Barriers to effective prescribing in older adults: applying the theoretical domains framework in the ambulatory setting - a scoping review

Assessing the prevalence of Beers medication utilization in the Medicare Part D population in 2020

BACKGROUND

Medication utilization has been increasing in the U.S. year-over-year for several decades. As older adults take more medications, there is a higher risk of them being exposed to drug-drug or drug-disease interactions. The American Geriatrics Society in 2019 updated their Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults. The objective of this study was to assess the prevalence of utilization of medications included in the 2019 Beers Criteria.

METHODS

An analysis was conducted using the Medicare Part D Provider Utilization and Payment Data Public Use File for calendar-year 2020. Medications identified in the 2019 Beers Criteria were applied to the analysis. Two categories of medications were assessed: (1) "Avoid" and (2) "Use With Caution."

RESULTS

In 2020, 56 million prescriptions were dispensed to Medicare patients 65 years and older that are recommended to be avoided without exception (4.7% of all prescriptions) totaling $957 million in medication costs. The most utilized medication classes in this category were benzodiazepines (25,949,994 prescriptions), "Z-drugs" (6,204,909 prescriptions), long-acting sulfonylureas (5,306,577 prescriptions), 1st-generation antihistamines (5,049,289 prescriptions), and tricyclic antidepressants (4,190,062 prescriptions). Additionally, 135 million prescriptions were dispensed to Medicare beneficiaries 65 years and older for medications which the Beers Criteria states to use caution (11.3% of all prescriptions) exceeding $2.85 billion in medication costs. The most utilized medications for this category were diuretics (74,599,126 prescriptions), selective serotonin reuptake inhibitors (30,033,121 prescriptions), serotonin and norepinephrine reuptake inhibitors (11,858,968 prescriptions), tramadol (11,450,878 prescriptions), and mirtazapine (5,737,304 prescriptions).

CONCLUSION

Even with the existence of the AGS Beers Criteria for PIM Use in Older Adults and its continued updated versions, 16% of medications dispensed to Medicare Part D were potentially inappropriate. Future studies are needed to assess if this has led to worsened outcomes among older adults who utilized these PIM.

Using multiple approaches to develop a physician-pharmacist collaborative care intervention to facilitate appropriate prescribing for older adults with multimorbidity

BACKGROUND AND OBJECTIVES

This article discusses the development process of an intervention to facilitate appropriate prescribing for older adults with multimorbidity at geriatric medicine outpatient clinics. Both effectiveness and implementability were key aims, which were achieved by a systematic combination of different approaches guided by published guidance.

METHODS

Various frameworks and tools were used to guide the intervention development. They include The Medical Research Council Framework for complex health interventions as the overarching framework, supplemented by the Framework of Actions for Intervention Development and a taxonomy of intervention development approaches.

RESULTS

A combination of theory and evidence-based-, implementation-based and partnership approaches were used to develop the intervention. The Behaviour Change Wheel and Theoretical Domains Framework were used for intervention design. Three scoping reviews and two modified Delphi studies were conducted to build an evidence base on prescribing-related barriers and existing interventions. The findings were synthesised, assessed for implementability, and culminated in a co-creation exercise with physicians and pharmacists. The final intervention aims to facilitate collaboration between physicians and pharmacists and to improve communication and documentation of prescribing decisions.

CONCLUSIONS

Multiple approaches may be required when developing interventions that are effective and implementable. The study team's experiences in using published guidance, integrating different approaches, and co-creating the intervention with healthcare professionals provide a useful case study with lessons and insights for developers of complex interventions. Furthermore, systematic reporting of such research-based efforts would contribute to advancement of intervention development in healthcare and reducing research waste.

Factors perceived by health professionals to be barriers or facilitators to caries prevention in children: a systematic review

BACKGROUND

Considered the most prevalent noncommunicable disease in childhood, dental caries is both an individual and a collective burden. While international guidelines highlight prevention as a major strategy for caries management in children, health professionals still struggle to implement prevention into their clinical practice. Further research is needed to understand the gap between the theoretical significance of dental prevention and its lack of implementation in the clinical setting. This systematic review aims to identify and classify factors perceived by health professionals to be barriers or facilitators to caries prevention in children.

METHOD

A systematic literature search was conducted in three electronic databases (Medline, Web of Science and Cairn). Two researchers independently screened titles, abstracts and texts. To be selected, studies had to focus on barriers or facilitators to caries prevention in children and include health professionals as study participants. Qualitative and quantitative studies were selected. The factors influencing caries prevention in children were sorted into 3 main categories (clinician-related factors, patient-related factors, and organizational-related factors) and then classified according to the 14 domains of the theoretical domains framework (TDF).

RESULTS

A total of 1771 references were found by combining manual and database searches. Among them, 26 studies met the inclusion criteria, of which half were qualitative and half were quantitative studies. Dentists (n = 12), pediatricians (n = 11), nurses (n = 9), and physicians (n = 5) were the most frequently interviewed health professionals in our analysis. Barriers and facilitators to caries prevention in children were categorized into 12 TDF domains. The most frequently reported domains were Environmental Context and Resources, Knowledge and Professional Role and Identity.

CONCLUSION

This systematic review found that a wide range of factors influence caries prevention in children. Our analysis showed that barriers to pediatric oral health promotion affect all stages of the health care system. By highlighting the incompatibility between the health care system's organization and the implementation of caries prevention, this study aims to help researchers and policy-makers design new interventions to improve children's access to caries prevention.

TRIAL REGISTRATION

PROSPERO CRD42022304545.

Regional variation of potentially inappropriate medication use and associated factors among older adults: A nationwide register study

BACKGROUND

Certain medications should be used with caution in older persons, which challenges rational prescribing. Potentially inappropriate medications (PIMs) are defined as medicines whose potential risk of harm typically outweighs the clinical benefits in geriatric population. Earlier studies have found regional differences in PIM use, but the factors underlying this phenomenon are unclear.

OBJECTIVE

To compare prescription PIM prevalence among Finnish hospital districts and determine which population characteristics and factors related to social and health care are associated with regional variation.

METHODS

This nationwide register study was based on the Prescription Centre data on all people aged ≥75 years in 2017-2019. Hospital district (n = 20) characteristics were drawn from the Finnish Institute for Health and Welfare's, Finnish Medical Association's, and Finnish Medicines Agency's publicly open data. PIMs were defined according to the Finnish Meds75+ database. A linear mixed-effect model was used to analyze potential associations of regional characteristics with PIM prevalence.

RESULTS

Prevalence of PIMs varied between 16.4% and 24.8% across regions. The highest prevalence was observed in the southern regions, while the lowest prevalence was on the west coast. Hospital district characteristics associated with higher PIM prevalence were higher share of population living alone, with excessive polypharmacy, or assessed using the Resident Assessment Instrument, shortage of general practitioners in municipal health centers, and low share of home care personnel. Waiting time in health care or share of population with morbidities were not associated with PIM use. Of the total variance in PIM prevalence, 86% was explained by group-level factors related to hospital districts. The regional variables explained 75% of this hospital-district-level variation.

CONCLUSIONS

PIM prevalence varied significantly across hospital districts. Findings suggest that higher PIM prevalence may be related to challenges in the continuity of care rather than differences in health care accessibility or share of the population with morbidities.

Development and Psychometric Properties of a Scale Measuring Barriers to Perioperative Hypothermia Prevention for Anesthesiologists and Nurses

PURPOSE

To develop a scale that measures barriers to perioperative hypothermia prevention (BPHP) as perceived by anesthesiologists and nurses.

DESIGN

A methodological and prospective psychometric study.

METHODS

Based on the theoretical domains framework, the item pool was created through a literature review, qualitative interviews, and expert consultation. The scale was pretested with a sample of 154 key stakeholders in perioperative temperature management and then field tested with 416 anesthesiologists and nurses working at three hospitals in Southeast China. Item analysis, and reliability and validity analysis were performed.

FINDINGS

The average content validity index was 0.94. According to exploratory factor analysis, seven factors were obtained that could explain 70.283% of the total variance. Confirmatory factor analysis showed excellent or acceptable goodness-of-fit indices. The reliability analysis demonstrated that the scale had high internal consistency and temporal stability, with Cronbach's α, split-half coefficient and test-retest values of 0.926, 0.878 and 0.835, respectively.

CONCLUSIONS

The BPHP scale meets the psychometric criteria for reliability and validity and promises to be a useful quality measure for IPH management during the perioperative period. Further investigations on educational or resource needs and the development of an optimal perioperative hypothermia prevention protocol to narrow the gap between research evidence and clinical practice should be performed.

Cluster-randomised trial of the Effectiveness of Quality Incentive Payments in General Practice (EQuIP-GP): Prescribing of medicines outcomes

BACKGROUND

The Effectiveness of Quality Incentive Payments in General Practice (EQuIP-GP) study investigated whether targeted financial incentives promoting access to a preferred general practitioner, post-hospitalisation follow-up and longer consultations, increase patient-perceived relational continuity in primary care. Secondary outcomes included the use of medicines.

OBJECTIVE

To evaluate whether introducing a general practice-level service model incorporating enrolment and continuous and graded quality improvement incentives influenced the total prescriptions written and potentially inappropriate prescribing of medicines.

METHODS

A 12-month cluster-randomised controlled trial, whereby participating patients within intervention practices were offered enrolment with a preferred general practitioner, a minimum of three longer appointments, and review within seven days of hospital admission or emergency department attendance. Control practice patients received usual care. Differences between intervention and control groups pre-post trial for total prescriptions were analysed, as an indicator of polypharmacy, along with prescriptions for four groups of drugs known to have common quality of medicines issues: antibiotics, benzodiazepines, opioids and proton pump inhibitors (PPIs).

RESULTS

A total of 774 patients, aged 18-65 years with a chronic illness or aged over 65 years, from 34 general practices in metropolitan, regional and rural Australia participated. The mean number of medicine prescriptions per month at baseline was 4.19 (SD 3.27) and 4.34 (SD 3.75) in the control and intervention arms, respectively, with no significant between-group differences in changes pre-post trial and also no significant between-group or within-group differences of prescription rates for antibiotics, benzodiazepines, opioids or PPIs.

CONCLUSIONS

Total prescribing volume and the use of key medicines were not influenced by quality-linked financial incentives for offering longer consultations and early post-hospital review for enrolled patients.

Assessment of Knowledge, Attitude and Practices of the Hospital and Community Pharmacists in Saudi Arabia (Jeddah) towards Inappropriate Medication Use in Older Adults

In Saudi Arabia, the older adult population is growing and is projected to increase three-fold by 2030. Potentially inappropriate medications (PIMs) are harmful to older adults' and have a direct impact on clinical, health and economic outcomes. Pharmacists have a vital role in medication tailoring for older adults as multidisciplinary team members. However, there is also a paucity of research regarding pharmacists' participation in detecting and avoiding PIMs use among older adults in Saudi Arabia. A cross-sectional, self-administered survey was conducted to assess the knowledge, practices, and attitude of pharmacists from seven hospitals and ten community pharmacies in Jeddah, Saudi Arabia. The survey comprised three sections; (i) identifying participants' general characteristics, (ii) assessing their knowledge of PIMs use in older adults and (iii) examining the pharmacist's attitude towards the procedures followed in dispensing for older adults. Inferential and descriptive statistics were used to analyse the survey data. A total of 157 community and hospital pharmacists participated in this study. Most of them dispensed medication weekly to older adults (85.4%), and 43.3% had relevant work experience of six to ten years. Though 44.6% of the participants were aware of PIMs that older adults should avoid, only 10.8% claimed adequate knowledge about PIMs. From the given three clinical case scenarios, a minority of pharmacists (21.7%) chose the correct answers, with a mean score of 2.38 ± 2.91 (95% CI 2.35-3.15). Participants who claimed to have knowledge of PIMs had a significantly higher mean score than those who did not, 4.59 ± 2.81 25 (95% CI 2.35-2.61). A minority of the pharmacists (14.7%) used screening tools such as STOPP, Beers criteria, or Medication Appropriateness Index (MAI) to detect PIMs in older adults. No statistically significant differences were detected when comparing the levels of knowledge of pharmacists with 1 to 5 years of practice to pharmacists with 6 to 15 and more years of experience (p = 0.431). Pharmacists' knowledge, attitude and practices toward PIMs use in older adults in Saudi Arabia should be improved. The application of PIMs detection tools such as STOPP/START or Beers criteria currently has no place in day-to-day pharmacists' roles in Saudi Arabia. Therefore, concerned stakeholders should develop educational programs to improve pharmacists' knowledge of PIMs and promote the effective use of PIM screening tools such as Beers and STOPP criteria in their practice.

Potentially inappropriate medications in older Chinese outpatients based on the Beers criteria and Chinese criteria

Objective: Polypharmacy increases the prevalence of potentially inappropriate drugs potentially inappropriate medications among older persons, lowering their quality of life. PIMs use can lead to higher mortality in older patients. This study aimed to compare the prevalence of PIMs in older Chinese outpatients according to the Beers criteria and the Chinese criteria and to analyze the risk factors. Second, we describe the differences between the two criteria, focusing on the inappropriate prescription of drugs in older outpatients.

Methods: In Chengdu, Southwest China, a cross-sectional study was undertaken using electronic medical data from 9 general hospitals s. Outpatients above the age of 60 who were treated in the Geriatrics Center of these medical institutions were included. The 2019 Beers criteria and the 2017 Chinese criteria were used to evaluate the PIM status of older outpatients, and binary logistic regression was used to identify potential risk factors for PIMs.

Results: There were 44,458 prescriptions from 2016 to 2018. The prevalence of PIMs among older outpatients was 30.05% (according to the Beers criteria) and 35.38% (according to the Chinese criteria), with statistical difference. Estazolam, hydrochlorothiazide and alprazolam were the top three PIMs in the Beers criteria, while the top three PIMs in the Chinese criteria were clopidogrel, estazolam and insulin. The prevalence of PIMs was associated with age, the number of diseases and the number of drugs. PIMs were shown to be more common in patients aged 70 and above, with more than 2 kinds of diseases and more than 4 kinds of drugs.

Conclusion: PIMs were shown to be common among older outpatients in China, according to this study. The detection rate of the Chinese criteria was higher than that of the Beers criteria.

Barriers and Enablers of Healthcare Providers to Deprescribe Cardiometabolic Medication in Older Patients: A Focus Group Study

Introduction

Benefits and risks of preventive medication change over time for ageing patients and deprescribing of medication may be needed. Deprescribing of cardiovascular and antidiabetic drugs can be challenging and is not widely implemented in daily practice.

Objective

The aim of this study was to identify barriers and enablers of deprescribing cardiometabolic medication as seen by healthcare providers (HCPs) of different disciplines, and to explore their views on their specific roles in the process of deprescribing.

Methods

Three focus groups with five general practitioners, eight pharmacists, three nurse practitioners, two geriatricians, and two elder care physicians were conducted in three cities in The Netherlands. Interviews were recorded and transcribed verbatim. Directed content analysis was performed on the basis of the Theoretical Domains Framework. Two researchers independently coded the data.

Results

Most HCPs agreed that deprescribing of cardiometabolic medication is relevant but that barriers include lack of evidence and expertise, negative beliefs and fears, poor communication and collaboration between HCPs, and lack of resources. Having a guideline was considered an enabler for the process of deprescribing of cardiometabolic medication. Some HCPs feared the consequences of discontinuing cardiovascular or antidiabetic medication, while others were not motivated to deprescribe when the patients experienced no problems with their medication. HCPs of all disciplines stated that adequate patient communication and involving the patients and relatives in the decision making enables deprescribing. Barriers to deprescribing included the use of medication initiated by specialists, the poor exchange of information, and the amount of time it takes to deprescribe cardiometabolic medication. The HCPs were uncertain about each other’s roles and responsibilities. A multidisciplinary approach including the pharmacist and nurse practitioner was seen as the best way to support the process of deprescribing and address barriers related to resources.

Conclusion

HCPs recognized the importance of deprescribing cardiometabolic medication as a medical decision that can only be made in close cooperation with the patient. To successfully accomplish the process of deprescribing they strongly recommended a multidisciplinary approach.

Barriers to appropriate prescribing in older adults with multimorbidity: A modified Delphi study

OBJECTIVES

We aimed to understand the barriers experienced by physicians when prescribing for older adults with multimorbidity in specialist outpatient clinics in Singapore.

METHODS

A modified Delphi study was conducted via email with 20 panel experts in the field of geriatric medicine. Barriers identified from an earlier scoping review were presented as statements to the panel.

RESULTS

Eleven barrier statements reached consensus with high importance according to the Delphi panel. Of these statements, seven (64%) belong to the domain of Environmental context and resources in the Theoretical Domains Framework (TDF), while the remaining barriers belong to the domains of skills, knowledge, intentions, and professional/social role and identity. The barriers are further linked to intervention functions in the Behaviour Change Wheel (BCW).

CONCLUSION

Linking the TDF domains to intervention functions revealed strategic directions for the development of an intervention to address the barriers and optimize prescribing.