Prescription peer academic detailing to reduce inappropriate prescribing for older patients: a cluster randomised controlled trial

Academic detailing to improve appropriate opioid prescribing: a mixed-methods process evaluation

BACKGROUND

Academic detailing, an educational outreach service for family physicians, was funded by the Ontario government to address gaps in opioid prescribing and pain management. We sought to evaluate the impact of academic detailing on opioid prescribing, and to understand how and why academic detailing may have influenced opioid prescribing.

METHODS

In this mixed-methods study, we collected quantitative and qualitative data concurrently from 2017 to 2019 in Ontario, Canada. We analyzed prescribing outcomes descriptively for a sample of participating physicians and compared them with a matched control group. We invited physicians to participate in qualitative interviews to discuss their experiences in academic detailing. Development and analysis of qualitative interviews was informed by the Theoretical Domains Framework. We triangulated qualitative and quantitative findings to understand the mechanisms that drove changes in opioid prescribing.

RESULTS

Physicians receiving academic detailing (n = 238) achieved a greater reduction in opioid prescribing than matched controls (n = 238). Seventeen physicians completed interviews and reported that academic detailing addressed barriers to pain care, including lack of confidence, difficult interactions with patients and prescribing and tapering decisions. Academic detailing reinforced knowledge about opioid prescribing and pain management. Discussion of complex patients and talking points to use during challenging conversations were described as key drivers of practice change.

INTERPRETATION

The findings of this real-world, mixed-methods evaluation explain how an academic detailing service addressed key barriers and enablers to limit high-risk opioid prescribing in primary care. This nuanced understanding will be used to inform, spread and scale academic detailing.

Barriers and enablers to deprescribing in long-term care: A qualitative investigation into the opinions of healthcare professionals in Ireland

INTRODUCTION

The prevalence of polypharmacy increases with age, increasing the exposure of older adults to potentially inappropriate medications (PIMs). Deprescribing has been shown to reduce PIMs for older residents in long-term care; however, deprescribing is not universally implemented. This study aims to identify the barriers and enablers to deprescribing in Irish long-term care facilities from the healthcare professionals' (HCPs) perspective.

METHODS

A qualitative descriptive approach was conducted using semi-structured interviews with HCPs working in long-term care (general practitioners, pharmacists and nurses). Purposive sampling with maximum variation was applied to select long-term care sites to identify HCPs, supplemented with convenience sampling of post-graduate HCPs from University College Cork. Data was thematically analysed and mapped to a framework of deprescribing barriers and enablers informed by the Theoretical Domains Framework.

RESULTS

Twenty-six HCPs participated from 13 long-term care facilities. The main barriers and enablers identified mapped to five domains. Barriers included insufficient resources, lack of co-ordination between healthcare settings and negative social influences. Additional barriers exist in private settings including deprescribing awareness, commitment and the need for incentives. Deprescribing enablers included interprofessional support and patient social influence. To encourage deprescribing, potential enablers include HCP education, pharmacist role expansion and tailored deprescribing guidelines within a structured process.

CONCLUSION

Interventions to support deprescribing should build on existing systems, involve stakeholders and utilise guidelines within a structured process. Any intervention must account for the nuanced barriers and enablers which exist in both public and private settings.

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

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

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

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

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

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The association between physician knowledge and inappropriate medications for older populations

BACKGROUND

Older patients are often prescribed potentially inappropriate medications (PIMs) given their age. We measured the association between a physician's general knowledge and their PIM prescribing.

METHODS

Using a 2013-2017 cross-sectional design, we related a general internist's knowledge (n = 8196) to their prescribing of PIMs to fee-for-service Medicare beneficiaries, age ≥ 66 years with part D coverage, which they saw in the outpatient setting the year after their exam (n = 875,132). Physician knowledge was based on the American Board of Internal Medicine's (ABIM) Internal Medicine Maintenance of Certification (IM-MOC) exam scores. Medications included 72 PIMs from the American Geriatric Society's Beers Criteria and appropriate alternatives to these medications. Logistic regressions controlled for physicians practice/training characteristics and patient-risk factors.

RESULTS

Annually, 11.0% of patients received a PIM and 57.2% received an appropriate alternative medication. Patients seen by physicians scoring in the top versus bottom quartile were 8.6% less likely (95% confidence interval [CI]: -12.7 to -4.5, p < 0.001) to be prescribed a PIM and 4.7% more likely (95% CI: 1.7 to 7.6, p = 0.001) to be prescribed an appropriate alternative medication. The difference in PIM prescribing grew to 12.1% fewer (95% CI: -15.1 to -9.1) patients when limiting the sample to the 58.9% of patients being prescribed a PIM or appropriate alternative medication. Among patients receiving any medication, this was similar to the percent difference in PIM prescribing between solo and large practices (≥50 physicians, -10.2%, 95% CI: 13.6-6.5, p < 0.001) or between group and academic practices (-11.7%, 95% CI: -15.3 to -7.9, p < 0.001). PIM prescribing was more positively associated with patient characteristics including age, gender, and total number of medications prescribed.

CONCLUSIONS

Better physician general knowledge, as measured by an ABIM exam, was associated with fewer PIM prescriptions. Future research should examine whether general educational interventions, such as MOC, effect PIM prescribing.

Improving drug prescription in general practice using a novel quality improvement model

INTRODUCTION

Quality improvement (QI) clusters have been established in many countries to improve healthcare using the Breakthrough Series' collaboration model. We investigated the effect of a novel QI approach based on this model of performed medication reviews and drug prescription in a Norwegian municipality.

METHODS

All 27 General Practitioners (GPs) in a mid-size Norwegian municipality were invited to join the intervention, consisting of three peer group meetings during a period of 7-8 months. Participants learned practical QI skills by planning and following up QI projects within drug prescription practice. Evaluation forms were used to assess participants' self-rated improvement, reported medication review reimbursement codes (MRRCs) were used as a process measure, and defined daily doses (DDDs) of potentially inappropriate drugs (PIDs) dispensed to patients aged 65 years or older were used as outcome measures.

RESULTS

Of the invited GPs, 25 completed the intervention. Of these, 76% self-reported improved QI skills and 67% reported improved drug prescription practices. Statistical process control revealed a non-random increase in the number of MRRCs lasting at least 7 months after intervention end. Compared with national average data, we found a significant reduction in dispensed DDDs in the intervention municipality for benzodiazepine derivates, benzodiazepine-related drugs, drugs for urinary frequency and incontinence and non-steroid anti-inflammatory and antirheumatic medications.

CONCLUSION

Intervention increased the frequency of medication reviews, resulting in fewer potentially inappropriate prescriptions. Moreover, there was self-reported improvement in QI skills in general, which may affect other practice areas as well. Intervention required relatively little absence from clinical practice compared with more traditional QI interventions and could, therefore, be easier to implement.KEY POINTThe current study investigated to what extent a novel model based on the Breakthrough Series' collaborative model affects GP improvement skills in general practice and changes their drug prescription.KEY FINDINGSMost participants reported better improvement skills and improved prescription practice.The number of dispensed potentially inappropriate drugs decreased significantly in the intervention municipality compared with the national average.The model seemed to lead to sustained changes after the end of the intervention.

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

OBJECTIVES

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

METHODS

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

RESULT

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

DISCUSSION

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

Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis

BACKGROUND

Polypharmacy and use of inappropriate medications have been linked to increased risk of falls, hospitalizations, cognitive impairment, and death. The primary objective of this review was to evaluate the effectiveness, comparative effectiveness, and harms of deprescribing interventions among community-dwelling older adults.

METHODS

We searched OVID MEDLINE Embase, CINAHL, and the Cochrane Library from 1990 through February 2019 for controlled clinical trials comparing any deprescribing intervention to usual care or another intervention. Primary outcomes were all-cause mortality, hospitalizations, health-related quality of life, and falls. The secondary outcome was use of potentially inappropriate medications (PIMs). Interventions were categorized as comprehensive medication review, educational initiatives, and computerized decision support. Data abstracted by one investigator were verified by another. We used the Cochrane criteria to rate risk of bias for each study and the GRADE system to determine certainty of evidence (COE) for primary outcomes.

RESULTS

Thirty-eight low and medium risk of bias clinical trials were included. Comprehensive medication review may have reduced all-cause mortality (OR 0.74, 95% CI: 0.58 to 0.95, I2 = 0, k = 12, low COE) but probably had little to no effect on falls, health-related quality of life, or hospitalizations (low to moderate COE). Nine of thirteen trials reported fewer PIMs in the intervention group. Educational interventions probably had little to no effect on all-cause mortality, hospitalizations, or health-related quality of life (low to moderate COE). The effect on falls was uncertain (very low COE). All 11 education trials that included PIMs reported fewer in the intervention than in the control groups. Two of 4 computerized decision support trials reported fewer PIMs in the intervention arms; none included any primary outcomes.

DISCUSSION

In community-dwelling people aged 65 years and older, medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications.

REGISTRY INFORMATION

PROSPERO - CRD42019132420.

Factors influencing trends in opioid prescribing for older people: a scoping review

Aim:

The review aimed to identify factors influencing opioid prescribing as regular pain-management medication for older people.

Background:

Chronic pain occurs in 45%–85% of older people, but appears to be under-recognised and under-treated. However, strong opiate prescribing is more prevalent in older people, increasing at the fastest rate in this age group.

Methods:

This review included all study types, published 1990–2017, which focused on opioid prescribing for pain management among older adults. Arksey and O’Malley’s framework was used to scope the literature. PubMed, EBSCO Host, the UK Drug Database, and Google Scholar were searched. Data extraction, carried out by two researchers, included factors explaining opioid prescribing patterns and prescribing trends.

Findings:

A total of 613 papers were identified and 53 were included in the final review consisting of 35 research papers, 10 opinion pieces and 8 grey literature sources. Factors associated with prescribing patterns were categorised according to whether they were patient-related, prescriber-driven, or system-driven. Patient factors included age, gender, race, and cognition; prescriber factors included attitudes towards opioids and judgements about ‘normal’ pain; and policy/system factors related to the changing policy landscape over the last three decades, particularly in the USA.

Conclusions:

A large number of context-dependent factors appeared to influence opioid prescribing for chronic pain management in older adults, but the findings were inconsistent. There is a gap in the literature relating to the UK healthcare system; the prescriber and the patient perspective; and within the context of multi-morbidity and treatment burden.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of a multifaceted intervention to reduce potentially inappropriate prescribing among discharged older adults: a before-and-after study

Background

Potentially inappropriate prescribing (PIP) is associated with the incidence of adverse drug reactions, drug-related hospitalization and other negative outcomes in older adults. After hospitalization, older adults might be discharged with several types of PIPs. Studies have found that the lack of healthcare professionals' (HCPs) knowledge regarding PIP is one of the major contributing factors in this issue. The purpose of this study is to investigate the impact of a multifaceted intervention on physicians' and clinical pharmacists' behavior regarding potentially inappropriate medication (PIM) and potential prescribing omission (PPO) among hospitalized older adults.

Methods

This is a before-and-after study that took place in a tertiary Malaysian hospital. Discharge medications of patients ≥65 years old were reviewed to identify PIMs/PPOs using version 2 of the STOPP/START criteria. The prevalence and pattern of PIM/PPO before and after the intervention were compared. The intervention targeted the physicians and clinical pharmacists and it consisted of academic detailing and a newly developed smartphone application (app).

Results

The study involved 240 patients before (control group) and 240 patients after the intervention. The prevalence of PIM was 22% and 27% before and after the intervention, respectively (P = 0.213). The prevalence of PPO in the intervention group was significantly lower than that in the control group (42% Vs. 53.3%); P = 0.014. This difference remained statistically significant after controlling for other variables (P = 0.015). The intervention was effective in reducing the two most common PPOs; the omission of vitamin D supplements in patients with a history of falls (P = 0.001) and the omission of angiotensin converting enzyme inhibitor in patients with coronary artery disease (P = 0.03).

Conclusions

The smartphone app coupled with academic detailing was effective in reducing the prevalence of PPO at discharge. However, it did not significantly affect the prevalence or pattern of PIM.

GP-Led Deprescribing in Community-Living Older Australians: An Exploratory Controlled Trial

OBJECTIVE

To assess feasibility, effectiveness, and safety of a multifaceted general practitioner (GP) led intervention to reduce potentially inappropriate polypharmacy in community-living older people.

DESIGN

Pragmatic, controlled, pre-post design.

SETTING

Five general practices in southeast Queensland, Australia.

PARTICIPANTS

Ten GPs from three practices, two pharmacists, and 78 patients comprised the intervention group, and 10 GPs from two practices and 67 patients comprised the usual care group. Patients were aged 65 years or older, receiving five or more regularly prescribed medicines, and capable of participating in telephone interviews in English.

INTERVENTION

A 5-hour interactive deprescribing training workshop for clinicians; an extended deprescribing consultation between GPs and enrolled patients, entailing a comprehensive review of their medicines using a standardized software template codesigned by GPs; and comprehensive medicine review by a pharmacist, at the GP's discretion.

OUTCOME MEASURES

Primary outcome was mean difference in number of regular medicines deprescribed (ie, ceased or dose reduced) per patient over an 18-week follow-up period. Medicine-specific and patient-reported outcomes, safety, and process measures were also evaluated.

RESULTS

At study completion, mean (SD) number of regular medicines deprescribed per patient was 0.99 (1.23) in the intervention group vs 0.43 (0.84) in the usual care group, equaling a mean difference of 0.55 (95% confidence interval = -0.90 to -0.21; P = .002). Crude totals showed 77 of 649 (11.9%) vs 29 of 571 (5.1%) regular medicines deprescribed in intervention and usual care groups, respectively (P < .001). Supplements, gastric acid suppressants, statins, oral hypoglycemics, and diuretics were medicine classes more frequently deprescribed. There were no statistically significant between-group differences in numbers of medicines commenced, self-reported unplanned hospitalizations, or worsened health-related quality of life. A subset of intervention patients reported greater certainty in the necessity and appropriateness of their medicines at study end.

CONCLUSION

The deprescribing intervention appears feasible, was modestly effective, and was not associated with any major safety events. J Am Geriatr Soc 68:403-410, 2020.

Shared Decision-Making in Chronic Patients with Polypharmacy: An Interventional Study for Assessing Medication Appropriateness

Potentially inappropriate medications are associated with polypharmacy and polypathology. Some interventions such as pharmacotherapy reviews have been designed to reduce the prescribing of inappropriate medications. The objective of this study is to evaluate how effective a decision-making support tool is for determining medication appropriateness in patients with one or more chronic diseases (hypertension, dyslipidaemia, and/or diabetes) and polypharmacy in the primary care setting. For this, a quasi-experimental study (randomised, controlled and multicentre) has been developed. The study compares an intervention group, which assesses medication appropriateness by applying a decision support tool, with a control group that follows the usual clinical practice. The intervention included a decision support tool in paper format, where participants were informed about polypharmacy, inappropriate medications, associated problems and available alternatives, as well as shared decision-making. This is an informative guide aimed at helping patients with decision-making by providing them with information about the secondary risks associated with inappropriate medications in their treatment, according to the Beers and START/STOPP criteria. The outcome measure was the proportion of medication appropriateness. The proportion of patients who confirmed medication appropriateness after six months of follow-up is greater in the intervention group (32.5%) than in the control group (27.9%) p = 0.008. The probability of medication appropriateness, which was calculated by the proportion of drugs withdrawn or replaced according to the STOPP/Beers criteria and those initiated according to the START criteria, was 2.8 times higher in the intervention group than in the control group (OR = 2.8; 95% CI 1.3–6.1) p = 0.008. In patients with good adherence to the treatment, the percentage of appropriateness was 62.1% in the shared decision-making group versus 37.9% in the control group (p = 0.005). The use of a decision-making support tool in patients with potentially inappropriate medications increases the percentage of medication appropriateness when compared to the usual clinical practice.

Quality of prescribing in older people from a broad family physician perspective: a descriptive pilot study

OBJECTIVES

To investigate the quality of drug treatment in older people from a broad family physician perspective, and to provide evidence for power calculations in full-scale studies on prescribing quality.

DESIGN

Descriptive, retrospective pilot study.

SETTING

A primary healthcare centre in Sweden.

PARTICIPANTS

123 consecutive patients, ≥65 years, with a non-urgent physician consultation in January 2016.

MEASURES

The drug treatment was assessed by a physician as either appropriate or suboptimal, taking individual factors like morbidity, life expectancy and concurrent drug treatment into account, and preceded by the application of 493 criteria from three screening tools for Potentially Inappropriate Medications (PIMs) and Potential Prescribing Omissions (PPOs). Suboptimal drug treatment was further categorised regarding priority: (1) immediate change suggested or (2) actions suggested in the longer term. Prevalence of the procedure code 'medication review' and the results thereof were also recorded.

RESULTS

Median age: 76 years; 48% women. When a family physician perspective was applied, and 593 PIMs/PPOs identified in 117 (95%) patients considered, 45 (37%) patients had suboptimal drug treatment. Immediate handling was suggested in 13 (11%) patients, most often concerning withdrawals of drugs for anxiety and insomnia. Handling in the longer term was suggested in 32 (26%) patients, most often concerning overuse of proton pump inhibitors. Over the last year, the procedure code 'medication review' was recorded for 65 (53%) patients. In medication reviews recorded during January 2016 (n=45), 23 (7%) drugs out of 309 were acted on, most often a dosage adjustment.

CONCLUSIONS

This pilot study shows that when a broad family physician perspective is applied, taking individual factors and medical priorities in the complex clinical situation into account, drug treatment in primary care is appropriate for the majority of older patients. The results may be useful in sample size considerations for future studies on prescribing practices.

The Effect of Pharmacy-Led, Small-Group Academic Detailing on Prescribing Patterns in an Ambulatory Care Clinic

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.

Quality circles for quality improvement in primary health care: Their origins, spread, effectiveness and lacunae- A scoping review

Quality circles or peer review groups, and similar structured small groups of 6–12 health care professionals meet regularly across Europe to reflect on and improve their standard practice. There is debate over their effectiveness in primary health care, especially over their potential to change practitioners’ behaviour. Despite their popularity, we could not identify broad surveys of the literature on quality circles in a primary care context. Our scoping review was intended to identify possible definitions of quality circles, their origins, and reported effectiveness in primary health care, and to identify gaps in our knowledge. We searched appropriate databases and included any relevant paper on quality circles published until December 2017. We then compared information we found in the articles to that we found in books and on websites. Our search returned 7824 citations, from which we identified 82 background papers and 58 papers about quality circles. We found that they originated in manufacturing industry and that many countries adopted them for primary health care to continuously improve medical education, professional development, and quality of care. Quality circles are not standardized and their techniques are complex. We identified 19 papers that described individual studies, one paper that summarized 3 studies, and 1 systematic review that suggested that quality circles can effectively change behaviour, though effect sizes varied, depending on topic and context. Studies also suggested participation may affirm self-esteem and increase professional confidence. Because reports of the effect of quality circles on behaviour are variable, we recommend theory-driven research approaches to analyse and improve the effectiveness of this complex intervention.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

ClinicalTrials.gov NCT01984034 . Registered 7 November 2013.

Potentially Inappropriate Prescribing to Older Patients: Criteria, Prevalence and an Intervention to Reduce It: The Prescription Peer Academic Detailing (Rx-PAD) Study - A Cluster-Randomized, Educational Intervention in Norwegian General Practice

Potentially inappropriate prescriptions (PIP) is drug treatment, which in general, at the group level for a median/mean patient, can be considered unfavourable meaning that the risks commonly may outweigh the benefits. This MiniReview reports and discusses the main findings in a large cluster-randomized educational intervention in Norwegian general practice, aimed at reducing the prevalence of PIPs to patients ≥70 years (The Rx-PAD study). Targets for the intervention were general practitioners (GPs) in continuing medical education (CME) groups receiving educational outreach visits (i.e. peer academic detailing). A Delphi consensus process, with a panel of medical experts, was undertaken to elaborate a list of explicit criteria defining PIPs for patients ≥70 years in general practice. Agreement was achieved for 36 explicit PIP criteria, the so-called Norwegian General Practice (NorGeP) criteria. Using a selection (n = 24) of these criteria during a 1-year baseline period on the prescribing practice of 454 GPs (i.e. those enrolled to participate in the intervention trial), we found a prevalence rate of 24.7 PIPs per 100 patients ≥70 years per year. In the Rx-PAD study, 449 GPs completed an educational intervention (96.6% of the included GPs), 250 in the intervention group and 199 in the control arm. Following the intervention, PIPs were reduced by 13% (95% CI 8.6-17.3), and the number of patients who were no longer exposed to one or more PIPs was reduced by 1173 (8.1%). The GPs who responded most strongly to the educational intervention were the oldest GPs (57-68 years), and these were the GPs with the highest prevalence of PIPs at baseline before the intervention.

General practitioners' prescriptions of benzodiazepines, Z-hypnotics and opioid analgesics for elderly patients during direct and indirect contacts. A cross-sectional, observational study

OBJECTIVE

To describe Norwegian general practitioners' (GPs') prescription patterns of benzodiazepines, Z-hypnotics and opioid analgesics (BZO-drugs) to elderly (≥70 years) patients.

DESIGN, SUBJECTS AND SETTING

Cross sectional, observational study. Contact- and prescription data from 148 Norwegian GPs, issued for elderly patients during eight months in 2008. GP-patient contacts were categorized as direct contacts (DC: face-to-face consultations) or indirect contacts (IC: via third party, phone or mail). Explanatory variables were characteristics linked to the GPs, patients, and practices. During analyses, GPs' number of listed patients, share of which for elderly patients, and total number of patient consultations during the period (proxy for practice activity), were categorized in quintiles (Q1-5) by number of GPs.

MAIN OUTCOME MEASURES

Number of BZO-drug prescriptions and quantities issued during direct- and indirect GP-patient contacts.

RESULTS

In total, 62% of BZO-prescriptions were issued during ICs. Of all prescriptions, 66% were large quantum packages (50 tablets or more), 62% out of which were prescribed during ICs. During the study period, 50% of the patients received repeat prescriptions. Prescribing during ICs was associated with low over all practice activity (Q1) and many (Q5) older patients on the GP's lists.

CONCLUSION

GPs' BZO-drug prescribing to elderly occur more frequently during ICs than within DCs, and are more commonly issued as large quantity packages. This indicates that regular- or long-term use among elderly is common, contrasting with previous and current national guidelines, which recommend regular clinical assessments and short time or intermittent use of BZO-drugs. Key Points GPs frequently prescribe benzodiazepines, Z-hypnotics and opioid (BZO) drugs for elderly people. BZO-drugs are frequently issued during indirect GP-patient contacts and in relatively large quantities, indicating regular or long-term use. GPs' BZO-drug prescribing patterns contrast with national guidelines recommending clinical assessment and short time or intermittent use of BZO-drugs.

A focus group study to understand biases and confounders in a cluster randomized controlled trial on low back pain in primary care in Norway

Background

Cluster randomized controlled trials are often used in research in primary care but creates challenges regarding biases and confounders. We recently presented a study on low back pain from primary care in Norway with equal effects in the intervention and the control group. In order to understand the specific mechanisms that may produce biases in a cluster randomized trial we conducted a focus group study among the participating health care providers. The aim of this study was to understand how the participating providers themselves influenced on the study and thereby possibly on the results of the cluster randomized controlled trial.

Methods

The providers were invited to share their experiences from their participation in the COPE study, from recruitment of patients to accomplishment of either the intervention or control consultations. Six clinicians from the intervention group and four from the control group took part in the focus group interviews. The group discussions focused on feasibility of the study in primary care and particularly on identifying potential biases and confounders in the study. The audio-recorded interviews were transcribed verbatim and analyzed according to a systematic text condensation. The themes for the analysis emerged from the group discussions.

Results

A personal interest for back pain, logistic factors at the clinics and an assessment of the patients’ capacity to accomplish the study prior to their recruitment was reported. The providers were allowed to provide additional therapy to the intervention and it turned out that some of these could be regarded as opposed to the messages of the intervention. The providers seemed to select different items from the educational package according to personal beliefs and their perception of the patients’ acceptance.

Conclusion

The study disclosed several potential biases to the COPE study which may have impacted on the study results. Awareness of these is highly important when planning and conducting a cluster randomized controlled trial. Procedures in the recruitment of both providers and patients seem to be key factors and the providers should be aware of their role in a scientific study in order to standardize the provision of the intervention.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0759-9) contains supplementary material, which is available to authorized users.

Characteristics of GPs responding to an educational intervention to minimise inappropriate prescriptions: subgroup analyses of the Rx-PAD study

Background

Interventions aimed at improving GPs’ prescribing practice usually apply a 'one size fits all' when analysing intervention effects. Few studies explore intervention effects by variables related to the GPs’ age, sex, specialist status, practice type (single-handed versus group), practice setting (urban versus rural), and baseline performance regarding the target of an intervention.

Aim

To explore the characteristics of the GPs responding to a comprehensive educational intervention.

Design & setting

A secondary analysis of a cluster, randomised educational intervention in Norwegian general practice. Pre-intervention data were captured from January 2005 to December 2005, and post-intervention data from June 2006 to June 2007. The intervention was carried out from January to June 2006.

Method

Eighty continuing medical education (CME) groups, including 449 GPs aged 27–68 years, were randomly allocated to either an education intervention arm (41 groups, 250 GPs) or a control arm (39 groups, 199 GPs). The primary outcome was GPs' change in potentially inappropriate prescriptions (PIPs) per 100 prescriptions issued to patients aged ≥70 years. The interaction between intervention outcome and variables related to the GPs and their practices were tested.

Results

Improvements in prescribing were highest among GPs aged 57–68 years (incidence rate ratio [IRR] = 0.77 [95% confidence interval {CI} = 0.73 to 0.81]), those who were specialists (IRR = 0.80 [95% CI = 0.78 to 0.82]), and those who worked in single-handed practices (IRR = 0.75 [95% CI = 0.68 to 0.83]), among GPs with 2.4 to 2.9 PIPs per 100 prescriptions at baseline (IRR = 0.74 [95% CI = 0.70 to 0.78]), and GPs with ≥15 prescriptions per patient per year at baseline (IRR = 0.77 [95% CI = 0.73 to 0.80]).

Conclusion

The GPs with the lowest adherence to recommended practice at baseline improved their practice most.

The use of external change agents to promote quality improvement and organizational change in healthcare organizations: a systematic review

Background

External change agents can play an essential role in healthcare organizational change efforts. This systematic review examines the role that external change agents have played within the context of multifaceted interventions designed to promote organizational change in healthcare—specifically, in primary care settings.

Methods

We searched PubMed, CINAHL, Cochrane, Web of Science, and Academic Search Premier Databases in July 2016 for randomized trials published (in English) between January 1, 2005 and June 30, 2016 in which external agents were part of multifaceted organizational change strategies. The review was conducted according to PRISMA guidelines. A total of 477 abstracts were identified and screened by 2 authors. Full text articles of 113 studies were reviewed. Twenty-one of these studies were selected for inclusion.

Results

Academic detailing (AD) is the most prevalently used organizational change strategy employed as part of multi-component implementation strategies. Out of 21 studies, nearly all studies integrate some form of audit and feedback into their interventions. Eleven studies that included practice facilitation into their intervention reported significant effects in one or more primary outcomes.

Conclusions

Our results demonstrate that practice facilitation with regular, tailored follow up is a powerful component of a successful organizational change strategy. Academic detailing alone or combined with audit and feedback alone is ineffective without intensive follow up. Provision of educational materials and use of audit and feedback are often integral components of multifaceted implementation strategies. However, we didn’t find examples where those relatively limited strategies were effective as standalone interventions. System-level support through technology (such as automated reminders or alerts) is potentially helpful, but must be carefully tailored to clinic needs.

REDUCING POTENTIALLY INAPPROPRIATE PRESCRIBING FOR OLDER PEOPLE IN PRIMARY CARE: COST-EFFECTIVENESS OF THE OPTI-SCRIPT INTERVENTION

Objectives: This study examines the cost-effectiveness of the OPTI-SCRIPT intervention on potentially inappropriate prescribing in primary care.

Methods: Economic evaluation, using incremental cost-effectiveness and cost utility analyses, conducted alongside a cluster randomized controlled trial of twenty-one general practices and 196 patients, to compare a multifaceted intervention with usual practice in primary care in Ireland. Potentially inappropriate prescriptions (PIPs) were determined by a pharmacist. Incremental costs, PIPs, and quality-adjusted life-years (QALYs) at 12-month follow-up were estimated using multilevel regression. Uncertainty was explored using cost-effectiveness acceptability curves.

Results: The intervention was associated with a nonsignificant mean cost increase of €407 (95 percent CIs, −357–1170), a significant mean reduction in PIPs of 0.379 (95 percent CI, 0.092–0.666), and a nonsignificant mean increase in QALYs of 0.013 (95 percent CIs, −0.016–0.042). The incremental cost per PIP avoided was €1,269 (95 percent CI, −1400–6302) and the incremental cost per QALY gained was €30,535 (95 percent CI, −334,846–289,498). The probability of the intervention being cost-effective was 0.602 at a threshold value of €45,000 per QALY gained and was at least 0.845 at threshold values of €2,500 per PIP avoided and higher.

Conclusions: While the OPTI-SCRIPT intervention was effective in reducing potentially inappropriate prescribing in primary care in Ireland, our findings highlight the uncertainty with respect to its cost-effectiveness. Further studies are required to explore the health and economic implications of interventions targeting potentially inappropriate prescribing.

Educational intervention on medication reviews aiming to reduce acute healthcare consumption in elderly patients with potentially inappropriate medicines-A pragmatic open-label cluster-randomized controlled trial in primary care

PURPOSE

Potentially inappropriate medicines (PIMs) may cause 10% of unplanned admissions in elderly people. We performed an educational intervention in primary care to reduce acute health care consumption and PIMs through the promotion of medication reviews (MRs) in elderly patients.

METHODS

This cluster-randomized controlled trial was conducted in the context of an official campaign promoting rational drug use in elderly people. Sixty-nine primary health care practices with 119,910 patients aged older than or equal to 65 were randomized, with 1 dropout in the intervention group. The intervention consisted of educational outreach visits with feedback on prescribing and the development of a working procedure on MRs. Follow-up was 9 months. Outcomes were assessed in an administrative health care database. The combined primary outcome was unplanned hospital admission and/or emergency department visit. Secondary outcomes were among other PIMs and rates of MRs. The risk differences in outcomes between intervention and control group were estimated by using regression models.

RESULTS

During follow-up, 22.8% of patients in the intervention and 22.0% in the control group were admitted unplanned to hospital and/or experienced at least 1 emergency department (nonsignificant risk difference 0.8%, 95% CI -0.7% to 2.4%). There were no significant differences regarding secondary outcomes such as PIMs or MRs.

CONCLUSIONS

No changes were seen in acute health care consumption, PIMs, and MRs in elderly patients after an educational intervention in primary care. The reasons for the lack of effect could be a suboptimal intervention, limitations in outcome measures, and the use of administrative data to monitor outcomes.

Interventions to Address Potentially Inappropriate Prescribing in Community-Dwelling Older Adults: A Systematic Review of Randomized Controlled Trials

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

Current controlled trials ISRCTN41694007 .

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

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

A qualitative study exploring the acceptability of the McNulty-Zelen design for randomised controlled trials evaluating educational interventions

Background

Traditional randomised controlled trials evaluating the effect of educational interventions in general practice may produce biased results as participants know they are being evaluated. We aimed to explore the acceptability of a McNulty-Zelen Cluster Randomised Control Trial (CRT) design which conceals from educational participants that they are in a RCT. Consent is obtained from a trusted third party considered appropriate to give consent on participants’ behalf, intervention practice staff then choose whether to attend the offered education as would occur with normal continuing professional development.

Methods

We undertook semi structured telephone interviews in England with 16 general practice (GP) staff involved in a RCT evaluating an educational intervention aimed at increasing chlamydia screening tests in general practice using the McNulty-Zelen design, 4 Primary Care (PC) Research Network officers, 5 Primary Care Trust leads in Public or sexual health, and one Research Ethics committee Chair. Interviews were undertaken by members of the original intervention evaluation McNulty-Zelen design RCT study team. These experienced qualitative interviewers used an agreed semi-structured interview schedule and were careful not to lead the participants. To further mitigate against bias, the data analysis was undertaken by a researcher (CR) not involved in the original RCT.

Results

We reached data saturation and found five main themes;

Support for the design: All found the McNulty-Zelen design acceptable because they considered that it generated more reliable evidence of the value of new educational interventions in real life GP settings.

Lack of familiarity with study design: The design was novel to all. GP staff likened the evaluation using the McNulty–Zelen design to audit of their activities with feedback, which were to them a daily experience and therefore acceptable.

Ethical considerations: Research stakeholders considered the consent procedure should be very clear and that these trial designs should go through at least a proportionate ethical review. GP staff were happy for the PCT leads to give consent on their behalf.

GP research capacity and trial participation: GP staff considered the design increased generalisability, as staff who would not normally volunteer to participate in research due to perceived time constraints and paperwork might do so.

Design ‘worth it’: All interviewees agreed that the advantages of the “more accurate” or “truer” results and information gained about uptake of workshops within Primary Care Trusts (PCTs) outweighed any disadvantages of the consent procedure.

Discussion

Our RCT was evaluating the effect of an educational intervention to increase chlamydia screening tests in general practices where there was routine monitoring of testing rates; our participants may have been less enthusiastic about the design if it had been evaluating a more controversial educational area, or if data monitoring was not routine.

Implications

The McNulty-Zelen design should be considered for the evaluation of educational interventions, but these designs should have clear consent protocols and proportionate ethical review.

Trial registration

The trial was registered on the UK Clinical Research Network Study Portfolio database. UKCRN9722.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0356-0) contains supplementary material, which is available to authorized users.

Effectiveness of a Multifaceted Intervention for Potentially Inappropriate Prescribing in Older Patients in Primary Care: A Cluster-Randomized Controlled Trial (OPTI-SCRIPT Study)

PURPOSE

Potentially inappropriate prescribing (PIP) is common in older people and can result in increased morbidity, adverse drug events, and hospitalizations. The OPTI-SCRIPT study (Optimizing Prescribing for Older People in Primary Care, a cluster-randomized controlled trial) tested the effectiveness of a multifaceted intervention for reducing PIP in primary care.

METHODS

We conducted a cluster-randomized controlled trial among 21 general practitioner practices and 196 patients with PIP. Intervention participants received a complex, multifaceted intervention incorporating academic detailing; review of medicines with web-based pharmaceutical treatment algorithms that provide recommended alternative-treatment options; and tailored patient information leaflets. Control practices delivered usual care and received simple, patient-level PIP feedback. Primary outcomes were the proportion of patients with PIP and the mean number of potentially inappropriate prescriptions. We performed intention-to-treat analysis using random-effects regression.

RESULTS

All 21 practices and 190 patients were followed. At intervention completion, patients in the intervention group had significantly lower odds of having PIP than patients in the control group (adjusted odds ratio = 0.32; 95% CI, 0.15-0.70; P = .02). The mean number of PIP drugs in the intervention group was 0.70, compared with 1.18 in the control group (P = .02). The intervention group was almost one-third less likely than the control group to have PIP drugs at intervention completion, but this difference was not significant (incidence rate ratio = 0.71; 95% CI, 0.50-1.02; P = .49). The intervention was effective in reducing proton pump inhibitor prescribing (adjusted odds ratio = 0.30; 95% CI, 0.14-0.68; P = .04).

CONCLUSIONS

The OPTI-SCRIPT intervention incorporating academic detailing with a pharmacist, and a review of medicines with web-based pharmaceutical treatment algorithms, was effective in reducing PIP, particularly in modifying prescribing of proton pump inhibitors, the most commonly occurring PIP drugs nationally.

Factors influencing prescribing of fall-risk-increasing drugs to the elderly: A qualitative study

OBJECTIVE

Explore the situations in which GPs associate drug use with falls among their elderly patients, and the factors influencing the prescribing and cessation of fall-risk-increasing drugs (FRIDs).

DESIGN

A qualitative study with 13 GPs who participated in two semi-structured focus groups in Central Norway. Participants were encouraged to share overall thoughts on the use of FRIDs among elderly patients and stories related to prescribing and cessation of FRIDs in their own practice.

RESULTS

The main finding was that GPs did not immediately perceive the use of FRIDs to be a prominent factor regarding falls in elderly patients, exceptions being when the patient presented with dizziness, reported a fall, or when prescribing FRIDs for the first time. It was reported as common to renew prescriptions without performing a drug review. Factors influencing the prescribing and cessation of FRIDs were categorized into GPs' clinical work conditions, uncertainty about outcome of changing prescriptions, patients' prescribing demands, and lack of patient information.

CONCLUSIONS

The results from this study indicate that GPs need to be reminded that there is a connection between FRID use and falls among elderly patients of enough clinical relevance to remember to assess the patient's drug list and perform regular drug reviews.

Variation in the pharmaceutical costs of New Zealand general practices: a national database linkage study

BACKGROUND

Variation in prescription costs between general practices and within practices over time is poorly understood.

METHODS

From New Zealand's national health data collections, we extracted dispensed medicines data for 1045 general practices in 2011 and 917 practices continuously existing 2008-11. Using indirect standardization to account for patient demographics and morbidity, a standardized prescribing cost ratio (SPR: the ratio of actual : expected prescription costs) was calculated for each practice in each year. Case studies of three outlier clinics explored reasons for their status.

RESULTS

SPRs ranged from 0.53 to 2.28 (median = 0.98). Of 469 practices with higher than expected costs (SPR > 1.0) in 2011, 204 (43.5%) had a single medicine or therapeutic drug class accounting for >15% of total costs. Case studies contrasted practices with overall pharmaceutical expenditure influenced strongly by a few patients needing high-cost medicines, more patients using medicines in one high-cost therapeutic drug class (antiretrovirals), and high medicine use across all therapeutic drug classes.

CONCLUSIONS

Routine data collections can measure inter-practice variation in prescription costs, adjusted for differences in the demography and morbidity profile of each practice's patients. Small groups of patients using high-cost medicines influence general practices' expenditure on pharmaceuticals.

A cluster randomised controlled trial of a pharmacist-led collaborative intervention to improve statin prescribing and attainment of cholesterol targets in primary care

BACKGROUND

Small trials with short term follow up suggest pharmacists' interventions targeted at healthcare professionals can improve prescribing. In comparison with clinical guidance, contemporary statin prescribing is sub-optimal and achievement of cholesterol targets falls short of accepted standards, for patients with atherosclerotic vascular disease who are at highest absolute risk and who stand to obtain greatest benefit. We hypothesised that a pharmacist-led complex intervention delivered to doctors and nurses in primary care, would improve statin prescribing and achievement of cholesterol targets for incident and prevalent patients with vascular disease, beyond one year.

METHODS

We allocated general practices to a 12-month Statin Outreach Support (SOS) intervention or usual care. SOS was delivered by one of 11 pharmacists who had received additional training. SOS comprised academic detailing and practical support to identify patients with vascular disease who were not prescribed a statin at optimal dose or did not have cholesterol at target, followed by individualised recommendations for changes to management. The primary outcome was the proportion of patients achieving cholesterol targets. Secondary outcomes were: the proportion of patients prescribed simvastatin 40 mg with target cholesterol achieved; cholesterol levels; prescribing of simvastatin 40 mg; prescribing of any statin and the proportion of patients with cholesterol tested. Outcomes were assessed after an average of 1.7 years (range 1.4-2.2 years), and practice level simvastatin 40 mg prescribing was assessed after 10 years.

FINDINGS

We randomised 31 practices (72 General Practitioners (GPs), 40 nurses). Prior to randomisation a subset of eligible patients were identified to characterise practices; 40% had cholesterol levels below the target threshold. Improvements in data collection procedures allowed identification of all eligible patients (n = 7586) at follow up. Patients in practices allocated to SOS were significantly more likely to have cholesterol at target (69.5% vs 63.5%; OR 1.11, CI 1.00-1.23; p = 0.043) as a result of improved simvastatin prescribing. Subgroup analysis showed the primary outcome was achieved by prevalent but not incident patients. Statistically significant improvements occurred in all secondary outcomes for prevalent patients and all but one secondary outcome (the proportion of patients with cholesterol tested) for incident patients. SOS practices prescribed more simvastatin 40 mg than usual care practices, up to 10 years later.

INTERPRETATION

Through a combination of educational and organisational support, a general practice based pharmacist led collaborative intervention can improve statin prescribing and achievement of cholesterol targets in a high-risk primary care based population.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials Register ISRCTN61233866.

Interventions to improve the appropriate use of polypharmacy for older people

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

In November 2013, for this first update, a range of literature databases including MEDLINE and EMBASE were searched, and handsearching of reference lists was performed. Search terms included 'polypharmacy', 'medication appropriateness' and 'inappropriate prescribing'.

SELECTION CRITERIA

A range of study designs were eligible. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people 65 years of age and older in which a validated measure of appropriateness was used (e.g. Beers criteria, Medication Appropriateness Index (MAI)).

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. Study-specific estimates were pooled, and a random-effects model was used to yield summary estimates of effect and 95% confidence intervals (CIs). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall quality of evidence for each pooled outcome.

MAIN RESULTS

Two studies were added to this review to bring the total number of included studies to 12. One intervention consisted of computerised decision support; 11 complex, multi-faceted pharmaceutical approaches to interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals, such as prescribers and pharmacists. Appropriateness of prescribing was measured using validated tools, including the MAI score post intervention (eight studies), Beers criteria (four studies), STOPP criteria (two studies) and START criteria (one study). Interventions included in this review resulted in a reduction in inappropriate medication usage. Based on the GRADE approach, the overall quality of evidence for all pooled outcomes ranged from very low to low. A greater reduction in MAI scores between baseline and follow-up was seen in the intervention group when compared with the control group (four studies; mean difference -6.78, 95% CI -12.34 to -1.22). Postintervention pooled data showed a lower summated MAI score (five studies; mean difference -3.88, 95% CI -5.40 to -2.35) and fewer Beers drugs per participant (two studies; mean difference -0.1, 95% CI -0.28 to 0.09) in the intervention group compared with the control group. Evidence of the effects of interventions on hospital admissions (five studies) and of medication-related problems (six studies) was conflicting.

AUTHORS' CONCLUSIONS

It is unclear whether interventions to improve appropriate polypharmacy, such as pharmaceutical care, resulted in clinically significant improvement; however, they appear beneficial in terms of reducing inappropriate prescribing.