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Ramsdale E, Mohamed M, Holmes HM, Zubkoff L, Bauer J, Norton SA, Mohile S. Decreasing polypharmacy in older adults with cancer: A pilot cluster-randomized trial protocol. J Geriatr Oncol 2024; 15:101687. [PMID: 38302299 PMCID: PMC10923001 DOI: 10.1016/j.jgo.2023.101687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/02/2023] [Accepted: 12/07/2023] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Polypharmacy is prevalent in older adults with cancer and associated with multiple adverse outcomes. A single-site, cluster-randomized clinical trial will enroll older adults with cancer and polypharmacy starting chemotherapy and will assess the effectiveness and feasibility of deprescribing interventions by comparing two arms: a pharmacist-led deprescribing intervention and a patient educational brochure. MATERIALS AND METHODS The study will be conducted in two phases. In phase I, focus groups and semi-structured individual interviews will guide adaptation of deprescribing interventions for the oncology clinic (phase Ia), and eight patients will undergo the pharmacist-led deprescribing intervention with iterative adaptations (phase Ib). In phase II, a pilot cluster-randomized trial (n = 72) will compare a pharmacist-led deprescribing intervention with a patient education brochure, with treating oncologists as the cluster. Both efficacy (relative dose intensity of planned chemotherapy, potentially inappropriate medications successfully deprescribed, chemotherapy toxicity, functional status, hospitalizations, falls, and symptoms) and implementation outcomes (barriers and facilitators) will be assessed. DISCUSSION This study is anticipated to provide pilot data to inform a nationwide randomized clinical trial of deprescribing in older adults starting cancer treatment. The cluster randomization is intended to provide an initial estimate for the intervention effect as well as oncologists' intra-class correlation coefficient. Deprescribing interventions may improve outcomes in older adults starting cancer treatment, but these interventions are understudied in this population, and it is unknown how best to implement them into oncology practice. The results of this trial will inform the design of large, randomized phase III trials of deprescribing. CLINICALTRIALS gov Identifier:NCT05046171. Date of registration: September 16, 2021.
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Affiliation(s)
- Erika Ramsdale
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA.
| | - Mostafa Mohamed
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, McGovern Medical School, TX, USA
| | - Lisa Zubkoff
- Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Jessica Bauer
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
| | - Sally A Norton
- School of Nursing, University of Rochester Medical Center, NY, USA
| | - Supriya Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
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2
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Olesen AE, Vaever TJ, Simonsen M, Simonsen PG, Høj K. Deprescribing in primary care without deterioration of health-related outcomes: A real-life, quality improvement project. Basic Clin Pharmacol Toxicol 2024; 134:72-82. [PMID: 37400998 DOI: 10.1111/bcpt.13925] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/29/2023] [Accepted: 06/29/2023] [Indexed: 07/05/2023]
Abstract
Medication reviews focusing on deprescribing can reduce potentially inappropriate medication; however, evidence regarding effects on health-related outcomes is sparse. In a real-life quality improvement project using a newly developed chronic care model, we investigated how a general practitioner-led medication review intervention focusing on deprescribing affected health-related outcomes. We performed a before-after intervention study including care home residents and community-dwelling patients affiliated with a large Danish general practice. The primary outcomes were changes in self-reported health status, general condition and functional level from baseline to 3-4 months follow-up. Of the 105 included patients, 87 completed the follow-up. From baseline to follow-up, 255 medication changes were made, of which 83% were deprescribing. Mean self-reported health status increased (0.55 [95% CI: 0.22 to 0.87]); the proportion with general condition rated as 'average or above' was stable (0.06 [95% CI: -0.02 to 0.14]); and the proportion with functional level 'without any disability' was stable (-0.05 [95% CI: -0.09 to 0.001]). In conclusion, this general practitioner-led medication review intervention was associated with deprescribing and increased self-reported health status without the deterioration of general condition or functional level in real-life primary care patients. The results should be interpreted carefully given the small sample size and lack of control group.
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Affiliation(s)
- Anne Estrup Olesen
- Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Tanja Joest Vaever
- Centre for Health and Care, Municipality of Frederikshavn, Frederikshavn, Denmark
| | - Martin Simonsen
- General practitioner practice 'Laegeklinikken Frederikshavn', Frederikshavn, Denmark
| | | | - Kirsten Høj
- Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
- Research Unit for General Practice, Aarhus, Denmark
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3
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Shantsila E, Lip GYH, Shantsila A, Kurpas D, Beevers G, Gill PS, Williams NH. Antihypertensive treatment in people of very old age with frailty: time for a paradigm shift? J Hypertens 2023; 41:1502-1510. [PMID: 37432893 DOI: 10.1097/hjh.0000000000003495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
The optimal management of hypertension in individuals aged 80 years or older with frailty remains uncertain due to multiple gaps in evidence. Complex health issues, polypharmacy, and limited physiological reserve make responding to antihypertensive treatments unpredictable. Patients in this age group may have limited life expectancy, so their quality of life should be prioritized when making treatment decisions. Further research is needed to identify which patients would benefit from more relaxed blood pressure targets and which antihypertensive medications are preferable or should be avoided. A paradigm shift is required in attitudes towards treatment, placing equal emphasis on deprescribing and prescribing when optimizing care. This review discusses the current evidence on managing hypertension in individuals aged 80 years or older with frailty, but further research is essential to address the gaps in knowledge and improve the care of this population.
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Affiliation(s)
- Eduard Shantsila
- Department of Primary Care and Mental Health, University of Liverpool
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Denmark
| | - Alena Shantsila
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Donata Kurpas
- Health Sciences Faculty, Wrocław Medical University, Wrocław, Poland
- Primary Care and Risk Factor Management Section, European Association of Preventative Cardiology, European Heart House, Les Templiers, Sophia Antipolis
- International Advisory Board of EURIPA (WONCA) - France
- International Foundation for Integrated Care (IFIC), Schiphol Airport, The Netherlands
| | - Gareth Beevers
- University of Birmingham, Department of Medicine, City Hospital, Birmingham
| | - Paramjit S Gill
- Academic Unit of Primary Care Warwick Medical School, University of Warwick Coventry, UK
| | - Nefyn H Williams
- Department of Primary Care and Mental Health, University of Liverpool
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4
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Al-Arkee S, Mason J, Lindenmeyer A, Jalal Z. Pharmacist management of atrial fibrillation in UK primary care: a qualitative study. J Pharm Policy Pract 2022; 15:98. [PMID: 36494739 PMCID: PMC9733171 DOI: 10.1186/s40545-022-00486-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/08/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) affects up to 2% of the UK population. AF is a potentially long-term condition that needs management, and as such primary care pharmacists may have a substantial role in supporting the management of AF. OBJECTIVES This study aims to explore the role of primary care pharmacists, working in community pharmacies and general practices (GPs), in supporting the management of AF. Furthermore, this study investigates pharmacists' confidence in their knowledge and their attitudes towards incorporating AF-associated mobile apps use into their current practice. METHODS A qualitative study was conducted, using one-to-one semi-structured, audio-recorded interviews with primary care pharmacists. The topic guide was developed based on pharmacy visits and included the most relevant constructs from the 'consolidated framework for implementation research (CFIR)'. All interviews were audio-recorded, transcribed verbatim and thematically analysed until saturation was achieved, guided by Braun and Clarke's 6-step research method. This study was given a favourable opinion on 5 September 2019 by the University of Birmingham (UOB) Research Ethics Committee (Reference ERN_19-0908). RESULTS Thematic saturation was achieved after 11 interviews with primary care pharmacists (seven community pharmacists, and four GP pharmacists). Three main themes emerged relating to (1) the clinical role of pharmacists in the management of AF; (2) knowledge and awareness; and (3) prioritisation of resources. The first highlighted that primary care pharmacists were an underutilised resource within AF management. The second demonstrated that pharmacists, especially those based in the community, felt a lack of confidence in their knowledge of AF and its management, mainly community pharmacists due to other roles taking precedence over clinical roles. Both community and GP pharmacists expressed the need to have further training in this therapeutic area to be able to effectively support patients with AF. The third shed light on the pharmacists' views relating to the technological revolution in healthcare. Pharmacists expressed an interest in using apps to support their current practice. CONCLUSIONS Primary care pharmacists supported an extended care to AF management from screening to consultations, yet the provision of such services remains limited and inconsistent. Future research should focus on understanding the ways in which pharmacists' role can be adapted toward greater involvement in clinical care.
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Affiliation(s)
- Shahd Al-Arkee
- grid.6572.60000 0004 1936 7486Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Julie Mason
- grid.6572.60000 0004 1936 7486Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Antje Lindenmeyer
- grid.6572.60000 0004 1936 7486Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Zahraa Jalal
- grid.6572.60000 0004 1936 7486Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom
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5
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Ng NM, Ng YS, Chu TK, Lau P. Factors affecting prescription of sodium-glucose co-transporter 2 inhibitors in patients with type 2 diabetes mellitus with established cardiovascular disease/ chronic kidney disease in Hong Kong: a qualitative study. BMC PRIMARY CARE 2022; 23:317. [PMID: 36476327 PMCID: PMC9730654 DOI: 10.1186/s12875-022-01928-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Sodium-glucose co-transporter 2 inhibitors (SGLT2 I) has cardiorenal protective properties and are recommended for patients with diabetes and established atherosclerotic cardiovascular disease (ASCVD) and/or chronic kidney disease (CKD). Although cardiorenal complications are high in diabetes and pose a significant financial burden on the Hong Kong health care system, the use of SGLT2 I in these populations remains low. And yet this issue has not been explored in Hong Kong primary care. This study aimed to explore factors affecting primary care doctors' prescribing of SGLT2 I in patients with diabetes and established ASCVD/CKD in Hong Kong. METHODS A phenomenological qualitative research using semi-structured interviews was conducted between January and May 2021 in one Hospital Authority cluster in Hong Kong. Purposive sampling was employed to recruit primary care doctors in the cluster. The Theoretical Domains Framework (TDF) underpinned the study and guided the development of the interview questions. Data was analysed using both inductive and deductive approaches. The Consolidated criteria for reporting qualitative research (COREQ) checklist was used to guide the reporting. RESULTS Interviews were conducted with 17 primary care doctors. Four overarching themes were inductively identified: knowledge and previous practice patterns influence prescription, balancing risks and benefits, doctors' professional responsibilities, and system barriers. The four themes were then deductively mapped to the nine specific domains of the TDF: knowledge; intention; memory; beliefs about capabilities; beliefs about consequences; goals; role and identity; emotion; and environmental constraints. Most interviewees, to varying extent, were aware of the cardio-renal advantages and safety profile of SGLT2 I but are reluctant to prescribe or change their patients to SGLT2 I because of their knowledge gap that the cardio-renal benefits of SGLT2 I was independent of glyacemic efficacy. Other barriers included their considerations of patients' age and renal impairment, and patients' perceptions and preferences. CONCLUSIONS Despite evidence-based recommendations of the utilisation of SGLT2 I in patients with established ASCVD/CKD, the prescription behaviour among primary care doctors was affected by various factors, most of which were amendable. Our findings will inform the development of structured interventions to address these factors to improve patients' cardio-renal outcomes.
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Affiliation(s)
- Ngai Mui Ng
- grid.417336.40000 0004 1771 3971Department of Family Medicine and Primary Health Care, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, New Territories, Hong Kong SAR, China
| | - Yeung Shing Ng
- grid.417336.40000 0004 1771 3971Department of Family Medicine and Primary Health Care, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, New Territories, Hong Kong SAR, China
| | - Tsun Kit Chu
- grid.417336.40000 0004 1771 3971Department of Family Medicine and Primary Health Care, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, New Territories, Hong Kong SAR, China
| | - Phyllis Lau
- grid.1008.90000 0001 2179 088XDepartment of General Practice, University of Melbourne, 780, Elizabeth Street, Melbourne, VIC 3010 Australia ,grid.1029.a0000 0000 9939 5719School of Medicine, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751 Australia
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Perspectives of primary care providers on multidisciplinary collaboration to prevent medication-related falls. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2022; 6:100149. [PMID: 35755717 PMCID: PMC9218163 DOI: 10.1016/j.rcsop.2022.100149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 04/14/2022] [Accepted: 06/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background The causes of falls are often multifactorial. The prevention of falls benefits from a multidisciplinary approach. As people who fall are generally older and users of polypharmacy who frequently visit pharmacies, pharmacists may contribute to fall prevention. Objective(s) This study aims to explore the perceptions of primary care providers on multidisciplinary collaboration in fall prevention especially with pharmacists. Methods Two focus groups were held with each of the following health disciplines: physiotherapists, home care nurses, and practice nurses. A topic list was developed based on the capability opportunity motivation – behaviour (COM-B) model and the theoretical domains framework (TDF). Focus groups were audiotaped and transcribed verbatim. Data were collected in the Netherlands between March and June 2021. Results Six online focus groups were held with 17 physiotherapists, 14 home care nurses, and 15 practice nurses. Participants reported to collaborate multidisciplinary to prevent falls, but they had very limited collaboration with community pharmacists regarding fall prevention. Participants had limited knowledge on drugs that increase the risk of falls. This contributed to their low awareness of the potential role of pharmacists in fall prevention. Other reasons for poor collaboration in fall prevention were lack of agreements with pharmacists, limited coordination and communication. Participants were open to more collaboration with pharmacists and believed this could potentially improve patient outcomes. Conclusions Multidisciplinary agreements among health care providers, including community pharmacists, about referral criteria, roles and responsibilities, communication and coordination, could stimulate further collaboration in fall prevention. Fall prevention needs to receive more attention from primary care providers. Primary care providers have low awareness of the potential role of pharmacists in fall prevention. Primary care providers are positive about collaborating with community pharmacists to prevent falls. Primary care providers need enhanced communication and coordination, clarification of roles, and agreements. Primary care providers expect community pharmacists to focus on deprescribing of fall risk-increasing drugs (FRIDs).
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7
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Millares Martin P. Reducing medication errors still needs a health informatics solution in clinical practice. HEALTH AND TECHNOLOGY 2022. [DOI: 10.1007/s12553-022-00644-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tangiisuran B, Rajendran V, Sha'aban A, Daud NAA, Nawi SNM. Physicians' perceived barriers and enablers for deprescribing among older patients at public primary care clinics: a qualitative study. Int J Clin Pharm 2021; 44:201-213. [PMID: 34642869 DOI: 10.1007/s11096-021-01336-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 09/28/2021] [Indexed: 10/20/2022]
Abstract
Background Increased harmful effects of medication resulting from polypharmacy, especially among older patients, is a significant concern globally. Hence, continuous medication review and withdrawal of inappropriate medications are essential to improve patient safety. Objective To explore physicians' perceived barriers and enablers of deprescribing among older patients in the public primary healthcare setting. Setting Public primary care clinics in the northern states of Malaysia. Methods A semi-structured, face-to-face interview was conducted among physicians working in eight primary care clinics in northern Malaysia using a purposive sampling approach. Interviews were conducted using validated topic guides. All the responses were recorded, transcribed verbatim, validated, and analysed for the emerging themes using thematic analysis. Main outcome measure Physicians perceived barriers and enablers of deprescribing among geriatric patients. Results A total of eleven physicians were interviewed. Seven emerging themes were identified, which are categorised under barriers and enablers of deprescribing. The barriers were patient-specific, prescriber-specific, and healthcare provision and system. Prescriber deprescribing competencies, medication-specific outcomes, availability of empirical evidence, and pharmacist's role were the enablers identified. Conclusion Patient-specific barriers were identified as a significant challenge for deprescribing. Improving competencies on deprescribing was the repeatedly adduced enabler by physicians. The development of targeted educational training can help to reduce the obstacles faced by prescribers.
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Affiliation(s)
- Balamurugan Tangiisuran
- National Poison Centre, Universiti Sains Malaysia, 11800 USM, Pulau Pinang, Malaysia. .,School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 USM, Pulau Pinang, Malaysia.
| | - Vijitha Rajendran
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 USM, Pulau Pinang, Malaysia
| | - Abubakar Sha'aban
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 USM, Pulau Pinang, Malaysia.,Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Ahmadu Bello University, Zaria, Nigeria
| | - Nur Aizati Athirah Daud
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 USM, Pulau Pinang, Malaysia
| | - Siti Nurbaya Mohd Nawi
- School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
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9
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Høj K, Pedersen HS, Lundberg ASB, Bro F, Nielsen LP, Saedder EA. External validation of the Medication Risk Score in polypharmacy patients in general practice: A tool for prioritizing patients at greatest risk of potential drug-related problems. Basic Clin Pharmacol Toxicol 2021; 129:319-331. [PMID: 34237199 DOI: 10.1111/bcpt.13636] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/14/2021] [Accepted: 07/05/2021] [Indexed: 11/29/2022]
Abstract
Drug-related problems are important causes of patient harm and increased healthcare costs. To assist general practitioners in prioritizing patients in need of a critical medication review, we aimed to assess the ability of the Medication Risk Score (MERIS) to stratify patients with polypharmacy in general practice according to their risk of drug-related problems. We conducted a cross-sectional multi-centre external validation study. Patients receiving more than five concomitant medications (polypharmacy) were eligible. The outcome was potentially serious drug-related problems as evaluated by expert consensus. Performance was assessed in terms of calibration and discrimination indices. Of 497 patients, 489 were included in the main analysis. The median age (interquartile range) was 70.5 years (60-79). In total, 372 potentially serious drug-related problems were observed in 253 patients (52%). The MERIS was well calibrated above a score level of 10. The area under the receiver operating characteristic curve was 0.70 (95% confidence interval: 0.65-0.74). The performance of the MERIS was fair in patients with polypharmacy in general practice. Given the scale of drug-related problems and the lack of efficient prioritization tools in this setting, the MERIS could be a useful risk indicator to complement usual practice.
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Affiliation(s)
- Kirsten Høj
- Research Unit for General Practice, Aarhus, Denmark.,Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Flemming Bro
- Research Unit for General Practice, Aarhus, Denmark.,Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Lars Peter Nielsen
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark.,Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Eva Aggerholm Saedder
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark.,Department of Biomedicine, Aarhus University, Aarhus, Denmark
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10
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Høj K, Mygind A, Bro F. Exploring implementation processes in general practice in a feedback intervention aiming to reduce potentially inappropriate prescribing: a qualitative study among general practitioners. Implement Sci Commun 2021; 2:4. [PMID: 33413692 PMCID: PMC7792001 DOI: 10.1186/s43058-020-00106-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 12/17/2020] [Indexed: 11/23/2022] Open
Abstract
Background Potentially inappropriate prescribing (PIP) has been linked with adverse health outcomes and increased healthcare costs. Feedback interventions targeting PIP have shown promising results. However, translation from research to everyday practice remains a challenge. With the Normalisation Process Theory (NPT) as overarching framework, we aimed to explore the implementation processes performed by general practices in a real-life, quality improvement intervention using feedback on practice-level prescribing. Methods All 376 general practices in the Central Denmark Region received a prescribing feedback intervention targeting selected types of PIP. Six months later, they received an evaluation questionnaire, to which 45% responded. Among 102 practices reporting to have made changes in response to the intervention, we conducted individual, semi-structured interviews with ten GPs. Maximum variation was sought in terms of baseline prescribing status, implementation activities, practice type and geographical location. The interviews were analysed thematically using NPT. Results The implementation processes in general practice reflected the four NPT constructs. Key motivators for implementation included the GPs’ professional values and interests, but pragmatic considerations were also of importance (coherence). A collective versus an individual approach to the engagement and planning of the implementation process (cognitive participation) was observed. Similarly, a distinction was evident between practice-level actions involving the entire practice team as opposed to individual-level actions performed by the individual GP (collective action). Several challenges to the implementation processes were identified, including patient influences and competing priorities at multiple levels (reflexive monitoring). Additionally, internal evaluation and normalisation of new practices occurred in varying degrees. Conclusion NPT provided a useful framework for understanding implementation processes in general practice. Our results emphasise that clear professional aims and feasible content of interventions are key for GP motivation. This may be ensured through cooperation with GPs’ professional organisation, which may strengthen intervention legitimacy and uptake. Two main implementation strategies were identified: practice-level and GP-level strategies. Intervention developers need to recognise both strategies to deliver intervention content and implementation support that promote sustainable improvements in prescribing practice. Competing demands and patient influences remain important challenges that need to be addressed in future studies to further facilitate the reduction of PIPs. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-020-00106-5.
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Affiliation(s)
- Kirsten Høj
- Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - Anna Mygind
- Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - Flemming Bro
- Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus C, Denmark.,Department of Public Health, Aarhus University, Aarhus, Denmark
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11
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Lau S, Lun P, Ang W, Tan KT, Ding YY. Barriers to effective prescribing in older adults: applying the theoretical domains framework in the ambulatory setting - a scoping review. BMC Geriatr 2020; 20:459. [PMID: 33167898 PMCID: PMC7650160 DOI: 10.1186/s12877-020-01766-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 09/10/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND As the population ages, potentially inappropriate prescribing (PIP) in the older adults may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing for older adults in the ambulatory setting. METHODS A scoping review was performed based on the five-stage methodological framework developed by Arksey and O'Malley. From 30 Aug 2018 to 5 Sep 2018, we conducted our search on PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data. RESULTS A total of 5731 articles were screened. Twenty-nine studies met the selection criteria for qualitative analysis. We mapped our results using the 14-domain TDF, eventually identifying 10 domains of interest for barriers to effective prescribing. Of these, significant domains include physician-related factors such as "Knowledge", "Skills", and "Social/Professional Role and Identity"; issues with "Environmental Context and Resources"; and the impact of "Social Influences" and "Emotion" on prescribing behaviour. CONCLUSION The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing for older adults in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Further work is needed to explore individual domains and guide development of frameworks to aid guide prescribing for older adults in the ambulatory setting.
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Affiliation(s)
- Sabrina Lau
- Department of Geriatric Medicine, Tan Tock Seng Hospital, TTSH Annex 2, Level 3, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| | - Penny Lun
- Geriatric Education & Research Institute, Singapore, Singapore
| | - Wendy Ang
- Pharmacy, Changi General Hospital, Singapore, Singapore
| | - Keng Teng Tan
- Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yew Yoong Ding
- Department of Geriatric Medicine, Tan Tock Seng Hospital, TTSH Annex 2, Level 3, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
- Geriatric Education & Research Institute, Singapore, Singapore
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12
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Carland JE, Elhage T, Baysari MT, Stocker SL, Marriott DJE, Taylor N, Day RO. Would they trust it? An exploration of psychosocial and environmental factors affecting prescriber acceptance of computerised dose-recommendation software. Br J Clin Pharmacol 2020; 87:1215-1233. [PMID: 32691902 DOI: 10.1111/bcp.14496] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/14/2020] [Accepted: 07/09/2020] [Indexed: 02/06/2023] Open
Abstract
AIMS Dose-prediction software can optimise vancomycin therapy, improving therapeutic drug monitoring processes and reducing drug toxicity. Success of software in hospitals may be dependent on prescriber uptake of software recommendations. This study aimed to identify the perceived psychosocial and environmental barriers and facilitators to prescriber acceptance of dose-prediction software. METHODS Semi-structured interviews, incorporating prescribing scenarios, were undertaken with 17 prescribers. Participants were asked to prescribe the next maintenance dose of vancomycin for a scenario(s) and then asked if they would accept a recommendation provided by a dose-prediction software. Interviews further explored opinions of dose-prediction software. Interview transcripts were analysed using an inductive approach to identify themes and the Theoretical Domains Framework was used to synthesise barriers and facilitators to software acceptance. RESULTS When presented with software recommendations, half of the participants were comfortable with accepting the recommendation. Key barriers to acceptance of software recommendations aligned with 2 Theoretical Domains Framework domains: Knowledge (uncertainty of software capability) and Beliefs about Consequences (perceived impact of software on clinical outcomes and workload). Key facilitators aligned with 2 domains: Beliefs about Consequences (improved efficiency) and Social Influences (influence of peers). A novel domain, Trust, was identified as influential. CONCLUSION Prescribers reported barriers to acceptance of dose-prediction software aligned with limited understanding of, and scepticism about, software capabilities, as well as concerns about clinical outcomes. Identification of key barriers and facilitators to acceptance provides essential information to design of implementation strategies to support the introduction of this intervention into the workplace.
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Affiliation(s)
- Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia
| | - Tania Elhage
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,School of Medical Sciences, University of NSW, Kensington, NSW, Australia
| | - Melissa T Baysari
- Sydney School of Health Sciences, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia
| | - Deborah J E Marriott
- St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia.,Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Natalie Taylor
- Sydney School of Health Sciences, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, NSW, Australia.,Cancer Council NSW, Woolloomooloo, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia.,School of Medical Sciences, University of NSW, Kensington, NSW, Australia
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13
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Association of a Novel Medication Risk Score with Adverse Drug Events and Other Pertinent Outcomes Among Participants of the Programs of All-Inclusive Care for the Elderly. PHARMACY 2020; 8:pharmacy8020087. [PMID: 32443719 PMCID: PMC7356194 DOI: 10.3390/pharmacy8020087] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/08/2020] [Accepted: 05/15/2020] [Indexed: 12/20/2022] Open
Abstract
Preventable adverse drug events (ADEs) represent a significant public health challenge for the older adult population, since they are associated with higher medical expenditures and more hospitalizations and emergency department (ED) visits. This study examines whether a novel medication risk prediction tool, the MedWise Risk Score™ (MRS), is associated with ADEs and other pertinent outcomes in participants of the Programs of All-Inclusive Care for the Elderly (PACE). Unlike other risk predictors, this tool produces actionable information that pharmacists can easily use to reduce ADE risk. This was a retrospective cross-sectional study that analyzed administrative medical claims data of 1965 PACE participants in 2018. To detect ADEs, we identified all claims that had ADE-related International Classification of Diseases and Health Related Problems, 10th revision (ICD-10) codes. Using logistic and linear regression models, we examined the association between the MRS and a variety of outcomes, including the number of PACE participants with an ADE, total medical expenditures, ED visits, hospitalizations, and hospital length of stay. We found significant associations for every outcome. Specifically, every point increase in the MRS corresponded to an 8.6% increase in the odds of having one or more ADEs per year (OR = 1.086, 95% CI: 1.060, 1.113), $1037 USD in additional annual medical spending (adjusted R2 of 0.739; p < 0.001), 3.2 additional ED visits per 100 participants per year (adjusted R2 of 0.568; p < 0.001), and 2.1 additional hospitalizations per 100 participants per year (adjusted R2 of 0.804; p < 0.001). Therefore, the MRS can risk stratify PACE participants and predict a host of important and relevant outcomes pertaining to medication-related morbidity.
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14
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Tadrous M, Fung K, Desveaux L, Gomes T, Taljaard M, Grimshaw JM, Bell CM, Ivers NM. Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotic Medication in Nursing Homes: A Cluster Randomized Clinical Trial. JAMA Netw Open 2020; 3:e205724. [PMID: 32453383 PMCID: PMC7251442 DOI: 10.1001/jamanetworkopen.2020.5724] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/17/2020] [Indexed: 01/22/2023] Open
Abstract
Importance Strategies to reduce the inappropriate prescription of antipsychotics have been the focus of recent attention but have shown considerable variation in their effectiveness. Objective To evaluate the effectiveness of academic detailing in nursing homes targeting appropriate prescribing of antipsychotics. Design, Setting, and Participants We conducted a pragmatic, cluster randomized clinical trial comparing the effect of academic detailing vs usual care on prescribing antipsychotics in 40 nursing homes with 5363 residents in Ontario, Canada. Data were collected from October 2015 to March 2016 and analyzed from April to August 2018. Primary analyses were conducted using intention to treat. Intervention Academic detailing delivered by health professionals (eg, nurses or pharmacists) who arranged meetings (with administrators, physicians, pharmacists, nurses, and support workers), presentations, group visits (with 2-6 clinicians), and 1-on-1 visits (traditional academic detailing visits). Academic detailers had direct and ongoing contact with the nursing homes from the time of launch. Main Outcomes and Measures The primary outcome, defined at the level of the resident, was whether continuous antipsychotics were dispensed in the past week. Secondary outcomes included prescribing of other psychotropic medications and clinical outcomes and scores. Prescribing outcomes were assessed at baseline and at 3, 6, and 12 months, and clinical outcomes and scores were assessed at baseline and 3 and 6 months. Results A total of 40 nursing homes with 5363 residents were randomized, with 18 intervention homes (45.0%; 2303 [42.9%] residents) and 22 control homes (55.0%; 3060 [57.1%] residents). Participants in the intervention and control groups had similar median (interquartile range) age (86 [79-91] years vs 85 [78-90] years) and sex (674 [29.3%] men vs 970 [31.7%] men). At 12 months, there was no statistically significant difference in the frequency of daily antipsychotic use (intervention: 569 patients [25.2%]; control: 769 [25.6%]; odds ratio, 1.06; 95% CI, 0.93-1.20; P = .49). There were no significant differences in the rates of health care utilization, but the intervention group did experience a statistically significant reduction in pain compared with the control group (mean [SD] pain score, 0.30 [0.59] vs 0.38 [0.66]; P < .001) and depression (mean [SD] Depression Rating Scale score, 2.18 [2.37] vs 2.81 [2.65]; P < .001) at 6 months. Conclusions and Relevance The intervention did not further reduce antipsychotic prescribing in nursing homes beyond system-level secular trends occurring alongside usual care. Our findings highlight the need for a more targeted approach to quality improvement strategies, including academic detailing, that account for the timing and topic of interventions. Trial Registration ClinicalTrials.gov Identifier: NCT02604056.
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Affiliation(s)
- Mina Tadrous
- ICES, Toronto, Ontario, Canada
- Women’s College Research Institute, Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | | | - Laura Desveaux
- Women’s College Research Institute, Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
- University of Ottawa School of Epidemiology, Public Health and Preventive Medicine, Ottawa, Ontario, Canada
| | - Jeremy M. Grimshaw
- University of Ottawa School of Epidemiology, Public Health and Preventive Medicine, Ottawa, Ontario, Canada
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Chaim M. Bell
- Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Noah M. Ivers
- ICES, Toronto, Ontario, Canada
- Women’s College Research Institute, Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Unviersity of Toronto, Toronto, Ontario, Canada
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15
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Bankes DL, Schamp RO, Knowlton CH, Bain KT. Prescriber-Initiated Engagement of Pharmacists for Information and Intervention in Programs of All-Inclusive Care for the Elderly. PHARMACY 2020; 8:pharmacy8010024. [PMID: 32098064 PMCID: PMC7151697 DOI: 10.3390/pharmacy8010024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/13/2020] [Accepted: 02/18/2020] [Indexed: 02/08/2023] Open
Abstract
Little is known about the types of drug information inquiries (DIIs) prescribers caring for older adults ask pharmacists during routine practice. The objective of this research was to analyze the types of DIIs prescribing clinicians of Programs of All-Inclusive Care for the Elderly (PACE) made to clinical pharmacists during routine patient care. This was a retrospective analysis of documented pharmacists' encounters with PACE prescribers between March through December, 2018. DIIs were classified using a developed taxonomy that describes prescribers' motivations for consulting with pharmacists and their drug information needs. Prescribers made 414 DIIs during the study period. Medication safety concerns motivated the majority of prescribers' inquiries (223, 53.9%). Inquiries received frequently involved modifying drug therapy (94, 22.7%), identifying or resolving adverse drug events (75, 18.1%), selecting or adjusting doses (61, 14.7%), selecting new drug therapies (57, 13.8%), and identifying or resolving drug interactions (52, 12.6%). Central nervous system medications (e.g., antidepressants and opioids), were involved in 38.6% (n = 160) of all DIIs. When answering DIIs, pharmacists made 389 recommendations. Start alternative medications (18.0%), start new medications (16.7%), and change doses (12.1%) were the most frequent recommendations rendered. Prescribers implemented at least 79.3% (n = 268) of recommendations based on pharmacy records (n = 338 verifiable recommendations). During clinical practice, PACE prescribers commonly ask pharmacists a variety of DIIs, largely related to medication safety concerns. In response to these DIIs, pharmacists provide medication management recommendations, which are largely implemented by prescribers.
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16
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Barry HE, Bedford LE, McGrattan M, Ryan C, Passmore AP, Robinson AL, Molloy GJ, Darcy CM, Buchanan H, Hughes CM. Improving medicines management for people with dementia in primary care: a qualitative study of healthcare professionals to develop a theory-informed intervention. BMC Health Serv Res 2020; 20:120. [PMID: 32059718 PMCID: PMC7023803 DOI: 10.1186/s12913-020-4971-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 02/11/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND People with dementia (PwD) face unique challenges with medicines management, yet little is known about these challenges from the perspectives of primary healthcare professionals, particularly general practitioners (GPs) and community pharmacists. Few medicines management interventions have been developed which are aimed at community-dwelling PwD. This study sought to develop an intervention to improve medicines management for PwD in primary care using a theory-informed approach. METHODS Semi-structured interviews were conducted with GPs (n = 15) and community pharmacists (n = 15) to explore participants' views and experiences of medicines management for PwD, and their perceptions of barriers and facilitators to successful medicines management for PwD. The 14-domain Theoretical Domains Framework was the underpinning theoretical guide, allowing key theoretical domains to be identified and mapped to behaviour change techniques (BCTs) which are considered the 'active ingredients' of an intervention. Draft interventions were developed to operationalise selected BCTs and were presented to GPs and community pharmacists during task groups. Final selection of an intervention for feasibility testing was guided by feedback provided during these task groups and through application of the APEASE (Affordability, Practicability, Effectiveness/cost-effectiveness, Acceptability, Side-effects/safety, Equity) criteria. RESULTS Participants expressed a number of concerns about medicines management for PwD, particularly monitoring adherence to medication regimens and conducting medication review. Two draft interventions comprising selected BCTs ('Modelling or demonstration of behaviour'; 'Salience of consequences'; 'Health consequences'; 'Social and environmental consequences'; 'Action planning'; Social support or encouragement', 'Self-monitoring of behaviour') were developed, each targeting GPs and community pharmacists. Following the task groups and discussions within the research team, the community pharmacy-based intervention was selected for future feasibility testing. The intervention will target community pharmacists to conduct a medication review (incorporating an adherence check) with a PwD, delivered as an online video demonstrating key behaviours. The video will include feedback emphasising positive outcomes of performing the behaviours. Action planning and a quick reference guide will be used as complementary intervention components. CONCLUSIONS A community pharmacist-based intervention has been developed targeting medicines management for PwD in primary care using a systematic, theory-informed approach. Future work will determine the usability and acceptability of implementing this intervention in clinical practice.
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Affiliation(s)
- Heather E Barry
- School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Laura E Bedford
- School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Máiréad McGrattan
- School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Cristín Ryan
- The School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - A Peter Passmore
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK.,Belfast Health & Social Care Trust, Belfast City Hospital, Belfast, Northern Ireland, UK
| | - A Louise Robinson
- Institute for Ageing and Institute for Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Gerard J Molloy
- School of Psychology, National University of Ireland, Galway, Ireland
| | | | | | - Carmel M Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK.
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17
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Courtenay M, Rowbotham S, Lim R, Peters S, Yates K, Chater A. Examining influences on antibiotic prescribing by nurse and pharmacist prescribers: a qualitative study using the Theoretical Domains Framework and COM-B. BMJ Open 2019; 9:e029177. [PMID: 31221892 PMCID: PMC6588983 DOI: 10.1136/bmjopen-2019-029177] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Respiratory tract infections are frequently managed by nurse and pharmacist prescribers, and these prescribers are responsible for 8% of all primary care antibiotic prescriptions. Few studies have explored antibiotic prescribing among these prescribers, and interventions to target their antibiotic prescribing behaviour do not exist. Research objectives were to: (1) use the Theoretical Domains Framework to identify the factors that influence nurse and pharmacist prescriber management of respiratory tract infections and (2) identify the behaviour change techniques (BCTs) that can be used as the basis for the development of a theoretically informed intervention to support appropriate prescribing behaviour. DESIGN Qualitative design comprising semistructured interviews, using the Theoretical Domains Framework and Capability, Opportunity and Motivation for Behaviour. SETTING Primary care. PARTICIPANTS Twenty one prescribers (4 pharmacists and 17 nurses). RESULTS A range of factors across 12 domains of the TDF were found to influence prescriber behaviour, and 40 BCTs were identified as supporting appropriate prescribing. For example, patient expectations (social influence) was identified as a factor influencing prescribing decisions, and a number of BCTs (problem solving, goal setting and information about health consequences) were identified as supporting prescribers in managing these expectations. CONCLUSION With increasing numbers of nurse and pharmacist prescribers managing infections in primary care, these findings will inform theoretically grounded interventions to support appropriate prescribing behaviour by these groups.
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Affiliation(s)
| | - Samantha Rowbotham
- Menzies Centre for Health Policy, University of Sydney, Sydney, New South Wales, Australia
| | - Rosemary Lim
- School of Pharmacy, Reading University, Reading, UK
| | - Sarah Peters
- Health Sciences, University of Manchester, Manchester, UK
| | - Kathryn Yates
- Londonwide LMC, Londonwode LMCs and Londonwide Enterprise Ltd, London, UK, UK
| | - Angel Chater
- Department of Sport Science and Physical, University of Bedfordshire, Luton, UK
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18
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Meid AD, Groll A, Heider D, Mächler S, Adler JB, Günster C, König HH, Haefeli WE. Prediction of Drug-Related Risks Using Clinical Context Information in Longitudinal Claims Data. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:1390-1398. [PMID: 30502782 DOI: 10.1016/j.jval.2018.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 04/12/2018] [Accepted: 05/15/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To develop and internally validate prediction models for medication-related risks arising from overuse, misuse, and underuse that utilize clinical context information and are suitable for routine risk assessment in claims data (i.e., medication-based models predicting the risk for hospital admission apparent in routine claims data or MEDI-RADAR). METHODS Based on nationwide claims from health-insured persons in Germany between 2010 and 2012, we drew a random sample of people aged ≥65 years (N = 22,500 randomly allocated to training set, N = 7500 to validation set). Individual duration of drug supply was estimated from prescription patterns to yield time-varying drug exposure windows. Together with concurrent medical conditions (ICD-10 diagnoses), exposure to the STOPP/START (screening tool of older persons' potentially inappropriate prescriptions/screening tool to alert doctors to the right treatment) criteria was derived. These were tested as time-dependent covariates together with time-constant covariates (patient demographics, baseline comorbidities) in regularized Cox regression models. RESULTS STOPP/START variables were iteratively refined and selected by regularization to include 2 up to 11 START variables and 8 up to 31 STOPP variables in parsimonious and liberal selections in the prediction modeling. The models discriminated well between patients with and without all-cause hospitalizations, potentially drug-induced hospitalizations, and mortality (parsimonious model c-indices with 95% confidence intervals: 0.63 [0.62-0.64], 0.67 [0.65-0.68], and 0.78 [0.76-0.80]). CONCLUSIONS The STOPP/START criteria proved to efficiently predict medication-related risk in models possessing good performance. Timely detection of such risks by routine monitoring in claims data can support tailored interventions targeting these modifiable risk factors. Their impact on older peoples' medication safety and effectiveness can now be explored in future implementation studies.
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Affiliation(s)
- Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Andreas Groll
- Department of Statistics and Econometrics, University of Göttingen, Göttingen, Germany
| | - Dirk Heider
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Mächler
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | | | | | - Hans-Helmut König
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany.
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19
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Walsh KA, Sinnott C, Fleming A, Mc Sharry J, Byrne S, Browne J, Timmons S. Exploring Antipsychotic Prescribing Behaviors for Nursing Home Residents With Dementia: A Qualitative Study. J Am Med Dir Assoc 2018; 19:948-958.e12. [PMID: 30241987 DOI: 10.1016/j.jamda.2018.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/03/2018] [Accepted: 07/07/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Caution is advised when prescribing antipsychotics to people with dementia. This study explored the determinants of appropriate, evidence-based antipsychotic prescribing behaviors for nursing home residents with dementia, with a view to informing future quality improvement efforts and behavior change interventions. DESIGN Semistructured qualitative interviews based on the Theoretical Domains Framework (TDF). SETTING AND PARTICIPANTS A purposive sample of 27 participants from 4 nursing homes, involved in the care of nursing home residents with dementia (8 nurses, 5 general practitioners, 5 healthcare assistants, 3 family members, 2 pharmacists, 2 consultant geriatricians, and 2 consultant psychiatrists of old age) in a Southern region of Ireland. MEASURES Using framework analysis, the predominant TDF domains and determinants influencing these behaviors were identified, and explanatory themes developed. RESULTS Nine predominant TDF domains were identified as influencing appropriate antipsychotic prescribing behaviors. Participants' effort to achieve "a fine balance" between the risks and benefits of antipsychotics was identified as the cross-cutting theme that underpinned many of the behavioral determinants. On one hand, neither healthcare workers nor family members wanted to see residents over-sedated and without a quality of life. Conversely, the reality of needing to protect staff, family members, and residents from potentially dangerous behavioral symptoms, in a resource-poor environment, was emphasized. The implementation of best-practice guidelines was illustrated through 3 explanatory themes ("human suffering"; "the interface between resident and nursing home"; and "power and knowledge: complex stakeholder dynamics"), which conceptualize how different nursing homes strike this "fine balance." CONCLUSIONS Implementing evidence-based antipsychotic prescribing practices for nursing home residents with dementia remains a significant challenge. Greater policy and institutional support is required to help stakeholders strike that "fine balance" and ultimately make better prescribing decisions. This study has generated a deeper understanding of this complex issue and will inform the development of an evidence-based intervention.
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Affiliation(s)
- Kieran A Walsh
- Center for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland; Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland; School of Public Health, University College Cork, Cork, Ireland.
| | - Carol Sinnott
- The Healthcare Improvement Studies (THIS) Institute, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Aoife Fleming
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland; Pharmacy Department, Mercy University Hospital, Cork, Ireland
| | - Jenny Mc Sharry
- Health Behavior Change Research Group, School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Stephen Byrne
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
| | - Suzanne Timmons
- Center for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
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20
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Bohlken J, Jacob L, van den Bussche H, Kostev K. The Influence of Polypharmacy on the Initiation of Anti-Dementia Therapy in Germany. J Alzheimers Dis 2018; 64:827-833. [PMID: 29889071 DOI: 10.3233/jad-180382] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Jens Bohlken
- Praxis für Neurologie und Psychiatrie, Berlin, Germany
| | - Louis Jacob
- Faculty of Medicine, University of Paris 5, Paris, France
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21
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Schjøtt J. Physicians' questions concerning drug use among older patients: experience from Norwegian drug information centres (RELIS) in the period 2010-2015. Aging Clin Exp Res 2018; 30:867-870. [PMID: 28929445 DOI: 10.1007/s40520-017-0832-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 09/05/2017] [Indexed: 02/04/2023]
Abstract
Questions from physicians to regional medicines information and pharmacovigilance centres in Norway (RELIS) concerning older patients were described. Question-answer pairs (QAPs) from the RELIS database indexed with the category "older", and concerning individual patients from the period 01 Jan 2010 to 31 Dec 2015, were analysed. Two-hundred and eight QAPs categorized with "older" were retrieved from a total of 16 710 in the study period, and 122 of 208 QAPs fulfilled the inclusion criteria. The most common categories of drugs in question (n = 228) according to the ATC system were N: Nervous system (30.3%) and C: Cardiovascular system (23.7%). Questions from physicians (n = 122) were most frequently about adverse effects (41.8%) and treatment (39.3%). The majority of questions to RELIS concerning older patients came from general practice (GP). The results suggest drug information efforts to GPs in care of older patients with regard to psychopharmacology and cardiovascular pharmacology.
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Affiliation(s)
- Jan Schjøtt
- Section of Clinical Pharmacology, Laboratory of Clinical Biochemistry, Haukeland University Hospital, 5021, Bergen, Norway.
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway.
- Regional Medicines Information and Pharmacovigilance Centre (RELIS Vest), Haukeland University Hospital, Bergen, Norway.
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22
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Gillespie RJ, Harrison L, Mullan J. Deprescribing medications for older adults in the primary care context: A mixed studies review. Health Sci Rep 2018; 1:e45. [PMID: 30623083 PMCID: PMC6266366 DOI: 10.1002/hsr2.45] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/27/2018] [Accepted: 04/03/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS This review investigates the factors that influence deprescribing of medications in primary care from the perspective of general practitioners (GPs) and community-living older adults. METHODS A mixed studies review structure was adopted searching Scopus, CINAHL, PsychINFO, ProQuest, and PubMed from January 2000 to December 2017. A manual search of reference lists was also conducted. Studies were included if they were original research available in English and explored general deprescribing rather than deprescribing of a specific class of medications. The Mixed Methods Assessment Tool was used to assess the quality of studies, and content analysis generated common categories across studies. RESULTS Thirty-eight articles were included, and 7 key categories were identified. The review found that the factors that influence deprescribing are similar across and within health systems and mostly act as barriers. These factors remained unchanged across the review period. The structural organisation of health systems remains poorly suited to facilitate deprescribing. Individual knowledge gaps of both GPs and older adults influence practices and attitudes towards deprescribing, and significant communication gaps occur between GPs and specialists and between GPs and older adults. As a result, deprescribing decision making is characterised by uncertainty, and deprescribing is often considered only when medication problems have already arisen. Trust plays a complex role, acting as both a barrier and facilitator of deprescribing. CONCLUSIONS Deprescribing is influenced by many factors. Despite recent interest, little change has occurred. Multilevel strategies aimed at reforming aspects of the health system and managing uncertainty at the practice and individual level, notably reducing knowledge limitations and closing communications gaps, may achieve change.
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Affiliation(s)
- Robyn J. Gillespie
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongAustralia
| | - Lindsey Harrison
- School of Health and Society, Faculty of Social SciencesUniversity of WollongongWollongongAustralia
| | - Judy Mullan
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongAustralia
- Centre for Health Research Illawarra Shoalhaven Population (CHRISP), Australian Health Services Research InstituteUniversity of WollongongNSW2522Australia
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23
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Muth C, Uhlmann L, Haefeli WE, Rochon J, van den Akker M, Perera R, Güthlin C, Beyer M, Oswald F, Valderas JM, Knottnerus JA, Gerlach FM, Harder S. Effectiveness of a complex intervention on Prioritising Multimedication in Multimorbidity (PRIMUM) in primary care: results of a pragmatic cluster randomised controlled trial. BMJ Open 2018; 8:e017740. [PMID: 29478012 PMCID: PMC5855483 DOI: 10.1136/bmjopen-2017-017740] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Investigate the effectiveness of a complex intervention aimed at improving the appropriateness of medication in older patients with multimorbidity in general practice. DESIGN Pragmatic, cluster randomised controlled trial with general practice as unit of randomisation. SETTING 72 general practices in Hesse, Germany. PARTICIPANTS 505 randomly sampled, cognitively intact patients (≥60 years, ≥3 chronic conditions under pharmacological treatment, ≥5 long-term drug prescriptions with systemic effects); 465 patients and 71 practices completed the study. INTERVENTIONS Intervention group (IG): The healthcare assistant conducted a checklist-based interview with patients on medication-related problems and reconciled their medications. Assisted by a computerised decision support system, the general practitioner optimised medication, discussed it with patients and adjusted it accordingly. The control group (CG) continued with usual care. OUTCOME MEASURES The primary outcome was a modified Medication Appropriateness Index (MAI, excluding item 10 on cost-effectiveness), assessed in blinded medication reviews and calculated as the difference between baseline and after 6 months; secondary outcomes after 6 and 9 months' follow-up: quality of life, functioning, medication adherence, and so on. RESULTS At baseline, a high proportion of patients had appropriate to mildly inappropriate prescriptions (MAI 0-5 points: n=350 patients). Randomisation revealed balanced groups (IG: 36 practices/252 patients; CG: 36/253). Intervention had no significant effect on primary outcome: mean MAI sum scores decreased by 0.3 points in IG and 0.8 points in CG, resulting in a non-significant adjusted mean difference of 0.7 (95% CI -0.2 to 1.6) points in favour of CG. Secondary outcomes showed non-significant changes (quality of life slightly improved in IG but continued to decline in CG) or remained stable (functioning, medication adherence). CONCLUSIONS The intervention had no significant effects. Many patients already received appropriate prescriptions and enjoyed good quality of life and functional status. We can therefore conclude that in our study, there was not enough scope for improvement. TRIAL REGISTRATION NUMBER ISRCTN99526053. NCT01171339; Results.
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Affiliation(s)
- Christiane Muth
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Justine Rochon
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Marjan van den Akker
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, The Netherlands
- Department of Public Health and Primary Care, Academic Center for General Practice, KU Leuven, Leuven, Belgium
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Corina Güthlin
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Martin Beyer
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Frank Oswald
- Interdisciplinary Ageing Research (IAW), Faculty of Educational Sciences, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Jose Maria Valderas
- APEx Collaboration for Academic Primary Care, University of Exeter Medical School, Exeter, UK
| | - J André Knottnerus
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Ferdinand M Gerlach
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Sebastian Harder
- Institute for Clinical Pharmacology, Johann Wolfgang Goethe University Hospital, Frankfurt / Main, Germany
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Stephan AJ, Kovacs E, Phillips A, Schelling J, Ulrich SM, Grill E. Barriers and facilitators for the management of vertigo: a qualitative study with primary care providers. Implement Sci 2018; 13:25. [PMID: 29422076 PMCID: PMC5806383 DOI: 10.1186/s13012-018-0716-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 01/25/2018] [Indexed: 11/23/2022] Open
Abstract
Background Although the management of patients presenting with vertigo and dizziness in primary care has been reported to be inefficient, little is known about the primary care providers’ (PCPs) perspectives, needs, and attitudes regarding vertigo management. The objective of this study was to understand which challenges and barriers PCPs see when diagnosing and treating patients presenting with vertigo or dizziness. Specifically, we wanted to identify facilitators and barriers of successful guideline implementation in order to inform the development of targeted interventions. Methods A theory-based interview structure was developed based on the implementation theory of capability, opportunity, and motivation for behaviour change (COM-B) using questions based on constructs from the Theoretical Domains Framework (TDF) and the Consolidated Framework for Implementation Research (CFIR). Transcripts of the semi-structured interviews were analysed using directed content analysis. The pathways through which guideline characteristics and supportive interventions affect the relationship between the PCPs’ perceived capability, opportunity, and motivation as well as their practice of managing vertigo patients were graphically presented using the COM-B model structure. Results Twelve PCPs from Bavaria in Southern Germany participated in semi-structured interviews. Diagnostics posed the biggest challenge in vertigo management to the PCPs. Requirements for an acceptable guideline were stakeholder involvement in the development process, clarity of presentation, and high applicability. Guideline implementation might be effectively supported through educational meetings and sustained by organisational interventions. Conclusions From the PCPs’ perspective, both guideline characteristics and interventions supporting guideline implementation may help resolve challenges in vertigo management in primary care. These results should be used to guide future interventions in the primary care setting to ensure successful and targeted patient management. Electronic supplementary material The online version of this article (10.1186/s13012-018-0716-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna-Janina Stephan
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistraße 17, 81377, Munich, Germany.
| | - Eva Kovacs
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistraße 17, 81377, Munich, Germany.,German Centre for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Amanda Phillips
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistraße 17, 81377, Munich, Germany.,German Centre for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Jörg Schelling
- Institute for General Practice and Family Medicine, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Susanne Marlene Ulrich
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistraße 17, 81377, Munich, Germany
| | - Eva Grill
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistraße 17, 81377, Munich, Germany.,German Centre for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.,Munich Centre of Health Sciences, Ludwig-Maximilians-Universität München, Munich, Germany
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25
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Riordan DO, Byrne S, Fleming A, Kearney PM, Galvin R, Sinnott C. GPs' perspectives on prescribing for older people in primary care: a qualitative study. Br J Clin Pharmacol 2017; 83:1521-1531. [PMID: 28071806 PMCID: PMC5465342 DOI: 10.1111/bcp.13233] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 12/22/2016] [Accepted: 01/08/2017] [Indexed: 11/30/2022] Open
Abstract
AIMS The aim of this study was firstly to reveal the determinants of GP prescribing behaviour for older adults in primary care and secondly to elicit GPs' views on the potential role for broad intervention strategies involving pharmacists and/or information technology systems in general practice. METHODS Semi-structured qualitative interviews were carried out with a purposive sample of GPs. Three multidisciplinary researchers independently coded the interview data using a framework approach. Emerging themes were mapped to the Theoretical Domains Framework (TDF), a tool used to apply behaviour change theories. RESULTS Sixteen GPs participated in the study. The following domains in the TDF were identified as being important determinants of GP prescribing behaviour: 'Knowledge', 'Skills', 'Reinforcement', 'Memory Attention and Decision Process', 'Environmental Context and Resources', 'Social Influences', 'Social/Professional Role and Identity'. Participants reported that the challenges associated with prescribing for an increasingly older population will require them to become more knowledgeable in pharmacology and drug interactions and they called for extra training in these topics. GPs viewed strategies such as academic detailing sessions delivered by pharmacists or information technology systems as having a positive role to play in optimizing prescribing. CONCLUSION This study highlights the complexities of behavioural determinants of prescribing for older people in primary care and the need for additional supports to optimize prescribing for this growing cohort of patients. Interventions that incorporate, but are not limited to interprofessional collaboration with pharmacists and information technology systems, were identified by GPs as being potentially useful for improving prescribing behaviour, and therefore require further exploration.
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Affiliation(s)
- David O. Riordan
- Pharmaceutical Care Research Group, School of PharmacyUniversity College CorkCorkRepublic of Ireland
| | - Stephen Byrne
- Pharmaceutical Care Research Group, School of PharmacyUniversity College CorkCorkRepublic of Ireland
| | - Aoife Fleming
- Pharmaceutical Care Research Group, School of PharmacyUniversity College CorkCorkRepublic of Ireland
| | - Patricia M. Kearney
- Department of Epidemiology & Public HealthUniversity College CorkCorkRepublic of Ireland
| | - Rose Galvin
- Department of Clinical Therapies, Health Research InstituteUniversity of LimerickLimerickRepublic of Ireland
| | - Carol Sinnott
- Department of General PracticeUniversity College CorkCorkRepublic of Ireland
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