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Robinson A, O'Brien N, Sile L, Guraya HK, Govind T, Harris V, Pilkington G, Todd A, Husband A. Recommendations for community pharmacy to improve access to medication advice for people from ethnic minority communities: A qualitative person-centred codesign study. Health Expect 2022; 25:3040-3052. [PMID: 36161966 DOI: 10.1111/hex.13611] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/11/2022] [Accepted: 09/08/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Medicines-centred consultations are vital to support medicine effectiveness and optimize health outcomes for patients. However, inequalities negatively impact ethnic minority populations when accessing medicines advice. It is important to identify opportunities to improve access for these communities however, knowledge of how best to achieve this is lacking; this study will generate recommendations to improve access to medicines advice from community pharmacies for people from ethnic minority communities. METHODS A series of codesign workshops, with four groups of patient-stakeholders, were conducted between September-November 2021; they took place in-person or via video call (adhering to COVID-19 restrictions). Existing evidence-based perceptions affecting access to medicines advice were critiqued and recommendations were generated, by use of reflexive thematic analysis, to improve access for ethnic minority patients. The workshops were audio-recorded and transcribed verbatim. QSR NVivo (Version 12) facilitated data analysis. RESULTS Twelve participants were recruited using purposive sampling; including eight UK citizens, two asylum seekers and two participants in receipt of residency visas. In total, four different ethnic minority groups were represented. Each participant took part in a first and second workshop to share and cocreate recommendations to improve access to medicines advice in community pharmacies. Three recommendations were developed and centred on: (i) delivering and providing culturally competent medicines advice; (ii) building awareness of accessing medicines advice from community pharmacies; and (iii) enabling better discussions with patients from ethnic minority communities. CONCLUSIONS These recommendations have the potential to support community pharmacy services to overcome ethnic inequalities affecting medicines advice; service commissioners should consider these findings to best meet the needs of ethnic minority patients. Cultural competence training for community pharmacy staff could support the creation of pharmacies as inclusive healthcare settings. Collaborative working with ethnic minority communities could enable specific tailoring of medicines-centred services to best meet their needs. PATIENT OR PUBLIC CONTRIBUTION The National Institute for Health Research (NIHR) and Newcastle University Patient and Public Involvement and Engagement group had extensive input in the study design and conceptualization. Seven patient champions were appointed to the steering group to ensure that the research was conducted, and findings were reported, with cultural competence. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Anna Robinson
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nicola O'Brien
- Department of Psychology, Northumbria University, Newcastle upon Tyne, UK
| | - Laura Sile
- Alumni, School of Pharmacy, Liverpool John Moores University, Liverpool, UK
| | | | - Thorrun Govind
- Chair of the English Pharmacy Board, Royal Pharmaceutical Society, London, UK
| | - Vicki Harris
- Connected Voice Haref, Higham House, Newcastle upon Tyne, UK
| | - Guy Pilkington
- West End Family Health Primary Care Network, Cruddas Park Surgery, Newcastle upon Tyne, UK
| | - Adam Todd
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Andy Husband
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Robinson A, Sile L, Govind T, Guraya HK, O'Brien N, Harris V, Pilkington G, Todd A, Husband A. 'He or she maybe doesn't know there is such a thing as a review': A qualitative investigation exploring barriers and facilitators to accessing medication reviews from the perspective of people from ethnic minority communities. Health Expect 2022; 25:1432-1443. [PMID: 35384182 PMCID: PMC9327850 DOI: 10.1111/hex.13482] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/04/2022] [Accepted: 03/09/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Regular reviews of medications, including prescription reviews and adherence reviews, are vital to support pharmacological effectiveness and optimize health outcomes for patients. Despite being more likely to report a long‐term illness that requires medication when compared to their white counterparts, individuals from ethnic minority communities are less likely to engage with regular medication reviews, with inequalities negatively affecting their access. It is important to understand what barriers may exist that impact the access of those from ethnic minority communities and to identify measures that may act to facilitate improved service accessibility for these groups. Methods Semi‐structured interviews were conducted between June and August 2021 using the following formats as permitted by governmental COVID‐19 restrictions: in person, over the telephone or via video call. Perspectives on service accessibility and any associated barriers and facilitators were discussed. Interviews were audio‐recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Health Research Authority (ref: 21/HRA/1426). Results In total 20 participants from ethnic minority communities were interviewed; these participants included 16 UK citizens, 2 refugees and 2 asylum seekers, and represented a total of 5 different ethnic groups. Three themes were developed from the data regarding the perceived barriers and facilitators affecting access to medication reviews and identified approaches to improve the accessibility of such services for ethnic minority patients. These centred on (1) building knowledge and understanding about medication reviews; (2) delivering medication review services; and (3) appreciating the lived experience of patients. Conclusion The results of this study have important implications for addressing inequalities that affect ethnic minority communities. Involving patients and practitioners to work collaboratively in coproduction approaches could enable better design, implementation and delivery of accessible medication review services that are culturally competent. Patient or Public Contribution The National Institute for Health Research Applied Research Collaboration and Patient and Public Involvement and Engagement group at Newcastle University supported the study design and conceptualization. Seven patient champions inputted to ensure that the research was conducted, and the findings were reported, with cultural sensitivity.
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Affiliation(s)
- Anna Robinson
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Sile
- School of Pharmacy, Faculty of Medical Sciences, Liverpool John Moores University, Liverpool, UK
| | - Thorrun Govind
- Chair of the English Pharmacy Board, Royal Pharmaceutical Society, London, UK
| | | | - Nicola O'Brien
- Department of Psychology, Northumbria University, Newcastle upon Tyne, UK
| | - Vicki Harris
- Connected Voice Haref, Higham House, Newcastle upon Tyne, UK
| | - Guy Pilkington
- West End Family Health Primary Care Network, Newcastle upon Tyne, UK
| | - Adam Todd
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Andy Husband
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Robinson A, Elarbi M, Todd A, Husband A. A qualitative exploration of the barriers and facilitators affecting ethnic minority patient groups when accessing medicine review services: Perspectives of healthcare professionals. Health Expect 2021; 25:628-638. [PMID: 34951087 PMCID: PMC8957739 DOI: 10.1111/hex.13410] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/29/2021] [Accepted: 12/07/2021] [Indexed: 12/26/2022] Open
Abstract
Introduction Healthcare inequalities and ethnicity are closely related. Evidence has demonstrated that patients from ethnic minority groups are more likely to report a long‐term illness than their white counterparts; yet, in some cases, minority groups have reported poorer adherence to prescribed medicines and may be less likely to access medicine services. Knowledge of the barriers and facilitators that impact ethnic minority access to medicine services is required to ensure that services are fit for purpose to meet and support the needs of all. Methods Semistructured interviews with healthcare professionals were conducted between October and December 2020, using telephone and video call‐based software. Perspectives on barriers and facilitators were discussed. Interviews were audio‐recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Newcastle University Faculty of Medical Sciences Ethics Committee. Results Eighteen healthcare professionals were interviewed across primary, secondary and tertiary care settings; their roles spanned medicine, pharmacy and dentistry. Three themes were developed from the data regarding the perceived barriers and facilitators affecting access to medicine services for ethnic minority patients. These centred around patient expectations of health services; appreciating cultural stigma and acceptance of certain health conditions; and individually addressing communication and language needs. Conclusion This study provides much‐needed evidence relating to the barriers and facilitators impacting minority ethnic communities when seeking medicine support. The results of this study have important implications for the delivery of person‐centred care. Involving patients and practitioners in coproduction approaches could enable the design and delivery of culturally sensitive and accessible medicine services. Patient or Public Contribution The Patient and Public Involvement and Engagement (PPIE) group at Newcastle University had extensive input in the design and concept of this study before the research was undertaken. Throughout the work, a patient champion (Harpreet Guraya) had input in the project by ensuring that the study was conducted, and the findings were reported, with cultural sensitivity.
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Affiliation(s)
- Anna Robinson
- School of Pharmacy, Newcastle University, Newcastle Upon Tyne, UK.,Institute of Population Health Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Muna Elarbi
- School of Pharmacy, Newcastle University, Newcastle Upon Tyne, UK
| | - Adam Todd
- School of Pharmacy, Newcastle University, Newcastle Upon Tyne, UK.,Institute of Population Health Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Andy Husband
- School of Pharmacy, Newcastle University, Newcastle Upon Tyne, UK.,Institute of Population Health Sciences, Newcastle University, Newcastle Upon Tyne, UK
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Rankin A, Cadogan CA, Patterson SM, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2018; 9:CD008165. [PMID: 30175841 PMCID: PMC6513645 DOI: 10.1002/14651858.cd008165.pub4] [Citation(s) in RCA: 196] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Audrey Rankin
- Queen's University BelfastSchool of Pharmacy97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
| | - Cathal A Cadogan
- Royal College of Surgeons in IrelandSchool of PharmacyDublinIreland
| | - Susan M Patterson
- No affiliationIntegrated Care40 Dunmore RoadBallynahinchNorthern IrelandUKBT24 8PR
| | - Ngaire Kerse
- University of AucklandDepartment of General Practice and Primary Health CarePrivate Bag 92019AucklandNew Zealand
| | - Chris R Cardwell
- Queen's University BelfastCentre for Public HealthSchool of MedicineDentistry and Biomedical SciencesBelfastNorthern IrelandUKBT12 6BJ
| | - Marie C Bradley
- National Cancer Institute9609 Medical Center DriveRockvilleMDUSA20850
| | - Cristin Ryan
- Trinity College DublinSchool of Pharmacy and Pharmaceutical Sciences111 St Stephen’s GreenDublin 2Ireland
| | - Carmel Hughes
- Queen's University BelfastSchool of Pharmacy97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
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REDUCING POTENTIALLY INAPPROPRIATE PRESCRIBING FOR OLDER PEOPLE IN PRIMARY CARE: COST-EFFECTIVENESS OF THE OPTI-SCRIPT INTERVENTION. Int J Technol Assess Health Care 2017; 33:494-503. [DOI: 10.1017/s0266462317000782] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objectives: This study examines the cost-effectiveness of the OPTI-SCRIPT intervention on potentially inappropriate prescribing in primary care.Methods: Economic evaluation, using incremental cost-effectiveness and cost utility analyses, conducted alongside a cluster randomized controlled trial of twenty-one general practices and 196 patients, to compare a multifaceted intervention with usual practice in primary care in Ireland. Potentially inappropriate prescriptions (PIPs) were determined by a pharmacist. Incremental costs, PIPs, and quality-adjusted life-years (QALYs) at 12-month follow-up were estimated using multilevel regression. Uncertainty was explored using cost-effectiveness acceptability curves.Results: The intervention was associated with a nonsignificant mean cost increase of €407 (95 percent CIs, −357–1170), a significant mean reduction in PIPs of 0.379 (95 percent CI, 0.092–0.666), and a nonsignificant mean increase in QALYs of 0.013 (95 percent CIs, −0.016–0.042). The incremental cost per PIP avoided was €1,269 (95 percent CI, −1400–6302) and the incremental cost per QALY gained was €30,535 (95 percent CI, −334,846–289,498). The probability of the intervention being cost-effective was 0.602 at a threshold value of €45,000 per QALY gained and was at least 0.845 at threshold values of €2,500 per PIP avoided and higher.Conclusions: While the OPTI-SCRIPT intervention was effective in reducing potentially inappropriate prescribing in primary care in Ireland, our findings highlight the uncertainty with respect to its cost-effectiveness. Further studies are required to explore the health and economic implications of interventions targeting potentially inappropriate prescribing.
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Khalil H, Bell B, Chambers H, Sheikh A, Avery AJ. Professional, structural and organisational interventions in primary care for reducing medication errors. Cochrane Database Syst Rev 2017; 10:CD003942. [PMID: 28977687 PMCID: PMC6485628 DOI: 10.1002/14651858.cd003942.pub3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Medication-related adverse events in primary care represent an important cause of hospital admissions and mortality. Adverse events could result from people experiencing adverse drug reactions (not usually preventable) or could be due to medication errors (usually preventable). OBJECTIVES To determine the effectiveness of professional, organisational and structural interventions compared to standard care to reduce preventable medication errors by primary healthcare professionals that lead to hospital admissions, emergency department visits, and mortality in adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases, and two trial registries on 4 October 2016, together with reference checking, citation searching and contact with study authors to identify additional studies. We also searched several sources of grey literature. SELECTION CRITERIA We included randomised trials in which healthcare professionals provided community-based medical services. We also included interventions in outpatient clinics attached to a hospital where people are seen by healthcare professionals but are not admitted to hospital. We only included interventions that aimed to reduce medication errors leading to hospital admissions, emergency department visits, or mortality. We included all participants, irrespective of age, who were prescribed medication by a primary healthcare professional. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data. Each of the outcomes (hospital admissions, emergency department visits, and mortality), are reported in natural units (i.e. number of participants with an event per total number of participants at follow-up). We presented all outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We used the GRADE tool to assess the certainty of evidence. MAIN RESULTS We included 30 studies (169,969 participants) in the review addressing various interventions to prevent medication errors; four studies addressed professional interventions (8266 participants) and 26 studies described organisational interventions (161,703 participants). We did not find any studies addressing structural interventions. Professional interventions included the use of health information technology to identify people at risk of medication problems, computer-generated care suggested and actioned by a physician, electronic notification systems about dose changes, drug interventions and follow-up, and educational interventions on drug use aimed at physicians to improve drug prescriptions. Organisational interventions included medication reviews by pharmacists, nurses or physicians, clinician-led clinics, and home visits by clinicians.There is a great deal of diversity in types of professionals involved and where the studies occurred. However, most (61%) of the interventions were conducted by pharmacists or a combination of pharmacists and medical doctors. The studies took place in many different countries; 65% took place in either the USA or the UK. They all ranged from three months to 4.7 years of follow-up, they all took place in primary care settings such as general practice, outpatients' clinics, patients' homes and aged-care facilities. The participants in the studies were adults taking medications and the interventions were undertaken by healthcare professionals including pharmacists, nurses or physicians. There was also evidence of potential bias in some studies, with only 18 studies reporting adequate concealment of allocation and only 12 studies reporting appropriate protection from contamination, both of which may have influenced the overall effect estimate and the overall pooled estimate. Professional interventionsProfessional interventions probably make little or no difference to the number of hospital admissions (risk ratio (RR) 1.24, 95% confidence interval (CI) 0.79 to 1.96; 2 studies, 3889 participants; moderate-certainty evidence). Professional interventions make little or no difference to the number of participants admitted to hospital (adjusted RR 0.99, 95% CI 0.92 to 1.06; 1 study, 3661 participants; high-certainty evidence). Professional interventions may make little or no difference to the number of emergency department visits (adjusted RR 0.71, 95% CI 0.50 to 1.02; 2 studies, 1067 participants; low-certainty evidence). Professional interventions probably make little or no difference to mortality in the study population (adjusted RR 0.98, 95% CI 0.82 to 1.17; 1 study, 3538 participants; moderate-certainty evidence). Organisational interventionsOverall, it is uncertain whether organisational interventions reduce the number of hospital admissions (adjusted RR 0.85, 95% CI 0.71 to 1.03; 11 studies, 6203 participants; very low-certainty evidence). Overall, organisational interventions may make little difference to the total number of people admitted to hospital in favour of the intervention group compared with the control group (adjusted RR 0.92, 95% CI 0.86 to 0.99; 13 studies, 152,237 participants; low-certainty evidence. Overall, it is uncertain whether organisational interventions reduce the number of emergency department visits in favour of the intervention group compared with the control group (adjusted RR 0.75, 95% CI 0.49 to 1.15; 5 studies, 1819 participants; very low-certainty evidence. Overall, it is uncertain whether organisational interventions reduce mortality in favour of the intervention group (adjusted RR 0.94, 95% CI 0.85 to 1.03; 12 studies, 154,962 participants; very low-certainty evidence. AUTHORS' CONCLUSIONS Based on moderate- and low-certainty evidence, interventions in primary care for reducing preventable medication errors probably make little or no difference to the number of people admitted to hospital or the number of hospitalisations, emergency department visits, or mortality. The variation in heterogeneity in the pooled estimates means that our results should be treated cautiously as the interventions may not have worked consistently across all studies due to differences in how the interventions were provided, background practice, and culture or delivery of the interventions. Larger studies addressing both professional and organisational interventions are needed before evidence-based recommendations can be made. We did not identify any structural interventions and only four studies used professional interventions, and so more work needs to be done with these types of interventions. There is a need for high-quality studies describing the interventions in more detail and testing patient-related outcomes.
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Affiliation(s)
- Hanan Khalil
- Faculty of Medicine, Nursing and Health Sciences, School of Rural Health, PO Box 973, Moe, Victoria, Australia, 3825
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Clyne B, Fitzgerald C, Quinlan A, Hardy C, Galvin R, Fahey T, Smith SM. Interventions to Address Potentially Inappropriate Prescribing in Community-Dwelling Older Adults: A Systematic Review of Randomized Controlled Trials. J Am Geriatr Soc 2017; 64:1210-22. [PMID: 27321600 DOI: 10.1111/jgs.14133] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To perform a systematic review to determine the effectiveness of interventions designed to reduce potentially inappropriate prescribing (PIP) in community-dwelling older adults. DESIGN Systematic review and narrative synthesis. SETTING Primary and community care. PARTICIPANTS Community-dwelling older adults. MEASUREMENTS The primary outcome was change in PIP measured using implicit or explicit tools. Studies were grouped into organizational, professional, financial, regulatory, and multifaceted interventions. RESULTS Twelve randomized controlled trials were identified with baseline PIP prevalence of 18% to 100%. Four of six organizational interventions reported a reduction in PIP, particularly through pharmacists conducting medication reviews. Evidence of the effectiveness of multidisciplinary teams was weak. Both of the two professional (targeting prescriber's directly) interventions were computerized clinical decision support interventions and were effective in decreasing new PIP but not existing PIP. Three of four multifaceted approaches were effective in reducing PIP. The risk of bias was often high, particularly in reporting selection bias. CONCLUSION Interventions including organizational (pharmacist interventions), professional (computerized clinical decision support systems), and multifaceted approaches appear beneficial in terms of reducing PIP, but the range of effect sizes reported was modest, and it is unclear whether such interventions can result in clinically significant improvements in patient outcomes. Ongoing assessment of interventions to reduce PIP is needed in community-dwelling older adults, particularly in relation to preventing initiation of PIP.
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Affiliation(s)
- Barbara Clyne
- Health Research Board Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ciaran Fitzgerald
- Health Research Board Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Aisling Quinlan
- Health Research Board Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Colin Hardy
- Health Research Board Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Rose Galvin
- Health Research Board Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Clinical Therapies, University of Limerick, Castletroy, Co., Limerick, Ireland
| | - Tom Fahey
- Health Research Board Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Susan M Smith
- Health Research Board Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
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Clyne B, Cooper JA, Boland F, Hughes CM, Fahey T, Smith SM. Beliefs about prescribed medication among older patients with polypharmacy: a mixed methods study in primary care. Br J Gen Pract 2017; 67:e507-e518. [PMID: 28533200 PMCID: PMC5540192 DOI: 10.3399/bjgp17x691073] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 02/23/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Polypharmacy (≥5 medications) is common in older patients and is associated with adverse outcomes. Patients' beliefs about medication can influence their expectations for medication, adherence, and willingness to deprescribe. Few studies have examined beliefs about prescribed medication among older patients with polypharmacy in primary care. AIM To explore medication-related beliefs in older patients with polypharmacy and factors that might influence beliefs. DESIGN AND SETTING A mixed methods study utilising data from a randomised controlled trial aiming to decrease potentially inappropriate prescribing in older patients (≥70 years) in Ireland. METHOD Beliefs were assessed quantitatively and qualitatively. Participants completed the Beliefs about Medicines Questionnaire by indicating their degree of agreement with individual statements about medicines on a 5-point Likert scale. Semi-structured qualitative interviews were conducted with a purposive sample of participants. Interviews were transcribed verbatim and a thematic analysis conducted. Quantitative and qualitative data were analysed separately and triangulated during the interpretation stage. RESULTS In total, 196 patients were included (mean age 76.7 years, SD 4.9, 54% male), with a mean of 9.5 (SD 4.1) medications per patient. The majority (96.3%) believed strongly in the necessity of their medication, while 33.9% reported strong concerns. Qualitative data confirmed these coexisting positive and negative attitudes to medications and suggested the importance of patients' trust in GPs in establishing positive beliefs and potential willingness to deprescribe. CONCLUSION Participants reported strong beliefs in medications with coexisting positive and negative attitudes. The doctor-patient relationship may have influenced beliefs and attitudes towards medicines, highlighting the importance of strong doctor-patient relationships, which need to be considered in the context of deprescribing.
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Affiliation(s)
- Barbara Clyne
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin
| | | | - Fiona Boland
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin
| | | | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin
| | - Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin
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Kouladjian L, Gnjidic D, Chen TF, Hilmer SN. Development, validation and evaluation of an electronic pharmacological tool: The Drug Burden Index Calculator©. Res Social Adm Pharm 2016; 12:865-875. [DOI: 10.1016/j.sapharm.2015.11.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 11/04/2015] [Accepted: 11/04/2015] [Indexed: 12/01/2022]
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Clyne B, Cooper JA, Hughes CM, Fahey T, Smith SM. 'Potentially inappropriate or specifically appropriate?' Qualitative evaluation of general practitioners views on prescribing, polypharmacy and potentially inappropriate prescribing in older people. BMC FAMILY PRACTICE 2016; 17:109. [PMID: 27515854 PMCID: PMC4982127 DOI: 10.1186/s12875-016-0507-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 08/03/2016] [Indexed: 11/12/2022]
Abstract
Background Potentially inappropriate prescribing (PIP) is common in older people in primary care, as evidenced by a significant body of quantitative research. However, relatively few qualitative studies have investigated the phenomenon of PIP and its underlying processes from the perspective of general practitioners (GPs). The aim of this paper is to explore qualitatively, GP perspectives regarding prescribing and PIP in older primary care patients. Method Semi-structured qualitative interviews were conducted with GPs participating in a randomised controlled trial (RCT) of an intervention to decrease PIP in older patients (≥70 years) in Ireland. Interviews were conducted with GP participants (both intervention and control) from the OPTI-SCRIPT cluster RCT as part of the trial process evaluation between January and July 2013. Interviews were conducted by one interviewer and audio recorded. Interviews were transcribed verbatim and a thematic analysis was conducted. Results Seventeen semi-structured interviews were conducted (13 male; 4 female). Three main, inter-related themes emerged (complex prescribing environment, paternalistic doctor-patient relationship, and relevance of PIP concept). Patient complexity (e.g. polypharmacy, multimorbidity), as well as prescriber complexity (e.g. multiple prescribers, poor communication, restricted autonomy) were all identified as factors contributing to a complex prescribing environment where PIP could occur, as was a paternalistic-doctor patient relationship. The concept of PIP was perceived to be of variable usefulness to GPs and the criteria to measure it may be at odds with the complex processes of prescribing for this patient population. Conclusions Several inter-related factors contributing to the occurrence of PIP were identified, some of which may be amenable to intervention. Improvement strategies focused on improved management of polypharmacy and multimorbidity, and communication across primary and secondary care could result in substantial improvements in PIP. Trial registration Current controlled trials ISRCTN41694007
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Affiliation(s)
- Barbara Clyne
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland.
| | - Janine A Cooper
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland.,School of Pharmacy, Queen's University Belfast (QUB), 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Carmel M Hughes
- School of Pharmacy, Queen's University Belfast (QUB), 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland
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Clyne B, Cooper JA, Hughes CM, Fahey T, Smith SM. A process evaluation of a cluster randomised trial to reduce potentially inappropriate prescribing in older people in primary care (OPTI-SCRIPT study). Trials 2016; 17:386. [PMID: 27488272 PMCID: PMC4973100 DOI: 10.1186/s13063-016-1513-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 07/20/2016] [Indexed: 11/15/2022] Open
Abstract
Background The OPTI-SCRIPT cluster randomised controlled trial (RCT) found that a three-phase multifaceted intervention including academic detailing with a pharmacist, GP-led medicines reviews, supported by web-based pharmaceutical treatment algorithms, and tailored patient information leaflets, was effective in reducing potentially inappropriate prescribing (PIP) in Irish primary care. We report a process evaluation exploring the implementation of the intervention, the experiences of those participating in the study and lessons for future implementation. Methods The OPTI-SCRIPT trial included 21 GP practices and 196 patients. The process evaluation used mixed methods. Quantitative data were collected from all GP practices and semi-structured interviews were conducted with GPs from intervention and control groups, and a purposive sample of patients from the intervention group. All interviews were transcribed verbatim and analysed using a thematic analysis. Results Despite receiving a standardised academic detailing session, intervention delivery varied among GP practices. Just over 70 % of practices completed medicines review as recommended with the patient present. Only single-handed practices conducted reviews without patients present, highlighting the influence of practice characteristics and resources on variation. Medications were more likely to be completely stopped or switched to another more appropriate medication when reviews were conducted with patients present. The patient information leaflets were not used by any of the intervention practices. Both GP (32 %) and patient (40 %) recruitment rates were modest. For those who did participate, overall, the experience was positively viewed, with GPs and patients referring to the value of medication reviews to improve prescribing and reduce unnecessary medications. Lack of time in busy GP practices and remuneration were identified as organisational barriers to future implementation. Conclusions The OPTI-SCRIPT intervention was positively viewed by both GPs and patients, both of whom valued the study’s objectives. Patient information leaflets were not a successful component of the intervention. Academic detailing and medication reviews are important components in changing PIP, and having patients present during the review process seems to be a more effective approach for decreasing PIP. Trial registration Current controlled trials ISRCTN41694007. Registered on 21 March 2012.
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Affiliation(s)
- Barbara Clyne
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland.
| | - Janine A Cooper
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland.,School of Pharmacy, Queen's University Belfast (QUB), 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Carmel M Hughes
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland.,School of Pharmacy, Queen's University Belfast (QUB), 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Tom Fahey
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland
| | - Susan M Smith
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland
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Clyne B, Smith SM, Hughes CM, Boland F, Cooper JA, Fahey T. Sustained effectiveness of a multifaceted intervention to reduce potentially inappropriate prescribing in older patients in primary care (OPTI-SCRIPT study). Implement Sci 2016; 11:79. [PMID: 27255504 PMCID: PMC4890249 DOI: 10.1186/s13012-016-0442-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 05/23/2016] [Indexed: 11/27/2022] Open
Abstract
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 .
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Affiliation(s)
- Barbara Clyne
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland.
| | - Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland
| | - Carmel M Hughes
- School of Pharmacy, Queen's University Belfast (QUB), 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland
| | - Janine A Cooper
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland
- School of Pharmacy, Queen's University Belfast (QUB), 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland
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Anderson K, Freeman C, Rowett D, Burrows J, Scott I, Rigby D. Polypharmacy, deprescribing and shared decision-making in primary care: the role of the accredited pharmacist. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/jppr.1164] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Kristen Anderson
- Centre of Research Excellence in Quality & Safety in Integrated Primary-Secondary Care, School of Medicine; The University of Queensland, Brisbane; Queensland Australia
- Charming Institute; Brisbane Australia
- School of Pharmacy; University of Queensland; Brisbane Australia
| | - Christopher Freeman
- Charming Institute; Brisbane Australia
- School of Pharmacy; University of Queensland; Brisbane Australia
| | - Debra Rowett
- School of Pharmacy; University of Queensland; Brisbane Australia
- Director, Drug and Therapeutic Information Service; Repatriation General Hospital; Daw Park Australia
| | - Judith Burrows
- School of Pharmacy; University of Queensland; Brisbane Australia
| | - Ian Scott
- Centre of Research Excellence in Quality & Safety in Integrated Primary-Secondary Care, School of Medicine; The University of Queensland, Brisbane; Queensland Australia
- Department of Internal Medicine and Clinical Epidemiology; Princess Alexandra Hospital; Woolloongabba Australia
- School of Medicine; University of Queensland; Brisbane Australia
| | - Deborah Rigby
- School of Pharmacy; University of Queensland; Brisbane Australia
- DR Pharmacy Consulting; Brisbane Australia
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Clyne B, Smith SM, Hughes CM, Boland F, Bradley MC, Cooper JA, Fahey T. Effectiveness of a Multifaceted Intervention for Potentially Inappropriate Prescribing in Older Patients in Primary Care: A Cluster-Randomized Controlled Trial (OPTI-SCRIPT Study). Ann Fam Med 2015; 13:545-53. [PMID: 26553894 PMCID: PMC4639380 DOI: 10.1370/afm.1838] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Potentially inappropriate prescribing (PIP) is common in older people and can result in increased morbidity, adverse drug events, and hospitalizations. The OPTI-SCRIPT study (Optimizing Prescribing for Older People in Primary Care, a cluster-randomized controlled trial) tested the effectiveness of a multifaceted intervention for reducing PIP in primary care. METHODS We conducted a cluster-randomized controlled trial among 21 general practitioner practices and 196 patients with PIP. Intervention participants received a complex, multifaceted intervention incorporating academic detailing; review of medicines 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. We performed intention-to-treat analysis using random-effects regression. RESULTS All 21 practices and 190 patients were followed. At intervention completion, patients in the intervention group had significantly lower odds of having PIP than patients in the control group (adjusted odds ratio = 0.32; 95% CI, 0.15-0.70; P = .02). The mean number of PIP drugs in the intervention group was 0.70, compared with 1.18 in the control group (P = .02). The intervention group was almost one-third less likely than the control group to have PIP drugs at intervention completion, but this difference was not significant (incidence rate ratio = 0.71; 95% CI, 0.50-1.02; P = .49). The intervention was effective in reducing proton pump inhibitor prescribing (adjusted odds ratio = 0.30; 95% CI, 0.14-0.68; P = .04). CONCLUSIONS The OPTI-SCRIPT intervention incorporating academic detailing with a pharmacist, and a review of medicines with web-based pharmaceutical treatment algorithms, was effective in reducing PIP, particularly in modifying prescribing of proton pump inhibitors, the most commonly occurring PIP drugs nationally.
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Affiliation(s)
- Barbara Clyne
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Dublin, Republic of Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Dublin, Republic of Ireland
| | - Carmel M Hughes
- School of Pharmacy, Queen's University Belfast (QUB), Belfast, Northern Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Dublin, Republic of Ireland
| | | | - Janine A Cooper
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Dublin, Republic of Ireland School of Pharmacy, Queen's University Belfast (QUB), Belfast, Northern Ireland
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Li Q, Spooner SA, Kaiser M, Lingren N, Robbins J, Lingren T, Tang H, Solti I, Ni Y. An end-to-end hybrid algorithm for automated medication discrepancy detection. BMC Med Inform Decis Mak 2015; 15:37. [PMID: 25943550 PMCID: PMC4427951 DOI: 10.1186/s12911-015-0160-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 04/27/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In this study we implemented and developed state-of-the-art machine learning (ML) and natural language processing (NLP) technologies and built a computerized algorithm for medication reconciliation. Our specific aims are: (1) to develop a computerized algorithm for medication discrepancy detection between patients' discharge prescriptions (structured data) and medications documented in free-text clinical notes (unstructured data); and (2) to assess the performance of the algorithm on real-world medication reconciliation data. METHODS We collected clinical notes and discharge prescription lists for all 271 patients enrolled in the Complex Care Medical Home Program at Cincinnati Children's Hospital Medical Center between 1/1/2010 and 12/31/2013. A double-annotated, gold-standard set of medication reconciliation data was created for this collection. We then developed a hybrid algorithm consisting of three processes: (1) a ML algorithm to identify medication entities from clinical notes, (2) a rule-based method to link medication names with their attributes, and (3) a NLP-based, hybrid approach to match medications with structured prescriptions in order to detect medication discrepancies. The performance was validated on the gold-standard medication reconciliation data, where precision (P), recall (R), F-value (F) and workload were assessed. RESULTS The hybrid algorithm achieved 95.0%/91.6%/93.3% of P/R/F on medication entity detection and 98.7%/99.4%/99.1% of P/R/F on attribute linkage. The medication matching achieved 92.4%/90.7%/91.5% (P/R/F) on identifying matched medications in the gold-standard and 88.6%/82.5%/85.5% (P/R/F) on discrepant medications. By combining all processes, the algorithm achieved 92.4%/90.7%/91.5% (P/R/F) and 71.5%/65.2%/68.2% (P/R/F) on identifying the matched and the discrepant medications, respectively. The error analysis on algorithm outputs identified challenges to be addressed in order to improve medication discrepancy detection. CONCLUSION By leveraging ML and NLP technologies, an end-to-end, computerized algorithm achieves promising outcome in reconciling medications between clinical notes and discharge prescriptions.
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Affiliation(s)
- Qi Li
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7024, Cincinnati, OH, 45229-3039, USA
| | - Stephen Andrew Spooner
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7024, Cincinnati, OH, 45229-3039, USA.,Chief Medical Information Officer, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Megan Kaiser
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7024, Cincinnati, OH, 45229-3039, USA
| | - Nataline Lingren
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7024, Cincinnati, OH, 45229-3039, USA
| | - Jessica Robbins
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7024, Cincinnati, OH, 45229-3039, USA
| | - Todd Lingren
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7024, Cincinnati, OH, 45229-3039, USA
| | - Huaxiu Tang
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7024, Cincinnati, OH, 45229-3039, USA
| | - Imre Solti
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7024, Cincinnati, OH, 45229-3039, USA.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Yizhao Ni
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7024, Cincinnati, OH, 45229-3039, USA.
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Vivas-Consuelo D, Usó-Talamantes R, Trillo-Mata JL, Mendez-Valera P. Methods to control the pharmaceutical cost impact of chronic conditions in the elderly. Expert Rev Pharmacoecon Outcomes Res 2015; 15:425-37. [DOI: 10.1586/14737167.2015.1017564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- David Vivas-Consuelo
- 1Research Centre for Health Economics and Management, Universitat Politècnica de València, Edificio7J, Campus de Vera s/n 46022-Valencia, Spain
| | - Ruth Usó-Talamantes
- 2Valencian Health Department (Conselleria de Sanitat), General Directorate of Pharmacy and Pharmaceutical Products, Valencia, Spain
| | - José Luis Trillo-Mata
- 2Valencian Health Department (Conselleria de Sanitat), General Directorate of Pharmacy and Pharmaceutical Products, Valencia, Spain
| | - Pablo Mendez-Valera
- 2Valencian Health Department (Conselleria de Sanitat), General Directorate of Pharmacy and Pharmaceutical Products, Valencia, Spain
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Cahir C, Bennett K, Teljeur C, Fahey T. Potentially inappropriate prescribing and adverse health outcomes in community dwelling older patients. Br J Clin Pharmacol 2015; 77:201-10. [PMID: 23711082 DOI: 10.1111/bcp.12161] [Citation(s) in RCA: 160] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 04/21/2013] [Indexed: 11/29/2022] Open
Abstract
AIMS This study aimed to determine the association between potentially inappropriate prescribing (PIP) and health related outcomes [adverse drug events (ADEs), health related quality of life (HRQOL) and hospital accident and emergency (A&E) visits] in older community dwelling patients. METHODS A retrospective cohort study of 931 community dwelling patients aged ≥70 years in 15 general practices in Ireland in 2010. PIP was defined by the Screening Tool of Older Person's Prescriptions (STOPP). ADEs were measured by patient self-report and medical record for the previous 6 months and reviewed by two independent clinicians. HRQOL was measured by the EQ-5D. A&E visits were measured by patients' medical records and self-report. Multilevel logistic, linear and Poisson regression examined how ADEs, HRQOL and A&E visits varied by PIP after adjusting for patient and practice level covariates: socioeconomic status, co-morbidity, number of drug classes and adherence. RESULTS The overall prevalence of PIP was 42% (n = 377). Patients with ≥2 PIP indicators were twice as likely to have an ADE (adjusted OR 2.21; 95% CI 1.02, 4.83, P < 0.05), have a significantly lower mean HRQOL utility (adjusted coefficient -0.09, SE 0.02, P < 0.001) and nearly a two-fold increased risk in the expected rate of A&E visits (adjusted IRR 1.85; 95% CI 1.32, 2.58, P < 0.001). The number of drug classes and adherence were also significantly associated with these same adverse health outcomes. CONCLUSIONS Reducing PIP in primary care may help lower the burden of ADEs, its associated health care use and costs and enhance quality of life in older patients.
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Affiliation(s)
- Caitriona Cahir
- Department of Pharmacology & Therapeutics, Trinity Centre for Health Sciences, St James Hospital, Dublin, 8
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18
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Santos APAL, Silva DT, Alves-Conceição V, Antoniolli AR, Lyra DP. Conceptualizing and measuring potentially inappropriate drug therapy. J Clin Pharm Ther 2015; 40:167-76. [PMID: 25682702 DOI: 10.1111/jcpt.12246] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 12/30/2014] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Elderly people are the principal consumers of prescription drugs. The more the medication used by the patient, the greater the likelihood there is of the patient being subjected to potentially inappropriate drug therapy (PIDT). PIDT has been measured in the literature with both implicit and explicit tools. The purpose of this review was to assess the use of tools to detect PIDT in various studies and to determine which terms are used to refer to PIDT in practice. METHODS A systematic review was conducted according to the following steps: the first was identification. In this step, studies were selected from different combinations of the descriptors 'aged', 'elderly', 'inappropriate prescribing' and 'drug utilization' in three different languages, using the Embase, Medline, Scielo, Scopus and Web of Science databases. Second, the papers that satisfied the inclusion criteria for data extraction were carefully examined by three evaluators to determine the tools used and terms that referred to PIDT. RESULTS AND DISCUSSION From the combinations of keywords, 8610 articles were found. At the end of the selection process, 119 of the articles complied with the specified criteria. The degree of agreement among evaluators was moderate for the study titles (κ1 = 0·479) and substantial for abstracts (κ2 = 0·647). With respect to the PIDT evaluation criteria used by the studies, 27·7% used two criteria. Of the 27 evaluation criteria identified, the Beers criteria were used by 82·3% of the studies. More than 50 different terms to identify PIDT were found in the literature. WHAT IS NEW AND CONCLUSION This review is the first study to conceptualize and discuss terms that refer to PIDT. At present, there is no consensus regarding terms used to refer to PIDT, with over 50 different terms currently in use. This review shows an increase in the number of articles aimed at evaluating PIDT using implicit and explicit tools.
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Affiliation(s)
- A P A L Santos
- Laboratory of Teaching and Research in Social Pharmacy (LEPFS), Pharmacy College, Federal University of Sergipe, São Cristóvão, Brazil
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Romera L, Orfila F, Segura JM, Ramirez A, Möller M, Fabra ML, Lancho S, Bastida N, Foz G, Fabregat MA, Martí N, Cullell M, Martinez D, Giné M, Bistuer A, Cendrós P, Pérez E. Effectiveness of a primary care based multifactorial intervention to improve frailty parameters in the elderly: a randomised clinical trial: rationale and study design. BMC Geriatr 2014; 14:125. [PMID: 25427568 PMCID: PMC4258273 DOI: 10.1186/1471-2318-14-125] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 11/13/2014] [Indexed: 11/30/2022] Open
Abstract
Background Frailty is a highly prevalent condition in old age leading to vulnerability and greater risk of adverse health outcomes and disability. Detecting and tackling frailty at an early stage can prevent disability. The purpose of this study is to evaluate the effectiveness of a multifactorial intervention program to modify frailty parameters, muscle strength, and physical and cognitive performance in people aged 65 years or more. It also assesses changes from baseline in falls, hospitalizations, nutritional risk, disability, institutionalization, and home-care. Methods/design The current study is a randomised single-blind, parallel-group clinical trial, with a one and a half year follow-up, conducted in eight Primary Health Care Centres located in the city of Barcelona. Inclusion criteria are to be aged 65 years or older with positive frailty screening, timed get-up-and-go test between 10 to 30 seconds, and Cognition Mini-Exam (MEC-35) of Lobo greater than or equal to 18. A total of 352 patients have been equally divided into two groups: intervention and control. Sample size calculated to detect a 0.5 unit difference in the Short Physical Performance Battery (Common SD: 1.42, 20% lost to follow-up). In the intervention group three different actions on frailty dimensions: rehabilitative therapy plus intake of hyperproteic nutritional shakes, memory workshop, and medication review are applied to sets of 16 patients. Participants in both intervention and control groups receive recommendations on nutrition, healthy lifestyles, and home risks. Evaluations are blinded and conducted at 0, 3, and 18 months. Intention to treat analyses will be performed. Multivariate analysis will be carried out to assess time changes of dependent variables. Discussion It is expected that this study will provide evidence of the effectiveness of a multidisciplinary intervention on delaying the progression from frailty to disability in the elderly. It will help improve the individual’s quality of life and also reduce the rates of falls, hospital admissions, and institutionalizations, thus making the health care system more efficient. This preventive intervention can be adapted to diverse settings and be routinely included in Primary Care Centres as a Preventive Health Programme. Trial registration ClinicalTrials.gov PRS:NCT01969526. Date of registration: 10/21/2013.
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Affiliation(s)
| | - Francesc Orfila
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.
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Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2014:CD008165. [PMID: 25288041 DOI: 10.1002/14651858.cd008165.pub3] [Citation(s) in RCA: 187] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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. OBJECTIVES This review sought 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 In November 2013, for this first update, a range of literature databases including MEDLINE and EMBASE were searched, and handsearching of reference lists was performed. Search terms included 'polypharmacy', 'medication appropriateness' and 'inappropriate prescribing'. SELECTION CRITERIA A range of study designs were eligible. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people 65 years of age and older in which a validated measure of appropriateness was used (e.g. Beers criteria, Medication Appropriateness Index (MAI)). DATA COLLECTION AND ANALYSIS Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. Study-specific estimates were pooled, and a random-effects model was used to yield summary estimates of effect and 95% confidence intervals (CIs). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall quality of evidence for each pooled outcome. MAIN RESULTS Two studies were added to this review to bring the total number of included studies to 12. One intervention consisted of computerised decision support; 11 complex, multi-faceted pharmaceutical approaches to interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals, such as prescribers and pharmacists. Appropriateness of prescribing was measured using validated tools, including the MAI score post intervention (eight studies), Beers criteria (four studies), STOPP criteria (two studies) and START criteria (one study). Interventions included in this review resulted in a reduction in inappropriate medication usage. Based on the GRADE approach, the overall quality of evidence for all pooled outcomes ranged from very low to low. A greater reduction in MAI scores between baseline and follow-up was seen in the intervention group when compared with the control group (four studies; mean difference -6.78, 95% CI -12.34 to -1.22). Postintervention pooled data showed a lower summated MAI score (five studies; mean difference -3.88, 95% CI -5.40 to -2.35) and fewer Beers drugs per participant (two studies; mean difference -0.1, 95% CI -0.28 to 0.09) in the intervention group compared with the control group. Evidence of the effects of interventions on hospital admissions (five studies) and of medication-related problems (six studies) was conflicting. AUTHORS' CONCLUSIONS It is unclear whether interventions to improve appropriate polypharmacy, such as pharmaceutical care, resulted in clinically significant improvement; however, they appear beneficial in terms of reducing inappropriate prescribing.
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Affiliation(s)
- Susan M Patterson
- No affiliation, 12-22 Linenhall Street, Belfast, Northern Ireland, UK, BT2 8BS
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Clyne B, Bradley MC, Hughes CM, Clear D, McDonnell R, Williams D, Fahey T, Smith SM. Addressing potentially inappropriate prescribing in older patients: development and pilot study of an intervention in primary care (the OPTI-SCRIPT study). BMC Health Serv Res 2013; 13:307. [PMID: 23941110 PMCID: PMC3751793 DOI: 10.1186/1472-6963-13-307] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 08/12/2013] [Indexed: 11/17/2022] Open
Abstract
Background Potentially inappropriate prescribing (PIP) in older people is common in primary care and can result in increased morbidity, adverse drug events, hospitalizations and mortality. The prevalence of PIP in Ireland is estimated at 36% with an associated expenditure of over €45 million in 2007. The aim of this paper is to describe the application of the Medical Research Council (MRC) framework to the development of an intervention to decrease PIP in Irish primary care. Methods The MRC framework for the design and evaluation of complex interventions guided the development of the study intervention. In the development stage, literature was reviewed and combined with information obtained from experts in the field using a consensus based methodology and patient cases to define the main components of the intervention. In the pilot stage, five GPs tested the proposed intervention. Qualitative interviews were conducted with the GPs to inform the development and implementation of the intervention for the main randomised controlled trial. Results The literature review identified PIP criteria for inclusion in the study and two initial intervention components - academic detailing and medicines review supported by therapeutic treatment algorithms. Through patient case studies and a focus group with a group of 8 GPs, these components were refined and a third component of the intervention identified - patient information leaflets. The intervention was tested in a pilot study. In total, eight medicine reviews were conducted across five GP practices. These reviews addressed ten instances of PIP, nine of which were addressed in the form of either a dose reduction or a discontinuation of a targeted medication. Qualitative interviews highlighted that GPs were receptive to the intervention but patient preference and time needed both to prepare for and conduct the medicines review, emerged as potential barriers. Findings from the pilot study allowed further refinement to produce the finalised intervention of academic detailing with a pharmacist, medicines review with web-based therapeutic treatment algorithms and tailored patient information leaflets. Conclusions The MRC framework was used in the development of the OPTI-SCRIPT intervention to decrease the level of PIP in primary care in Ireland. Its application ensured that the intervention was developed using the best available evidence, was acceptable to GPs and feasible to deliver in the clinical setting. The effectiveness of this intervention is currently being tested in a pragmatic cluster randomised controlled trial. Trial registration Current controlled trials ISRCTN41694007
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Affiliation(s)
- Barbara Clyne
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland.
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