Evaluating sustained quality improvements: long-term effectiveness of a physician-focused intervention to reduce potentially inappropriate medication prescribing in an older population

Effectiveness of Interventions to Reduce Potentially Inappropriate Medication in Older Patients: A Systematic Review

Background: Age-related multiple comorbidities cause older adults to be prone to the use of potentially inappropriate medicines (PIM) resulting in an increased risk of adverse events. Several strategies have emerged to support PIM prescription, and a huge number of interventions to reduce PIM have been proposed. This work aims to analyze the effectiveness of PIM interventions directed to older adults.

Methods: A systematic review was performed searching the literature in the MEDLINE PubMed, EMBASE, and Cochrane scientific databases for interventional studies that assessed the PIM interventions in older adults (≥65 years).

Results: Forty-seven articles were included, involving 52 to 124,802 patients. Various types of interventions were analyzed such as medication review, educational strategies, clinical decision support system, and organizational and multifaceted approaches. In the hospital, the most successful intervention was medication review (75.0%), while in primary care, the analysis of all included studies revealed that educational strategies were the most effective. However, the analysis of interventions that have greater evidence by its design was inconclusive.

Conclusion: The results obtained in this work suggested that PIM-setting-directed interventions should be developed to promote the wellbeing of the patients through PIM reduction. Although the data obtained suggested that medication review was the most assertive strategy to decrease the number of PIM in the hospital setting, more studies are necessary.

Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021233484], identifier [PROSPERO 2021 CRD42021233484].

Using the behavior change wheel to link published deprescribing strategies to identified local primary healthcare needs

BACKGROUND

Polypharmacy is a major global problem. Evidence in primary care shows deprescribing can be beneficial. Behaviour change theories such as the Theoretical Domains Framework (TDF) and the Behaviour Change Wheel (BCW) can help develop successful implementation of deprescribing initiatives.

OBJECTIVES

To link locally identified deprescribing influencers with components of successfully trialed deprescribing strategies, with the aim of informing the development of local deprescribing initiatives.

METHODS

Two background studies were completed. A qualitative study of interviews and focus groups identified influencers of deprescribing from local primary care physicians, nurse practitioners, and pharmacists. Transcripts were coded using the TDF and mapped to the Intervention Functions of the BCW. A scoping review identified studies that investigated primary care deprescribing strategies, which were mapped to the BCW Intervention Functions and the Behaviour Change Techniques (BCTs). For this analysis, six main TDF domains from the qualitative study were linked to the BCTs identified in the scoping review through the Intervention Functions of the BCW.

RESULTS

Within the BCW component Capability, one TDF domain identified in the qualitative study, Memory, Attention and Decision Process, was linked to strategies like academic detailing from the scoping review. For the Opportunity component, two TDF domains, Social Influences and Environmental Context and Resources, were linked to strategies such as pharmacist medication reviews, providing patient information leaflets, and evidence-based deprescribing tools. For the Motivation component, three TDF domains, Social/Professional Role and Identity, Intentions, and Beliefs about Consequences, were linked to strategies such as sending deprescribing information to prescribers, using tools to identify eligible patients, and having patients report adverse events of medications.

CONCLUSIONS

This analysis identified deprescribing strategies that can be used to address influencers related to behaviour change from the perspective of primary care providers, and to assist with future deprescribing initiative development and implementation in the local context.

Process evaluation of implementation strategies to reduce potentially inappropriate medication prescribing in older population: A scoping review

OBJECTIVES

Several implementation strategies can reduce potentially inappropriate medication (PIM) prescribing. Although use of PIMs has declined in recent years, it remains prevalent. Various strategies exist to improve the appropriateness of medication use. However, little is known about the processes of these different implementation strategies. This scoping review aims to investigate how the process evaluation of implementation strategies for reducing PIM prescribing in the older population has been studied.

METHODS

We searched for process evaluations of implementation strategies for reducing PIM prescribing in PUBMED, SCOPUS and Web of Science published between January 2000 and November 2019 in English. We applied the following inclusion criteria: patients aged ≥65 years, validated PIM criteria, and implementation process evaluated. The review focuses on decision support for health care professionals. We described the findings of the process evaluations, and compared the authors' concepts of process evaluation of the included publications to those of Proctor et al.( 2010).

RESULT

Of 9131 publications screened, 29 met our inclusion criteria. Different process evaluation conceptualizations were identified. Most process evaluations took place in the initial stages of the process (acceptability, adoption, appropriateness, and feasibility) and sustainability and implementation costs were seldom evaluated. None of the included publications evaluated fidelity. Multifaceted interventions were the most studied implementation strategies. Medication review was more common in acceptability evaluations, multidisciplinary interventions in adoption evaluations, and computerized systems and educational interventions in feasibility evaluations. Process evaluations were studied from the health care professionals' viewpoint in most of the included publications, but the management viewpoint was missing.

DISCUSSION

The conceptualization of process evaluation in the field of PIM prescribing is indeterminate. There is also a current gap in the knowledge of sustainability and implementation costs. Clarifying the conceptualization of implementation process evaluation is essential in order to effectively translate research knowledge into practice.

Reduction in unplanned hospitalizations associated with a physician focused intervention to reduce potentially inappropriate medication use among older adults: a population-based cohort study

Background

A multimodal general practitioner-focused intervention in the Local Health Authority (LHA) of Parma, Italy, substantially reduced the prevalence of potentially inappropriate medication (PIM) use among older adults. Our objective was to estimate changes in hospitalization rates associated with the Parma LHA quality improvement initiative that reduced PIM use.

Methods

This population-based longitudinal cohort study was conducted among older residents (> 65 years) using the Parma LHA administrative healthcare database. Crude and adjusted unplanned hospitalization rates were estimated in 3 periods (pre-intervention: 2005–2008, intervention: 2009–2010, post-intervention: 2011–2014). Multivariable negative binomial models estimated trends in quarterly hospitalization rates among individuals at risk during each period using a piecewise linear spline for time, adjusted for time-dependent and time-fixed covariates.

Results

The pre-intervention, intervention, and post-intervention periods included 117,061, 107,347, and 121,871 older adults and had crude hospitalization rates of 146.2 (95% CI: 142.2–150.3), 146.8 (95% CI: 143.6–150.0), and 140.8 (95% CI: 136.9–144.7) per 1000 persons per year, respectively. The adjusted pre-intervention hospitalization rate was declining by 0.7% per quarter (IRR = 0.993; 95% CI: 0.991–0.995). The hospitalization rate declined more than twice as fast during the intervention period (1.8% per quarter, IRR = 0.982; 95% CI: 0.979–0.985) and was nearly constant post-intervention (IRR: 0.999; 95% CI: 0.997–1.001). Contrasting model predictions for the intervention period (Q1 2009 to Q4 2010), the intervention was associated with 1481 avoided hospitalizations.

Conclusion

In a large population of older adults, a multimodal general practitioner-focused intervention to decrease PIM use was associated with a decline in the unplanned hospitalization rate. Such interventions to reduce high risk medication use among older adults warrant consideration by health systems seeking to improve health outcomes and reduce high-cost acute care utilization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02172-3.

Deprescribing interventions in primary health care mapped to the Behaviour Change Wheel: A scoping review

BACKGROUND

Polypharmacy and inappropriate medication use are an increasing concern. Deprescribing may improve medication use through planned and supervised dose reduction or stopping of medications. As most medication management occurs in primary health care, which is generally described as the first point of access for day-to-day care, deprescribing in primary health care is the focus on this review.

OBJECTIVE

This scoping review aimed to identify and characterize strategies for deprescribing in primary health care and map the strategies to the Behaviour Change Wheel (BCW).

METHODS

A scoping review was conducted that involved searches of six databases (2002-2018) and reference lists of relevant systematic reviews and included studies. Studies that described and evaluated deprescribing strategies in primary health care were eligible. Two independent reviewers screened articles and completed data charting with charting verified by a third. Deprescribing strategies were mapped to the intervention functions of the BCW and linked to specific Behaviour Change Techniques (BCT).

RESULTS

Searches yielded 6871 citations of which 43 were included. Nineteen studies were randomized, 24 were non-randomized. Studies evaluated deprescribing in terms of medication changes, feasibility, and prescriber/patient perspectives. Deprescribing strategies involved various professionals (physicians, pharmacists, nurses), as well as patients and were generally multifaceted. A wide range of intervention functions were identified, with 41 BCTs mapped to Environmental restructuring, 38 BCTs mapped to Enablement, and 34 BCTs mapped to Persuasion.

CONCLUSIONS

Deprescribing strategies in primary health care have used a variety of BCTs to address individual professionals (e.g. education) as well as strategies that addressed the practice setting, including support from additional team members (e.g. pharmacists, nurses and patients). Further research is warranted to determine comparative effectiveness of different BCTs, which can help facilitate implementation of deprescribing strategies, thereby reducing polypharmacy, in primary health care.

Prescriber Variation in Relation to Prescribing Trends within the Preferred Drugs Initiative in Ireland (2012-2015): An Interrupted Time-Series Study Using Latent Curve Models

OBJECTIVES

To examine the impact of the Preferred Drugs Initiative (PDI), an Irish health policy aimed at reducing prescribing variation.

DESIGN

Interrupted time series spanning 2012 to 2015.

SETTING

Health Service Executive pharmacy claims data for General Medical Services (GMS) patients, approximately 40% of the Irish population.

PARTICIPANTS

Prescribers issuing preferred drug group items to GMS adults before and after PDI guidelines.

PRIMARY OUTCOME

The percentage coverage of PDI medications within each drug class per calendar quarter per prescriber.

METHODS

Latent curve models with structured residuals (LCM-SRs) were used to model coverage of the preferred drugs over time. The number of GMS adults receiving medication and the percentage who were 65 years and older at the start of the study were included as covariates.

RESULTS

In the quarter following PDI guidelines, coverage of the preferred drugs increased most in absolute terms for proton pump inhibitors (PPIs) (1.50% [SE 0.15], P < 0.001) and selective and norepinephrine reuptake inhibitors (SNRIs) (1.17% [SE 0.26], P < 0.001). Variation between prescribers remained relatively unchanged and increased for urology medications. Prescribers who increased coverage of the preferred PPI also increased coverage of the preferred statin immediately following guidelines (correlation 0.47 [SE 0.13], P < 0.001). Where guidelines were disseminated simultaneously, coverage of one preferred drug did not significantly predict coverage of the other preferred drug in the next calendar quarter. Prescribing of preferred drugs was not moderated by prescriber-level factors.

CONCLUSIONS

Modest changes in prescribing of the preferred drugs have been observed over the course of the PDI. However, the guidelines have had little impact in reducing variation between prescribers. Further strategies may be necessary to reduce variation in clinical practice and enhance patient care.

Effectiveness of educational outreach visits compared with usual guideline dissemination to improve family physician prescribing-an 18-month open cluster-randomized trial

BACKGROUND

Educational outreach visits are meant to improve the practice of health professionals by promoting face-to-face visits to deliver educational contents. They have been shown to change prescription behavior, but long-term effects are still uncertain. This trial aimed to determine if they improve family physician prescribing compared with passive guideline dissemination.

METHODS

Parallel, open, superiority, and cluster-randomized trial. National Health Service primary care practices (clusters) were recruited in the Lisbon region-Portugal between March 2013 and January 2014. They could enter if they had at least four family physicians willing to participate and not planning to retire in the follow-up period. Three national guidelines were chosen for dissemination: acid secretion modifiers, non-steroidal anti-inflammatory drugs, and antiplatelets. Physicians in the intervention group received one 15 to 20 min educational outreach visit at their workplace for each guideline. Physicians in the control group had access to guidelines through the Directorate-General for Health's website (passive dissemination). Primary outcomes were the proportion of COX-2 inhibitors prescribed within the NSAID class and the proportion of omeprazole within the PPI class at 18 months after the intervention. A cost-benefit analysis was performed. Practices were randomized by minimization. Data analyses were done at individual physician level using generalized mixed-effects regression models. Participants could not be blinded.

RESULTS

Thirty-eight practices with 239 physicians were randomized (120 to intervention and 119 to control). Of 360 planned visits, 322 were delivered. No differences were found between physicians in the intervention and control groups regarding the proportion of omeprazole prescribed among PPIs 18 months after the visit (46.28 vs 47.15%, p = 0.971) or the proportion of COX-2 inhibitors among NSAIDs (12.07 vs 13.08%, p = 0.085). All secondary outcome comparisons showed no effect. There was no difference in cumulative drug costs at 18 months (3223.50€/1000 patients in the intervention group and 3143.92€/1000 patients in the control group, p = 0.848).

CONCLUSIONS

Educational outreach visits were unsuccessful in improving compliance with guideline recommendations among Portuguese family physicians. No effects were observed at 1, 6, and 18 months after the intervention, and there were no associated cost savings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01984034 . Registered 7 November 2013.

Interventions to improve the appropriate use of polypharmacy for older people

BACKGROUND

Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing. This is the second update of this Cochrane Review.

OBJECTIVES

To determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 7 February 2018, together with handsearching of reference lists to identify additional studies.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older, prescribed polypharmacy (four or more medicines), which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We identified 32 studies, 20 from this update. Included studies consisted of 18 randomised trials, 10 cluster randomised trials (one of which was a stepped-wedge design), two non-randomised trials and two controlled before-after studies. One intervention consisted of computerised decision support (CDS); and 31 were complex, multi-faceted pharmaceutical-care based approaches (i.e. the responsible provision of medicines to improve patient's outcomes), one of which incorporated a CDS component as part of their multi-faceted intervention. Interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists and geriatricians, and all were conducted in high-income countries. Assessments using the Cochrane 'Risk of bias' tool, found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low.It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool), mean difference (MD) -4.76, 95% CI -9.20 to -0.33; 5 studies, N = 517; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs), (standardised mean difference (SMD) -0.22, 95% CI -0.38 to -0.05; 7 studies; N = 1832; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIMs, (risk ratio (RR) 0.79, 95% CI 0.61 to 1.02; 11 studies; N = 3079; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.81, 95% CI -0.98 to -0.64; 2 studies; N = 569; low-certainty evidence), however it must be noted that this effect estimate is based on only two studies, which had serious limitations in terms of risk bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPOs (RR 0.40, 95% CI 0.18 to 0.85; 5 studies; N = 1310; very low-certainty evidence). Pharmaceutical care may make little or no difference in hospital admissions (data not pooled; 12 studies; N = 4052; low-certainty evidence). Pharmaceutical care may make little or no difference in quality of life (data not pooled; 12 studies; N = 3211; low-certainty evidence). Medication-related problems were reported in eight studies (N = 10,087) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies.

AUTHORS' CONCLUSIONS

It is unclear whether interventions to improve appropriate polypharmacy, such as reviews of patients' prescriptions, resulted in clinically significant improvement; however, they may be slightly beneficial in terms of reducing potential prescribing omissions (PPOs); but this effect estimate is based on only two studies, which had serious limitations in terms of risk bias.

Assessing long-term sustainment of clinic participation in NIATx200: Results and a new methodological approach

BACKGROUND

Sustainability frameworks differentiate between sustainability capacity and sustainment of organizational change. Multiple studies have examined sustainability capacity. Methodological approaches to assess long-term sustainment have not been explored. This study addresses this gap by describing the development of a long-term sustainment methodology and evaluating its application utilizing data from substance abuse clinics participating in a quality improvement collaborative.

METHODS

The study involved clinics (n = 121) in three states (MI, NY and WA) participating in the 2007-2009 NIATx200 quality improvement (QI) intervention. It extended the primary analysis to focus on clinics' long-term sustainment of wait time, retention and admission improvements. Long-term sustainment was defined as two years post end of the active implementation period (Calendar Years 2010 and 2011). The analysis defined case exclusion criteria and spline "knot" time intervals; allowed for C_p statistic use to address clinic data volatility; established the structure of sustainment plots and explored differences between NIATx implementation strategies.

RESULTS

Example spline and sustain plots highlight the application of the long-term sustainment methodology for NIATx200 clinics. In clinics with available longitudinal outcome data, 40.8% (n = 31 of 76 clinics) sustained improvements in wait time, 26.7% (n = 20 of 75 clinics) in retention, and 28.1% (n = 32 of 114 clinics) for admissions. Clinic assignment to a NIATx200 implementation strategy did not significantly influence a clinics' long-term sustainment except for lower wait time changes in the interest circle interventions. Thirty clinics (24.8%) sustained improvements for two outcomes and six clinics (5.0%) did so for all three outcomes. The clinics that sustained multiple outcome improvements were assigned to the interest circle (n = 12), learning session (n = 10), combination (n = 8), and coaching (n = 6) implementation strategies. Guidance for applying the long-term sustainment methodology in other quality improvement settings is described.

CONCLUSIONS

Research about sustainability capacity and sustainment of change has become increasingly important in dissemination and implementation research. Assessment of long-term sustainment in a multi-organizational quality improvement collaborative (QIC) is needed to identify when program drift and intervention decay occurs. If "cut-points" indicate when effects diminish, specific sustainability modules could be developed and introduced within the structure of a QIC to improve organizational long-term sustainment. Coaches and change teams could be trained to focus on organizational change sustainment and strengthen the likelihood of institutionalization. ClinicalTrials.gov Identifier: NCT00934141 Registered July 6, 2009. Retrospectively registered.

An evaluation of prescribing trends and patterns of claims within the Preferred Drugs Initiative in Ireland (20112016): an interrupted time-series study

OBJECTIVE

To examine the impact of the Preferred Drugs Initiative (PDI), an Irish health policy aimed at enhancing evidence-based cost-effective prescribing, on prescribing trends and the cost of prescription medicines across seven medication classes.

DESIGN

Retrospective repeated cross-sectional study spanning the years 2011-2016.

SETTING

Health Service Executive Primary Care Reimbursement Service pharmacy claims data for General Medical Services (GMS) patients, approximately 40% of the Irish population.

PARTICIPANTS

Adults aged ≥18 years between 2011 and 2016 are eligible for the GMS scheme.

PRIMARY AND SECONDARY OUTCOMES

The percentage of PDI medications within each drug class per calendar quarter. Linear regression was used to model prescribing of the preferred drug within each medication group and to assess the impact of PDI guidelines and other relevant changes in prescribing practice. Savings in drug expenditure were estimated.

RESULTS

Between 2011 and 2016, around a quarter (23.59%) of all medications were for single-agent drugs licensed in the seven drug classes. There was a small increase in the percentage of PDI drugs, increasing from 4.64% of all medications in 2011 to 4.76% in 2016 (P<0.001). The percentage of preferred drugs within each drug class was significantly higher immediately following publication of the guidelines for all classes except urology, with the largest increases noted for lansoprazole (1.21%, 95% CI: 0.84% to 1.57%, P<0.001) and venlafaxine (0.71%, 95% CI: 0.15% to 1.27%, P=0.02). Trends in prescribing of the preferred drugs between PDI guidelines and the end of 2016 varied between drug classes. Total cost savings between 2013 and 2016 were estimated to be €2.7 million.

CONCLUSION

There has been a small increase in prescribing of PDI drugs in response to prescribing guidelines, with inconsistent changes observed across therapeutic classes. These findings are relevant where health services are seeking to develop more active prescribing interventions aimed at changing prescribing practice.

Factors influencing the long-term sustainment of quality improvements made in addiction treatment facilities: a qualitative study

BACKGROUND

A greater understanding of the factors that influence long-term sustainment of quality improvement (QI) initiatives is needed to promote organizational ability to sustain QI practices over time, help improve future interventions, and increase the value of QI investments.

METHODS

We approached 83 of 201 executive sponsors or change leaders at addiction treatment organizations that participated in the 2007-2009 NIATx200 QI intervention. We completed semi-structured interviews with 33 individuals between November 2015 and April 2016. NIATx200 goals were to decrease wait time, increase admissions and improve retention in treatment. Interviews sought to understand factors that either facilitated or impeded long-term sustainment of organizational QI practices made during the intervention. We used thematic analysis to organize the data and group patterns of responses. We assessed available quantitative outcome data and intervention engagement data to corroborate qualitative results.

RESULTS

We used narrative analysis to group four important themes related to long-term sustainment of QI practices: (1) finding alignment between business- and client-centered practices; (2) staff engagement early in QI process added legitimacy which facilitated sustainment; (3) commitment to integrating data into monitoring practices and the identification of a data champion; and (4) adequate organizational human resources devoted to sustainment. We found four corollary factors among agencies which did not sustain practices: (1) lack of evidence of impact on business practices led to discontinuation; (2) disengaged staff and lack of organizational capacity during implementation period led to lack of sustainment; (3) no data integration into overall business practices and no identified data champion; and (4) high staff turnover. In addition, we found that many agencies' current use of NIATx methods and tools suggested a legacy effect that might improve quality elsewhere, even absent overall sustainment of original study outcome goals. Available quantitative data on wait-time reduction demonstrated general concordance between agency perceptions of, and evidence for, sustainment 2 years following the end of the intervention. Additional quantitative data suggested that greater engagement during the intervention period showed some association with sustainment.

CONCLUSIONS

Factors identified in QI frameworks as important for short-term sustainment-organizational capacity (e.g. staffing and leadership) and intervention characteristics (e.g. flexibility and fit)-are also important to long-term sustainment.

Hospitalization rates during potentially inappropriate medication use in a large population-based cohort of older adults

BACKGROUND AND AIMS

The temporal relationship between potentially inappropriate medication (PIM) use and hospitalization remains uncertain. We examined whether current PIM use increases the rate of hospitalization and estimated the rate of hospitalization during exposure to individual PIMs.

METHODS

A retrospective population-based cohort study of 1 480 137 older adults was conducted using the 2003-2013 Italian Emilia-Romagna Regional administrative healthcare database (~4.5 million residents), which includes demographic, hospital and outpatient prescription information. Each day of follow-up was defined as exposed/unexposed to PIMs that 'should always be avoided', according to the Maio criteria, an Italian modified version of the Beers criteria. The study outcome was all-cause hospitalizations. Crude PIM-related hospitalization rates were calculated for individual PIMs. Repeated-events Cox proportional hazards models with time-dependent covariates estimated adjusted hazard ratios for hospitalization during PIM exposure, as defined by three versions of the Maio criteria (v2007, v2011, v2014).

RESULTS

During >10 million person-years of follow-up, 54.2% of individuals used ≥1 PIM and 10.9% of all person-time was exposed to v2014 PIMs. Among 1 604 901 hospitalizations, 15.6% occurred during v2014 PIM exposure. Crude hospitalization rates during v2014 PIM-exposed and unexposed person-time were 228.1 and 152.1 per 1000 person-years, respectively. The PIM with the highest rate of hospitalization was ketorolac, while nonsteroidal anti-inflammatory drugs had the most exposure time. The hazard of hospitalization was 16% greater (hazard ratio = 1.16; 95% confidence interval 1.14, 1.18) among patients exposed to v2014 PIMs. The v2007 and v2011 estimates were similar.

CONCLUSIONS

In this large population-based cohort of older adults, we found a 16% increased hospitalization risk associated with PIM exposure.

Improving Discharge Instructions in a Pediatric Emergency Department: Impact of a Quality Initiative

BACKGROUND

Effective communication between physician and patient is essential to optimize care after discharge from the emergency department (ED). Written discharge care instructions (DCI) complement verbal instructions and have been shown to improve communication and patient management. In 2012, Centers for Medicare and Medicaid Services proposed a quality measure (OP-19) that assesses compliance with key elements considered essential for high-quality written DCI.

OBJECTIVE

To evaluate the impact of a QI intervention on improving quality of written DCI in a pediatric emergency department (PED).

METHODS

A QI initiative was conducted at a tertiary PED with greater than 60,000 annual visits. Based on Centers for Medicare and Medicaid Services OP-19 measure and group consensus, 8 elements were defined a priori as requisites for good quality DCI. These elements are:Providers reviewed a random sample of DCI of patients. Proportion of DCI that had each element documented was compared between preintervention phase (PRE) and postintervention phase (POST).

RESULTS

Three hundred twenty-nine DCI (PRE) and 1434 DCI (POST) were reviewed. The POST DCI showed statistically significant improvement for each of the 8 elements. The bundle measure (proportion containing all 8 elements) increased from 23% (PRE) to 79% (POST) (P < 0.001).

CONCLUSIONS

The ED DCI improved in all 8 elements after a QI intervention. A detailed DCI at ED discharge enhances the patient's ability to comply with postdischarge treatment plan. Further studies are needed to evaluate the impact of improving DCI on ED return rates and other outcomes.

Sustained effectiveness of a multifaceted intervention to reduce potentially inappropriate prescribing in older patients in primary care (OPTI-SCRIPT study)

BACKGROUND

Potentially inappropriate prescribing (PIP) is common in older people in primary care and can result in increased morbidity, adverse drug events and hospitalisations. We previously demonstrated the success of a multifaceted intervention in decreasing PIP in primary care in a cluster randomised controlled trial (RCT).

OBJECTIVE

We sought to determine whether the improvement in PIP in the short term was sustained at 1-year follow-up.

METHODS

A cluster RCT was conducted with 21 GP practices and 196 patients (aged ≥70) with PIP in Irish primary care. Intervention participants received a complex multifaceted intervention incorporating academic detailing, medicine review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options, and tailored patient information leaflets. Control practices delivered usual care and received simple, patient-level PIP feedback. Primary outcomes were the proportion of patients with PIP and the mean number of potentially inappropriate prescriptions at 1-year follow-up. Intention-to-treat analysis using random effects regression was used.

RESULTS

All 21 GP practices and 186 (95 %) patients were followed up. We found that at 1-year follow-up, the significant reduction in the odds of PIP exposure achieved during the intervention was sustained after its discontinuation (adjusted OR 0.28, 95 % CI 0.11 to 0.76, P = 0.01). Intervention participants had significantly lower odds of having a potentially inappropriate proton pump inhibitor compared to controls (adjusted OR 0.40, 95 % CI 0.17 to 0.94, P = 0.04).

CONCLUSION

The significant reduction in the odds of PIP achieved during the intervention was sustained after its discontinuation. These results indicate that improvements in prescribing quality can be maintained over time.

TRIAL REGISTRATION

Current controlled trials ISRCTN41694007 .

What doctors need to know: Prescribing or not for the oldest old

Given the global increase in the number of people over the age of 85, there is a growing body of work concerning this group, termed the oldest old. Much of this work is confined to the literature specialising in geriatrics and the more generic health care papers refer to 'older people' with little definition of what is meant by 'older'. Iatrogenesis (ill health caused by doctors) is a major issue and general practitioners (GPs) need practical help in prescribing for the oldest old. This paper presents a narrative review of the literature on prescribing and the oldest old. The results showed that all papers sourced referred to prescribing for the 'old' as those aged over 65, with only scant mention of oldest old. Yet prescribing for the oldest old involves clinical judgement and knowledge of the patient. It includes weighing up what will do good, cause no harm and is acceptable to the individual. GPs have to make treatment choices mostly in isolation from colleagues, during time-limited consultations and with few relevant guidelines on managing multi-morbidities in the oldest old. A major issue in prescribing for people over the age of 85 is that guidelines for diseases are based on trials with younger adults, outline the best practice for one disease in isolation (i.e. not in the presence of other diseases) and take little account of the interactions between the drugs used in managing several diseases in frail older people. There is a growing body of work, however, calling for specialist services for the oldest old.

Inappropriate prescribing in a large community-dwelling older population: a focus on prevalence and how it relates to patient and physician characteristics

WHAT IS KNOWN AND OBJECTIVE

The prescription of potentially inappropriate medications (PIMs) for older adults is a well-known population health concern. Updated country-specific estimates of inappropriate prescribing in older adults using germane explicit criteria are needed to facilitate physician-tailored quality improvement strategies. Therefore, we sought to determine the prevalence of PIMs for older adults in Emilia-Romagna, Italy, using the updated Maio criteria. We also evaluated patient and general practitioner (GP) characteristics related to inappropriate prescribing.

METHODS

Older adults (≥ 65) in 2012 were evaluated in a one-year retrospective study using administrative health care data. The 2011 Maio criteria includes 25 medications reimbursed by the Italian National Formulary, in the following categories in terms of severity: 16 medications that 'should always be avoided,' 3 that are 'rarely appropriate,' and 6 that have 'some indications although they are often misused.' To evaluate the extent of associations between patient and GP related characteristics, we used generalized estimating equations with an exchangeable covariance design to fit robust logistic regression models.

RESULTS AND DISCUSSION

A total of 865,354 older adults were in the cohort and 28% had at least one PIM. Of the entire cohort, 8%, 10%, and 14% of individuals were prescribed at least one medication that 'should always be avoided,' is 'rarely appropriate,' and has 'some indications but are often misused,' respectively. Older patients (≥ 75) and females were more likely to be exposed to PIMs. 2,923 GPs were identified in the region, each having prescribed at least one PIM, of which older GPs (≥ 56), male GPs, and solo practice GPs were more likely to prescribe PIMs to their older patients.

WHAT IS NEW AND CONCLUSION

The high prevalence of PIM exposure among older adults is a substantial issue in the region. Knowing how patient and GP characteristics relate to PIMs exposure may improve the design and targeting of initiatives for improving prescribing safety in this population.