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Kummer I, Reissigová J, Lukačišinová A, Ortner Hadžiabdić M, Stuhec M, Liperoti R, Finne-Soveri H, Onder G, van Hout H, Fialová D. Polypharmacy and potentially inappropriate prescribing of benzodiazepines in older nursing home residents. Ann Med 2024; 56:2357232. [PMID: 38833339 DOI: 10.1080/07853890.2024.2357232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 04/30/2024] [Indexed: 06/06/2024] Open
Abstract
INTRODUCTION Previous research has raised concerns about high prevalence of drug-related problems, polypharmacy and inappropriate benzodiazepine prescribing in nursing homes (NHs) and confirmed lack of studies from Central and South-Eastern Europe. The aim of our study was to determine the prevalence and characteristics of polypharmacy, hyperpolypharmacy and inappropriate benzodiazepine prescribing in NH residents in Croatia. METHODS Data from 226 older NH residents from five Croatian NHs were collected using the InterRAI Long-Term Care Facilities assessment form. The prevalence and determinants of polypharmacy/hyperpolypharmacy and patterns of inappropriate benzodiazepine prescribing were documented. RESULTS The prevalence of polypharmacy (49.6%) and hyperpolypharmacy (25.7%) among NH residents was high. In our study, 72.1% of NH residents were prescribed at least one psychotropic agent, 36.7% used 2-3 psychotropics and 6.6% used 4+ psychotropics. Among benzodiazepine users (55.8%), 28% of residents were prescribed benzodiazepines in higher than recommended geriatric doses, 75% used them for the long term and 48% were prescribed concomitant interacting medications. The odds of being prescribed polypharmacy/hyperpolypharmacy were significantly higher for older patients with polymorbidity (6+ disorders, proportional odds ratio (POR) = 19.8), type II diabetes (POR = 5.2), ischemic heart disease (POR = 4.6), higher frailty (Clinical Frailty Scale (CFS ≥5); POR = 4.3) and gastrointestinal problems (POR = 4.8). CONCLUSIONS Our research underscores the persistent challenge of inappropriate medication use and drug-related harms among older NH residents, despite existing evidence and professional campaigns. Effective regulatory and policy interventions, including the implementation of geriatrician and clinical pharmacy services, are essential to address this critical issue and ensure optimal medication management for vulnerable NH populations.
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Affiliation(s)
- Ingrid Kummer
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, The Czech Republic
| | - Jindra Reissigová
- Department of Statistical Modelling, Institute of Computer Science of the Czech Academy of Sciences, Prague, The Czech Republic
| | - Anna Lukačišinová
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, The Czech Republic
| | - Maja Ortner Hadžiabdić
- Center for Applied Pharmacy, Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Matej Stuhec
- Department of Pharmacology, Faculty of Medicine Maribor, University of Maribor, Maribor, Slovenia
- Department of Clinical Pharmacy, Ormoz Psychiatric Hospital, Ormoz, Slovenia
| | - Rosa Liperoti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Graziano Onder
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Hein van Hout
- Departments of General Practice and Medicine for Older People, Amsterdam University Medical Center, location Vrije Universiteit, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Daniela Fialová
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, The Czech Republic
- Department of Geriatrics and Gerontology, 1st Faculty of Medicine, Charles University, Prague, The Czech Republic
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Seki S, Candon M, Murthy S, Sahota G, Kelz RR, Neuman MD. Evaluation of a behavioural intervention to reduce perioperative midazolam administration to older adults. BJA OPEN 2023; 7:100206. [PMID: 37638081 PMCID: PMC10457488 DOI: 10.1016/j.bjao.2023.100206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/11/2023] [Indexed: 08/29/2023]
Abstract
Background Older patients commonly receive benzodiazepines during anaesthesia despite guidelines recommending avoidance. Interventions to reduce perioperative benzodiazepine use are not well studied. We hypothesized an automated electronic medical record alert targeting anaesthesia providers would reduce administration of benzodiazepines to older adults undergoing general anaesthesia. Methods We conducted a retrospective study of adults who underwent surgery at 5 hospitals within one US academic health system. One of the hospitals received an intervention consisting of provider education and an automated electronic medical record alert discouraging benzodiazepine administration to patients aged 70 years or older. We used difference-in-differences analysis to compare patterns of midazolam use 12-months before and after intervention at the intervention hospital, using the 4 non-intervention hospitals as contemporaneous comparators. Results The primary analysis sample included 20,347 cases among patients aged 70 and older. At the intervention hospital, midazolam was administered in 454/4,240 (10.7%) cases pre-alert versus 250/3,750 (6.7%) post-alert (p<0.001). At comparator hospitals, respective rates were 3,186/6,366 (50.0%) versus 2,935/5,991 (49.0%) (p=0.24). After adjustment, the intervention was associated with a 3.2 percentage point (p.p.) reduction in the percentage of cases with midazolam administration (95% CI: (-5.2, -1.1); p=0.002). Midazolam dose was unaffected (adjusted mean difference -0.01 mg, 95% CI: (-0.20, 0.18); p=0.90). In 76,735 cases among patients aged 18-69, the percentage of cases with midazolam administration decreased by 6.9 p. p. (95% CI: (-8.0, -5.7); p<0.001). Conclusion Provider-facing alerts in the intraoperative electronic medical record, coupled with education, can reduce midazolam administration to older patients presenting for surgery but may affect care of younger patients.
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Affiliation(s)
- Scott Seki
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Centers for Perioperative Outcomes Research and Transformation, PA, USA
| | - Molly Candon
- Department of Psychiatry, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Health Care Management, The Wharton School, The University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Sushila Murthy
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gurmukh Sahota
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel R. Kelz
- Department of Surgery, Center for Surgery and Health Economics, Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark D. Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Centers for Perioperative Outcomes Research and Transformation, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Carney G, Maclure M, Patrick DM, Fisher A, Stanley D, Bassett K, Dormuth CR. A cluster randomized trial assessing the impact of personalized prescribing feedback on antibiotic prescribing for uncomplicated acute cystitis to family physicians. PLoS One 2023; 18:e0280096. [PMID: 37523381 PMCID: PMC10389722 DOI: 10.1371/journal.pone.0280096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 07/13/2023] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVE To evaluate the impact of personalized prescribing portraits on antibiotic prescribing for treating uncomplicated acute cystitis (UAC) by Family Physicians (FPs). DESIGN Cluster randomized control trial. SETTING The intervention was conducted in the primary care setting in the province of BC between December 2010 and February 2012. PARTICIPANTS We randomized 4 833 FPs by geographic location into an Early intervention arm (n = 2 417) and a Delayed control arm (n = 2 416). INTERVENTION The Education for Quality Improvement in Patient Care (EQIP) program mailed to each FP in BC, a 'portrait' of their individual prescribing of antibiotics to women with UAC, plus therapeutic recommendations and a chart of trends in antibiotic resistance. MAIN OUTCOME MEASURES Antibiotic prescribing preference to treat UAC. RESULTS Implementing exclusion criteria before and after a data system change in the Ministry of Health caused the arms to be unequal in size-intervention arm (1 026 FPs, 17 637 UAC cases); control arm (1 352 FPs, 25 566 UAC cases)-but they were well balanced by age, sex and prior rates of prescribing antibiotics for UAC. In the early intervention group probability of prescribing nitrofurantoin increased from 28% in 2010 to 38% in 2011, a difference of 9.9% (95% confidence interval [CI], 9.1% to 10.7. Ciprofloxacin decreased by 6.2% (95% CI: 5.6% to 6.9%) and TMP-SMX by 3.7% (95% CI: 3.1% to 4.2%). Among 295 FPs who completed reflective surveys, 52% said they were surprized by the E. coli resistance statistics and 57% said they planned to change their treatment of UAC. CONCLUSION The EQIP intervention demonstrated that feedback of personal data to FPs on their prescribing, plus population data on antibiotic resistance, with a simple therapeutic recommendation, can significantly improve prescribing of antibiotics. Trial registration: ISRCTN 16938907.
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Affiliation(s)
- Greg Carney
- Therapeutics Initiative, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Malcolm Maclure
- Therapeutics Initiative, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - David M Patrick
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Anat Fisher
- Therapeutics Initiative, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Dana Stanley
- Therapeutics Initiative, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Ken Bassett
- Therapeutics Initiative, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Colin R Dormuth
- Therapeutics Initiative, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
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Budakoğlu Iİ, Coşkun Ö, Kıyak YS, Uluoğlu C. Teaching rational prescribing in undergraduate medical education: a systematic search and review. Eur J Clin Pharmacol 2023; 79:341-348. [PMID: 36622428 DOI: 10.1007/s00228-022-03448-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/20/2022] [Indexed: 01/10/2023]
Abstract
AIM This study aimed to reveal the current status of the literature on rational prescribing training in undergraduate medical education. METHODS This study followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. An online search using 50 keywords in four databases was performed to access the studies published between 2008 and 2020. Specific features of the training such as aims or objectives of teaching, methods or model, and evaluation of effectiveness were extracted. Kirkpatrick levels were used to evaluate the effectiveness of teaching. RESULTS Of 74 studies included in the full review, 16 (21.6%) of them reported the use of WHO 6-Step Model for Rational Prescribing in their educational interventions. In terms of effectiveness, only two of the studies investigated changes in learner behavior in the context for which they are being trained, and only one study showed the effect of training on patient outcomes. CONCLUSION The evidence on the effectiveness of rational prescribing training has been presented mostly by using student satisfaction surveys and test of knowledge and skills. A higher level of evidence such as patient outcomes of the training needs to be reported.
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Affiliation(s)
- Işıl İrem Budakoğlu
- Department of Medical Education and Informatics, Faculty of Medicine, Gazi University, Gazi Üniversitesi Hastanesi E Blok 9. Kat, 06500, Beşevler, Ankara, Turkey.
| | - Özlem Coşkun
- Department of Medical Education and Informatics, Faculty of Medicine, Gazi University, Gazi Üniversitesi Hastanesi E Blok 9. Kat, 06500, Beşevler, Ankara, Turkey
| | - Yavuz Selim Kıyak
- Department of Medical Education and Informatics, Faculty of Medicine, Gazi University, Gazi Üniversitesi Hastanesi E Blok 9. Kat, 06500, Beşevler, Ankara, Turkey
| | - Canan Uluoğlu
- Department of Medical Pharmacology, Gazi University Faculty of Medicine, Gazi Üniversitesi Hastanesi E Blok 9. Kat, 06500, Beşevler, Ankara, Turkey
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Rahman MM, Alam Tumpa MA, Zehravi M, Sarker MT, Yamin M, Islam MR, Harun-Or-Rashid M, Ahmed M, Ramproshad S, Mondal B, Dey A, Damiri F, Berrada M, Rahman MH, Cavalu S. An Overview of Antimicrobial Stewardship Optimization: The Use of Antibiotics in Humans and Animals to Prevent Resistance. Antibiotics (Basel) 2022; 11:667. [PMID: 35625311 PMCID: PMC9137991 DOI: 10.3390/antibiotics11050667] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 12/10/2022] Open
Abstract
Antimicrobials are a type of agent widely used to prevent various microbial infections in humans and animals. Antimicrobial resistance is a major cause of clinical antimicrobial therapy failure, and it has become a major public health concern around the world. Increasing the development of multiple antimicrobials has become available for humans and animals with no appropriate guidance. As a result, inappropriate use of antimicrobials has significantly produced antimicrobial resistance. However, an increasing number of infections such as sepsis are untreatable due to this antimicrobial resistance. In either case, life-saving drugs are rendered ineffective in most cases. The actual causes of antimicrobial resistance are complex and versatile. A lack of adequate health services, unoptimized use of antimicrobials in humans and animals, poor water and sanitation systems, wide gaps in access and research and development in healthcare technologies, and environmental pollution have vital impacts on antimicrobial resistance. This current review will highlight the natural history and basics of the development of antimicrobials, the relationship between antimicrobial use in humans and antimicrobial use in animals, the simplistic pathways, and mechanisms of antimicrobial resistance, and how to control the spread of this resistance.
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Affiliation(s)
- Md. Mominur Rahman
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.A.A.T.); (M.T.S.); (M.Y.); (M.R.I.); (M.H.-O.-R.); (M.A.)
| | - Mst. Afroza Alam Tumpa
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.A.A.T.); (M.T.S.); (M.Y.); (M.R.I.); (M.H.-O.-R.); (M.A.)
| | - Mehrukh Zehravi
- Department of Clinical Pharmacy Girls Section, Prince Sattam Bin Abdul Aziz University, Alkharj 11942, Saudi Arabia;
| | - Md. Taslim Sarker
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.A.A.T.); (M.T.S.); (M.Y.); (M.R.I.); (M.H.-O.-R.); (M.A.)
| | - Md. Yamin
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.A.A.T.); (M.T.S.); (M.Y.); (M.R.I.); (M.H.-O.-R.); (M.A.)
| | - Md. Rezaul Islam
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.A.A.T.); (M.T.S.); (M.Y.); (M.R.I.); (M.H.-O.-R.); (M.A.)
| | - Md. Harun-Or-Rashid
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.A.A.T.); (M.T.S.); (M.Y.); (M.R.I.); (M.H.-O.-R.); (M.A.)
| | - Muniruddin Ahmed
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.A.A.T.); (M.T.S.); (M.Y.); (M.R.I.); (M.H.-O.-R.); (M.A.)
| | - Sarker Ramproshad
- Department of Pharmacy, Ranada Prasad Shaha University, Narayanganj 1400, Bangladesh; (S.R.); (B.M.)
| | - Banani Mondal
- Department of Pharmacy, Ranada Prasad Shaha University, Narayanganj 1400, Bangladesh; (S.R.); (B.M.)
| | - Abhijit Dey
- Department of Life Sciences, Presidency University, Kolkata 700073, India;
| | - Fouad Damiri
- Labortory of Biomolecules and Organic Synthesis (BioSynthO), Department of Chemistry, Faculty of Sciences Ben M’Sick, University Hassan II of Casablanca, Casablanca 20000, Morocco; (F.D.); (M.B.)
| | - Mohammed Berrada
- Labortory of Biomolecules and Organic Synthesis (BioSynthO), Department of Chemistry, Faculty of Sciences Ben M’Sick, University Hassan II of Casablanca, Casablanca 20000, Morocco; (F.D.); (M.B.)
| | - Md. Habibur Rahman
- Department of Global Medical Science, Wonju College of Medicine, Yonsei University, Wonju 26426, Korea
| | - Simona Cavalu
- Faculty of Medicine and Pharmacy, University of Oradea, P-ta 1 Decembrie 10, 410087 Oradea, Romania
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Damschroder LJ, Sussman JB, Pfeiffer PN, Kurlander JE, Freitag MB, Robinson CH, Spoutz P, Christopher MLD, Battar S, Dickerson K, Sedgwick C, Wallace-Lacey AG, Barnes GD, Linsky AM, Ulmer CS, Lowery JC. Maintaining Implementation through Dynamic Adaptations (MIDAS): protocol for a cluster-randomized trial of implementation strategies to optimize and sustain use of evidence-based practices in Veteran Health Administration (VHA) patients. Implement Sci Commun 2022; 3:53. [PMID: 35568903 PMCID: PMC9107220 DOI: 10.1186/s43058-022-00297-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background The adoption and sustainment of evidence-based practices (EBPs) is a challenge within many healthcare systems, especially in settings that have already strived but failed to achieve longer-term goals. The Veterans Affairs (VA) Maintaining Implementation through Dynamic Adaptations (MIDAS) Quality Enhancement Research Initiative (QUERI) program was funded as a series of trials to test multi-component implementation strategies to sustain optimal use of three EBPs: (1) a deprescribing approach intended to reduce potentially inappropriate polypharmacy; (2) appropriate dosing and drug selection of direct oral anticoagulants (DOACs); and (3) use of cognitive behavioral therapy as first-line treatment for insomnia before pharmacologic treatment. We describe the design and methods for a harmonized series of cluster-randomized control trials comparing two implementation strategies. Methods For each trial, we will recruit 8–12 clinics (24–36 total). All will have access to relevant clinical data to identify patients who may benefit from the target EBP at that clinic and provider. For each trial, clinics will be randomized to one of two implementation strategies to improve the use of the EBPs: (1) individual-level academic detailing (AD) or (2) AD plus the team-based Learn. Engage. Act. Process. (LEAP) quality improvement (QI) learning program. The primary outcomes will be operationalized across the three trials as a patient-level dichotomous response (yes/no) indicating patients with potentially inappropriate medications (PIMs) among those who may benefit from the EBP. This outcome will be computed using month-by-month administrative data. Primary comparison between the two implementation strategies will be analyzed using generalized estimating equations (GEE) with clinic-level monthly (13 to 36 months) percent of PIMs as the dependent variable. Primary comparative endpoint will be at 18 months post-baseline. Each trial will also be analyzed independently. Discussion MIDAS QUERI trials will focus on fostering sustained use of EBPs that previously had targeted but incomplete implementation. Our implementation approaches are designed to engage frontline clinicians in a dynamic optimization process that integrates the use of actional clinical data and making incremental changes, designed to be feasible within busy clinical settings. Trial registration ClinicalTrials.gov: NCT05065502. Registered October 4, 2021—retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00297-z.
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Affiliation(s)
- Laura J Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.
| | - Jeremy B Sussman
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Paul N Pfeiffer
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Jacob E Kurlander
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Michelle B Freitag
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Claire H Robinson
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Patrick Spoutz
- Veterans Health Affairs VISN 20 Pharmacy Benefits Management, Vancouver, WA, USA
| | - Melissa L D Christopher
- Pharmacy Benefits Management Services, Veterans Health Administration, 810 Vermont Ave NW, Washington DC, 20420, USA
| | - Saraswathy Battar
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
| | | | - Christopher Sedgwick
- Department of Veterans Affairs, VA Heartland Network (VISN 15), Kansas City, MO, USA
| | | | - Geoffrey D Barnes
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.,Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Amy M Linsky
- Section of General Medicine, VA Boston Healthcare System, Boston, MA, USA.,Center for Health Organizations and Implementation Research, VA Boston Healthcare System, Boston, MA, USA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Christi S Ulmer
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Julie C Lowery
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
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7
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Vicens C, Leiva A, Bejarano F, Sempere-Verdú E, Rodríguez-Rincón RM, Fiol F, Mengual M, Ajenjo-Navarro A, Do Pazo F, Mateu C, Folch S, Alegret S, Coll JM, Martín-Rabadán M, Socias I. Evaluation of a multicomponent intervention consisting of education and feedback to reduce benzodiazepine prescriptions by general practitioners: The BENZORED hybrid type 1 cluster randomized controlled trial. PLoS Med 2022; 19:e1003983. [PMID: 35522626 PMCID: PMC9075619 DOI: 10.1371/journal.pmed.1003983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 04/07/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Current benzodiazepine (BZD) prescription guidelines recommend short-term use to minimize the risk of dependence, cognitive impairment, and falls and fractures. However, many clinicians overprescribe BZDs and chronic use by patients is common. There is limited evidence on the effectiveness of interventions delivered by general practitioners (GPs) on reducing prescriptions and long-term use of BZDs. We aimed to evaluate the effectiveness of a multicomponent intervention for GPs that seeks to reduce BZD prescriptions and the prevalence of long-term users. METHODS AND FINDINGS We conducted a multicenter two-arm, cluster randomized controlled trial in 3 health districts in Spain (primary health centers [PHCs] in Balearic Islands, Catalonia, and Valencian Community) from September 2016 to May 2018. The 81 PHCs were randomly allocated to the intervention group (n = 41; 372 GPs) or the control group (n = 40; 377 GPs). GPs were not blinded to the allocation; however, pharmacists, researchers, and trial statisticians were blinded to the allocation arm. The intervention consisted of a workshop about the appropriate prescribing of BZDs and tapering-off long-term BZD use using a tailored stepped dose reduction with monthly BZD prescription feedback and access to a support web page. The primary outcome, based on 700 GPs (351 in the control group and 349 in the intervention group), compared changes in BZD prescriptions in defined daily doses (DDDs) per 1,000 inhabitants per day after 12 months. The 2 secondary outcomes were the proportion of long-term users (≥6 months) and the proportion of long-term users over age 65 years. Intention-to-treat (ITT) analysis was used to assess all clinical outcomes. Forty-nine GPs (21 intervention group and 28 control group) were lost to follow-up. However, all GPs were included in the ITT analysis. After 12 months, there were a statistically significant decline in total BZD prescription in the intervention group compared to the control group (mean difference: -3.24 DDDs per 1,000 inhabitants per day, 95% confidence interval (CI): -4.96, -1.53, p < 0.001). The intervention group also had a smaller number of long-term users. The adjusted absolute difference overall was -0.36 (95% CI: -0.55, -0.16, p > 0.001), and the adjusted absolute difference in long-term users over age 65 years was -0.87 (95% CI: -1.44, -0.30, p = 0.003). A key limitation of this clustered design clinical trial is the imbalance of some baseline characteristics. The control groups have a higher rate of baseline BZD prescription, and more GPs in the intervention group were women, GPs with a doctorate degree, and trainers of GP residents. CONCLUSIONS A multicomponent intervention that targeted GPs and included educational meeting, feedback about BZD prescriptions, and a support web page led to a statistically significant reduction of BZD prescriptions and fewer long-term users. Although the effect size was small, the high prevalence of BZD use in the general population suggests that large-scale implementation of this intervention could have positive effects on the health of many patients. TRIAL REGISTRATION ISRCTN ISRCTN28272199.
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Affiliation(s)
- Caterina Vicens
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS)-Balearic Islands Health Research Institute (IdISBa), Mallorca, Spain
| | - Alfonso Leiva
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS)-Balearic Islands Health Research Institute (IdISBa), Mallorca, Spain
- Balearic Health Service IbSalut, Reseach Unit Primary care Mallorca, Palma, Illes Balears, Spain
- * E-mail:
| | - Ferran Bejarano
- Catalan Institute of Health Cat-salut, DAP Camp de Tarragona, Tarragona, Catalunya, Spain
| | - Ermengol Sempere-Verdú
- Conselleria de Sanitat Universal i Salut Pública, Paterna Healthcare Centre, Valencia, Comunitat Valenciana, Spain
| | - Raquel María Rodríguez-Rincón
- Balearic Health Service IbSalut Hospital Universitari Son Espases, Pharmacy Department,Palma de Mallorca, Illes Balears, Spain
| | - Francisca Fiol
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
| | - Marta Mengual
- Catalan Institute of Health Cat-salut, DAP Camp de Tarragona, Tarragona, Catalunya, Spain
| | - Asunción Ajenjo-Navarro
- Conselleria de Sanitat Universal i Salut Pública, Paterna Healthcare Centre, Valencia, Comunitat Valenciana, Spain
| | - Fernando Do Pazo
- Balearic Health Service IbSalut Hospital Universitari Son Espases, Pharmacy Department,Palma de Mallorca, Illes Balears, Spain
| | - Catalina Mateu
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
| | - Silvia Folch
- Catalan Institute of Health Cat-salut, DAP Camp de Tarragona, Tarragona, Catalunya, Spain
| | - Santiago Alegret
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
| | - Jose Maria Coll
- Balearic Health Service IbSalut, Menorca Primary Care Management, Maó, Illes Baleares, Spain
| | - María Martín-Rabadán
- Balearic Health Service IbSalut, Can Misses Healthcare Centre Ibiza, Illes Baleares, Spain
| | - Isabel Socias
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS)-Balearic Islands Health Research Institute (IdISBa), Mallorca, Spain
- Balearic Health Service IbSalut, Manacor Healthcare Centre, Manacor, Illes Baleares, Spain
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8
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Cook DA, Stephenson CR, Wilkinson JM, Maloney S, Foo J. Cost-effectiveness and Economic Benefit of Continuous Professional Development for Drug Prescribing: A Systematic Review. JAMA Netw Open 2022; 5:e2144973. [PMID: 35080604 PMCID: PMC8792887 DOI: 10.1001/jamanetworkopen.2021.44973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/01/2021] [Indexed: 11/19/2022] Open
Abstract
Importance The economic impact of continuous professional development (CPD) education is incompletely understood. Objective To systematically identify and synthesize published research examining the costs associated with physician CPD for drug prescribing. Evidence Review MEDLINE, Embase, PsycInfo, and the Cochrane Database were searched from inception to April 23, 2020, for comparative studies that evaluated the cost of CPD focused on drug prescribing. Two reviewers independently screened all articles for inclusion and reviewed all included articles to extract data on participants, educational interventions, study designs, and outcomes (costs and effectiveness). Results were synthesized for educational costs, health care costs, and cost-effectiveness. Findings Of 3338 articles screened, 38 were included in this analysis. These studies included at least 15 659 health care professionals and 1 963 197 patients. Twelve studies reported on educational costs, ranging from $281 to $183 554 (median, $15 664). When economic outcomes were evaluated, 31 of 33 studies (94%) comparing CPD with no intervention found that CPD was associated with reduced health care costs (drug costs), ranging from $4731 to $6 912 000 (median, $79 373). Four studies found reduced drug costs for 1-on-1 outreach compared with other CPD approaches. Regarding cost-effectiveness, among 5 studies that compared CPD with no intervention, the incremental cost-effectiveness ratio for a 10% improvement in prescribing ranged from $15 390 to $437 027 to train all program participants. Four comparisons of alternative CPD approaches found that 1-on-1 educational outreach was more effective but more expensive than group education or mailed materials (incremental cost-effectiveness ratio, $18-$4105 per physician trained). Conclusions and Relevance In this systematic review, CPD for drug prescribing was associated with reduced health care (drug) costs. The educational costs and cost-effectiveness of CPD varied widely. Several CPD instructional approaches (including educational outreach) were more effective but more costly than comparators.
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Affiliation(s)
- David A. Cook
- School of Continuous Professional Development, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Stephen Maloney
- School of Primary and Allied Health Care, Monash University, Victoria, Australia
| | - Jonathan Foo
- School of Primary and Allied Health Care, Monash University, Victoria, Australia
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9
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Sharma A, Singh A, Dar MA, Kaur RJ, Charan J, Iskandar K, Haque M, Murti K, Ravichandiran V, Dhingra S. Menace of antimicrobial resistance in LMICs: Current surveillance practices and control measures to tackle hostility. J Infect Public Health 2021; 15:172-181. [PMID: 34972026 DOI: 10.1016/j.jiph.2021.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 12/12/2022] Open
Abstract
Antimicrobial Resistance (AMR) is significant challenge humanity faces today, with many patients losing their lives every year due to AMR. It is more widespread and has shown a higher prevalence in low- and middle-income countries (LMICs) due to lack of awareness and other associated reasons. WHO has suggested some crucial guidelines and specific strategies such as antimicrobial stewardship programs taken at the institutional level to combat AMR. Creating awareness at the grassroots level can help to reduce the AMR and promote safe and effective use of antimicrobials. Control strategies in curbing AMR also comprise hygiene and sanitation as microbes travel from contaminated surroundings to the human body surface. As resistance to multiple drugs increases, vaccines can play a significant role in curbing the menace of AMR. This article summarizes the current surveillance practices and applied control measures to tackle the hostility in these countries with particular reference to the role of antimicrobial stewardship programs and the responsibilities of regulatory authorities in managing the situation.
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Affiliation(s)
- Ayush Sharma
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, Bihar, India
| | - Akanksha Singh
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, Bihar, India
| | - Mukhtar Ahmad Dar
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, Bihar, India
| | - Rimple Jeet Kaur
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Jaykaran Charan
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Katia Iskandar
- Lebanese University, School of Pharmacy, Beirut, Lebanon; INSPECT-LB: Institute National de Sante Publique, Epidemiologie Clinique et Toxicologie, Beirut, Lebanon; Universite Paul Sabatier UT3, INSERM, UMR1295, Toulouse, France
| | - Mainul Haque
- The Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Perdana Sungai Besi, Kuala Lumpur, Malaysia
| | - Krishna Murti
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, Bihar, India
| | - V Ravichandiran
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, Bihar, India; Department of Natural Products, National Institute of Pharmaceutical Education and Research, Kolkata, West Bengal, India
| | - Sameer Dhingra
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, Bihar, India.
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10
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Krakower DS, Naja-Riese GM, Edelstein ZR, Gandhi AD, Wahnich A, Fischer MA. Academic Detailing to Increase Prescribing of HIV Pre-exposure Prophylaxis. Am J Prev Med 2021; 61:S87-S97. [PMID: 34686295 DOI: 10.1016/j.amepre.2021.05.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/27/2021] [Accepted: 05/10/2021] [Indexed: 10/20/2022]
Abstract
Although HIV pre-exposure prophylaxis can decrease new cases of HIV by up to 99%, many patients who could benefit from pre-exposure prophylaxis never receive prescriptions for it. Because pre-exposure prophylaxis is indicated for patients who do not have an infectious disease, increasing pre-exposure prophylaxis prescribing by primary care and generalist clinicians represents a key element of the Ending the HIV Epidemic in the U.S. initiative. This review provides an overview of academic detailing and how it is currently being used to increase pre-exposure prophylaxis prescribing. Academic detailing is outreach education that engages with clinicians in 1-to-1 or small group interactions focused on identifying and addressing an individual clinician's needs to increase their use of evidence-based practices. Academic detailing has been proven in multiple previous research studies, and the principles required for successful implementation include interactivity, clinical relevance of content, and focus on defined behavior change objectives. Clinician barriers to pre-exposure prophylaxis prescribing may occur in the domains of knowledge, attitudes, or behavior, and academic detailing has the potential to address all of these areas. State and local health departments have developed academic detailing programs focused on pre-exposure prophylaxis prescribing and other elements of HIV prevention-sometimes describing the approach as public health detailing. Few studies of academic detailing for pre-exposure prophylaxis have been published to date; rigorous evaluation of HIV-specific adaptations and innovations of the approach would represent an important contribution. In the setting of the COVID-19 pandemic, interest in virtual delivery of academic detailing has grown, which could inform efforts to implement academic detailing in rural communities and other underserved areas. Increasing this capacity could make an important contribution to Ending the HIV Epidemic in the U.S. and other HIV prevention efforts.
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Affiliation(s)
- Douglas S Krakower
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Beth Israel Lahey Health, Boston, Massachusetts; The Fenway Institute, Boston, Massachusetts; Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| | - Gary M Naja-Riese
- San Francisco Department of Public Health, Population Health Division, Center for Learning and Innovation, San Francisco, California
| | - Zoe R Edelstein
- Prevention Program, Bureau of HIV, New York City Department of Health and Mental Hygiene, New York, New York
| | - Anisha D Gandhi
- Prevention Program, Bureau of HIV, New York City Department of Health and Mental Hygiene, New York, New York
| | - Amanda Wahnich
- Prevention Program, Bureau of HIV, New York City Department of Health and Mental Hygiene, New York, New York
| | - Michael A Fischer
- National Resource Center for Academic Detailing, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts.
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11
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Lam TT, Dang DA, Tran HH, Do DV, Le H, Negin J, Jan S, Marks GB, Nguyen TA, Fox GJ, Beardsley J. What are the most effective community-based antimicrobial stewardship interventions in low- and middle-income countries? A narrative review. J Antimicrob Chemother 2021; 76:1117-1129. [PMID: 33491090 DOI: 10.1093/jac/dkaa556] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Antimicrobial resistance (AMR) is a major global issue and antimicrobial stewardship is central to tackling its emergence. The burden of AMR disproportionately impacts low- and middle-income countries (LMICs), where capacity for surveillance and management of resistant pathogens is least developed. Poorly regulated antibiotic consumption in the community is a major driver of AMR, especially in LMICs, yet community-based interventions are neglected in stewardship research, which is often undertaken in high-income settings and/or in hospitals. We reviewed the evidence available to researchers and policymakers testing or implementing community-based antimicrobial stewardship strategies in LMICs. We critically appraise that evidence, deliver recommendations and identify outstanding areas of research need. We find that multifaceted, education-focused interventions are likely most effective in our setting. We also confirm that the quality and quantity of community-based stewardship intervention research is limited, with research on microbiological, clinical and economic sustainability most urgently needed.
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Affiliation(s)
- Thanh Tuan Lam
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam
| | - Duc Anh Dang
- National Institute of Hygiene and Epidemiology, Hai Ba Trung, Hanoi, Vietnam
| | - Huy Hoang Tran
- National Institute of Hygiene and Epidemiology, Hai Ba Trung, Hanoi, Vietnam
| | - Dung Van Do
- The University of Medicine and Pharmacy, Hong Bang, Q5, Ho Chi Minh City, Vietnam
| | - Hien Le
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam
| | - Joel Negin
- The Sydney School of Public Health, University of Sydney, NSW 2006, Australia
| | - Stephen Jan
- The George Institute for Global Health, Sydney, NSW 2042, Australia
| | - Guy B Marks
- The University of New South Wales, Sydney, NSW 2052, Australia
| | - Thu Anh Nguyen
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam.,The Central Clinical School, The Faculty of Medicine and Health, The University of Sydney, NSW 2006, Australia
| | - Greg J Fox
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam.,The Central Clinical School, The Faculty of Medicine and Health, The University of Sydney, NSW 2006, Australia
| | - Justin Beardsley
- The Marie Bashir Institute, Westmead Institute for Medical Research, The University of Sydney, NSW 2145, Australia.,Oxford University Clinical Research Unit, Vo Van Kiet, Q5, Ho Chi Minh City, Vietnam
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12
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Omer U, Danopoulos E, Veysey M, Crampton P, Finn G. A Rapid Review of Prescribing Education Interventions. MEDICAL SCIENCE EDUCATOR 2021; 31:273-289. [PMID: 34457882 PMCID: PMC8368780 DOI: 10.1007/s40670-020-01131-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Many studies conducted on the causes and nature of prescribing errors have highlighted the inadequacy of teaching and training of prescribers. Subsequently, a rapid review was undertaken to update on the nature and effectiveness of educational interventions aimed at improving the prescribing skills and competencies. METHODS Twenty-two studies taking place between 2009 and 2019 were identified across nine databases. RESULTS AND DISCUSSION This review reinforced the importance of the WHO Guide to Good Prescribing to prescribing curriculum design as well as the effectiveness of small group teaching. However, it also highlighted the lack of innovation in prescribing education and lack of longitudinal follow-up regarding the effectiveness of prescribing education interventions.
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Affiliation(s)
- Usmaan Omer
- Health Professions Education Unit, Hull York Medical School, University of York, York, YO10 5DD UK
| | - Evangelos Danopoulos
- Health Professions Education Unit, Hull York Medical School, University of York, York, YO10 5DD UK
| | - Martin Veysey
- Health Professions Education Unit, Hull York Medical School, University of York, York, YO10 5DD UK
| | - Paul Crampton
- Health Professions Education Unit, Hull York Medical School, University of York, York, YO10 5DD UK
| | - Gabrielle Finn
- Health Professions Education Unit, Hull York Medical School, University of York, York, YO10 5DD UK
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13
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Mahabaleshwarkar R, DeSantis A. Metformin dosage patterns in type 2 diabetes patients in a real-world setting in the United States. Diabetes Res Clin Pract 2021; 172:108531. [PMID: 33157115 DOI: 10.1016/j.diabres.2020.108531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/25/2020] [Accepted: 10/26/2020] [Indexed: 11/21/2022]
Abstract
AIM To examine metformin dosage patterns among adults with type 2 diabetes in an integrated healthcare system in the US. METHODS Using electronic medical records, the proportions of patients receiving different initial metformin doses were reported. Proportion of patients receiving ≥1500 mg metformin daily at initiation or within six months after initiation and the associated sociodemographic and clincal factors were examined. RESULTS The cohort included 715 patients (52.6% female, 64.1% white, and mean age = 57.0 ± 12.7 years). Of these, 31.3% received an initial daily metformin dose of <850 mg, 46.9% received 850-1499 mg, and 21.8% received ≥1500 mg and 244 (34.1%) patients received ≥1500 mg metformin daily at initiation or within six months after initiation. Patients aged 65-79 years (vs. those aged <50 years) and blacks (vs. whites) were less likely and Hispanics (vs. whites) and patients with higher HbA1c before metformin initiation were more likely to receive ≥1500 mg metformin daily at initiation or within six months after initiation. CONCLUSIONS Study findings suggest a need for efforts to maximize the proportion of eligible patients receiving a recommended metformin dose. Factors impacting metformin dosage identified in the study could be a useful guidance.
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Affiliation(s)
- Rohan Mahabaleshwarkar
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, United States.
| | - Andrea DeSantis
- Department of Family Practice, Atrium Health, Charlotte, NC, United States
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14
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Dhingra S, Rahman NAA, Peile E, Rahman M, Sartelli M, Hassali MA, Islam T, Islam S, Haque M. Microbial Resistance Movements: An Overview of Global Public Health Threats Posed by Antimicrobial Resistance, and How Best to Counter. Front Public Health 2020; 8:535668. [PMID: 33251170 PMCID: PMC7672122 DOI: 10.3389/fpubh.2020.535668] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 08/14/2020] [Indexed: 12/11/2022] Open
Abstract
Antibiotics changed medical practice by significantly decreasing the morbidity and mortality associated with bacterial infection. However, infectious diseases remain the leading cause of death in the world. There is global concern about the rise in antimicrobial resistance (AMR), which affects both developed and developing countries. AMR is a public health challenge with extensive health, economic, and societal implications. This paper sets AMR in context, starting with the history of antibiotics, including the discovery of penicillin and the golden era of antibiotics, before exploring the problems and challenges we now face due to AMR. Among the factors discussed is the low level of development of new antimicrobials and the irrational prescribing of antibiotics in developed and developing countries. A fundamental problem is the knowledge, attitude, and practice (KAP) regarding antibiotics among medical practitioners, and we explore this aspect in some depth, including a discussion on the KAP among medical students. We conclude with suggestions on how to address this public health threat, including recommendations on training medical students about antibiotics, and strategies to overcome the problems of irrational antibiotic prescribing and AMR.
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Affiliation(s)
- Sameer Dhingra
- School of Pharmacy, Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Nor Azlina A. Rahman
- Department of Physical Rehabilitation Sciences, Kulliyyah of Allied Health Sciences, International Islamic University Malaysia, Kuantan, Malaysia
| | - Ed Peile
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Motiur Rahman
- Oxford University Clinical Research Unit, Wellcome Trust Asia Programme, The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Massimo Sartelli
- Department of General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Mohamed Azmi Hassali
- The Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Minden, Malaysia
| | | | - Salequl Islam
- Department of Microbiology, Jahangirnagar University, Dhaka, Bangladesh
| | - Mainul Haque
- The Unit of Pharmacology, Faculty of Medicine and Defence Health, National Defence University of Malaysia, Kuala Lumpur, Malaysia
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15
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The Patient Perceptions of Deprescribing (PPoD) Survey: Short-Form Development. Drugs Aging 2020; 37:909-916. [PMID: 33026638 DOI: 10.1007/s40266-020-00802-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Deprescribing, the intentional reduction of medication, is recognized as an important component of clinical care; however, standardized identification of patient attitudes and beliefs that contribute to deprescribing may be limited due to the length of current surveys. We sought to develop a short-form (≤ 15 items) of the patient perceptions of deprescribing (PPoD) questionnaire, a validated 30-item instrument that assesses dimensions relevant to deprescribing, to be used in clinical and research settings. METHODS We conducted a secondary analysis of data from 803 US veteran respondents to the original PPoD survey, randomly divided into derivation and validation samples. In the derivation sample, we used ordinary least squares linear regression with R2 model selection to identify candidate items reflective of overall readiness for deprescribing. We then used iterative multitrait analysis, followed by confirmatory factor analysis (CFA) in the validation sample to assess the psychometric properties of the proposed short form. RESULTS The resulting short-form PPoD consisted of 11 items representing two overarching domains reflective of overall readiness for deprescribing: 'Motivation for Deprescribing' and 'Primary Care Provider Relationship'. CFA fit statistics supported the proposed structure and the two new scales demonstrated high internal consistency reliability (Cronbach alphas: 0.82 and 0.91, respectively) and good discriminant validity (interscale correlation - 0.30). DISCUSSION The proposed short-form PPoD captures two important sources of variance in patient readiness for deprescribing: motivation and patients' relationships with their primary care providers. This brief, 11-item survey may help foster the inclusion of patient perceptions into clinical decision making for deprescribing to yield safer, more appropriate medication use.
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16
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Rattanachotphanit T, Waleekhachonloet O. Effect of a Rational Drug Use Policy on the prescribing safety in outpatient settings in Thailand. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2020; 28:608-616. [PMID: 32813302 DOI: 10.1111/ijpp.12665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 07/01/2020] [Accepted: 07/23/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In Thailand, the 'Rational Drug Use (RDU) policy' has been implemented in the Ministry of Public Health (MOPH) hospitals since October 2016. This study aimed to explore the effects of the RDU policy on prescribing safety indicators for elderly patients and those with common chronic diseases. METHOD Electronic outpatient databases were obtained from 15 MOPH hospitals. The selected indicators were the (1) glibenclamide prescribing in patients with diabetes mellitus who were elderly or had renal impairment; (2) duplicate prescribing of renin angiotensin system (RAS) blockers in patients with hypertension; (3) non-steroidal anti-inflammatory drugs (NSAIDs) prescribing in patients with chronic kidney disease stages 3-5; and (4) long-acting benzodiazepines prescribing in patients ≥65 years. The policy effects in terms of changes in prescribing trends were estimated using interrupted time-series analysis based on quarterly (Q) data. The postpolicy trends (2016, Q4-2017, Q4) were compared with the prepolicy trend (2014, Q1-2016, Q3). KEY FINDINGS The unsafe prescribing of glibenclamide in patients with diabetes mellitus was 19.2% in Q1, 2014 and decreased significantly due to the RDU policy to 11.0% in Q4, 2017 (-4.23 percentage points quarterly, P < 0.001). The unsafe prescribing of RAS blockers and long-acting benzodiazepines was relatively low in Q1, 2014 (1.0% and 1.1%, respectively) and did not decrease further after the RDU policy. The unsafe prescribing of NSAIDs was 4.2% in Q1, 2014, increased abruptly one quarter after the policy and decreased afterwards. CONCLUSION The RDU policy seemed to be a contributing factor that decreased the unsafe prescribing of glibenclamide, while the policy effect was minimal for the other indicators.
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17
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Hawes L, Buising K, Mazza D. Antimicrobial Stewardship in General Practice: A Scoping Review of the Component Parts. Antibiotics (Basel) 2020; 9:E498. [PMID: 32784918 PMCID: PMC7459857 DOI: 10.3390/antibiotics9080498] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/02/2020] [Accepted: 08/05/2020] [Indexed: 02/07/2023] Open
Abstract
There is no published health-system-wide framework to guide antimicrobial stewardship (AMS) in general practice. The aim of this scoping review was to identify the component parts necessary to inform a framework to guide AMS in general practice. Six databases and nine websites were searched. The sixteen papers included were those that reported on AMS in general practice in a country where antibiotics were available by prescription from a registered provider. Six multidimensional components were identified: 1. Governance, including a national action plan with accountability, prescriber accreditation, and practice level policies. 2. Education of general practitioners (GPs) and the public about AMS and antimicrobial resistance (AMR). 3. Consultation support, including decision support with patient information resources and prescribing guidelines. 4. Pharmacist and nurse involvement. 5. Monitoring of antibiotic prescribing and AMR with feedback to GPs. 6. Research into gaps in AMS and AMR evidence with translation into practice. This framework for AMS in general practice identifies health-system-wide components to support GPs to improve the quality of antibiotic prescribing. It may assist in the development and evaluation of AMS interventions in general practice. It also provides a guide to components for inclusion in reports on AMS interventions.
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Affiliation(s)
- Lesley Hawes
- Department of General Practice, School of Primary and Allied Health Care, Monash University, Level 1, 270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia;
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Level 5, 792 Elizabeth Street Melbourne, Victoria 3000, Australia;
| | - Kirsty Buising
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Level 5, 792 Elizabeth Street Melbourne, Victoria 3000, Australia;
- Acting Director, Victorian Infectious Diseases Service, Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria 3050, Australia
| | - Danielle Mazza
- Department of General Practice, School of Primary and Allied Health Care, Monash University, Level 1, 270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia;
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Level 5, 792 Elizabeth Street Melbourne, Victoria 3000, Australia;
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18
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Sparrow RT, Khan AM, Ferreira-Legere LE, Ko DT, Jackevicius CA, Goodman SG, Anderson TJ, Stacey D, Tiszovszky I, Farkouh ME, Tu JV, Udell JA. Effectiveness of Interventions Aimed at Increasing Statin-Prescribing Rates in Primary Cardiovascular Disease Prevention: A Systematic Review of Randomized Clinical Trials. JAMA Cardiol 2020; 4:1160-1169. [PMID: 31461127 DOI: 10.1001/jamacardio.2019.3066] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Statins are a cornerstone medication in cardiovascular disease prevention, but their use in clinical practice remains suboptimal, with less than half of people who are indicated for statins actually taking the medication. Objective To perform a systematic review and synthesis of the literature on patient-oriented and physician-oriented interventions aimed at increasing statin-prescribing rates in adults without a history of cardiovascular disease. Evidence Review PubMed, Embase, and the Cochrane Library were searched for randomized clinical trials published between January 2000 and May 2019. Data abstraction was performed using the Cochrane Public Health Review Group's data collection template, and a narrative synthesis of study results was conducted. The risk of bias in each study was qualitatively assessed, and a funnel plot was created to further evaluate the risk of publication bias. Findings Among 7948 citations and 128 full-text articles reviewed, 20 studies (of 109 807 patients) were included in the review. Eight trials reported a statistically significant increases in statin-prescribing rates. Among the effective trials, absolute effect sizes ranged from 4.2% (95% CI, 2.2%-6.4%) to 23% (95% CI, 7.3%-38.9%) and odds ratios from 1.29 (95% CI, 1.01-1.66) to 11.8 (95% CI, 8.8-15.9). Patient-education initiatives were the most commonly effective intervention, with 4 of 7 trials indicating increases in statin-prescribing rates. Two trials combined electronic decision-support tools with audit-and-feedback systems, both of which were effective overall. Physician-education programs without dynamic input regarding patient risk or updated treatment recommendations were generally found to be less effective. Conclusions and Relevance While heterogeneous in their interventions and outcomes, a number of interventions have demonstrated increases in statin-prescribing rates, with patient-education initiatives demonstrating more promising results than those focused on physician education alone. As opposed to more education about generic recommendations, tailored patient-focused and physician-focused interventions were more effective when they provided personalized cardiovascular risk information, dynamic decision-support tools, or audit-and-feedback reports in a multicomponent program. There are a number of modestly successful approaches to implement increases in rates of statin prescribing, a proven yet underused cardiovascular disease prevention class of therapy.
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Affiliation(s)
- Robert T Sparrow
- Faculty of Medical Science, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Anam M Khan
- ICES, Toronto, Ontario, Canada.,School of Public Health, University of Michigan, Ann Arbor
| | | | - Dennis T Ko
- ICES, Toronto, Ontario, Canada.,Schulich Heart Centre, Sunnybrook Health Services Centre, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Cynthia A Jackevicius
- ICES, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Western University of Health Sciences, Pomona, California
| | - Shaun G Goodman
- University of Toronto, Toronto, Ontario, Canada.,St. Michael's Hospital, Toronto, Ontario, Canada
| | - Todd J Anderson
- Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
| | - Dawn Stacey
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Ildiko Tiszovszky
- Patient Partnership, Community Heart Outcomes Improvement and Cholesterol Education Study (CHOICES) Trial at ICES, Toronto, Ontario, Canada
| | - Michael E Farkouh
- University of Toronto, Toronto, Ontario, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Jack V Tu
- ICES, Toronto, Ontario, Canada.,Schulich Heart Centre, Sunnybrook Health Services Centre, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Jacob A Udell
- ICES, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.,Women's College Hospital, Toronto, Ontario, Canada
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A pragmatic controlled trial to improve the appropriate prescription of drugs in adult outpatients: design and rationale of the EDU.RE.DRUG study. Prim Health Care Res Dev 2020. [PMCID: PMC7372175 DOI: 10.1017/s1463423620000249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Introduction: Pharmacological intervention is an important component of patient care. However, drugs are often inappropriately used. It is necessary for countries to implement strategies to improve the rational use of drugs, including independent information for healthcare professionals and the public, which must be supported by well-trained staff. The primary objectives of the EDU.RE.DRUG (Effectiveness of informative and/or educational interventions aimed at improving the appropriate use of drugs designed for general practitioners and their patients) study are the retrospective evaluation of rates of appropriate prescribing indicators (APIs) and the assessment of the effectiveness of informative and/or educational interventions addressed to general practitioners (GPs) and their patients, aimed at improving prescribing quality and promoting proper drug use. Methods and analysis: This is a prospective, multicentre, open-label, parallel-arm, controlled, pragmatic trial directed to GPs and their patients in two Italian regions (Campania and Lombardy). The study data are retrieved from administrative databases (Demographic, Pharmacy-refill, and Hospitalization databases) containing healthcare information of all beneficiaries of the National Health Service in the Local Health Units (LHUs) involved. According to LHU, the GPs/patients will be assigned to one of the following four intervention arms: (1) intervention on GPs and patients; (2) intervention on GPs; (3) intervention on patients; and (4) no intervention (control). The intervention designed for GPs consists of reports regarding the status of their patients according to the APIs determined at baseline and in two on-line Continuous Medical Education (CME) courses. The intervention designed for patients consists in flyers and posters distributed in GPs ambulatories and community pharmacies, focusing on correct drug use. A set of indicators (such as potential drug–drug interactions, unnecessary duplicate prescriptions, and inappropriate prescriptions in the elderly), adapted to the Italian setting, has been defined to determine inappropriate prescription at baseline and after the intervention phase. The primary outcome was a composite API. Ethics and dissemination: The study was approved by the Ethics Committee of the University of Milan on 7th June 2017 (code 15/17). The investigators will communicate trial results to stakeholders, collaborators, and participants via appropriate presentations and publications. Registration details: NCT04030468. EudraCT number 2017-002622-21
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Nkera-Gutabara JG, Ragaven LB. Adherence to prescription-writing guidelines for outpatients in Southern Gauteng district hospitals. Afr J Prim Health Care Fam Med 2020; 12:e1-e11. [PMID: 32634012 PMCID: PMC7343925 DOI: 10.4102/phcfm.v12i1.2263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 02/12/2020] [Accepted: 02/22/2020] [Indexed: 11/05/2022] Open
Abstract
Background Medical prescription writing is legally and professionally regulated in order to prevent errors that can result in patients being harmed. This study assesses prescriber adherence to such regulations in primary care settings. Methods A cross-sectional study of 412 prescriptions from four district hospital outpatient departments (OPDs) was conducted in March 2015. Primary outcome data were obtained by scoring prescriptions for accuracy across four categories: completion of essential elements, use of generic names of medications, use of recommended abbreviations and decimals and legibility. Secondary outcome data sought associations between accuracy scores and characteristics of the OPDs that might influence prescriber adherence. Results Completion of the essential elements, including patient identifiers, prescriber identifiers, treatment regimen and date scored 44%, 77%, 99% and 99% respectively. Legibility, the use of generic names of medications and the use of recommended abbreviations and decimals scored 90%, 39% and 35%, respectively. Only 38% of prescriptions achieved a global accuracy score (GAS) of between 80% and 100%. A significant association was found between lower GAS and the number of prescriptions written per day (p = 0.001) as well as with the number of prescribers working on that day (p = 0.005), suggesting a negative impact on prescribers’ performance because of workload pressures. Conclusion Low GAS values indicate poor adherence to prescription-writing regulations. Elements requiring substantial improvement include completion of patient and prescriber identifiers, use of generic medication names and the use of recommended abbreviations and decimals. This study provides baseline data for future initiatives for improvement in prescription-writing quality.
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Affiliation(s)
- Jacques G Nkera-Gutabara
- Department of Family Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and, Johannesburg Metro Health District, Gauteng Department of Health, Johannesburg.
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21
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Burningham Z, Jackson GL, Kelleher J, Stevens M, Morris I, Cohen J, Maloney G, Vaughan CP. The Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department (EQUIPPED) Potentially Inappropriate Medication Dashboard: A Suitable Alternative to the In-person Academic Detailing and Standardized Feedback Reports of Traditional EQUIPPED? Clin Ther 2020; 42:573-582. [DOI: 10.1016/j.clinthera.2020.02.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/15/2020] [Accepted: 02/20/2020] [Indexed: 11/25/2022]
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Murshid MA, Mohaidin Z, Zayed M. Development and validation of an instrument designed to measure factors influencing physician prescribing decisions. Pharm Pract (Granada) 2020; 17:1616. [PMID: 31897258 PMCID: PMC6935548 DOI: 10.18549/pharmpract.2019.4.1616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 12/08/2019] [Indexed: 12/02/2022] Open
Abstract
Background: Previous attempts to develop an instrument to measure factors that influence prescribing decisions among physicians were relatively insufficient and lacked validation scale. Objective: We present a new tool that attempts to address this shortcoming. Hence, this study aims to develop and validate a self-administrated instrument to explain factors that influence the prescribing decisions of physicians. Methods: The questionnaire was developed based on literature and then subjected to an exhaustive assessment by a board of professionals and a pilot examination before being administered to 705 physicians. Three pre-tests were carried out to evaluate the quality of the survey items. In pre-test 1, after items are generated and the validity of their content is assessed by academics and physicians. In pre-test 2, the scale is carried out with a small sample of 20 respondents of physicians. In pre-test 3, fifty drop-off questionnaires were piloted amongst physicians to test the reliability. Results: On the basis of partial least squares structural equation modelling (PLS-SEM) analyses using SmartPLS 3, the content and convergent validity of the instrument were confirmed with 44 items grouped into four categories, namely, marketing efforts, patient characteristics, pharmacist variables, and contextual factors with 13 reflective constructs. Conclusions: The study outcomes prove that the scale is more valid and reliable for measuring factors that influence the decision of the physician to prescribe the drug. The development and presentation of a scale of thirteen factors related to physicians prescribing decisions help to ensure valid findings and facilitates comparisons of studies and research settings.
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Affiliation(s)
- Mohsen Ali Murshid
- PhD. Faculty of Administrative Sciences, Thamar University. Dhamar (Yemen). mohsen092@gmail
| | - Zurina Mohaidin
- PhD. Senior lecturer. Graduate School of Business (GSB), University of Science Malaysia. Penang (Malaysia).
| | - Mohammad Zayed
- PhD. Graduate School of Business, University of Science Malaysia. Penang (Malaysia).
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Weersink RA, Taxis K, Drenth JPH, Houben E, Metselaar HJ, Borgsteede SD. Prevalence of Drug Prescriptions and Potential Safety in Patients with Cirrhosis: A Retrospective Real-World Study. Drug Saf 2020; 42:539-546. [PMID: 30357649 PMCID: PMC6450857 DOI: 10.1007/s40264-018-0744-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Introduction Patients with cirrhosis are at risk for adverse drug reactions (ADRs) due to altered pharmacokinetics and pharmacodynamics. We aimed to determine the prevalence of drug prescriptions and the potential safety of these prescriptions in a real-world cohort of patients with cirrhosis. Methods This was a retrospective cohort study based on linked real-world data from the Out-patient Pharmacy Database and the Hospitalisation Database of the PHARMO Database Network. Patients with a diagnosis of cirrhosis between January 1998 and December 2015 were included. Follow-up ended when the patient underwent a liver transplant, died, transferred out of the database, or on 31 December 2015. Prescription data were derived from a community pharmacy database and were compared with our previously developed safety recommendations for 209 drugs. Results In total, 5618 patients were included and followed for a median of 3 years (interquartile range [IQR] 1–7). In the first year after the diagnosis, patients used a median of nine drugs (IQR 5–14), with proton pump inhibitors (prevalence 53.9%), aldosterone antagonists (43.6%), and sulfonamide diuretics (41.3%) being the most commonly used drug groups. Almost half (48.3%) of 102,927 prescriptions consisted of drugs with a safety recommendation. The prevalence of potentially unsafe drug use was 60.0% during the total follow-up. Three nonsteroidal anti-inflammatory drugs (NSAIDs) were among the five most commonly used potentially unsafe drugs. Conclusions Patients with cirrhosis use a large number of drugs. Almost two-thirds of patients in our cohort used potentially unsafe drugs. To prevent ADRs in these frail patients, personalised pharmacotherapy is necessary. Electronic supplementary material The online version of this article (10.1007/s40264-018-0744-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rianne A Weersink
- Department of Clinical Decision Support, Health Base Foundation, Papiermolen 36, 3994 DK, Houten, The Netherlands. .,Department of Pharmacy, Unit of Pharmacotherapy, -Epidemiology and Economics, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands.
| | - Katja Taxis
- Department of Pharmacy, Unit of Pharmacotherapy, -Epidemiology and Economics, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Eline Houben
- PHARMO Institute for Drug Outcomes Research, Van Deventerlaan 30-40, 3528 AE, Utrecht, The Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Sander D Borgsteede
- Department of Clinical Decision Support, Health Base Foundation, Papiermolen 36, 3994 DK, Houten, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
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Puil L, Lexchin J, Bero L, Mangin D, Hallgreen CE, Wong GWK, Mintzes B. The impact of post-market regulatory safety advisories on patients, prescribers, and the healthcare system. Hippokratia 2019. [DOI: 10.1002/14651858.cd013510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Lorri Puil
- University of British Columbia; Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine; 2176 Health Sciences Mall Vancouver BC Canada V6T 1Z3
| | - Joel Lexchin
- York University; School of Health Policy and Management; 121 Walmer Rd Toronto ON Canada M5R 2X8
| | - Lisa Bero
- The University of Sydney; Charles Perkins Centre and School of Pharmacy, Faculty of Medicine and Health; D17, 6th floor, Charles Perkins Centre, , The University of Sydney
- NSW
- 2006 Camperdown, Sydney NSW Australia 2006
| | - Dee Mangin
- McMaster University; Family Medicine; Hamilton Canada
| | - Christine E Hallgreen
- University of Copenhagen; Copenhagen Centre for Regulatory Science (CORS), Department of Pharmacy, Faculty of Health and Medical Sciences; Universitetsparken 2 Copenhagen Denmark 2100
| | - Gavin WK Wong
- University of British Columbia; Centre for Clinical Epidemiology and Evaluation; 828 West 10th Avenue Vancouver British Columbia Canada V5Z 1M9
| | - Barbara Mintzes
- The University of Sydney; Charles Perkins Centre and School of Pharmacy, Faculty of Medicine and Health; D17, 6th floor, Charles Perkins Centre, , The University of Sydney
- NSW
- 2006 Camperdown, Sydney NSW Australia 2006
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Gold R, Bunce A, Cowburn S, Davis JV, Nelson JC, Nelson CA, Hicks E, Cohen DJ, Horberg MA, Melgar G, Dearing JW, Seabrook J, Mossman N, Bulkley J. Does increased implementation support improve community clinics' guideline-concordant care? Results of a mixed methods, pragmatic comparative effectiveness trial. Implement Sci 2019; 14:100. [PMID: 31805968 PMCID: PMC6894475 DOI: 10.1186/s13012-019-0948-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 10/14/2019] [Indexed: 11/18/2022] Open
Abstract
Background Disseminating care guidelines into clinical practice remains challenging, partly due to inadequate evidence on how best to help clinics incorporate new guidelines into routine care. This is particularly true in safety net community health centers (CHCs). Methods This pragmatic comparative effectiveness trial used a parallel mixed methods design. Twenty-nine CHC clinics were randomized to receive increasingly intensive implementation support (implementation toolkit (arm 1); toolkit + in-person training + training webinars (arm 2); toolkit + training + webinars + offered practice facilitation (arm 3)) targeting uptake of electronic health record (EHR) tools focused on guideline-concordant cardioprotective prescribing for patients with diabetes. Outcomes were compared across study arms, to test whether increased support yielded additive improvements, and with 137 non-study CHCs that share the same EHR as the study clinics. Quantitative data from the CHCs’ EHR were used to compare the magnitude of change in guideline-concordant ACE/ARB and statin prescribing, using adjusted Poisson regressions. Qualitative data collected using diverse methods (e.g., interviews, observations) identified factors influencing the quantitative outcomes. Results Outcomes at CHCs receiving higher-intensity support did not improve in an additive pattern. ACE/ARB prescribing did not improve in any CHC group. Statin prescribing improved overall and was significantly greater only in the arm 1 and arm 2 CHCs compared with the non-study CHCs. Factors influencing the finding of no additive impact included: aspects of the EHR tools that reduced their utility, barriers to providing the intended implementation support, and study design elements, e.g., inability to adapt the provided support. Factors influencing overall improvements in statin outcomes likely included a secular trend in awareness of statin prescribing guidelines, selection bias where motivated clinics volunteered for the study, and study participation focusing clinic staff on the targeted outcomes. Conclusions Efforts to implement care guidelines should: ensure adaptability when providing implementation support and conduct formative evaluations to determine the optimal form of such support for a given clinic; consider how study data collection influences adoption; and consider barriers to clinics’ ability to use/accept implementation support as planned. More research is needed on supporting change implementation in under-resourced settings like CHCs. Trial registration ClinicalTrials.gov, NCT02325531. Registered 15 December 2014.
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Affiliation(s)
- Rachel Gold
- Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR, 97227, USA. .,OCHIN, Inc., 1881 NW Naito Pkwy, Portland, OR, 97201, USA.
| | - Arwen Bunce
- OCHIN, Inc., 1881 NW Naito Pkwy, Portland, OR, 97201, USA
| | - Stuart Cowburn
- OCHIN, Inc., 1881 NW Naito Pkwy, Portland, OR, 97201, USA
| | - James V Davis
- Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR, 97227, USA
| | - Joan C Nelson
- OCHIN, Inc., 1881 NW Naito Pkwy, Portland, OR, 97201, USA
| | | | - Elisabeth Hicks
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Deborah J Cohen
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Michael A Horberg
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, 2101 East Jefferson St, Rockville, MD, 20852, USA
| | - Gerardo Melgar
- Cowlitz Family Health Center, 1057 12th Avenue, Longview, WA, 98632, USA
| | - James W Dearing
- Michigan State University, 404 Wilson Rd, Room 473, East Lansing, MI, 48824, USA
| | - Janet Seabrook
- Community HealthNet Health Centers, 1021 West 5th Avenue, Gary, IN, 46402, USA
| | - Ned Mossman
- OCHIN, Inc., 1881 NW Naito Pkwy, Portland, OR, 97201, USA
| | - Joanna Bulkley
- Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR, 97227, USA
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Kunstler BE, Lennox A, Bragge P. Changing prescribing behaviours with educational outreach: an overview of evidence and practice. BMC MEDICAL EDUCATION 2019; 19:311. [PMID: 31412928 PMCID: PMC6693161 DOI: 10.1186/s12909-019-1735-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/26/2019] [Indexed: 05/28/2023]
Abstract
BACKGROUND General practitioners (GPs), or family practitioners, are tasked with prescribing medications that can be harmful to the community if they are inappropriately prescribed or used (e.g. opioids). Educational programs, such as educational outreach (EO), are designed to change the behaviour of health professionals. The purpose of this study was to identify the efficacy of EO programs at changing the prescribing behaviour of GPs. METHODS This study included an evidence and practice review, comprising a rapid review supplemented by interviews with people who are familiar with EO implementation for regulation purposes. Seven databases were searched using terms related to health professionals and prescribing. Systematic and narrative reviews published in English after 2007 were included. Non-statistical analysis was used to report intervention efficacy. Three government representatives participated in semi-structured interviews to aid in understanding the relevance of review findings to the Victorian context. Interviews were transcribed verbatim and thematically analysed for emerging themes. RESULTS Fourteen reviews were identified for the evidence review. Isolated (e.g. EO program delivered by itself) and multifaceted (e.g. EO program supplemented by other interventions) programs were found to change prescribing behaviours. However, limited evidence suggests that EO can successfully change prescribing behaviours specific to GPs. Isolated EO can successfully change health professional prescribing behaviours, although cheaper alternatives such as letters might be just as effective. Multifaceted EO can also successfully change health professional prescribing behaviours, especially in older adults, but it remains unclear as to what combination of interventions works best. Success factors for EO reported by government representatives included programs having practical rather than didactic foci; making EO compulsory; focussing EO on preventing adverse events; using monetary or professional development incentives; and in-person delivery. CONCLUSIONS Educational outreach can successfully change prescribing behaviours but evidence specific to GPs is lacking. Key characteristics of EO that could optimise success include ensuring the EO program is tailored, involves practical learning and uses incentives that are meaningful to clinicians.
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Affiliation(s)
- Breanne E. Kunstler
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton, Melbourne, VIC 3800 Australia
| | - Alyse Lennox
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton, Melbourne, VIC 3800 Australia
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton, Melbourne, VIC 3800 Australia
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Hendriks JM, Brooks AG, Rowett D, Moss JR, Gallagher C, Nyfort-Hansen K, Simmons S, Middeldorp ME, Jones T, Thomas G, Lau DH, Sanders P. Home-Based Education and Learning Program for Atrial Fibrillation: Rationale and Design of the HELP-AF Study. Can J Cardiol 2019; 35:846-854. [DOI: 10.1016/j.cjca.2019.03.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/24/2019] [Accepted: 03/24/2019] [Indexed: 11/16/2022] Open
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Floyd T, Mårtensson S, Bailey J, Kay D, McGarity B, Brew BK. The MOWER (middle of the week everyone gets a re-chart) pilot study: reducing in-hospital charting error with a multi-intervention. BMC Health Serv Res 2019; 19:397. [PMID: 31221157 PMCID: PMC6585035 DOI: 10.1186/s12913-019-4230-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 06/07/2019] [Indexed: 11/19/2022] Open
Abstract
Background Medication charting errors occur often and can be harmful for patients. Interventions to improve charting errors have demonstrated some success particularly if the intervention uses multiple approaches including an education component. The aim of this pilot study was to determine whether a multi-faceted intervention, including education of junior doctors and weekday re-charting could reduce in-hospital charting error. Methods Medication charts (n = 579) of all patients admitted to the medical ward of a medium sized regionally-based hospital in Australia over nine months (baseline and during intervention) were inspected for errors. The intervention ran for three months and involved implementation of a National Inpatient Medication Chart targeted error tool with eight targeted charting requirements which was used for visual reminders in the ward and training of junior doctors. In addition, mid-weekly re-charting (MOWER) was performed by a senior and junior doctor team. Results The mean number of charting requirement errors significantly reduced during the intervention by 26% from 4.6 ± 1.3 to 3.4 ± 1.7 per chart (p < 0.001). Re-chart errors reduced on average by 50% (4.4 ± 1.4 to 2.2 ± 1.7 per chart, p < 0.001) and primary (initial) charts by 20% (4.6 ± 1.3 to 3.7 ± 1.5 per chart, p < 0.001) during the intervention. Failing to provide indication information for a drug, prescriber name, and failing to use generic rather than brand names were the categories with the most errors at baseline and also showed the largest error reductions during the intervention. Conclusions A multi-intervention including education of junior doctors, visual reminders and midweek re-charting are effective in reducing the rate of charting errors. We advise that a larger study is now conducted using the same multi-intervention strategy in different ward settings to evaluate feasibility and sustainability of this intervention. Electronic supplementary material The online version of this article (10.1186/s12913-019-4230-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tony Floyd
- NSW Department of Health, Sydney, NSW, Australia
| | - Siri Mårtensson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jannine Bailey
- Bathurst Rural Clinical School, Western Sydney University, PO Box 9008, Bathurst, NSW, 2795, Australia.
| | - Derek Kay
- NSW Department of Health, Sydney, NSW, Australia
| | - Bruce McGarity
- NSW Department of Health, Sydney, NSW, Australia.,Bathurst Rural Clinical School, Western Sydney University, PO Box 9008, Bathurst, NSW, 2795, Australia
| | - Bronwyn K Brew
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Bathurst Rural Clinical School, Western Sydney University, PO Box 9008, Bathurst, NSW, 2795, Australia
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Awad MH, Ulbrich TR, Furdich KM, Schneider SR, Gothard MD. The Effect of Pharmacy-Led, Small-Group Academic Detailing on Prescribing Patterns in an Ambulatory Care Clinic. J Pharm Technol 2019; 35:56-63. [DOI: 10.1177/8755122518818826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background: While academic detailing seems to be the most promising intervention to improve prescribing patterns, implementation could be challenging for small community practices. Objective: A pharmacy-led, interactive, and tailored small-group academic detailing in a federally qualified health center is described. The primary objective of the study was to determine if the small-group academic detailing improved the prescribing patterns of the medical providers for select disease states: type 2 diabetes mellitus (T2DM), hyperlipidemia (HLD), and essential hypertension (HTN). Methods: Prescribing patterns in a federally qualified health center were examined in relation to small-group academic detailing sessions from April 2010 to March 2015. The markers for improvement were the increase in utilizing metformin and statins in patients diagnosed with T2DM and HLD, respectively, and the reduction of β-blocker use in patients diagnosed with essential HTN. Changes in prescribing patterns were evaluated using Pearson’s χ2and Fisher’s exact tests. Results: The average number of active, adult patients with T2DM, HLD, and essential HTN was 839, 1768, and 2547, respectively. Utilization of metformin in T2DM increased from 5.5% at baseline to 37.7%, statin utilization in HLD increased from 77.1% to 86.9%, and β-blocker use in HTN decreased from 17.9% to 13.8% ( P < .005). Conclusions: A pharmacy-led, small-group academic detailing program improved and maintained appropriate prescribing patterns in an underserved community practice. This study serves as a successful pilot emphasizing the pharmacist’s role as an educator and a resource to medical providers regarding appropriate medication use.
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Affiliation(s)
- Magdi H. Awad
- AxessPointe Community Health Center, Akron, OH, USA
- Northeast Ohio Medical University, Rootstown, OH, USA
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Kline TV, Savage RL, Greenslade JH, Lock CL, Pattullo C, Bell AJ. Affecting emergency department oxycodone discharge prescribing: An educational intervention. Emerg Med Australas 2019; 31:580-586. [DOI: 10.1111/1742-6723.13261] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/22/2018] [Accepted: 11/11/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Taylor V Kline
- Faculty of MedicineThe University of Queensland Brisbane Queensland Australia
| | - Rina L Savage
- Royal Brisbane and Women's Hospital Brisbane Queensland Australia
| | - Jaimi H Greenslade
- Faculty of MedicineThe University of Queensland Brisbane Queensland Australia
- Royal Brisbane and Women's Hospital Brisbane Queensland Australia
| | - Caitlin L Lock
- Royal Brisbane and Women's Hospital Brisbane Queensland Australia
| | | | - Anthony J Bell
- Faculty of MedicineThe University of Queensland Brisbane Queensland Australia
- Royal Brisbane and Women's Hospital Brisbane Queensland Australia
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Reeve E, Low LF, Hilmer SN. Attitudes of Older Adults and Caregivers in Australia toward Deprescribing. J Am Geriatr Soc 2019; 67:1204-1210. [PMID: 30756387 DOI: 10.1111/jgs.15804] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 12/20/2018] [Accepted: 01/03/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Use of harmful and/or unnecessary medications in older adults is common. Understanding older adult and caregiver attitudes toward deprescribing will contribute to medication optimization in practice. The aims of this study were to capture the attitudes and beliefs of older adults and caregivers toward deprescribing and determine what participant characteristics and/or attitudes (if any) predicted reported willingness to have a medication deprescribed. DESIGN Self-completed questionnaire. SETTING Australia. PARTICIPANTS Older adults (n = 386), 65 years or older, taking one or more regular prescription medications and caregivers of older adults (n = 205) who could self-complete a written questionnaire in English. MEASUREMENTS Older adult and caregiver versions of the validated revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire were completed. The rPATD includes two global questions and four factors: perceived burden of medications, belief in appropriateness of medications, concerns about stopping, and involvement in medication management. Participant characteristics, self-rated health, trust in physician, and health autonomy were also collected. RESULTS Older adult participants had a median age of 74 years (interquartile range [IQR] = 70-81 y), and caregivers were aged 67 years (IQR = 59-76) and were caring for a person aged 81 years (IQR = 75-86.25 y). Most of both older adults (88%) and caregivers (84%) agreed or strongly agreed that they would be willing to stop one or more of their or their care recipient's medications if their or their care recipient's doctor said it was possible. In a binary logistic regression model, a low concern about stopping factor score was the strongest predictor of willingness to have a medication deprescribed in older adults (odds ratio [OR] = 0.12; 95% confidence interval [CI] = 0.04-0.34). Excellent/good rating of physical health was the strongest predictor in caregivers (OR = 3.71; 95% CI = 1.13-12.23). CONCLUSIONS Most older adults and caregivers are willing to have one of their or their care recipient's medication deprescribed, although different predictors (characteristics/attitudes) of this willingness were identified in these two groups.
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Affiliation(s)
- Emily Reeve
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia.,Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.,College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lee-Fay Low
- University of Sydney, Sydney, New South Wales, Australia
| | - Sarah N Hilmer
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia.,Departments of Aged Care and Clinical Pharmacology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Wetzel M, Hockenberry J, Raval MV. Interventions for Postsurgical Opioid Prescribing. JAMA Surg 2018; 153:948-954. [DOI: 10.1001/jamasurg.2018.2730] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Martha Wetzel
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Mehul V. Raval
- Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
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Ng JY, Gagliardi AR. The design of behavioural interventions labelled as patient-mediated: A scoping review. Health Expect 2018; 21:695-706. [PMID: 29120511 PMCID: PMC6117495 DOI: 10.1111/hex.12653] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2017] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Patient-mediated interventions (PMIs) directed at patients and/or physicians improve patient or provider behaviour and patient outcomes. However, what constitutes a PMI is not clear. This study described interventions explicitly labelled as "patient-mediated" in primary research. METHODS MEDLINE, EMBASE, Allied and Complementary Medicine, PsychINFO, HealthSTAR, Social Work Abstracts, CINAHL and Cochrane Library were searched from inception on 1 January 2017 for English language studies that developed or evaluated behavioural interventions referred to as "patient-mediated" or "patient mediated" in the full text. Screening and data extraction were independently duplicated. Data were extracted and summarized on study and intervention characteristics. Interventions were categorized as 1 of 4 PMI pathways. RESULTS Eight studies (4 randomized controlled trials, 1 observational study and 3 qualitative studies) were included. No studies explicitly defined PMI, and few PMIs were described in terms of content and format. Although 3 studies employed physician interventions, only patient interventions were considered PMIs. One study achieved positive improvement in patient behaviour. CONCLUSIONS Research is needed to generate consensus on the PMI concept, employ theory when designing or evaluating PMIs, establish the effectiveness of different types of PMIs, and understand when and how to employ PMIs alone or combined with other interventions.
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Affiliation(s)
- Jeremy Y. Ng
- Toronto General Hospital Research InstituteUniversity Health NetworkTorontoONCanada
| | - Anna R. Gagliardi
- Toronto General Hospital Research InstituteUniversity Health NetworkTorontoONCanada
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Elnaem MH, Nik Mohamed MH, Zaman Huri H, Azarisman SM. Impact of educational outreach intervention on enhancing health care providers' knowledge about statin therapy prescribing in Malaysian patients with type 2 diabetes mellitus. J Eval Clin Pract 2018; 24:521-527. [PMID: 29508492 DOI: 10.1111/jep.12903] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 02/05/2018] [Accepted: 02/06/2018] [Indexed: 11/30/2022]
Abstract
RATIONALE Previous research reported underutilization of statin therapy among patients with type 2 diabetes mellitus. Improving health care providers' awareness and understanding of the benefits and risks of statin treatment could be of assistance in optimizing the statin prescribing process. AIMS AND OBJECTIVES This study aimed to assess health care providers' knowledge related to statin therapy and the impact of educational outreach intervention based on the perceived knowledge. METHODS This was a cross-sectional study based on educational outreach intervention targeting physicians and pharmacists in 1 major tertiary hospital in the state of Pahang, Malaysia. Participants responded to a 12-item, validated questionnaire both prior to and after the outreach educational program. Two sessions were conducted separately for 2 cohorts of pharmacists and physicians. The knowledge scores prior to and after the educational intervention were calculated and compared using a paired-samples t-test. RESULTS The response rate to both pre-and post-educational outreach questionnaires was 91% (40/44). Prior to the intervention, around 84% (n37) of the participants decided to initiate statin therapy for both pre-assessment clinical case scenarios; however, only 27% (n12) could state the clinical benefits of statin therapy. Forty-five percent (n20) could state the drug to drug interactions, and 52.3% (n23) could identify the statin therapy that can be given at any time day/evening. The educational outreach program increased participants' knowledge scores of 1.450 (95% CI, 0.918 to 1.982) point, P < .0005, which is statistically significant. Forty respondents (91%) were of the opinion that statin side effects are the most common cause of treatment discontinuation. CONCLUSION This work demonstrated the impact of an educational outreach intervention on improving health care providers' knowledge and beliefs about statin therapy. This type of intervention is considered effective for short-term knowledge enhancement. Further research is needed to test the long-term efficacy of such intervention.
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Affiliation(s)
- Mohamed Hassan Elnaem
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Mohamad Haniki Nik Mohamed
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Hasniza Zaman Huri
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shah M Azarisman
- Department of Internal Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
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Saha SK, Hawes L, Mazza D. Improving antibiotic prescribing by general practitioners: a protocol for a systematic review of interventions involving pharmacists. BMJ Open 2018; 8:e020583. [PMID: 29654036 PMCID: PMC5898351 DOI: 10.1136/bmjopen-2017-020583] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Effective antibiotic options in general practice for patients with infections are declining significantly due to antibiotic over-prescribing and emerging antibiotic resistance. To better improve antibiotic prescribing by general practitioner (GP), pharmacist-GP collaborations have been promoted under antibiotic stewardship programmes. However, there is insufficient information about whether and how pharmacists help GPs to more appropriately prescribe antibiotics. This systematic review aims to determine whether pharmacist-led or pharmacist-involved interventions are effective at improving antibiotic prescribing by GPs. METHODS AND ANALYSIS A systematic review of English language randomised controlled trials (RCTs), cluster RCTs, controlled before-and-after studies and interrupted time series studies cited in MEDLINE, EMBASE, EMCARE, CINAHL Plus, PubMed, PsycINFO, Cochrane Central Register of Controlled Trials and Web of Science databases will be conducted. Studies will be included if a pharmacist is involved as the intervention provider and GPs are the intervention recipients in general practice setting. Data extraction and management will be conducted using Effective Practice and Organisation of Care data abstraction tools and a template for intervention description and replication. The Cochrane and ROBINS-I risk of bias assessment tools will be used to assess the methodological quality of studies. Primary outcome measures include changes (overall, broad spectrum and guidelines concordance) of GP-prescribed antibiotics. Secondary outcomes include quality of antibiotic prescribing, delayed antibiotic use, acceptability and feasibility of interventions. Meta-analysis for combined effect and forest plots, χ2 test and I2 statistics for detailed heterogeneity and sensitivity analysis will be performed if data permit. Grading of Recommendations Assessment, Development and Evaluation and Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidance will be used to report findings. ETHICS AND DISSEMINATION No ethics approval is required as no primary, personal or confidential data are being collected in this study. The findings will be disseminated to national and international scientific sessions and published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42017078478.
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Affiliation(s)
- Sajal K Saha
- Department of General Practice, School of Primary Health Care, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Melbourne, Victoria 3168, Australia
| | - Lesley Hawes
- Department of General Practice, School of Primary Health Care, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Melbourne, Victoria 3168, Australia
| | - Danielle Mazza
- Department of General Practice, School of Primary Health Care, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Melbourne, Victoria 3168, Australia
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Wu J, Taylor D, Ovchinikova L, Heaney A, Morgan T, Dartnell J, Holbrook R, Humphreys L, Weekes L, Blogg S. Relationship between antimicrobial-resistance programs and antibiotic dispensing for upper respiratory tract infection: An analysis of Australian data between 2004 and 2015. J Int Med Res 2018; 46:1326-1338. [PMID: 29332434 PMCID: PMC6091814 DOI: 10.1177/0300060517740813] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/11/2017] [Indexed: 11/16/2022] Open
Abstract
Objective NPS MedicineWise aims to ensure that medicines are prescribed and used in a manner consistent with current evidence-based best practice. A series of nationwide educational and advertising interventions for general practitioners and consumers were implemented in Australia between 2009 and 2015 with the aim of reducing antibiotic prescriptions for upper respiratory tract infections (URTIs). The work described in this paper quantifies the change in antibiotic dispensing following these interventions. Methods Antibiotic dispensing data between 2004 and 2015 were obtained from a national claims database. A Bayesian structural time series model was used to forecast a series of antibiotic dispensing volumes expected to have occurred if the interventions had not taken place. These were compared with the volumes that were actually observed to estimate the intervention effect. Results On average, 126,536 fewer antibiotics were dispensed each month since the intervention programs began in 2009 (95% Bayesian credible interval = 71,580-181,490). This change represents a 14% total reduction in dispensed scripts after the series of intervention programs began in 2009. Conclusions Continual educational intervention programs that emphasise the judicious use of antibiotics may effectively reduce inappropriate prescribing of antibiotics for the treatment of URTIs at a national level.
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Affiliation(s)
- Jianyun Wu
- NPS MedicineWise, Surry Hills, Sydney, New South Wales, Australia
- School of Mathematical Sciences, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Daniel Taylor
- NPS MedicineWise, Surry Hills, Sydney, New South Wales, Australia
| | | | - Aine Heaney
- NPS MedicineWise, Surry Hills, Sydney, New South Wales, Australia
| | - Tessa Morgan
- NPS MedicineWise, Surry Hills, Sydney, New South Wales, Australia
| | | | - Rachel Holbrook
- NPS MedicineWise, Surry Hills, Sydney, New South Wales, Australia
| | - Lauren Humphreys
- NPS MedicineWise, Surry Hills, Sydney, New South Wales, Australia
| | - Lynn Weekes
- NPS MedicineWise, Surry Hills, Sydney, New South Wales, Australia
| | - Suzanne Blogg
- NPS MedicineWise, Surry Hills, Sydney, New South Wales, Australia
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Larson EL, Murray MT, Cohen B, Simpser E, Pavia M, Jackson O, Jia H, Hutcheon RG, Mosiello L, Neu N, Saiman L. Behavioral Interventions to Reduce Infections in Pediatric Long-term Care Facilities: The Keep It Clean for Kids Trial. Behav Med 2018; 44. [PMID: 28632004 PMCID: PMC5732083 DOI: 10.1080/08964289.2017.1288607] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Children in pediatric long-term care facilities (pLTCF) represent a highly vulnerable population and infectious outbreaks occur frequently, resulting in significant morbidity, mortality, and resource use. The purpose of this quasi-experimental trial using time series analysis was to assess the impact of a 4-year theoretically based behavioral intervention on infection prevention practices and clinical outcomes in three pLTCF (288 beds) in New York metropolitan area including 720 residents, ages 1 day to 26 years with mean lengths of stay: 7.9-33.6 months. The 5-pronged behavioral intervention included explicit leadership commitment, active staff participation, work flow assessments, training staff in the World Health Organization "'five moments of hand hygiene (HH)," and electronic monitoring and feedback of HH frequency. Major outcomes were HH frequency, rates of infections, number of hospitalizations associated with infections, and outbreaks. Mean infection rates/1000 patient days ranged from 4.1-10.4 pre-intervention and 2.9-10.0 post-intervention. Mean hospitalizations/1000 patient days ranged from 2.3-9.7 before and 6.4-9.8 after intervention. Number of outbreaks/1000 patient days per study site ranged from 9-24 pre- and 9-18 post-intervention (total = 95); number of cases/outbreak ranged from 97-324 (total cases pre-intervention = 591 and post-intervention = 401). Post-intervention, statistically significant increases in HH trends occurred in one of three sites, reductions in infections in two sites, fewer hospitalizations in all sites, and significant but varied changes in the numbers of outbreaks and cases/outbreak. Modest but inconsistent improvements occurred in clinically relevant outcomes. Sustainable improvements in infection prevention in pLTCF will require culture change; increased staff involvement; explicit administrative support; and meaningful, timely behavioral feedback.
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Linsky A, Simon SR, Stolzmann K, Meterko M. Patient attitudes and experiences that predict medication discontinuation in the Veterans Health Administration. J Am Pharm Assoc (2003) 2018; 58:13-20. [PMID: 29154017 PMCID: PMC6788281 DOI: 10.1016/j.japh.2017.10.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 10/16/2017] [Accepted: 10/20/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Polypharmacy is associated with adverse medication effects. One potential solution is deprescribing, which is the intentional, proactive, rational discontinuation of a medication that is no longer indicated or for which the potential harms outweigh the potential benefits. We identified patient characteristics, attitudes, and health care experiences associated with medication discontinuation. DESIGN, SETTING, AND PARTICIPANTS We conducted a national mail survey, with the use of the Patient Perceptions of Discontinuation (PPoD) instrument, of 1600 veterans receiving primary care at Veterans Affairs (VA) medical centers and prescribed 5 or more concurrent medications. MAIN OUTCOME MEASURES The primary outcome was the response to: "Have you ever stopped taking a medicine (with or without your doctor's knowledge)?" The primary predictors of interest were 8 validated attitudinal scales. Other predictors included demographics, health status, and health care experiences. RESULTS Respondents (n = 803; adjusted response rate 52%) were predominantly male (85%); non-Hispanic white (68%), 65 years of age or older (60%), and with poor (16%) or fair (45%) health. Participant attitudes toward medications and their providers were generally favorable. One in 3 patients (34%) reported having stopped a medicine in the past. In a multivariable logistic regression model (P < 0.001; pseudo-R2 = 0.31; c-statistic = 0.82), factors associated with discontinuation included being told or asking to stop a medicine, greater interest in deprescribing and shared decision making, and higher education. Factors associated with decreased discontinuation were more prescriptions, higher trust in provider, and seeing a VA clinical pharmacist. CONCLUSION More highly educated patients with interest in deprescribing and shared decision making may be more receptive to discontinuation discussions. Future research evaluating how to incorporate this survey and these findings into clinical workflow through the design of clinical interventions may help to promote safe and rational medication use.
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Affiliation(s)
- Amy Linsky
- General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA 02130
| | - Steven R. Simon
- General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA 02130
| | - Kelly Stolzmann
- General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA 02130
| | - Mark Meterko
- General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA 02130
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Worthington HC, Cheng L, Majumdar SR, Morgan SG, Raymond CB, Soumerai SB, Law MR. The impact of a physician detailing and sampling program for generic atorvastatin: an interrupted time series analysis. Implement Sci 2017; 12:141. [PMID: 29178960 PMCID: PMC5702229 DOI: 10.1186/s13012-017-0671-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 11/13/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In 2011, Manitoba implemented a province-wide program of physician detailing and free sampling for generic atorvastatin to increase use of this generic statin. We examined the impact of this unique combined program of detailing and sampling for generic atorvastatin on the use and cost of statin medicines, market share of generic atorvastatin, the choice of starting statin for new users, and switching from a branded statin to generic atorvastatin. METHODS We conducted a retrospective study of Manitoba insurance claims data for all continuously enrolled patients who filled one or more prescriptions for a statin between 2008 and 2013. Data were linked to physician-level data on the number of detailing visits and sample provision. We used interrupted time series analyses to assess policy-related changes in the use and cost of statin medicines, market share of generic atorvastatin, the choice of starting statin for new users, and switching from a branded statin to generic atorvastatin. RESULTS The detailing program reached 31% (651/2103) of physicians who prescribed a statin during the study period. Collectively, these physicians prescribed 61% of statins dispensed in the province. Free sample cards were provided to 61% (394/651) of the detailed physicians. The program did not change the level or trend in the overall statin use rate and the total cost of statins or increase the number of patients switching from another branded statin to generic atorvastatin. We found the program had a small impact on atorvastatin's market share of new prescriptions, with a level increase of 2.6%. CONCLUSIONS Though physician detailers were skilled at targeting high-prescribing physicians, a combined program of detailing visits and sample provision for generic atorvastatin did not lower overall statin costs or lead to switching from branded statins to the generic. The preceding introduction of generic atorvastatin appeared sufficient to modify prescribing patterns and decrease costs.
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Affiliation(s)
- Heather C. Worthington
- Centre for Health Services and Policy Research, School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia Canada
- 201-2206 East Mall, Vancouver, BC V6T 1Z3 Canada
| | - Lucy Cheng
- Centre for Health Services and Policy Research, School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia Canada
| | - Sumit R. Majumdar
- Department of Medicine, University of Alberta, Edmonton, Alberta Canada
| | - Steven G. Morgan
- School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia Canada
| | - Colette B. Raymond
- Manitoba Centre for Health Policy, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba Canada
| | | | - Michael R. Law
- Centre for Health Services and Policy Research, School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia Canada
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Ciapponi A, Lewin S, Herrera CA, Opiyo N, Pantoja T, Paulsen E, Rada G, Wiysonge CS, Bastías G, Dudley L, Flottorp S, Gagnon M, Garcia Marti S, Glenton C, Okwundu CI, Peñaloza B, Suleman F, Oxman AD. Delivery arrangements for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev 2017; 9:CD011083. [PMID: 28901005 PMCID: PMC5621087 DOI: 10.1002/14651858.cd011083.pub2] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services. OBJECTIVES To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review. METHODS We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries. MAIN RESULTS We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions. AUTHORS' CONCLUSIONS A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.
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Affiliation(s)
- Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Simon Lewin
- Norwegian Institute of Public HealthPO Box 4404OsloNorway0403
- South African Medical Research CouncilHealth Systems Research UnitPO Box 19070TygerbergSouth Africa7505
| | - Cristian A Herrera
- Pontificia Universidad Católica de ChileDepartment of Public Health, School of MedicineMarcoleta 434SantiagoChile
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
| | - Newton Opiyo
- CochraneCochrane Editorial UnitSt Albans House, 57‐59 HaymarketLondonUKSW1Y 4QX
| | - Tomas Pantoja
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | | | - Gabriel Rada
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Internal Medicine and Evidence‐Based Healthcare Program, Faculty of MedicineLira 44, Decanato Primer pisoSantiagoChile
| | - Charles S Wiysonge
- South African Medical Research CouncilCochrane South AfricaFrancie van Zijl Drive, Parow ValleyCape TownWestern CapeSouth Africa7505
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Gabriel Bastías
- Pontificia Universidad Católica de ChileDepartment of Public Health, School of MedicineMarcoleta 434SantiagoChile
| | - Lilian Dudley
- Stellenbosch UniversityDivision of Community Health, Faculty of Medicine and Health SciencesFransie Van Zyl DriveTygerbergCape TownSouth Africa7505
| | - Signe Flottorp
- Norwegian Institute of Public HealthDepartment for Evidence SynthesisPO Box 4404 NydalenOsloNorway0403
| | - Marie‐Pierre Gagnon
- CHU de Québec ‐ Université Laval Research CentrePopulation Health and Optimal Health Practices Research Unit10 Rue de l'Espinay, D6‐727Québec CityQCCanadaG1L 3L5
| | - Sebastian Garcia Marti
- Institute for Clinical Effectiveness and Health PolicyBuenos AiresCapital FederalArgentinaC1056ABH
| | - Claire Glenton
- Norwegian Institute of Public HealthGlobal Health UnitPO Box 7004 St Olavs plassOsloNorwayN‐0130
| | - Charles I Okwundu
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Blanca Peñaloza
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Fatima Suleman
- University of KwaZulu‐NatalDiscipline of Pharmaceutical Sciences, School of Health SciencesPrivate Bag X54001DurbanKZNSouth Africa4000
| | - Andrew D Oxman
- Norwegian Institute of Public HealthPO Box 4404OsloNorway0403
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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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Linsky A, Meterko M, Stolzmann K, Simon SR. Supporting medication discontinuation: provider preferences for interventions to facilitate deprescribing. BMC Health Serv Res 2017; 17:447. [PMID: 28659157 PMCID: PMC5490086 DOI: 10.1186/s12913-017-2391-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 06/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND One approach to prevent adverse drug events is to discontinue ("deprescribe") medications that are outdated, not indicated, or of limited benefit relative to risk for a particular patient. However, there is little guidance to clinicians about how to integrate the process of deprescribing into the workflow of clinical practice. We sought to determine clinical prescribers' preferences for interventions that would improve their ability to appropriately and proactively discontinue medications. METHODS We conducted a national web-based survey of 2475 prescribers [physicians, nurse practitioners (NP), physician assistants (PA), and clinical pharmacy specialists] practicing in US Veterans Affairs (VA) primary care clinics. One survey question presented 15 potential changes to medication-related practices and respondents ranked their top three choices for changes that would "most improve [their] ability to discontinue medications." We summed the weighted rankings for each of the 15 response options. Preferences were determined for the whole sample and within subgroups of respondents defined by demographic and background characteristics, medication-relevant experience, and beliefs. RESULTS Among the 326 respondents who provided rankings, the top choice for a change that would help improve their ability to discontinue medications was "Requiring all medication prescriptions to have an associated 'indication for use.'" This preference was followed by "Assistance with follow-up of patients as they taper or discontinue medications is performed by another member of the Patient Aligned Care Team (PACT)" and "Increased patient involvement in prescribing decisions." This combination of options, albeit in varying rank order, was the most commonly selected, with 250 respondents (77%) who answered the question including at least one of these items in their three highest ranked choices, regardless of their demographics, experience, or beliefs. CONCLUSIONS Continued efforts to improve clinicians' ability to make prescribing decisions, especially around deprescribing, have many potential benefits, including decreased pharmaceutical and health care costs, fewer adverse drug events and complications, and improved patient involvement and satisfaction with their care. Future work, whether as research or quality improvement, should incorporate clinicians' preferences for interventions, as greater buy-in from front-line staff leads to better adoption of changes.
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Affiliation(s)
- Amy Linsky
- Section of General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave, Boston, MA, 02130, USA. .,Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System and ENRM Veterans Affairs Medical Center, 150 S. Huntington Ave, Boston, MA, USA. .,Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA.
| | - Mark Meterko
- Performance Measurement, VHA, Office of Reporting, Analytics, Performance, Improvement and Deployment (RAPID), Bedford, MA, USA.,Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System and ENRM Veterans Affairs Medical Center, 150 S. Huntington Ave, Boston, MA, USA
| | - Steven R Simon
- Section of General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave, Boston, MA, 02130, USA.,Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System and ENRM Veterans Affairs Medical Center, 150 S. Huntington Ave, Boston, MA, USA.,Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
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Abstract
BACKGROUND AND OBJECTIVES Successful mechanisms for engaging patients in the deprescribing process remain unknown but may include: (1) triggering motivation to deprescribe by increasing patients' knowledge and concern about medications; (2) building capacity to taper by augmenting self-efficacy and (3) creating opportunities to discuss and receive support for deprescribing from a healthcare provider. We tested these mechanisms during theEliminating Medications through Patient Ownership of End Results (EMPOWER) () trial and investigated the contexts that led to positive and negative deprescribing outcomes. DESIGN A realist evaluation using a sequential mixed methods approach, conducted alongside the EMPOWER randomised clinical trial. SETTING Community, Quebec, Canada. PARTICIPANTS 261 older chronic benzodiazepine consumers, who received the EMPOWER intervention and had complete 6-month follow-up data. INTERVENTION Mailed deprescribing brochure on benzodiazepines. MEASUREMENTS Motivation (intent to discuss deprescribing; change in knowledge test score; change in beliefs about the risk-benefits of benzodiazepines, measured with the Beliefs about Medicines Questionnaire), capacity (self-efficacy for tapering) and opportunity (support from a physician or pharmacist). RESULTS The intervention triggered the motivation to deprescribe among 167 (n=64%) participants (mean age 74.6 years±6.3, 72% women), demonstrated by improved knowledge (risk difference, 58.50% (95% CI 46.98% to 67.44%)) and increased concern about taking benzodiazepines (risk difference, 67.67% (95% CI 57.36% to 74.91%)). Those who attempted to taper exhibited increased self-efficacy (risk difference, 56.90% (95% CI 45.41% to 65.77%)). Contexts where the deprescribing mechanisms failed included lack of support from a healthcare provider, a focus on short-term quality of life, intolerance to withdrawal symptoms and perceived poor health. CONCLUSION Deprescribing mechanisms that target patient motivation and capacity to deprescribe yield successful outcomes in contexts where healthcare providers are supportive, and patients do not have internal competing desires to remain on drug therapy. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT01148186.
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Affiliation(s)
- Philippe Martin
- Faculty of Pharmacy, Université de Montréal, Montreal, Québec, Canada
- Institut Universitaire de Gériatrie de Montréal, Montreal, Québec, Canada
| | - Cara Tannenbaum
- Institut Universitaire de Gériatrie de Montréal, Montreal, Québec, Canada
- Université de Montréal, Faculties of Medicine and Pharmacy, Montreal, Québec, Canada
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Brax H, Fadlallah R, Al-Khaled L, Kahale LA, Nas H, El-Jardali F, Akl EA. Association between physicians' interaction with pharmaceutical companies and their clinical practices: A systematic review and meta-analysis. PLoS One 2017; 12:e0175493. [PMID: 28406971 PMCID: PMC5391068 DOI: 10.1371/journal.pone.0175493] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 03/27/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Pharmaceutical company representatives likely influence the prescribing habits and professional behaviors of physicians. The objective of this study was to systematically review the association between physicians' interactions with pharmaceutical companies and their clinical practices. METHODS We used the standard systematic review methodology. Observational and experimental study designs examining any type of targeted interaction between practicing physicians and pharmaceutical companies were eligible. The search strategy included a search of MEDLINE and EMBASE databases up to July 2016. Two reviewers selected studies, abstracted data, and assessed risk of bias in duplicate and independently. We assessed the quality of evidence using the GRADE approach. RESULTS Twenty articles reporting on 19 studies met our inclusion criteria. All of these studies were conducted in high-income countries and examined different types of interactions, including detailing, industry-funded continuing medical education, and receiving free gifts. While all included studies assessed prescribing behaviors, four studies also assessed financial outcomes, one assessed physicians' knowledge, and one assessed their beliefs. None of the studies assessed clinical outcomes. Out of the 19 studies, 15 found a consistent association between interactions promoting a medication, and inappropriately increased prescribing rates, lower prescribing quality, and/or increased prescribing costs. The remaining four studies found both associations and lack of significant associations for the different types of exposures and drugs examined in the studies. A meta-analysis of six of these studies found a statistically significant association between exposure and physicians' prescribing behaviors (OR = 2.52; 95% CI 1.82-3.50). The quality of evidence was downgraded to moderate for risk of bias and inconsistency. Sensitivity analysis excluding studies at high risk of bias did not substantially change these results. A subgroup analysis did not find a difference by type of exposure. CONCLUSION There is moderate quality evidence that physicians' interactions with pharmaceutical companies are associated with their prescribing patterns and quality.
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Affiliation(s)
- Hneine Brax
- Faculty of Medicine, Université Saint Joseph, Beirut, Lebanon
| | - Racha Fadlallah
- Center for Systematic Reviews of Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
| | - Lina Al-Khaled
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Lara A. Kahale
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Hala Nas
- Faculty of Medicine, University of Damascus, Damascus, Syria
| | - Fadi El-Jardali
- Center for Systematic Reviews of Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Elie A. Akl
- Center for Systematic Reviews of Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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Ferguson J, Keyworth C, Tully MP. 'If no-one stops me, I'll make the mistake again': Changing prescribing behaviours through feedback; A Perceptual Control Theory perspective'. Res Social Adm Pharm 2017; 14:241-247. [PMID: 28283306 DOI: 10.1016/j.sapharm.2017.03.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/28/2017] [Accepted: 03/01/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Doctors at all levels make prescribing errors which can prolong patients' hospital stay, increase the risk of death, and place a significant financial burden on the health system. Doctors have previously reported receiving little or no feedback on their prescribing errors. The effectiveness of feedback in modifying future practice varies widely, depending on how feedback is delivered. To date there is little evidence about why and how feedback interventions do or do not work. Behavioural theories can be used to evaluate this process and provide explanatory accounts to inform recommendations for future interventions. OBJECTIVE To explore the experiences of prescribers receiving different methods of feedback about their prescribing errors. Perceptual Control Theory (PCT) was used as a theoretical framework to explain which aspects of feedback were most likely to influence prescribing behaviour. METHODS A secondary analysis of 31 semi-structured qualitative interviews with junior doctors who had taken part one of three studies in which they received feedback on their prescribing errors. A hybrid approach to analysis involved inductive thematic analysis, and deductive a priori template of codes using PCT as a framework to guide data analysis and interpretation. RESULTS Feedback was most useful for learning and most likely to influence future prescribing behaviour when it was timely, and provided a comprehensive, contextualised benchmark to which participants could compare their prescribing behaviours and current level of knowledge. Group discussions and completing directly-observed prescribing event forms were thought most likely to impact future prescribing; email feedback alone was perceived as least effective in changing prescribing behaviour. CONCLUSION Feedback has the potential to change future prescribing behaviour. Behaviour change can only take place if prescribers are made aware of these discrepancies, either via providing appropriate reference values or benchmarks before mistakes are made, or by providing timely and comprehensive feedback after mistakes are made.
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Affiliation(s)
- Jane Ferguson
- Manchester Pharmacy, School, University of Manchester, Oxford Road, Manchester, M13 9PL, United Kingdom.
| | - Chris Keyworth
- Manchester Pharmacy, School, University of Manchester, Oxford Road, Manchester, M13 9PL, United Kingdom.
| | - Mary P Tully
- Manchester Pharmacy, School, University of Manchester, Oxford Road, Manchester, M13 9PL, United Kingdom.
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ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group. J Am Coll Cardiol 2017; 69:1076-1092. [DOI: 10.1016/j.jacc.2016.11.004] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Chan WV, Pearson TA, Bennett GC, Cushman WC, Gaziano TA, Gorman PN, Handler J, Krumholz HM, Kushner RF, MacKenzie TD, Sacco RL, Smith SC, Stevens VJ, Wells BL, Castillo G, Heil SKR, Stephens J, Vann JCJ. ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017; 135:e122-e137. [PMID: 28126839 DOI: 10.1161/cir.0000000000000481] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. OBJECTIVES Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. METHODS This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. RESULTS Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). CONCLUSION The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.
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Affiliation(s)
- Wiley V Chan
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Thomas A Pearson
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Glen C Bennett
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - William C Cushman
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Thomas A Gaziano
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Paul N Gorman
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Joel Handler
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Harlan M Krumholz
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Robert F Kushner
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Thomas D MacKenzie
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Ralph L Sacco
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Sidney C Smith
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Victor J Stevens
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Barbara L Wells
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
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Rosich Martí I, Allepuz A, Rodriguez Palomar G, Ortin Font F, Soler Cera M. Impact of an intervention on the prescription of aliskiren after new evidence on safety reported. Pharmacoepidemiol Drug Saf 2016; 26:91-96. [PMID: 27859873 DOI: 10.1002/pds.4136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 09/30/2016] [Accepted: 10/23/2016] [Indexed: 01/27/2023]
Abstract
PURPOSE The purpose of the study is to analyze the impact of an intervention to disseminate safety alerts on the utilization of Aliskiren added to angiotensin converting enzyme inhibitor (ACEI) or an angiotensin-receptor blocker (ARB). METHODS Quasi-experimental design (non-randomized intervention) comparing the utilization of Aliskiren + ACEI or ARB in a primary care area-intervention (PCA-I) with a primary care area-control (PCA-C) following a safety alert. All physicians were provided with a list of diabetic patients (DM) on Aliskiren + ACEI or ARB. Physicians in the PCA-I received also a non-DM patients list, a report with recommendations and information on the utilization of Aliskiren + ACEI or ARB in their area. Information was obtained from electronic medical records, period from May 2010 to December 2012. Interrupted time series analysis were used to assess the effect of the intervention on the number of patients on Aliskiren + ACEI or ARB. RESULTS The number of DM receiving Aliskiren + ACEI or ARB at the time of the alert (23 December 2011) was 106 in the PCA-I (91 non-DM) and 45 in the PCA-C (25 non-DM). After the alert, a decreased in the number of patients on Aliskiren + ACEI or ARB was noted at both PCAs, although the average of daily treatments ended was significantly higher in the PCA-I, both in the DM group (slope after alert: -0.81, 95%CI -0.91 to -0.71 vs. -0.30, 95%CI -0.37 to -0.22) as well as in the non-DM group (-0.56, 95%CI -0.67 to -0.45 vs. -0.10 95%CI -0.17 to -0.04). CONCLUSIONS The prescription of Aliskiren + ACEI or ARB decreased at both PCAs, albeit such decreased was more significant at the PCA-I. The intervention led to a more expeditious implementation of the safety alert recommendations. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Isabel Rosich Martí
- Primary Care Service Alt Penedès-Garraf, Catalan Health Institute, Barcelona, Spain
| | - Alejandro Allepuz
- Primary Care Service Alt Penedès-Garraf, Catalan Health Institute, Barcelona, Spain
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Abstract
Most diabetes care is provided in primary care settings, but typical primary care clinicians struggle to keep up with the latest evidence on diabetes screening, pharmacotherapy, and monitoring. Accordingly, many patients with diabetes are not receiving optimal guideline-based therapy. Relying on front-line clinicians on their own to assess the huge volume of new literature and incorporate it into their practice is unrealistic, and conventional continuing medical education has not proven adequate to address gaps in care. Academic detailing, direct educational outreach to clinicians that uses social marketing techniques to provide specific evidence-based recommendations, has been proven in clinical trials to improve the quality of care for a range of conditions. By directly engaging with clinicians to assess their needs, identify areas for change in practice, and provide them with specific tools to implement these changes, academic detailing can serve as a tool to improve care processes and outcomes for patients with diabetes.
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Affiliation(s)
- Michael A Fischer
- National Resource Center for Academic Detailing, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 1620 Tremont St, suite 3030, Boston, MA, 02120, USA.
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Bazzano LAL, Marshall MK, Harrold R, Pak KJ, van Driel ML. Interventions to improve evidence-based prescribing in heart failure. Hippokratia 2016. [DOI: 10.1002/14651858.cd011253.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Lydia AL Bazzano
- Ochsner Health System; Internal Medicine Residency/Dept of Hospital Medicine-Ochsner; 1514 Jefferson Hwy New Orleans Louisiana USA 70121
| | - Marilyn K Marshall
- University of Queensland Ochsner Clinical School at Ochsner Medical Center; School of Medicine; 1415 Jefferson Hwy New Orleans Louisiana USA 70121
| | - Robert Harrold
- University of Queensland Ochsner Clinical School at Ochsner Medical Center; School of Medicine; 1415 Jefferson Hwy New Orleans Louisiana USA 70121
| | - Kirk J Pak
- Ochsner Clinic Foundation; Department of Internal Medicine; 1514 Jefferson Hwy New Orleans Louisiana USA 70121
| | - Mieke L van Driel
- The University of Queensland; Discipline of General Practice, School of Medicine; Brisbane Queensland Australia 4029
- Ghent University; Department of Family Medicine and Primary Health Care; 1K3, De Pintelaan 185 Ghent Belgium 9000
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