1
|
Moriarty F, Barry A, Kenny RA, Fahey T. Aspirin prescribing for cardiovascular disease in middle-aged and older adults in Ireland: Findings from The Irish Longitudinal Study on Ageing. Prev Med 2021; 147:106504. [PMID: 33667470 DOI: 10.1016/j.ypmed.2021.106504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/19/2021] [Accepted: 02/27/2021] [Indexed: 10/22/2022]
Abstract
Aspirin use for cardiovascular indications is widespread despite evidence not supporting use in patients without cardiovascular disease (CVD). This study characterises aspirin prescribing among people aged ≥50 years in Ireland for primary and secondary prevention, and factors associated with prescription. This cross-sectional study includes participants from wave 3 (2014-2015) of The Irish Longitudinal Study on Ageing. We identified participants reporting use of prescribed aspirin, other antiplatelets/anticoagulants, and doctor-diagnosed CVD (MI, angina, stroke, TIA) and other cardiovascular conditions. We examined factors associated with aspirin use for primary and secondary prevention in multivariate regression. For a subset, we also examined 10-year cardiovascular risk (using the Framingham general risk score) as a predictor of aspirin use. Among 6618 participants, the mean age was 66.9 years (SD 9.4) and 55.6% (3679) were female. Prescribed aspirin was reported by 1432 participants (21.6%), and 77.6% of aspirin users had no previous CVD. Among participants with previous CVD, 16.5% were not prescribed aspirin/another antithrombotic. This equates to 201,000 older adults nationally using aspirin for primary prevention, and 16,000 with previous CVD not prescribed an antithrombotic. Among those without CVD, older age, male sex, free health care, and more GP visits were associated with aspirin prescribing. Cardiovascular risk was significantly associated with aspirin use (adjusted relative risk 1.15, 95%CI 1.08-1.23, per 1% increase in cardiovascular risk). Almost four-fifths of people aged ≥50 years on aspirin have no previous CVD, equivalent to 201,000 adults nationally, however prescribing appears to target higher cardiovascular risk patients.
Collapse
Affiliation(s)
- Frank Moriarty
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Ireland; The Irish Longitudinal Study on Ageing, Trinity College Dublin, Ireland.
| | - Alan Barry
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Ireland
| |
Collapse
|
2
|
Irawati S, Prayudeni S, Rachmawati R, Wita IW, Willfert B, Hak E, Taxis K. Key factors influencing the prescribing of statins: a qualitative study among physicians working in primary healthcare facilities in Indonesia. BMJ Open 2020; 10:e035098. [PMID: 32540888 PMCID: PMC7299032 DOI: 10.1136/bmjopen-2019-035098] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To elicit key factors influencing physicians' decision to prescribe statins. DESIGN A qualitative study using a phenomenological approach within a pragmatism interpretive framework. A combination of purposive and snowball sampling was used to recruit physicians. Data were collected through face-to-face, semistructured interviews with physicians working in primary healthcare facilities in a capital of a province in Indonesia. We recorded and verbatim transcribed the interviews. Coding was done independently by two researchers and data were analysed using phenomenological data analyses. Key factors influencing physicians' decision to prescribe statins were classified into factors at the microlevels, mesolevels and macrolevels according to the structural model by Scoggins et al. PARTICIPANTS AND SETTING: Physicians working in primary healthcare facilities in a capital of a province in Indonesia. RESULTS Ten physicians were included in the study. Key factors at the microlevel were that physicians knew guidelines in general, but there was uncertainty how to take into account the level of total cholesterol in combination with other cardiovascular risk factors such as diabetes and hypertension. At the macrolevel, the new National Health Insurance System (NHIS) that appeared to facilitate the prescription of statins though more clinical information should be integrated in the system's platform to support appropriate prescribing. CONCLUSIONS The findings indicate lack of awareness of specific details in current guideline recommendations. Appropriate prescribing of statins should be enhanced using the new NHIS.
Collapse
Affiliation(s)
- Sylvi Irawati
- PharmacoTherapy, -Epidemiology & -Economics, University of Groningen, Groningen, The Netherlands
- Centre for Medicines Information and Pharmaceutical Care, Faculty of Pharmacy, Universitas Surabaya, Surabaya, Indonesia
- Department of Clinical and Community Pharmacy, Faculty of Pharmacy, Universitas Surabaya, Surabaya, Indonesia
| | - Sari Prayudeni
- Faculty of Pharmacy, Universitas Surabaya, Surabaya, Indonesia
| | | | - I Wayan Wita
- Department of Cardiovascular Medicine, Udayana University, Denpasar, Bali, Indonesia
| | - Bob Willfert
- PharmacoTherapy, -Epidemiology & -Economics, University of Groningen, Groningen, The Netherlands
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, Groningen, Indonesia
| | - Eelko Hak
- PharmacoTherapy, -Epidemiology & -Economics, University of Groningen, Groningen, The Netherlands
| | - Katja Taxis
- PharmacoTherapy, -Epidemiology & -Economics, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
3
|
Safer DJ. Overprescribed Medications for US Adults: Four Major Examples. J Clin Med Res 2019; 11:617-622. [PMID: 31523334 PMCID: PMC6731049 DOI: 10.14740/jocmr3906] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 07/15/2019] [Indexed: 12/24/2022] Open
Abstract
To understand possible medication overprescribing, it would be important to know which classes are the most prescribed, for which indications, for what duration, and for which age groups. Among the 10 most frequently prescribed medication classes for US adults, four were evaluated for overprescribing, and systematically assessed in relation to their primary indication. The assessment included usage patterns, trends, age of recipients, treatment duration, and benefits versus adverse consequences. The findings in this selective review are supported by an extensive search of the medical literature. The four selected medication categories and their most common indication included opioids for chronic pain, proton pump inhibitors for indigestion, levothyroxine for subclinical hypothyroidism, and antidepressants for subsyndromal levels of depression. These medications, grouped by their most frequent indication along with polypharmacy, have experienced major prescription increases in recent years, particularly among older patients. Most concerning is that they have been frequently prescribed for extended periods, usually with inadequate evidence of benefit. High drug usage patterns can aid in quantifying overprescribing within polypharmacy by age group.
Collapse
Affiliation(s)
- Daniel J Safer
- Departments of Psychiatry and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| |
Collapse
|
4
|
Saad CY, Fogel J, Rubinstein S. Awareness and Knowledge Among Internal Medicine Resident Trainees for Dose Adjustment of Analgesics and Neuropsychotropic Medications in CKD. South Med J 2018; 111:155-162. [PMID: 29505650 DOI: 10.14423/smj.0000000000000781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Errors in drug dosing lead to poor patient outcomes and are common in patients with chronic kidney disease (CKD). Because the majority of patients with CKD are being treated by physicians specializing in internal medicine, we studied the awareness and knowledge that internal medicine resident trainees (IMRTs) have regarding the correct dosage of commonly used analgesic and neuropsychotropic medications for patients with CKD. METHODS We surveyed 353 IMRTs about their awareness of whether a medication needs dose adjustment in patients with CKD and knowledge for medication adjustment by level of glomerular filtration rate. RESULTS There were high percentages for lack of awareness and knowledge. For analgesics, this lack of awareness/knowledge was highest for acetaminophen (awareness 83.0%, knowledge 90.9%). For neuropsychotropics, this was highest for paroxetine (awareness 74.5%, knowledge 91.5%). Analyses for postgraduate year (PGY) -1 trainees and PGY-2 trainees for analgesics showed higher odds for lack of awareness for tramadol (PGY-1 odds ratio [OR] 2.37, 95% confidence interval [CI] 1.2-4.62, P < 0.05; PGY-2 OR 2.34, 95% CI 1.16-4.72, P < 0.05) and for lack of knowledge for meperedine (PGY-1 OR 4.01, 95% CI 1.81-8.89, P < 0.05; PGY-2 OR 3.30, 95% CI 1.44-7.59, P < 0.05). Nephrology residency rotation for the neuropsychotropic medication of gabapentin showed lower odds for both lack of awareness (OR 0.56, 95% CI 0.32-0.97, P < 0.05) and knowledge (OR 0.52, 95% CI 0.27-0.997, P < 0.05). CONCLUSIONS Awareness and knowledge are poor among IMRTs for dose adjustments of analgesics and neuropsychotropic medication classes in patients with CKD. There should be a renewed focus during IMRTs' residency on additional nephrology exposure and formal didactic educational training to help them better manage complex treatment regimens to prevent medication dosing errors.
Collapse
Affiliation(s)
- Chadi Y Saad
- From the Division of Nephrology and Hypertension, Nassau University Medical Center, East Meadow, New York, and the Department of Business Management, Brooklyn College, Brooklyn, New York
| | - Joshua Fogel
- From the Division of Nephrology and Hypertension, Nassau University Medical Center, East Meadow, New York, and the Department of Business Management, Brooklyn College, Brooklyn, New York
| | - Sofia Rubinstein
- From the Division of Nephrology and Hypertension, Nassau University Medical Center, East Meadow, New York, and the Department of Business Management, Brooklyn College, Brooklyn, New York
| |
Collapse
|
5
|
van C, McInerney P, Cooke R. Patients' involvement in improvement initiatives: a qualitative systematic review. ACTA ACUST UNITED AC 2018; 13:232-90. [PMID: 26571293 DOI: 10.11124/jbisrir-2015-1452] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Over the last 20 years, quality improvement in health has become an important strategy in health services in many countries. With the emphasis on quality health care, there has been a shift in social paradigms towards including service users in their own health on different levels. There is growing evidence in literature on the positive impact on health outcomes where patients are active participants in their personal care. There is however less information available on the broader influence of users on improvement in systems. OBJECTIVES The objective of this review was to identify the barriers and enablers to patients being involved in quality improvement efforts directed towards their own health care. INCLUSION CRITERIA This review considered studies that included adults and children of any age experiencing any health problem.The review considered studies that explored patient or user participation in quality improvement and the factors enabling and hindering this processThe qualitative component of this review considered studies that focused on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Other texts such as opinion papers and reports were also considered. SEARCH STRATEGY The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. The searches using all identified keywords and index terms included the databases PubMed, PsycINFO, Medline, Scopus, EBSCOhost and CINAHL.Qualitative, text and opinion papers were considered for inclusion in this review.Closely related concepts like community involvement, family involvement, patients' involvement in their own care (for example, in the case of shared decision making), and patient centeredness in the context of a consultation were excluded. METHODOLOGICAL QUALITY Qualitative and textual papers selected for retrieval were assessed by two independent reviewers for authenticity prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute. DATA EXTRACTION Qualitative and textual data were extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute. DATA SYNTHESIS The above findings were pooled and through the identification of categories, a final meta-synthesis was formulated. RESULTS Two synthesized findings were created from the included papers. Firstly, there are barriers to patients' participation in quality improvement in health and in spite of policy support for user involvement in quality improvement, it is a difficult strategy to implement. The second synthesized finding was that there are enablers to patients' involvement in quality improvement: when patients are involved in quality improvement efforts in health care, there are innovative, often unexpected, outcomes at different levels of the process, and sustaining these efforts is possible with ongoing individual or group support.Five categories which supported the synthesized findings were created through the meta-aggregative process. CONCLUSIONS There are enablers and barriers to involving patients in quality improvement in health care that need to be considered when planning such interventions.Relationships and roles will need to be very clear from the outset. A developmental approach needs to be considered where support and training is part of the project. Where patients are truly engaged in service improvement, unexpected innovation occurs.There are many more reports and opinion papers published regarding this topic than there are rigorous research studies. This leaves the field open to the development of good methodological studies related to quality improvement and in particular to the participation of patients.
Collapse
Affiliation(s)
- Claire van
- 1Department of Family Medicine, University of the Witwatersrand, Johannesburg, South Africa2The Witwatersrand Center for Evidence Based Practice: an Affiliate Center of the Joanna Briggs Institute3Center for Health Science Education, Faculty of Health Science Education, University of the Witwatersrand.4Center for Rural Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | | |
Collapse
|
6
|
Barfoed BL, Jarbøl DE, Paulsen MS, Christensen PM, Halvorsen PA, Nielsen JB, Søndergaard J. GPs' Perceptions of Cardiovascular Risk and Views on Patient Compliance: A Qualitative Interview Study. INTERNATIONAL JOURNAL OF FAMILY MEDICINE 2015; 2015:214146. [PMID: 26495143 PMCID: PMC4606097 DOI: 10.1155/2015/214146] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 09/16/2015] [Indexed: 06/05/2023]
Abstract
Objective. General practitioners' (GPs') perception of risk is a cornerstone of preventive care. The aims of this interview study were to explore GPs' professional and personal attitudes and experiences regarding treatment with lipid-lowering drugs and their views on patient compliance. Methods. The material was drawn from semistructured qualitative interviews. We sampled GPs purposively from ten selected practices, ensuring diversity of demographic, professional, and personal characteristics. The GPs were encouraged to describe examples from their own practices and reflect on them and were informed that the focus was their personal attitudes and experiences. Systematic text condensation was applied for analysis in order to uncover the concepts and themes. Results. The analysis revealed the following 3 main themes: (1) use of cardiovascular guidelines and risk assessment tools, (2) strategies for managing patient compliance, and (3) GPs' own risk management. There were substantial differences in the attitudes concerning all three themes. Conclusions. The substantial differences in the GPs' personal and professional risk perceptions may be a key to understanding why GPs do not always follow cardiovascular guidelines. The impact on daily clinical practice, personal consultation style, and patient behaviour with regard to prevention is worth studying further.
Collapse
Affiliation(s)
- Benedicte Lind Barfoed
- Research Unit for General Practice, University of Southern Denmark, JB Winsløws Vej 9A, 5000 Odense C, Denmark
| | - Dorte Ejg Jarbøl
- Research Unit for General Practice, University of Southern Denmark, JB Winsløws Vej 9A, 5000 Odense C, Denmark
| | - Maja Skov Paulsen
- Danish Quality Unit for General Practice, JB Winsløws Vej 9A, 5000 Odense C, Denmark
| | | | - Peder Andreas Halvorsen
- Department of Community Medicine, University of Tromsø, The Arctic University of Norway, 9037 Tromsø, Norway
| | - Jesper Bo Nielsen
- Research Unit for General Practice, University of Southern Denmark, JB Winsløws Vej 9A, 5000 Odense C, Denmark
| | - Jens Søndergaard
- Research Unit for General Practice, University of Southern Denmark, JB Winsløws Vej 9A, 5000 Odense C, Denmark
| |
Collapse
|
7
|
Fàbregas M, Berges I, Fina F, Hermosilla E, Coma E, Méndez L, Medina M, Calero S, Serrano E, Morros R, Monteagudo M, Bolíbar B. Effectiveness of an intervention designed to optimize statins use: a primary prevention randomized clinical trial. BMC FAMILY PRACTICE 2014; 15:135. [PMID: 25027229 PMCID: PMC4112648 DOI: 10.1186/1471-2296-15-135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 07/08/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although hypercholesterolemia is considered a cardiovascular risk factor, in isolation it is not necessarily sufficient cause for a cardiovascular event. To improve event prediction, cardiovascular risk calculators have been developed; the REGICOR calculator has been validated for use in our population. The objective of this project is to develop an intervention with general practitioners (GPs) and evaluate its impact on prescription adequacy of cholesterol-lowering drugs in primary prevention of cardiovascular disease and in controlling the costs associated with this disease. METHODS This nonblinded, cluster-randomized clinical trial analyzes data from primary care electronic medical records (ECAP) and other databases. Inclusion criteria are patients aged 35 to 74 years with no known cardiovascular disease and a new prescription for cholesterol-lowering drugs during the 2-year study period. Dependent variables include the following: RETIRA, defined as new cholesterol-lowering drugs initiated during the year preceding the intervention, considered inadequate, and withdrawn during the study period; EVITA, defined as new cholesterol-lowering drugs initiated during the study period and considered inadequate; COST, defined as the total cost of inadequate new treatments prescribed; and REGISTER, defined as the recording of cardiovascular risk factors. Independent variables include the GP's quality-of-care indicators and randomly assigned study group (intervention vs control), patient demographics, and clinical variables. Aggregated descriptive analysis will be done at the GP level and multilevel analysis will be performed to estimate the intervention effect, adjusted for individual and GP variables. DISCUSSION The study objective is to generate evidence about the effectiveness of implementing feedback information programs directed to GPs in the context of Primary Care. The goal is to improve the prescription adequacy of lipid-lowering therapies for primary prevention. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01997671. November 28, 2013.
Collapse
Affiliation(s)
- Mireia Fàbregas
- ABS La Marina, SAP Esquerra, Institut Català de la Salut, Barcelona, Spain
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | | | - Francesc Fina
- Sistemes d’Informació d’Atenció Primària (SISAP) – Sistema d’Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAP), Institut Català de la Salut, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Eduardo Hermosilla
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Ermengol Coma
- Sistemes d’Informació d’Atenció Primària (SISAP) – Sistema d’Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAP), Institut Català de la Salut, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Leonardo Méndez
- Sistemes d’Informació d’Atenció Primària (SISAP) – Sistema d’Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAP), Institut Català de la Salut, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Manuel Medina
- Sistemes d’Informació d’Atenció Primària (SISAP) – Sistema d’Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAP), Institut Català de la Salut, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Sebastià Calero
- Àrea de Desenvolupament Clínic, Direcció Adjunta d’Afers Assistencials, Institut Català de la Salut, Institut Universitari d'investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Elena Serrano
- Centre d’Atenció Primària Baix a Mar, Consell comarcal del Garraf, Vilanova i la Geltrú, Barcelona, Spain
| | - Rosa Morros
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Mònica Monteagudo
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Bonaventura Bolíbar
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| |
Collapse
|
8
|
Diaz E, Raza A, Sandvik H, Hjorleifsson S. Immigrant and native regular general practitioners in Norway. A comparative registry-based observational study. Eur J Gen Pract 2013; 20:93-9. [DOI: 10.3109/13814788.2013.823600] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
9
|
Damiani G, Silvestrini G, Federico B, Cosentino M, Marvulli M, Tirabassi F, Ricciardi W. A systematic review on the effectiveness of group versus single-handed practice. Health Policy 2013; 113:180-7. [PMID: 23910731 DOI: 10.1016/j.healthpol.2013.07.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 06/25/2013] [Accepted: 07/04/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Since the 1970s, many countries have employed the use of the General practitioner group practice, but there is contrasting evidence about its effectiveness. A systematic review was performed to assess whether group practice has a more positive impact compared with the single-handed practice on different aspects of health care. METHODS A systematic review was conducted by querying electronic databases and reviewing articles published between 1990 and 2012. A quality assessment was performed. The effect of group practice was evaluated by collecting all items analysed by the articles into four main categories: (1) studies of quality (measured in terms of clinical processes) and productivity (measured in terms of throughput), named "Clinical process measures and throughput"; (2) studies exploring physician's opinion--"Doctor's perspective"; (3) studies looking into the use of innovation, information and communication technology (ICT) and quality assurance--"Innovation, ICT and quality assurance"; (4) studies focused on patient's opinion--"Patient's perspective". The results were synthesized according to three levels of scientific evidence. RESULTS A total of 26 studies were selected. The most studied category was Clinical process measures and throughput (58%). A positive impact of group medicine on "Clinical process measures and throughput", "Doctor's perspective", "Innovation, ICT and quality assurance" was found. There was contrasting evidence considering the "Patient's perspective". CONCLUSIONS Group practice might be a successful organizational requirement to improve the quality of clinical practice in Primary Health Care. Further comparative studies are needed to investigate the impact of organizational and professional determinants such as physician's economic incentives, mode of payment, size of the groups and multispecialty on the effectiveness of medical primary care.
Collapse
Affiliation(s)
- Gianfranco Damiani
- Department of Public Health, Catholic University of the Sacred Heart, Rome, Italy.
| | | | | | | | | | | | | |
Collapse
|
10
|
Visca M, Donatini A, Gini R, Federico B, Damiani G, Francesconi P, Grilli L, Rampichini C, Lapini G, Zocchetti C, Di Stanislao F, Brambilla A, Moirano F, Bellentani D. Group versus single handed primary care: a performance evaluation of the care delivered to chronic patients by Italian GPs. Health Policy 2013; 113:188-98. [PMID: 23800605 DOI: 10.1016/j.healthpol.2013.05.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 05/20/2013] [Accepted: 05/25/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVES In family medicine contrasting evidence exists on the effectiveness of team practice compared with solo practice on chronic disease management. In Italy, several experiences of team practice have been introduced since the late 1990s but few studies detail their impact on the quality of care. The aim of this paper is to evaluate the impact of team practice in family medicine in six Italian regions using chronic disease management process indicators as a measure of outcome. METHODS Cross-sectional studies were performed to assess impact on quality of care for diabetes, congestive heart failure and ischaemic heart disease. The impact of team vs. solo practice was approximated through performance comparison of general practitioners (GPs) adhering to a team with respect to GPs working in a solo practice. Among the 2082 practitioners working in the 6 regions those assisting 300+ patients were selected. Quality of care towards 164,267 patients having at least one of three chronic conditions was estimated for the year 2008 using administrative databases. Quality indicators (% of patients receiving appropriate care) were selected (4 for diabetes, 4 for congestive heart failure, 3 for ischaemic heart disease) and a total score was computed for each patient. For each disease the response variable associated to each physician was the average score of the patients on his/her list. A multilevel model was estimated assessing the impact of team vs. solo practice. RESULTS No impact was found for diabetes and heart failure. For ischaemic heart disease a slightly significant impact was observed (0.040; 95% CI: 0.015, 0.065). CONCLUSIONS No significant difference was found between team practice and solo practice on chronic disease management in six Italian regions.
Collapse
Affiliation(s)
- Modesta Visca
- Agenas - Agenzia Nazionale per i Servizi Sanitari Regionali, Via Puglie, 23, 00187 Roma, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Sandvik H, Hunskaar S, Diaz E. Clinical practice patterns among native and immigrant doctors doing out-of-hours work in Norway: a registry-based observational study. BMJ Open 2012; 2:e001153. [PMID: 22798255 PMCID: PMC3400071 DOI: 10.1136/bmjopen-2012-001153] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 06/25/2012] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To evaluate whether immigrant and native Norwegian doctors differ in their practice patterns. DESIGN Observational study. SETTING Out-of-hours (OOH) emergency primary healthcare in Norway, 2008. PARTICIPANTS All primary care physicians doing OOH work, altogether 4165 physicians. MAIN OUTCOME MEASURES Number of patient contacts per doctor. Use of laboratory tests, minor surgery, sickness certification and length of consultations. Use of diagnoses related to psychiatric and sexual health. Choice of management strategy with psychiatric patients (psychotherapy or hospitalisation). RESULTS 21.4% of the physicians were immigrants, and they had 30.6% of the patient contacts. Immigrant doctors from Asia, Africa and Latin America had most patient contacts, 633 (95% CI 549 to 716), while native Norwegian doctors had 306 (95% CI 288 to 325). In multivariate analyses, immigrant physicians did not differ significantly from native Norwegians regarding use of laboratory tests, minor surgery or length of consultations, but immigrant doctors wrote more sickness certificates, OR 1.75 (95% CI 1.24 to 2.47) for immigrant doctors from Europe, North America and Oceania versus native Norwegian doctors and OR 1.56 (95% CI 1.15 to 2.11) for immigrant doctors from Asia, Africa and Latin America versus native Norwegians. Immigrant physicians from Europe, North America and Oceania used more diagnoses related to pregnancy, family planning and female genitals, OR 1.55 (95% CI 1.11 to 2.16), versus native Norwegian physicians. Immigrant doctors from Asia, Africa and Latin America used less psychiatric diagnoses, OR 0.71 (95% CI 0.53 to 0.95), versus native Norwegian doctors but did not differ significantly in their management of recognised psychiatric illness. CONCLUSIONS Immigrant doctors make an important contribution to OOH emergency primary healthcare in Norway. The authors found only modest evidence that their clinical practice patterns are different from that of native Norwegian doctors.
Collapse
Affiliation(s)
- Hogne Sandvik
- National Centre for Emergency Primary Health Care, Uni Health, Uni Research, Bergen, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, Uni Health, Uni Research and Research Group for General Practice, Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway
| | - Esperanza Diaz
- Research Group for General Practice, Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway
| |
Collapse
|
12
|
Keller H, Krones T, Becker A, Hirsch O, Sönnichsen AC, Popert U, Kaufmann-Kolle P, Rochon J, Wegscheider K, Baum E, Donner-Banzhoff N. Arriba: effects of an educational intervention on prescribing behaviour in prevention of CVD in general practice. Eur J Prev Cardiol 2011; 19:322-9. [DOI: 10.1177/1741826711404502] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Evidence on the effectiveness of educational interventions on prescribing behaviour modification in prevention of cardiovascular disease is still insufficient. We evaluated the effects of a brief educational intervention on prescription of hydroxymethylglutaryl-CoA reductase inhibitors (statins), inhibitors of platelet aggregation (IPA), and antihypertensive agents (AH). Design: Cluster randomised controlled trial with continuous medical education (CME) groups of general practitioners (GPs). Methods: Prescription of statins, IPA, and AH were verified prior to study start (BL), immediately after index consultation (IC), and at follow-up after 6 months (FU). Prescription in patients at high risk (>15% risk of a cardiovascular event in 10 years, based on the Framingham equation) and no prescription in low-risk patients (≤ 15%) were considered appropriate. Results: An intervention effect on prescribing could only be found for IPA. Generally, changes in prescription over time were all directed towards higher prescription rates and persisted to FU, independent of risk status and group allocation. Conclusions: The active implementation of a brief evidence-based educational intervention on global risk in CVD did not lead directly to risk-adjusted changes in prescription. Investigations on an extended time scale would capture whether decision support of this kind would improve prescribing risk-adjusted sustainably.
Collapse
Affiliation(s)
| | - Tanja Krones
- Department of General Practice, University of Marburg, Germany
- Clinical Ethics, University Hospital Zurich & Institute of Biomedical Ethics, University of Zurich, Switzerland
| | - Annette Becker
- Department of General Practice, University of Marburg, Germany
| | - Oliver Hirsch
- Department of General Practice, University of Marburg, Germany
| | - Andreas C Sönnichsen
- Institute of General Practice, Family Medicine and Prevention, Paracelsus Medical University, Salzburg, Austria
| | - Uwe Popert
- Department of Family Medicine, University of Göttingen, Germany
| | - Petra Kaufmann-Kolle
- AQUA-Institute for Applied Quality Improvement and Research in Health Care, Göttingen, Germany
| | - Justine Rochon
- Institute of Medical Biometry and Informatics, University of Heidelberg, Germany
| | - Karl Wegscheider
- Department of Medical Biometry and Epidemiology, University of Hamburg, Germany
| | - Erika Baum
- Department of General Practice, University of Marburg, Germany
| | | |
Collapse
|
13
|
Persell SD, Zei C, Cameron KA, Zielinski M, Lloyd-Jones DM. Potential use of 10-year and lifetime coronary risk information for preventive cardiology prescribing decisions: a primary care physician survey. ACTA ACUST UNITED AC 2010; 170:470-7. [PMID: 20212185 DOI: 10.1001/archinternmed.2009.525] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Data are sparse regarding how physicians use coronary risk information for prescribing decisions. METHODS We presented 5 primary prevention scenarios to primary care physicians affiliated with an academic center and surveyed their responses after they were provided with (1) patient risk factor information, (2) 10-year estimated coronary disease risk information, and (3) 10-year and lifetime risk estimates. We asked about aspirin prescribing, lipid testing, and lipid-lowering drug prescribing. RESULTS Of 202 physicians surveyed, 99 (49%) responded. The physicians made guideline-concordant aspirin decisions 51% to 91% of the time using risk factor information alone. Providing 10-year risk estimates increased concordant aspirin prescribing when the 10-year coronary risk was moderately high (15%) and decreased guideline-discordant prescribing when the 10-year risk was low (2 of 4 cases). Providing the lifetime risk information sometimes increased guideline-discordant aspirin prescribing. The physicians selected guideline-concordant thresholds for initiating treatment with lipid-lowering drugs 44% to 75% of the time using risk factor information alone. Selecting too low or too high low-density lipoprotein cholesterol thresholds was common. Ten-year risk information improved concordance when the 10-year risk was moderately high. Providing lifetime risk information increased willingness to initiate pharmacotherapy at low-density lipoprotein cholesterol levels that were lower than those recommended by guidelines when the 10-year risk was low but the lifetime risk was high. CONCLUSIONS Providing 10-year coronary risk information improved some hypothetical aspirin-prescribing decisions and improved lipid management when the short-term risk was moderately high. High lifetime risk sometimes led to more intensive prescription of aspirin or lipid-lowering medication. This outcome suggests that, to maximize the benefits of risk-calculating tools, specific guideline recommendations should be provided along with risk estimates.
Collapse
|
14
|
Abstract
A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Medication errors can occur in deciding which medicine and dosage regimen to use (prescribing faults--irrational, inappropriate, and ineffective prescribing, underprescribing, overprescribing); writing the prescription (prescription errors); manufacturing the formulation (wrong strength, contaminants or adulterants, wrong or misleading packaging); dispensing the formulation (wrong drug, wrong formulation, wrong label); administering or taking the medicine (wrong dose, wrong route, wrong frequency, wrong duration); monitoring therapy (failing to alter therapy when required, erroneous alteration). They can be classified, using a psychological classification of errors, as knowledge-, rule-, action- and memory-based errors. Although medication errors can occasionally be serious, they are not commonly so and are often trivial. However, it is important to detect them, since system failures that result in minor errors can later lead to serious errors. Reporting of errors should be encouraged by creating a blame-free, non-punitive environment. Errors in prescribing include irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing (collectively called prescribing faults) and errors in writing the prescription (including illegibility). Avoiding medication errors is important in balanced prescribing, which is the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm. In balanced prescribing the mechanism of action of the drug should be married to the pathophysiology of the disease.
Collapse
Affiliation(s)
- J K Aronson
- Department of Primary Health Care, Rosemary Rue Building, Old Road Campus, Headington, Oxford OX3 7LF, UK.
| |
Collapse
|
15
|
Denton BT, Kurt M, Shah ND, Bryant SC, Smith SA. Optimizing the start time of statin therapy for patients with diabetes. Med Decis Making 2009; 29:351-67. [PMID: 19429836 DOI: 10.1177/0272989x08329462] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clinicians often use validated risk models to guide treatment decisions for cardiovascular risk reduction. The most common risk models for predicting cardiovascular risk are the UKPDS, Framingham, and Archimedes models. In this article, the authors propose a model to optimize the selection of patients for statin therapy of hypercholesterolemia, for patients with type 2 diabetes, using each of the risk models. For each model,they evaluate the role of age, gender, and metabolic state on the optimal start time for statins. METHOD Using clinical data from the Mayo Clinic electronic medical record, the authors construct a Markov decision process model with health states composed of cardiovascular events and metabolic factors such as total cholesterol and high-density lipoproteins. They use it to evaluate the optimal start time of statin treatment for different combinations of cardiovascular risk models and patient attributes. RESULTS The authors find that treatment decisions depend on the cardiovascular risk model used and the age, gender, and metabolic state of the patient. Using the UKPDS risk model to estimate the probability of coronary heart disease and stroke events, they find that all white male patients should eventually start statin therapy; however, using Framingham and Archimedes models in place of UKPDS, they find that for male patients at lower risk, it is never optimal to initiate statins. For white female patients, the authors also find some patients for whom it is never optimal to initiate statins. Assuming that age 40 is the earliest possible start time, the authors find that the earliest optimal start times for UKPDS, Framingham, and Archimedes are 50, 46, and 40, respectively, for women. For men, the earliest optimal start times are 40, 40, and 40, respectively. CONCLUSIONS In addition to age, gender, and metabolic state, the choice of cardiovascular risk model influences the apparent optimal time for starting statins in patients with diabetes.
Collapse
Affiliation(s)
- Brian T Denton
- North Carolina State University, Edward P. Fitts Department of Industrial & Systems Engineering, Raleigh, North Carolina 27613, USA. bdenton@ ncsu.edu
| | | | | | | | | |
Collapse
|
16
|
Cavazos JM, Naik AD, Woofter A, Abraham NS. Barriers to physician adherence to nonsteroidal anti-inflammatory drug guidelines: a qualitative study. Aliment Pharmacol Ther 2008; 28:789-98. [PMID: 19145734 PMCID: PMC3717404 DOI: 10.1111/j.1365-2036.2008.03791.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite wide availability of physician guidelines for safer use of nonsteroidal anti-inflammatory drugs (NSAIDs) and widespread use of these drugs in the US, NSAID prescribing guidelines have been only modestly effective. AIM To identify and describe comprehensively barriers to provider adherence to NSAID prescribing guidelines. METHODS We conducted interviews with 25 physicians, seeking to identify the major influences explaining physician non-adherence to guidelines. Interviews were standardized and structured probes were used for clarification and detail. All interviews were audio-taped and transcribed. Three independent investigators analysed the transcripts, using the constant-comparative method of qualitative analysis. RESULTS Our analysis identified six dominant physician barriers explaining non-adherence to established NSAID prescribing guidelines. These included (i) lack of familiarity with guidelines, (ii) perceived limited validity of guidelines, (iii) limited applicability of guidelines among specific patients, (iv) clinical inertia, (v) influences of prior anecdotal experiences and (vi) medical heuristics. CONCLUSIONS A heterogeneous set of influences are barriers to physician adherence to NSAID prescribing guidelines. Suggested measures for improving guideline-concordant prescribing should focus on measures to improve physician education and confidence in guidelines, implementation of physician/pharmacist co-management strategies and expansion of guideline scope.
Collapse
Affiliation(s)
- J. M. Cavazos
- Houston Center for Quality of Care & Utilization Studies, Baylor College of Medicine, Houston, TX, USA,Gastrointestinal Outcomes in Geriatrics (GO-GERI) Unit, Baylor College of Medicine, Houston, TX, USA
| | - A. D. Naik
- Houston Center for Quality of Care & Utilization Studies, Baylor College of Medicine, Houston, TX, USA,Gastrointestinal Outcomes in Geriatrics (GO-GERI) Unit, Baylor College of Medicine, Houston, TX, USA
| | - A. Woofter
- Gastroenterology, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - N. S. Abraham
- Houston Center for Quality of Care & Utilization Studies, Baylor College of Medicine, Houston, TX, USA,Gastrointestinal Outcomes in Geriatrics (GO-GERI) Unit, Baylor College of Medicine, Houston, TX, USA,Gastroenterology, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
17
|
Levenson SA, Morley JE. Evidence rocks in long-term care, but does it roll? J Am Med Dir Assoc 2007; 8:493-501. [PMID: 17931572 DOI: 10.1016/j.jamda.2007.07.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Indexed: 01/10/2023]
Abstract
This article reviews the problems with the implementation of evidence-based care in long-term care. It highlights the fact that many common practices are incompatible with evidence and that available evidence, including evidence about inadvisable and ineffective treatments, is often not followed. Often, there is a tendency to follow recommendations for younger persons (for example, the management of hypertension and elevated cholesterol), or to use questionable interventions (for example, choices for treating constipation). In many cases, the treatments used have only marginal efficacy and increased potential for side effects. This article makes recommendations for improving the approach to evidence-based care in long-term care and strongly urges the FDA to require drug studies in nursing homes.
Collapse
Affiliation(s)
- Steven A Levenson
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | | |
Collapse
|