University, St. John’s, Canada
| | | | - Mark Dobrow
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Megan Greenough
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Canada
| | | | - Michael Hillmer
- Information Management, Data, and Analytics, Health System Information Management Division, Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - Tanya Horsley
- Royal College of Physicians and Surgeons of Canada, Ottawa, Canada
| | - Alan Katz
- Manitoba Centre for Health Policy, Department of Community Health Sciences and Family Medicine, University of Manitoba, Winnipeg, Canada
| | - Christina Krause
- British Columbia Patient Safety & Quality Council, Vancouver, Canada
| | - Wendy Levinson
- Institute of Health Policy, Management, and Evaluation, Department of Medicine, University of Toronto, Toronto, Canada
| | - Adrian Levy
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
| | | | | | - Steve Morgan
- Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Letitia Nadalin Penno
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Canada
- Canadore College, North Bay, Canada
| | | | - Tamara Rader
- Canadian Agency for Drugs and Technologies in Health, Ottawa, Canada
| | | | - Gary Teare
- Alberta Health Services - Alberta Cancer Prevention Legacy Fund, Population, Public and Indigenous Health, Calgary, Canada
| | - Joshua Tepper
- Department of Family and Community Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Amanda Vandyk
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Canada
| | | | - Michael Wilson
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, Canada
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Bobo WV, Grossardt BR, Lapid MI, Leung JG, Stoppel C, Takahashi PY, Hoel RW, Chang Z, Lachner C, Chauhan M, Flowers L, Brue SM, Frye MA, St. Sauver J, Rocca WA, Sutor B. Frequency and predictors of the potential overprescribing of antidepressants in elderly residents of a geographically defined U.S. population. Pharmacol Res Perspect 2019; 7:e00461. [PMID: 30693088 PMCID: PMC6344796 DOI: 10.1002/prp2.461] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/07/2018] [Accepted: 12/18/2018] [Indexed: 12/20/2022] Open
Abstract
The purpose of this study was to estimate the extent of potential antidepressant overprescribing in a geographically defined U.S. population, and to determine the indications and factors that account for it. We conducted a cohort study of new antidepressant prescriptions for elderly residents of Olmsted County, Minnesota, 2005-2012, using the Rochester Epidemiology Project medical records-linkage system. Indications for antidepressants were abstracted from health records for all cohort members. Potential antidepressant overprescribing was defined based on regulatory approval, the level of evidence identified from a standardized drug information database, and multidisciplinary expert review. Predictors of potential antidepressant overprescribing were investigated using logistic regression models, stratified by general antidepressant indication (general medical indication, specific psychiatric diagnosis, and non-specific psychiatric symptoms). Potential antidepressant overprescribing occurred in 24% of 3199 incident antidepressant prescriptions during the study period, and involved primarily newer antidepressants that were prescribed for non-specific psychiatric symptoms and subthreshold diagnoses. Potential antidepressant overprescribing was associated with nursing home residence, having a higher number of comorbid medical conditions and outpatient prescribers, taking more concomitant medications, having greater use of urgent or acute care services in the year preceding the index antidepressant prescription, and being prescribed antidepressants via telephone, e-mail, or patient portal. In conclusion, potential antidepressant overprescribing occurred in elderly persons and involved mainly newer antidepressants used for non-specific psychiatric symptoms and subthreshold diagnoses, and was associated with indicators of higher clinical complexity or severity and with prescribing without face-to-face patient contact.
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Affiliation(s)
- William V. Bobo
- Department of Psychiatry & PsychologyMayo ClinicJacksonvilleFlorida
| | - Brandon R. Grossardt
- Division of Biomedical Statistics and InformaticsDepartment of Health Sciences ResearchMayo ClinicRochesterMinnesota
| | - Maria I. Lapid
- Department of Psychiatry & PsychologyMayo ClinicRochesterMinnesota
| | | | - Cynthia Stoppel
- Department of Psychiatry & PsychologyMayo ClinicRochesterMinnesota
| | - Paul Y. Takahashi
- Department of Primary Care Internal MedicineMayo ClinicRochesterMinnesota
| | - Robert W. Hoel
- Department of Pharmacy ServicesMayo ClinicRochesterMinnesota
| | - Zheng Chang
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | | | - Mohit Chauhan
- Department of Psychiatry & PsychologyMayo ClinicJacksonvilleFlorida
| | - Lee Flowers
- Department of Psychiatry & PsychologyMayo ClinicRochesterMinnesota
| | - Scott M. Brue
- Biomedical Informatics Support SystemMayo ClinicRochesterMinnesota
| | - Mark A. Frye
- Department of Psychiatry & PsychologyMayo ClinicRochesterMinnesota
| | - Jennifer St. Sauver
- Division of EpidemiologyDepartment of Health Sciences ResearchMayo ClinicRochesterMinnesota
| | - Walter A. Rocca
- Division of EpidemiologyDepartment of Health Sciences ResearchMayo ClinicRochesterMinnesota
- Department of NeurologyMayo ClinicRochesterMinnesota
| | - Bruce Sutor
- Department of Psychiatry & PsychologyMayo ClinicRochesterMinnesota
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Crema M, Verbano C. Lean Management to support Choosing Wisely in healthcare: the first evidence from a systematic literature review. Int J Qual Health Care 2018; 29:889-895. [PMID: 29045684 DOI: 10.1093/intqhc/mzx135] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2017] [Indexed: 12/25/2022] Open
Abstract
Purpose Choosing Wisely (CW) is an emergent approach to identify and reduce unnecessary care, such as tests and treatments that do not add value for patients and may even cause harm. The purpose of this paper is to investigate whether and how Lean Healthcare Management (LHM) can support CW objectives, focusing on customer needs and on waste elimination. Data sources A systematic literature review has been performed in Scopus, PubMed and Web of Science. Study selection Peer reviewed articles published in English language have been selected. Papers were considered if they regarded LHM and its possible support for achieving CW objectives. Data extraction. The links between the LHM purposes of adoption and the pursued CW objectives were investigated. Moreover, LHM tools, practices and interventions to support CW were grasped. Results of data synthesis Sixteen articles were included in the analysis. Links between the identified LHM purposes of adoption and CW objectives were discovered: through process understanding, optimization, evaluation and control, LHM contributes to the reduction of overuses in healthcare, but also to the delivery of a more effective and evidence-based care (EBC). Moreover, it provides an objective approach useful for choosing the most cost-effective solution among different alternatives. Conclusions Results highlight how LHM, and with which tools and practices, can be adopted to enhance the healthcare appropriateness pursued by CW, paving the way for interesting future research about this emerging topic.
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Affiliation(s)
- Maria Crema
- Department of Management and Engineering, University of Padova, Stradella San Nicola, 3, 36100 Vicenza, Italy
| | - Chiara Verbano
- Department of Management and Engineering, University of Padova, Stradella San Nicola, 3, 36100 Vicenza, Italy
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Rieckert A, Sommerauer C, Krumeich A, Sönnichsen A. Reduction of inappropriate medication in older populations by electronic decision support (the PRIMA-eDS study): a qualitative study of practical implementation in primary care. BMC FAMILY PRACTICE 2018; 19:110. [PMID: 29986668 PMCID: PMC6038343 DOI: 10.1186/s12875-018-0789-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/31/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Within the EU-funded project PRIMA-eDS (Polypharmacy in chronic diseases: Reduction of Inappropriate Medication and Adverse drug events in older populations by electronic Decision Support) an electronic decision support tool (the "PRIMA-eDS-tool") was developed for general practitioners (GPs) to reduce inappropriate medication in their older polypharmacy patients. After entering patient data relevant to prescribing in an electronic case report form the physician received a comprehensive medication review (CMR) on his/her screen displaying recommendations regarding missing indications, necessary laboratory tests, evidence-base of current medication, dose adjustments for renal malfunction, potentially harmful drug-drug interactions, contra-indications, and possible adverse drug events. We set out to explore the usage of the PRIMA-eDS tool and the adoption of the recommendations provided by the CMR to optimise the tool and prepare it for its future implementation. METHODS In a qualitative study carried out in North Rhine-Westphalia, Germany, 21 GPs using the PRIMA-eDS tool within the PRIMA-eDS study were interviewed. Interviews encompassed the GPs' attitudes regarding use of the electronic case report form and the CMR, their response to the recommendations, and the implementation of the tool into daily practice routine. The collected data were analysed applying thematic qualitative text analysis. RESULTS GPs found the patient data entry into the electronic case report form to be inconvenient and time-consuming. The CMR was conducted often outside practice hours and without the patient present. GPs found that the PRIMA-eDS CMR provided relevant information for and had several positive effects on the caring process. However, they encountered several barriers when wanting to change medication. CONCLUSIONS It is unlikely that the PRIMA-eDS CMR will be used in the future as it is now as patient data entry is too time-consuming. Several barriers towards deprescribing medications were found which are common in deprescribing studies. Given the positive attitude towards the CMR, a new way of entering patient data into the PRIMA-eDS tool to create the CMR needs to be developed.
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Affiliation(s)
- Anja Rieckert
- Institute of General Practice and Family Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Str. 50, 58448, Witten, Germany.
| | - Christina Sommerauer
- Institute of General Practice and Family Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Str. 50, 58448, Witten, Germany
| | - Anja Krumeich
- Department of Health, Ethics, and Society, Faculty of Health, Medicine, and Lifesciences, Maastricht University, Debyeplein 1, 6229 HA, Maastricht, The Netherlands
| | - Andreas Sönnichsen
- Institute of General Practice and Family Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Str. 50, 58448, Witten, Germany.,Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Oxford Rd 176, Manchester, M13 9PL, UK
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17
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Prescribing pattern of higher generation antibiotics in the out-patient setting in Bhutan hospitals. ASIAN BIOMED 2018. [DOI: 10.2478/abm-2010-0043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Background: The emergence of antibiotic resistance is a complex problem contributed by the interplay of various parties such as prescribers, patients or health settings. In particular, prescribers play a vital role in the use of antibiotics both in rational prescribing of drugs and influencing patients on the appropriate use. Objectives: Determine the appropriateness of the higher generation antibiotics (cephalosporin and flouroquonolone groups) in the out-patient setting of Bhutan hospitals. Materials and method: A cross-sectional study was conducted in three referral hospitals of Bhutan where the prescriptions were collected from the pharmacy. All prescriptions containing higher generation antibiotics were selected based on the appropriateness using a modified Medication Appropriateness Index. Three hundred thirty three prescriptions containing higher generation antibiotics were analyzed. Results: The use of antibiotics was common with 37.1% of the prescriptions containing antibiotics out of which 14% were higher generation antibiotics. When assessed on the appropriateness of the prescription, 55.9% of the prescriptions containing higher generation antibiotics were prescribed inappropriately. In addition, only 47.1% of the prescriptions had appropriate indications for higher generation antibiotics. Conclusion: There is a widespread inappropriate use of higher generation antibiotics in Bhutan.
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Lombardi N, Wei L, Ghaleb M, Pasut E, Leschiutta S, Rossi P, Troncon MG. Evaluation of the implementation of a clinical pharmacy service on an acute internal medicine ward in Italy. BMC Health Serv Res 2018; 18:259. [PMID: 29631587 PMCID: PMC5891983 DOI: 10.1186/s12913-018-2988-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 03/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Successful implementation of clinical pharmacy services is associated with improvement of appropriateness of prescribing. Both high clinical significance of pharmacist interventions and their high acceptance rate mean that potential harm to patients could be avoided. Evidence shows that low acceptance rate of pharmacist interventions can be associated with lack of communication between pharmacists and the rest of the healthcare team. The objective of this study was to evaluate the effect of a structured communication strategy on acceptance rate of interventions made by a clinical pharmacist implementing a ward-based clinical pharmacy service targeting elderly patients at high risk of drug-related problems. Characteristics of interventions made to improve appropriateness of prescribing, their clinical significance and intervention acceptance rate by doctors were recorded. METHODS A clinical pharmacy intervention study was conducted between September 2013 and December 2013 in an internal medicine ward of a teaching hospital. A trained clinical pharmacist provided pharmaceutical care to 94 patients aged over 70 years. The clinical pharmacist used the following communication and marketing tools to implement the service described: Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis; Specific, Measurable, Achievable, Realistic and Timely (SMART) goals; Awareness, Interest, Desire, Action (AIDA) model. RESULTS A total of 740 interventions were made by the clinical pharmacist. The most common drug classes involved in interventions were: antibacterials for systemic use (11.1%) and anti-parkinson drugs (10.8%). The main drug-related problem categories triggering interventions were: no specific problem (15.9%) and prescription writing error (12.0%). A total of 93.2% of interventions were fully accepted by physicians. After assessment by an external panel 63.2% of interventions (96 interventions/ per month) were considered of moderate clinical significance and 23.4% (36 interventions/ per month) of major clinical significance. The most frequent interventions were to educate a healthcare professional (20.4%) and change dose (16.1%). CONCLUSIONS To our knowledge this is the first study evaluating the effect of a structured communication strategy on acceptance rate of pharmacist interventions. Pharmaceutical care delivered by the clinical pharmacist is likely to have had beneficial outcomes. Clinical pharmacy services like the one described should be implemented widely to increase patient safety.
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Affiliation(s)
- Nicola Lombardi
- Department of Pharmacy, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, Cambridgeshire, CB2 0QQ, UK.
| | - Li Wei
- Department of Pharmacy Practice and Policy, University College London School of Pharmacy, 29-39 Brunswick Square, Bloomsbury, London, WC1N 1AX, UK
| | - Maisoon Ghaleb
- School of Life and Medical Science, Department of Pharmacy, Pharmacology & Postgraduate Medicine, University of Hertfordshire, Hatfield, Hertfordshire, AL10 9AB, UK
| | - Enrico Pasut
- Department of Pharmacy, Azienda Sanitaria Universitaria Integrata di Udine, Via Pozzuolo, 330-33100, Udine, Friuli Venezia Giulia, Italy
| | - Silvia Leschiutta
- Department of Pharmacy, Azienda Sanitaria Universitaria Integrata di Udine, Via Pozzuolo, 330-33100, Udine, Friuli Venezia Giulia, Italy
| | - Paolo Rossi
- Division of Internal Medicine, Azienda Sanitaria Universitaria Integrata di Udine, Via Pozzuolo, 330 - 33100, Udine, Friuli Venezia Giulia, Italy
| | - Maria Grazia Troncon
- Department of Pharmacy, Azienda Sanitaria Universitaria Integrata di Udine, Via Pozzuolo, 330-33100, Udine, Friuli Venezia Giulia, Italy
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Elsadig H, Weiss M, Scott J, Laaksonen R. Use of clinical guidelines in cardiology practice in Sudan. J Eval Clin Pract 2018; 24:127-134. [PMID: 28585254 DOI: 10.1111/jep.12746] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 02/24/2017] [Accepted: 02/24/2017] [Indexed: 01/12/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVE The aim of this study was to explore the views of prescribers in cardiology in Sudan about the use of guidelines in clinical practice and the extent to which guidelines whether national or international can be adopted in clinical practice in Sudan. METHODS Interviews were conducted with the consultants in 2 of the main cardiac hospitals in Sudan. This was followed by a survey amongst the doctors in the hospitals to examine the views of a larger population of prescribers about the matter investigated. RESULTS Twelve consultants were interviewed, and 47 prescribers (60%) replied to the questionnaire that followed. Most doctors relied on foreign guidelines to prescribe for their patients. The doctors acknowledged the limitation of using foreign guidelines in Sudan. A number of doctors were not in favour of following any guidelines, as they perceived that the practice in Sudan does not allow implementation of guidelines. CONCLUSION The prescribers in Sudan had to rely on guidelines made in foreign countries if they want to get the benefit of evidence-based medicine to their patients, but they had to find a way to adapt these guidelines to their patients and to the health care system they are working within. However, it is not known if this adaptation of foreign guidelines is providing the benefits intended or is risking evidence-based medicine.
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Affiliation(s)
| | | | - Jenny Scott
- Department of Pharmacy, University of Bath, Bath, UK
| | - Raisa Laaksonen
- Faculty of Pharmacy, University of Helsinki, Helsinki, Finland
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20
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Gion M, Trevisiol C, Fabricio ASC. Appropriateness of tumor marker request: a case of study. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:274. [PMID: 28758100 DOI: 10.21037/atm.2017.06.19] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Appropriateness is crucial to provide efficient and high-quality health services at affordable costs. Laboratory medicine is a sector of special interest for the investigation of inappropriateness, due to the high rate of technological innovation and its pivotal role in many diseases and clinical settings. Some subjective aspects related to either the patient or physician seem to have a major role on inappropriateness rates. Given the psychological impact of cancer on both patients and physicians, tumor markers represent a case of study for appropriateness. The assessment of inappropriateness of laboratory tests has been focused mainly on ordering patterns. Appropriateness can barely be appraised by matching the requested test with the clinical problem because clinical information on the test requisition form is usually inadequate. Monitoring inappropriateness through individual clinical information may be feasible in inpatient (clinical data are available), while an indirect approach should be used for outpatients. To estimate inappropriateness in outpatients our group developed innovative models based on comparison between the actually ordered and expected requests of tumor marker, calculated according to recommendations of clinical practice guidelines (CPGs) applied to figures of cancer prevalence. The implementation of the model at national scale in Italy led to recognize a very high rate of overordering of tumor markers. The model was further focused by a dedicated algorithm to be adapted to different clinical conditions or organizational settings by applying performance indicators to cohort-wide structured information in electronic health records (EHRs). With this novel approach, we showed that inappropriateness is multifaceted even within the specific category of tumour markers. The model was effective in identifying both over- and underordering. Implementation of evidence based information and monitoring their impact on the clinical practice are parts of the same, multistage, process aimed at the progressive improvement of health care.
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Affiliation(s)
- Massimo Gion
- Regional Center for Biomarkers, Department of Clinical Pathology and Transfusion Medicine, Azienda ULSS3 Serenissima, Venice, Italy
| | | | - Aline S C Fabricio
- Regional Center for Biomarkers, Department of Clinical Pathology and Transfusion Medicine, Azienda ULSS3 Serenissima, Venice, Italy
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21
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van Mil JWF, Henman M. Terminology, the importance of defining. Int J Clin Pharm 2016; 38:709-13. [PMID: 27073076 DOI: 10.1007/s11096-016-0294-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/22/2016] [Indexed: 10/22/2022]
Abstract
Multiple terms and definitions exist to describe specific aspects of pharmacy practice and service provision. This commentary explores the reasons for different interpretations of words and concepts in pharmaceutical care and pharmacy practice research. Reasons for this variation can be found in language, culture, profession and may also depend on developments over time. A list of words is provided where the authors think that currently multiple interpretations are possible. To make sure that the reader understands the essence, it seems imperative that authors include a definition of the topics that they actually study in their papers, and that they clearly cite existing definitions or refer to collections of definitions such as existing glossaries. It is important that presenters, authors and reviewers of pharmacy practice papers pay more attention to this aspect of describing studies.
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Affiliation(s)
| | - Martin Henman
- School of Pharmacy & Pharmaceutical Sciences, Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
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22
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Liu W, Yuan S, Wei F, Yang J, Zhang Z, Zhu C, Ma J. Reliability and Validity of the Chinese Version Appropriateness Evaluation Protocol. PLoS One 2015; 10:e0136498. [PMID: 26305363 PMCID: PMC4549286 DOI: 10.1371/journal.pone.0136498] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 08/05/2015] [Indexed: 11/18/2022] Open
Abstract
Objective To adapt the Appropriateness Evaluation Protocol (AEP) to the specific settings of health care in China and to validate the Chinese version AEP (C-AEP). Methods Forward and backward translations were carried out to the original criteria. Twenty experts participated in the consultancy to form a preliminary version of the C-AEP. To ensure applicability, tests of reliability and validity were performed on 350 admissions and 3,226 hospital days of acute myocardial infraction patients and total hip replacement patients in two tertiary hospitals by two C-AEP reviewers and two physician reviewers. Overall agreement, specific agreement, and Cohen’s Kappa were calculated to compare the concordance of decisions between pairs of reviewers to test inter-rater reliability and convergent validity. The use of “overrides” and opinions of experts were recorded as measurements of content validity. Face validity was tested through collecting perspectives of nonprofessionals. Sensitivity, specificity, and predictive values were also reported. Results There are 14 admission and 24 days of care criteria in the initial version of C-AEP. Kappa coefficients indicate substantial agreement between reviewers: with regard to inter-rater reliability, Kappa (κ) coefficients are 0.746 (95% confidence interval [CI] 0.644–0.834) and 0.743 (95% CI 0.698–0.767) of admission and hospital days, respectively; for convergent validity, the κ statistics are 0.678 (95% CI 0.567–0.778) and 0.691 (95% CI 0.644–0.717), respectively. Overrides account for less than 2% of all judgments. Content validity and face validity were confirmed by experts and nonprofessionals, respectively. According to the C-AEP reviewers, 18.3% of admissions and 28.5% of inpatient days were deemed inappropriate. Conclusions The C-AEP is a reliable and valid screening tool in China’s tertiary hospitals. The prevalence of inappropriateness is substantial in our research. To reduce inappropriate utilization, further investigation is needed to elucidate the reasons and risk factors for this inappropriateness.
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Affiliation(s)
- Wenwei Liu
- Antai College of Economics and Management, Shanghai Jiao Tong University, Shanghai, China
| | - Suwei Yuan
- School of Public Health, Shanghai Jiao Tong University, Shanghai, China
| | - Fengqing Wei
- School of Public Health, Shanghai Jiao Tong University, Shanghai, China
| | - Jing Yang
- Department of Medical Administration, Shanghai Rui Jin Hospital, Shanghai, China
| | - Zhe Zhang
- School of Public Health, Shanghai Jiao Tong University, Shanghai, China
| | - Changbin Zhu
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jin Ma
- School of Public Health, Shanghai Jiao Tong University, Shanghai, China
- * E-mail:
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Gillette C, Prunty L, Wolcott J, Broedel-Zaugg K. A new lexicon for polypharmacy: Implications for research, practice, and education. Res Social Adm Pharm 2014; 11:468-71. [PMID: 25280463 DOI: 10.1016/j.sapharm.2014.08.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 08/17/2014] [Accepted: 08/17/2014] [Indexed: 10/24/2022]
Abstract
Previous research suggests that polypharmacy is a significant challenge for health care systems. However, polypharmacy has been defined in at least 24 distinct ways, which has understandably caused confusion among researchers, educators, and students in health care. Previous definitions of polypharmacy capture what could be both inappropriate therapy, i.e. too many medications, as well as evidence-based therapy that is appropriate. Previous research has tried to focus on the number of medications a patient is prescribed to define polypharmacy; however only focusing on the number of medications a patient is taking may be of limited value in determining whether that patient will experience an adverse event. This paper proposes a lexicon change for polypharmacy. It suggests that in future research, polypharmacy be defined as patients going to more than one pharmacy for their prescriptions. The authors also proffer a new term, 'extraordinary prescribing,' to define patients who are taking medications that are either grossly excessive or not beneficial for that patient. This definition is different than the current use of polypharmacy because the number of medications a patient is taking is irrelevant, especially if that patient has multiple chronic diseases. This paper is meant to start a dialog within the health services research community to inform future research that examines why inefficient prescribing may harm patients and the broader health care system.
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Affiliation(s)
- Chris Gillette
- Marshall University School of Pharmacy, Department of Pharmacy Practice, Administration, and Research, 1 John Marshall Dr., Huntington, WV 25755, USA.
| | - Leesa Prunty
- Marshall University School of Pharmacy, Department of Pharmacy Practice, Administration, and Research, 1 John Marshall Dr., Huntington, WV 25755, USA
| | - Janet Wolcott
- Marshall University School of Pharmacy, Department of Pharmacy Practice, Administration, and Research, 1 John Marshall Dr., Huntington, WV 25755, USA
| | - Kimberly Broedel-Zaugg
- Marshall University School of Pharmacy, Department of Pharmacy Practice, Administration, and Research, 1 John Marshall Dr., Huntington, WV 25755, USA
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24
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Two-part payments for the reimbursement of investments in health technologies. Health Policy 2014; 115:230-6. [DOI: 10.1016/j.healthpol.2013.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 09/13/2013] [Accepted: 10/21/2013] [Indexed: 11/22/2022]
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Yap KZ, Kua EH, Chan SY, Lee JYC. Improving the Appropriateness of Antipsychotic Prescribing for Behavioral and Psychological Symptoms of Dementia (BPSD): A Pilot Study of the Psychotropic Use Monitoring (PUM) Program. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojpsych.2014.42020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
SummaryPrescribing for older people is often complex and challenging. With age, people almost invariably develop diseases leading to the prescription of drugs and the risk of multiple prescribing increases, especially if there is strict adherence to single disease guidelines. There remains a paucity of evidence from clinical trials as to the efficacy of many drugs in patients aged over 80 years due to the gross under-representation of older people in clinical trials. Older people are also at increased risk of adverse drug events, which are an important cause of morbidity and mortality. A significant percentage of these are both predictable and potentially avoidable.In this updated review the concept of appropriate prescribing in older people is explored, including the importance of individualized care and shared decision-making. The available tools to enhance prescribing practice are examined, including those aimed at reducing inappropriate prescriptions and under prescribing. The limitations of existing tools are discussed and areas with particular promise and scope for advancement are highlighted, including the development of integrated IT systems and software engines to aid clinicians in appropriate prescribing.
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Poudel A, Hubbard RE, Nissen L, Mitchell C. Frailty: a key indicator to minimize inappropriate medication in older people. QJM 2013; 106:969-75. [PMID: 23824943 DOI: 10.1093/qjmed/hct146] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Older populations are more likely to have multiple co-morbid diseases that require multiple treatments, which make them a large consumer of medications. As a person grows older, their ability to tolerate medications becomes less due to age-related changes in pharmacokinetics and pharmacodynamics often heading along a path that leads to frailty. Frail older persons often have multiple co-morbidities with signs of impairment in activities of daily living. Prescribing drugs for these vulnerable individuals is difficult and is a potentially unsafe activity. Inappropriate prescribing in older population can be detected using explicit (criterion-based) or implicit (judgment-based) criteria. Unfortunately, most current therapeutic guidelines are applicable only to healthy older adults and cannot be generalized to frail patients. These discrepancies should be addressed either by developing new criteria or by refining the existing tools for frail older people. The first and foremost step is to identify the frail patient in clinical practice by applying clinically validated tools. Once the frail patient has been identified, there is a need for specific measures or criteria to assess appropriateness of therapy that consider such factors as quality of life, functional status and remaining life expectancy and thus modified goals of care.
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Affiliation(s)
- A Poudel
- Pharmacy Australia Centre of Excellence (PACE), School of Pharmacy, The University of Queensland, Brisbane, Australia.
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West LM, Cordina M, Cunningham S. Clinical pharmacist evaluation of medication inappropriateness in the emergency department of a teaching hospital in Malta. Pharm Pract (Granada) 2012; 10:181-7. [PMID: 24155835 PMCID: PMC3780501 DOI: 10.4321/s1886-36552012000400001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 11/07/2012] [Indexed: 12/03/2022] Open
Abstract
Appropriate prescribing remains an important priority in all medical areas of
practice. Objective The objective of this study was to apply a Medication Appropriateness Index
(MAI) to identify issues of inappropriate prescribing amongst patients
admitted from the Emergency Department (ED). Methods This study was carried out at Malta's general hospital on 125 patients
following a two-week pilot period on 10 patients. Patients aged 18 years and
over and on medication therapy were included. Medication treatment for
inappropriateness was assessed by using the MAI. Under-prescribing was also
screened for. Results Treatment charts of 125 patients, including 697 medications, were assessed
using a MAI. Overall, 115 (92%) patients had one or more medications with
one or more MAI criteria rated as inappropriate, giving a total of 384
(55.1%) medications prescribed inappropriately. The mean SD MAI score per
drug was 1.78 (SD=2.19). The most common medication classes with
appropriateness problems were biguanides (100%), anti-arrhythmics (100%) and
anti-platelets (96.8%). The most common problems involved incorrect
directions (26%) and incorrect dosages (18.5%). There were 36 omitted
medications with untreated indications. Conclusions There is considerable inappropriate prescribing which could have significant
negative effects regarding patient care.
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Galván-Banqueri M, Santos-Ramos B, Vega-Coca MD, Alfaro-Lara ER, Nieto-Martín MD, Pérez-Guerrero C. [Suitability of pharmacological treatment in patients with multiple chronic conditions]. Aten Primaria 2012; 45:6-18. [PMID: 23218683 PMCID: PMC6983536 DOI: 10.1016/j.aprim.2012.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 02/15/2012] [Accepted: 03/18/2012] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To identify tools for measuring the appropriateness of drug therapy useful in patients with multiple chronic conditions. DESIGN We performed a literature review. DATA SOURCES The following database were consulted (December 2009): Pubmed, EMBASE, CINAHL, PsycINFO and Spanish Medical Index (IME) to detect tools for measuring the appropriateness of treatment in patients with multiple chronic conditions, or otherwise elderly or polypharmacy. STUDY SELECTION Studies were identified both qualitative and quantitative methodology, both theoretical and field work, both original and revised work and included work from all areas of the health system. 108 articles were retrieved, of which we selected 59. The consultation of their references include 20 jobs allowed, resulting in a total of 59 articles. DATA EXTRACTION Of all the tools identified, the researchers performed a selection of those with possible utility for classified PP. The articles were classified into implicit and explicit methods and the characteristics of the field works were tabulated. RESULTS We identified two implicit methods (MAI and Hamdy) and 6 explicit methods (Beers criteria, IPET, STOPP/START, ACOVE, CRIME and NORGEP). None was specific to patients with multiple chronic conditions. The questionnaire MAI, the Beers criteria and its modifications are most often used in literature. The advantages of explicit criteria means that many of them have been developed recently. CONCLUSION There are several tools to measure the appropriateness and none of them has been designed for a population of patients with multiple chronic conditions yet, which by its nature requires a specific approach spreads.
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Affiliation(s)
- Mercedes Galván-Banqueri
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, Sevilla, España.
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Naughton C, Drennan J, Hyde A, Allen D, O'Boyle K, Felle P, Butler M. An evaluation of the appropriateness and safety of nurse and midwife prescribing in Ireland. J Adv Nurs 2012; 69:1478-88. [DOI: 10.1111/jan.12004] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Corina Naughton
- School of Nursing, Midwifery and Health Systems; University College Dublin (UCD); Belfield Dublin Ireland
| | - Jonathan Drennan
- School of Nursing, Midwifery and Health Systems; University College Dublin (UCD); Belfield Dublin Ireland
| | - Abbey Hyde
- School of Nursing, Midwifery and Health Systems; University College Dublin (UCD); Belfield Dublin Ireland
| | - Deirdre Allen
- School of Nursing, Midwifery and Health Systems; University College Dublin (UCD); Belfield Dublin Ireland
| | - Kathleen O'Boyle
- School of Biomolecular and Biomedical Science; University College Dublin (UCD); Belfield Dublin Ireland
| | - Patrick Felle
- School of Medicine and Medical Science; University College Dublin (UCD); Belfield Dublin Ireland
| | - Michelle Butler
- School of Nursing, Midwifery and Health Systems; University College Dublin (UCD); Belfield Dublin Ireland
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31
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Drug-related problems (DRPs) identified from geriatric medication safety review clinics. Arch Gerontol Geriatr 2012; 54:168-74. [DOI: 10.1016/j.archger.2011.02.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Revised: 01/28/2011] [Accepted: 01/29/2011] [Indexed: 11/21/2022]
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Javed N, Tully MP. Content validity of indicators of the appropriateness of long-term prescribing started during a hospital admission. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2011. [DOI: 10.1111/j.2042-7174.2002.tb00659.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Abstract
Focal points
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Affiliation(s)
- N Javed
- School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester M13 9PL
| | - M P Tully
- School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester M13 9PL
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Abstract
Abstract
The aim of this paper is to review the methodologies employed by health service and pharmacy practice researchers in the evaluation of pharmacy services. The review is in two parts. Part 1 discusses the application of different study designs and frameworks in the evaluation of existing and innovative services and interventions; part 2, to be published in a later issue, will address the methods and measures employed in the evaluation process. The studies included in this review were selected to give examples of different study objectives, designs and frameworks and their application in pharmacy settings. Although many of the issues regarding study design and evaluation frameworks may be relevant to clinical trials comparing the efficacy of alternative drug therapies, the focus of this paper is on pharmacy services.
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Affiliation(s)
- Felicity Smith
- Centre for Pharmacy Practice, School of Pharmacy, University of London, 29/39 Brunswick Square, London, England WC1N 1AX
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34
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Volume CI, Burback LM, Farris KB. Reassessing the MAI: elderly people's opinions about medication appropriateness. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2011. [DOI: 10.1111/j.2042-7174.1999.tb00959.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Objectives
To identify the criteria that the elderly use to assess the appropriateness of their medications, rank the identified criteria in terms of importance, and compare elderly people's and clinicians' ratings of the importance of medication appropriateness index (MAI) criteria
Methods
A qualitative method was used to understand why elders' rankings of appropriateness criteria may or may not differ from clinicians'. Five focus groups with 38 elderly people were completed and content analysed. The participants also completed a written ranking of 10 criteria, indicating them as being of high importance, moderate importance or low importance
Key findings
Overall, the group discussion cited indication, effectiveness and drug-drug interactions as most important. The written ranking of the MAI criteria suggested drug-drug interactions and correct directions as being most important. Elderly people appeared to have difficulty ranking the criteria of indication and effectiveness, as there was some evidence that they took these criteria for granted. Differences among focus group participants appeared to be due to their varied medication use experience
Conclusion
These findings suggest that drug-drug interactions may be ranked highly important and practicality ranked moderately important when elderly patients' opinions are sought about medication appropriateness. Further research should be conducted to assess whether the MAI is accountable to patient viewpoints
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Affiliation(s)
- Carlyn I Volume
- Faculty of Pharmacy and Pharmaceutical Sciences, 3118 Dentistry/Pharmacy Building, University of Alberta, Edmonton, Alberta, Canada T6G 2N8
| | - Lisa M Burback
- Faculty of Pharmacy and Pharmaceutical Sciences, 3118 Dentistry/Pharmacy Building, University of Alberta, Edmonton, Alberta, Canada T6G 2N8
| | - Karen B Farris
- Faculty of Pharmacy and Pharmaceutical Sciences, 3118 Dentistry/Pharmacy Building, University of Alberta, Edmonton, Alberta, Canada T6G 2N8
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Quintana JM, Arostegui I, Alberdi T, Escobar A, Perea E, Navarro G, Elizalde B, Andradas E. Decision trees for indication of cataract surgery based on changes in visual acuity. Ophthalmology 2010; 117:1471-8, 1478.e1-3. [PMID: 20416951 DOI: 10.1016/j.ophtha.2009.12.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Revised: 12/11/2009] [Accepted: 12/29/2009] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE To develop decision trees based on prospectively collected data for determining the appropriateness of cataract extraction. DESIGN Prospective observational cohort study. PARTICIPANTS Consecutive patients with a diagnosis of cataract who are on waiting lists to undergo cataract extraction by phacoemulsification. METHODS Patients were randomly assigned to 1 of 2 independent cohorts: The derivation cohort included 3691 patients, and the validation cohort included 2416 patients. Sociodemographic and clinical data, including visual acuity (VA) and the Visual Function Index 14 (VF-14), were collected before and after cataract extraction. Univariate and multivariate linear regression, and regression trees analysis were performed in the derivation cohort. Decision trees obtained in the derivation cohort were validated in the validation cohort. Final results were divided into appropriate or inappropriate indications and compared with a previously established benchmark of desirable VA and VF-14 gain in relation to preintervention VA classes. MAIN OUTCOME MEASURES Preintervention VA and changes 6 weeks after the intervention. RESULTS Among patients with simple cataract, predictors of significant improvement in VA after cataract extraction were preintervention VA and negative surgical complexity. Among patients with cataract and other ocular comorbidity, preintervention visual function and expected postintervention VA also predicted change in VA. When compared with a benchmark based on the minimal clinically important difference in VA after cataract extraction, sensitivity for the decision trees was 83% for both diagnostic groups and specificities ranged from 36.2 to 54.8. CONCLUSIONS A simple decision tree based on changes in VA can help identify appropriate patients for cataract extraction and be used to evaluate clinical practice or for quality control.
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Affiliation(s)
- José M Quintana
- Unidad de Investigación, Hospital Galdakao-Usansolo-CIBER Epidemiología y Salud Pública, Galdakao, Vizcaya, Spain.
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Abstract
1. To understand medication errors and to identify preventive strategies, we need to classify them and define the terms that describe them. 2. The four main approaches to defining technical terms consider etymology, usage, previous definitions, and the Ramsey-Lewis method (based on an understanding of theory and practice). 3. A medication error is 'a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient'. 4. Prescribing faults, a subset of medication errors, should be distinguished from prescription errors. A prescribing fault is 'a failure in the prescribing [decision-making] process that leads to, or has the potential to lead to, harm to the patient'. The converse of this, 'balanced prescribing' is 'the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm'. This excludes all forms of prescribing faults, such as irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing. 5. A prescription error is 'a failure in the prescription writing process that results in a wrong instruction about one or more of the normal features of a prescription'. The 'normal features' include the identity of the recipient, the identity of the drug, the formulation, dose, route, timing, frequency, and duration of administration. 6. Medication errors can be classified, invoking psychological theory, as knowledge-based mistakes, rule-based mistakes, action-based slips, and memory-based lapses. This classification informs preventive strategies.
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Zanaboni P, Scalvini S, Bernocchi P, Borghi G, Tridico C, Masella C. Teleconsultation service to improve healthcare in rural areas: acceptance, organizational impact and appropriateness. BMC Health Serv Res 2009; 9:238. [PMID: 20021651 PMCID: PMC2803179 DOI: 10.1186/1472-6963-9-238] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Accepted: 12/18/2009] [Indexed: 11/22/2022] Open
Abstract
Background Nowadays, new organisational strategies should be indentified to improve primary care and its link with secondary care in terms of efficacy and timeliness of interventions thus preventing unnecessary hospital accesses and costs saving for the health system. The purpose of this study is to assess the effects of the use of teleconsultation by general practitioners in rural areas. Methods General practitioners were provided with a teleconsultation service from 2006 to 2008 to obtain a second opinion for cardiac, dermatological and diabetic problems. Access, acceptance, organisational impact, effectiveness and economics data were collected. Clinical and access data were systematically entered in a database while acceptance and organisational data were evaluated through ad hoc questionnaires. Results There were 957 teleconsultation contacts which resulted in access to health care services for 812 symptomatic patients living in 30 rural communities. Through the teleconsultation service, 48 general practitioners improved the appropriateness of primary care and the integration with secondary care. In fact, the level of concordance between intentions and consultations for cardiac problems was equal to 9%, in 86% of the cases the service entailed a saving of resources and in 5% of the cases, it improved the timeliness. 95% of the GPs considered the overall quality positively. For a future routine use of this service, trust in specialists, duration and workload of teleconsultations and reimbursement should be taken into account. Conclusions Managerial and policy implications emerged mainly related to the support to GPs in the provision of high quality primary care and decision-making processes in promoting similar services.
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Affiliation(s)
- Paolo Zanaboni
- Department of Management, Economics and Industrial Engineering, Politecnico di Milano, Milano, Italy.
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39
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Cantrill JA, Dowell J, Roland MO. General practitioners' views on the appropriateness of their long-term prescribing. Eur J Gen Pract 2009. [DOI: 10.3109/13814780009074499] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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40
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Blades S, Eccles M, McColl E, Campbell M. Understanding the Appropriateness of Prescribing in Primary Care. Eur J Gen Pract 2009. [DOI: 10.3109/13814789809160795] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Castelino RL, Bajorek BV, Chen TF. Targeting suboptimal prescribing in the elderly: a review of the impact of pharmacy services. Ann Pharmacother 2009; 43:1096-106. [PMID: 19470856 DOI: 10.1345/aph.1l700] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the currently available literature on the impact of interventions by pharmacists on suboptimal prescribing in the elderly. DATA SOURCES MEDLINE, EMBASE, and International Pharmaceutical Abstracts databases were searched for studies published between January 1992 and December 2008. Key words included medication review, drug regimen review, pharmaceutical services, pharmaceutical care, pharmacists, medications, appropriateness, suboptimal, underuse, aged, elderly, randomized controlled trial, inappropriate, prescribing, and intervention. STUDY SELECTION AND DATA EXTRACTION To be included in the review, studies must have been conducted in patients 65 years or older, published in English, randomized and controlled, and must have included an intervention delivered by a pharmacist or had a pharmacist as a member of the intervention team. From each relevant study, the following data were extracted: study duration, country, number of patients, year of publication, objective, type and impact of the intervention, method used to assess suboptimal prescribing, and data concerning the quality of the study. DATA SYNTHESIS A total of 38 articles were identified, of which 12 matched our inclusion criteria. Seven articles included interventions initiated by pharmacists, and the remaining 5 described interventions in which the pharmacist was a part of the multidisciplinary team. A broad range of tools was used to measure prescribing appropriateness; we found that a consensus on the best approach has not been reached. Most of the studies involving pharmacists showed significant improvement in suboptimal prescribing at one or more time points. However, most of these interventions were directed toward reducing the overuse or misuse of medications. CONCLUSIONS Pharmacy services to reduce suboptimal prescribing have shown promising and noteworthy improvements. More research is needed to address the underutilization of medications in the elderly and healthcare impact of reducing suboptimal prescribing.
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Abstract
RATIONALE, AIM AND OBJECTIVE As the prescribing of drugs in secondary care is known to influence prescribing in primary care and because an understanding of prescribers' reasoning is essential for evaluating prescribing appropriateness, the aim of this study was to investigate secondary care doctors' views of appropriate prescribing, using qualitative individual interviews. METHOD Qualitative, semi-structured individual interviews were conducted with 15 hospital doctors working in different medical specialities. The interviews, covering the doctors' views of the meaning of 'appropriate' prescribing, were audiotaped and analysed from an interpretivist perspective. RESULTS Three different main themes were identified in the analysis of how the doctors perceived appropriate prescribing: 'individualization of treatment', 'cost' and 'time'. Most importantly, treatment should be adjusted to the individual patient, although cost should also be justified. Ongoing medication reviews should be carried out, to adjust to changes in patient-related factors over time. CONCLUSIONS The hospital doctors brought up continuous review as a necessary part of appropriate prescribing. Thus, from the prescribers' point of view, this time perspective should be explicitly incorporated in definitions of appropriate prescribing, in addition to individualization of treatment and cost considerations.
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43
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Appropriateness of healthcare interventions: Concepts and scoping of the published literature. Int J Technol Assess Health Care 2008; 24:342-9. [DOI: 10.1017/s0266462308080458] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Objectives:This report is a scoping review of the literature with the objective of identifying definitions, conceptual models and frameworks, as well as the methods and range of perspectives, for determining appropriateness in the context of healthcare delivery.Methods:To lay groundwork for future, intervention-specific research on appropriateness, this work was carried out as a scoping review of published literature since 1966. Two reviewers, with two screens using inclusion/exclusion criteria based on the objective, focused the research and articles chosen for review.Results:The first screen examined 2,829 abstracts/titles, with the second screen examining 124 full articles, leaving 37 articles deemed highly relevant for data extraction and interpretation. Appropriateness is defined largely in terms of net clinical benefit to the average patient and varies by service and setting. The most widely used method to assess appropriateness of healthcare services is the RAND/UCLA Model. There are many related concepts such as medical necessity and small-areas variation.Conclusions:A broader approach to determining appropriateness for healthcare interventions is possible and would involve clinical, patient and societal perspectives.
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Abstract
Optimal prescribing is critical to the goals of geriatric medicine of curing disease, eliminating or reducing symptoms, and improving functioning. However, prescribing decisions in older people are often complex. There is marked heterogeneity in health status and functional capacity amongst older people, who range from fit, active, independent individuals to those who are physically and mentally frail, with limited physiological reserve. Age-related changes in physiology affect drug pharmacokinetics and pharmacodynamics, and together with various pathological processes, increase the risk of adverse drug events (ADEs). This risk is heightened by prescription of multiple medications to treat multiple co-morbidities. Consequently, balancing safety and quality of prescribing for older people with appropriate treatment of all co-morbidities can be challenging.
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45
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Latter S, Maben J, Myall M, Young A. Evaluating the clinical appropriateness of nurses' prescribing practice: method development and findings from an expert panel analysis. Qual Saf Health Care 2007; 16:415-21. [PMID: 18055884 DOI: 10.1136/qshc.2005.017038] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The number of nurses independently prescribing medicines in England is rising steadily. There had been no attempt systematically to evaluate the clinical appropriateness of nurses' prescribing decisions. AIMS (i) To establish a method of assessing the clinical appropriateness of nurses' prescribing decisions; (ii) to evaluate the prescribing decisions of a sample of nurses, using this method. METHOD A modified version of the Medication Appropriateness Index (MAI) was developed, piloted and subsequently used by seven medical prescribing experts to rate transcripts of 12 nurse prescriber consultations selected from a larger database of 118 audio-recorded consultations collected as part of a national evaluation. Experts were also able to give written qualitative comments on each of the MAI dimensions applied to each of the consultations. ANALYSIS Experts' ratings were analysed using descriptive statistics. Qualitative comments were subjected to a process of content analysis to identify themes within and across both MAI items and consultations. RESULTS Experts' application of the modified MAI to transcripts of nurse prescriber consultations demonstrated validity and feasibility as a method of assessing the clinical appropriateness of nurses' prescribing decisions. In the majority of assessments made by the expert panel, nurses' prescribing decisions were rated as clinically appropriate on all nine items in the MAI. CONCLUSION A valid and feasible method of assessing the clinical appropriateness of nurses' prescribing practice has been developed using a modified MAI and transcripts of audio-recorded consultations sent to a panel of prescribing experts. Prescribing nurses in this study were generally considered to be making clinically appropriate prescribing decisions. This approach to measuring prescribing appropriateness could be used as part of quality assurance in routine practice, as a method of identifying continuing professional development needs, or in future research as the expansion of non-medical prescribing continues.
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Affiliation(s)
- Sue Latter
- School of Nursing and Midwifery, Building 67, University of Southampton, Highfield, Southampton SO17 1BJ, England.
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46
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Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, Hanlon JT. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet 2007; 370:173-184. [PMID: 17630041 DOI: 10.1016/s0140-6736(07)61091-5] [Citation(s) in RCA: 713] [Impact Index Per Article: 41.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Prescription of medicines is a fundamental component of the care of elderly people, and optimisation of drug prescribing for this group of patients has become an important public-health issue worldwide. Several characteristics of ageing and geriatric medicine affect medication prescribing for elderly people and render the selection of appropriate pharmacotherapy a challenging and complex process. In the first paper in this series we aim to define and categorise appropriate prescribing in elderly people, critically review the instruments that are available to measure it and discuss their predictive validity, critically review recent randomised controlled intervention studies that assessed the effect of optimisation strategies on the appropriateness of prescribing in elderly people, and suggest directions for future research and practice.
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Affiliation(s)
- Anne Spinewine
- Center for Clinical Pharmacy, School of Pharmacy, Université catholique de Louvain, Brussels, Belgium.
| | - Kenneth E Schmader
- Aging Center and Department of Medicine (Geriatrics), School of Medicine, Duke University Medical Center, Durham, NC, USA; Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA
| | - Nick Barber
- Department of Practice and Policy, School of Pharmacy, University of London, London, UK
| | | | - Kate L Lapane
- Department of Community Health, Brown Medical School, Providence, RI, USA
| | - Christian Swine
- Department of Geriatric Medicine, Mont-Godinne University Hospital, Université catholique de Louvain, Brussels, Belgium
| | - Joseph T Hanlon
- Institute on Aging, and Department of Medicine (Geriatrics), School of Medicine and Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA; Center for Health Equity Research and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
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47
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Abstract
As people age they almost invariably develop diseases which lead to the prescription of drugs – both to prevent disease progression and for symptomatic relief. Unfortunately, drug treatment in later life is also problematic. There is a dearth of evidence on the efficacy of drugs in people over the age of 80, and members of this age group are at highest risk of adverse drug reactions (ADR).
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48
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Davis RG, Hepfinger CA, Sauer KA, Wilhardt MS. Retrospective evaluation of medication appropriateness and clinical pharmacist drug therapy recommendations for home-based primary care veterans. ACTA ACUST UNITED AC 2007; 5:40-7. [PMID: 17608246 DOI: 10.1016/j.amjopharm.2007.03.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The Medication Appropriateness Index (MAI) has demonstrated reliability in several outpatient settings. Clinical pharmacists play key roles as members of an interdisciplinary team in determining medication appropriateness. OBJECTIVE The goal of this study was to examine medication appropriateness using the MAI and the degree of recommendation acceptance associated with clinical pharmacist medication reviews for veterans enrolled in the Home-Based Primary Care (HBPC) program. METHODS A retrospective analysis of clinical pharmacist medication reviews was performed by accessing the computerized patient medical record. Patients included in the study were enrolled in the HBPC program between March 2002 and January 2004. The data were examined to determine a total MAI score associated with medication recommendations after each review. The number and types of pharmacist recommendations, their acceptance rate, and the total number of medications discontinued were also evaluated. RESULTS Seventy-nine patients (mean [SD] age, 75.3 [10.3] years) identified through the pharmacy database met the inclusion criteria and were included in the study. No patients identified were excluded from the analysis. A statistically significant decrease in the overall MAI score was observed from the initial review to the end of the study (P < 0.001). Recommendations to patients' primary care providers included medication initiation/discontinuation, laboratory monitoring, dosage adjustment, and other issues associated with appropriate prescribing that could be categorized using the MAI. Recommendations to home health nurses included monitoring for medication adherence, efficacy, and adverse events. Pharmacist recommendation acceptance rates for primary care providers and home health nurses were 69% and 56%, respectively. Overall, 121 medications were discontinued during the study period. CONCLUSIONS By using the MAI for evaluation, pharmacist recommendations significantly improved the appropriateness of medication use among veterans receiving home health care. A majority of pharmacist recommendations were accepted.
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Affiliation(s)
- Ryan G Davis
- Carl T Hayden VA Medical Center, Phoenix, Arizona 85012, USA
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49
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Abstract
We have previously described and analysed some terms that are used in drug safety and have proposed definitions. Here we discuss and define terms that are used in the field of medication errors, particularly terms that are sometimes misunderstood or misused. We also discuss the classification of medication errors. A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Errors can be classified according to whether they are mistakes, slips, or lapses. Mistakes are errors in the planning of an action. They can be knowledge based or rule based. Slips and lapses are errors in carrying out an action - a slip through an erroneous performance and a lapse through an erroneous memory. Classification of medication errors is important because the probabilities of errors of different classes are different, as are the potential remedies.
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Affiliation(s)
- Robin E Ferner
- West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham, UK
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Straand J, Fetveit A, Rognstad S, Gjelstad S, Brekke M, Dalen I. A cluster-randomized educational intervention to reduce inappropriate prescription patterns for elderly patients in general practice--The Prescription Peer Academic Detailing (Rx-PAD) study [NCT00281450]. BMC Health Serv Res 2006; 6:72. [PMID: 16764734 PMCID: PMC1525163 DOI: 10.1186/1472-6963-6-72] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2006] [Accepted: 06/11/2006] [Indexed: 11/10/2022] Open
Abstract
Background Age-related alterations in metabolism and excretion of medications increase the risk of adverse drug events in the elderly. Inappropriate polypharmacy and prescription practice entails increased burdens of impaired quality of life and drug related morbidity and mortality. The main objective of this trial is to evaluate effects of a tailored educational intervention towards general practitioners (GPs) aimed at supporting the implementation of a safer drug prescribing practice for elderly patients ≥ 70 years. Methods/design Approximately 80 peer continuing medical education (CME) groups (about 600 GPs) in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. The control group will not receive any intervention towards prescription patterns in elderly, but will be the target of an educational intervention for prescription of antibiotics for respiratory tract infections. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, a set of quality indicators (QIs), i.e. explicit recommendations for safer prescribing for elderly patients, will be presented and discussed. Software will be handed out for installation in participants' practice computers to enable extraction of pre-defined prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Feedback reports will include QI-scores on individual- and group levels, before and after the intervention. The main outcome of this trial is the change in proportions of inappropriate prescriptions (QIs) for elderly patients ≥ 70 years following intervention, compared to baseline levels. Discussion Improvement of prescription patterns in medical practice is a challenging task. Evidence suggests that a thorough evaluation of diagnostic indications for drug treatment in the elderly and/or a reduction of potentially inappropriate drugs may impose significant clinical benefits. Our hypothesis is that an educational intervention program will be effective in improving prescribing patterns for elderly patients in GP settings.
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Affiliation(s)
- Jørund Straand
- Department of General Practice and Community Medicine, University of Oslo, PO Box 1130 Blindern, 0317 Oslo, Norway
| | - Arne Fetveit
- Department of General Practice and Community Medicine, University of Oslo, PO Box 1130 Blindern, 0317 Oslo, Norway
| | - Sture Rognstad
- Department of General Practice and Community Medicine, University of Oslo, PO Box 1130 Blindern, 0317 Oslo, Norway
| | - Svein Gjelstad
- Department of General Practice and Community Medicine, University of Oslo, PO Box 1130 Blindern, 0317 Oslo, Norway
| | - Mette Brekke
- Department of General Practice and Community Medicine, University of Oslo, PO Box 1130 Blindern, 0317 Oslo, Norway
| | - Ingvild Dalen
- Institute of Basic Medical Sciences, Department of Biostatistics, University of Oslo, PO Box 1122 Blindern, 0317 Oslo, Norway
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