Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts in a computerized provider order entry system

ObjectiveComputerized provider order entry systems commonly contain alerting mechanisms for patient allergies, incorrect doses, or drug–drug interactions when ordering medications. Providers have the option to override (bypass) these alerts and continue with the order unchanged. This study examines the effect of customizing medication alert override options on the appropriateness of override selection related to patient allergies, drug dosing, and drug–drug interactions when ordering medications in an electronic medical record.Materials and methodsIn this prospective, randomized crossover study, providers were randomized into cohorts that required a reason for overriding a medication alert from a customized or non-customized list of override reasons and/or by free-text entry. The primary outcome was to compare override responses that appropriately correlate with the alert type between the customized and non-customized configurations. The appropriateness of a subset of free-text responses that represented an affirmative and active acknowledgement of the alert without further explanation was classified as “indeterminate.” Results were analyzed in three different ways by classifying indeterminate answers as either appropriate, inappropriate, or excluded entirely. Secondary outcomes included the appropriateness of override reasons when comparing cohorts and individual providers, reason selection based on order within the override list, and the determination of the frequency of free-text use, nonsensical responses, and multiple selection responses.ResultsTwenty-two clinicians were randomized into 2 cohorts and a total of 1829 alerts with a required response were generated during the study period. The customized configuration had a higher rate of appropriateness when compared to the non-customized configuration regardless of how indeterminate responses were classified (p < 0.001). When comparing cohorts, appropriateness was significantly higher in the customized configuration regardless of the classification of indeterminate responses (p < 0.001) with one exception: when indeterminate responses were considered inappropriate for the cohort of providers that were first exposed to the non-customized list (p = 0.103). Free-text use was higher in the customized configuration overall (p < 0.001), and there was no difference in nonsensical response between configurations (p = 0.39).ConclusionThere is a benefit realized by using a customized list for medication override reasons. Poor application design or configuration can negatively affect provider behavior when responding to important medication alerts.     

Cost-effectiveness of shared pharmaceutical care for older patients: RESPECT trial findings

Background

Pharmaceutical care serves as a collaborative model for medication review. Its use is advocated for older patients, although its cost-effectiveness is unknown. Although the accompanying article on clinical effectiveness from the RESPECT (Randomised Evaluation of Shared Prescribing for Elderly people in the Community over Time) trial finds no statistically significant impact on prescribing for older patients undergoing pharmaceutical care, economic evaluations are based on an estimation, rather than hypothesis testing.

Aim

To evaluate the cost-effectiveness of pharmaceutical care for older people compared with usual care, according to National Institute for Health and Clinical Excellence (NICE) reference case standards.

Methods

An economic evaluation was undertaken in which NICE reference case standards were applied to data collected in the RESPECT trial.

Results

On average, pharmaceutical care is estimated to cost an incremental £10 000 per additional quality-adjusted life year (QALY). If the NHS''s cost-effectiveness threshold is between £20 000 and £30 000 per extra QALY, then the results indicate that pharmaceutical care is cost-effective despite a lack of statistical significance to this effect. However, the statistical uncertainty surrounding the estimates implies that the probability that pharmaceutical care is not cost-effective lies between 0.22 and 0.19. Although results are not sensitive to assumptions about costs, they differ between subgroups: in patients aged >75 years pharmaceutical care appears more cost-effective for those who are younger or on fewer repeat medications.

Conclusion

Although pharmaceutical care is estimated to be cost-effective in the UK, the results are uncertain and further research into its long-term benefits may be worthwhile.     

Effect of shared care on blood pressure in patients with chronic kidney disease: a cluster randomised controlled trial

Background

Chronic kidney disease (CKD) is highly prevalent in patients with diabetes or hypertension in primary care. A shared care model could improve quality of care in these patients

Aim

To assess the effect of a shared care model in managing patients with CKD who also have diabetes or hypertension.

Design and setting

A cluster randomised controlled trial in nine general practices in The Netherlands.

Method

Five practices were allocated to the shared care model and four practices to usual care for 1 year. Primary outcome was the achievement of blood pressure targets (130/80 mmHg) and lowering of blood pressure in patients with diabetes mellitus or hypertension and an estimated glomerular filtration rate (eGFR)<60ml/min/1.73m².

Results

Data of 90 intervention and 74 control patients could be analysed. Blood pressure in the intervention group decreased with 8.1 (95% CI = 4.8 to 11.3)/1.1 (95% CI = −1.0 to 3.2) compared to −0.2 (95% CI = −3.8 to 3.3)/−0.5 (95% CI = −2.9 to 1.8) in the control group. Use of lipid-lowering drugs, angiotensin-system inhibitors and vitamin D was higher in the intervention group than in the control group (73% versus 51%, 81% versus 64%, and 15% versus 1%, respectively, [P = 0.004, P = 0.01, and P = 0.002]).

Conclusion

A shared care model between GP, nurse practitioner and nephrologist is beneficial in reducing systolic blood pressure in patients with CKD in primary care.     

Factors related to adherence to medication regimens in pediatric seizure patients

Factors related to medication adherence were studied in 35 pediatric seizure patients at a public hospital serving primarily low-income minority patients. Adherence ratings by pediatric neurologists were based primarily on three blood assays drawn at monthly intervals and patients were rated as adherent on 1, 2, or 3 visits. Parent and child satisfaction with medical care was associated with greater adherence. Parental worry about the child's health was positively correlated with the number of behavioral restrictions placed on the child, and both variables were negatively related to adherence. The authors hypothesize that anxiety-based denial and perceived threats to patient autonomy may interfere with medication adherence. Implications for the development of intervention strategies for improving adherence among pediatric seizure patients are discussed.     

Effectiveness of shared pharmaceutical care for older patients: RESPECT trial findings

Background

The pharmaceutical care approach serves as a model for medication review, involving collaboration between GPs, pharmacists, patients, and carers. Its use is advocated with older patients who are typically prescribed several drugs. However, it has yet to be thoroughly evaluated.

Aim

To estimate the effectiveness of pharmaceutical care for older people, shared between GPs and community pharmacists in the UK, relative to usual care.

Design of study

Multiple interrupted time-series design in five primary care trusts which implemented pharmaceutical care at 2-month intervals in random order. Patients acted as their own controls, and were followed over 3 years including their 12 months'' participation in pharmaceutical care.

Setting

In 2002, 760 patients, aged ≥75 years, were recruited from 24 general practices in East and North Yorkshire. Sixty-two community pharmacies also took part. A total of 551 participants completed the study.

Method

Pharmaceutical care was undertaken by community pharmacists who interviewed patients, developed and implemented pharmaceutical care plans together with patients'' GPs, and thereafter undertook monthly medication reviews. Pharmacists and GPs attended training before the intervention. Outcome measures were the UK Medication Appropriateness Index, the Short Form–36 Health Survey (SF-36), and serious adverse events.

Results

The intervention did not lead to any statistically significant change in the appropriateness of prescribing or health outcomes. Although the mental component of the SF-36 decreased as study participants become older, this trend was not affected by pharmaceutical care.

Conclusion

The RESPECT model of pharmaceutical care (Randomised Evaluation of Shared Prescribing for Elderly people in the Community over Time) shared between community pharmacists and GPs did not significantly change the appropriateness of prescribing or quality of life in older patients.     

肾移植受者服药依从性及其与人格特质的关系

目的:探讨肾移植受者服药依从性及其与人格特质的关系。方法:选取130例肾移植受者,应用一般资料调查表、免疫抑制剂治疗依从性Basel评估量表(BAASIS)和中国大五人格问卷简式版(CBF-PI-B)进行调查。结果:肾移植受者服药依从性差者占43.8%;多元线性回归显示,移植术后时间与服药依从性负向关联(β=-0.45),宜人性和开放性人格特质与服药依从性正向关联(β=0.29、0.23)。结论:肾移植受者服药依从性处于较低水平,移植术后时间越长、宜人性和开放性人格特质得分越低,其服药依从性可能越差。     

Which factors are associated with higher rates of chronic kidney disease recording in primary care? A cross-sectional survey of GP practices

The prevalence of chronic kidney disease (CKD) at stage 3–5 is estimated at 8.5% in the UK, but the recorded rate of CKD from Quality and Outcomes Framework (QOF) registers in 2007–2008 was 2.9%. This study aimed to identify practice or patient characteristics associated with recorded rates of CKD. Demographic and QOF data for 230 general practices were combined into a database for cross-sectional analysis. Regression analyses investigated factors associated with CKD recording; deprivation, location in Leicester city or Northamptonshire, and low recording of hypertension and stroke were associated with low CKD recording.     

Self-regulation predictors of medication adherence among ethnically different pediatric patients with renal transplants.

OBJECTIVE: To predict medication adherence among ethnically different pediatric patients with renal transplants between the ages of 6 and 20 years old, using self-regulation variables including motivation, perceived control and responsibility, and perceived support. METHODS: Twenty-six African American children and 42 Caucasian children were verbally administered the Self-Regulation of Medication Adherence Battery to assess their (1) motivation to be medication adherent, (2) perceived control of and responsibility for medication adherence, and (3) perceived support of medication adherence from their primary caregiver. Four measures were used to assess medication adherence: self-ratings, nephrologists' ratings, cyclosporine levels, and pill count/refill histories. RESULTS: For the African American patients, regression analyses revealed that responses to motivation and perceived control questions that focused on self-efficacy were unique predictors of medication adherence as rated by their primary nephrologist. For the Caucasian patients, one motivation question regarding how often they forget to take their medication predicted their self-reported adherence. CONCLUSIONS: Facilitating their beliefs that they can regularly take their medications may help promote medication adherence among African American children with renal transplants, whereas for Caucasian children, providing cues and reminders to take their medications may help. We discuss implications of the results for multimodal assessment of medication adherence and for ethnic group-specific medication adherence research and interventions.     

Orthostatic hypotension,diabetes, and falling in older patients: a cross-sectional study

Background

Although orthostatic hypotension (OH) is more prevalent in old age, and in patients with diabetes, the prevalence of OH in older patients with type 2 diabetes mellitus is unknown.

Aim

To establish the prevalence of OH, and its association with falling, in home-dwelling older participants with and without type 2 diabetes.

Design and setting

A cross-sectional study in primary care in the Netherlands.

Method

A total of 352 patients with type 2 diabetes, and 211 without participated in this study. OH was defined as a fall in blood pressure of at least 20 mmHg systolic or 10 mmHg diastolic after either 1 or 3 minutes in an upright position. Feelings of dizziness, light-headedness, or faintness during the standing period were documented as orthostatic complaints. Fall risk was assessed with a validated risk profile instrument.

Results

The prevalence of OH was 28% (95% CI = 24% to 33%) and 18% (95% CI = 13% to 23%) in participants with and without type 2 diabetes, respectively. OH was not related to falling, while the presence of orthostatic complaints in itself was associated with both previous fall incidents as well as a high fall risk, even after adjustment for OH. The adjusted odds ratios were 1.65 (95% CI = 1.00 to 2.72) and 8.21 (95% CI = 4.17 to 16.19), respectively.

Conclusion

OH is highly prevalent in home-dwelling older people with and without type 2 diabetes. Those with orthostatic complaints had an increased risk for falling, whereas those with OH were not.     

Development of prescribing-safety indicators for GPs using the RAND Appropriateness Method

Background

In the UK, a process of revalidation is being introduced to allow doctors to demonstrate that they meet current professional standards, are up-to-date, and fit to practise. Given the serious risks to patients from hazardous use of medicines it will be appropriate, as part of the revalidation process, to assess the safety of prescribing by GPs.

Aim

To identify a set of potential prescribing-safety indicators forthe purposes of revalidation of individual GPs in the UK.

Design and setting

The RAND Appropriateness Method was used to identify, develop, and obtain agreement on the indicators in UK general practice.

Method

Twelve GPs from across the UK with a wide variety of characteristics assessed indicators for appropriateness of use in revalidation.

Results

Forty-seven safety indicators were considered appropriate for assessing the prescribing safety of individual GPs forthe purposes of revalidation (appropriateness was defined as an overall panel median score of ≥7 (on a 1-9 scale), with no more than three panel members rating the indicator outside the 3-point distribution around the median]. After removing indicators that were variations on the same theme, a final set of 34 indicators was obtained; these cover hazardous prescribing across a range of therapeutic areas, hazardous drug-drug combinations, prescribing with a history of allergy, and inadequate laboratory-test monitoring.

Conclusion

This study identified a set of 34 indicators that were considered, by a panel of 12 GPs, to be appropriate for use in assessing the safety of GP prescribing forthe purposes of revalidation. Violation of any of the 34 indicators indicates a potential patient-safety problem.     

A qualitative study of lay beliefs about influenza immunisation in older people

BACKGROUND: Although influenza immunisation is now recommended for all people aged 65 years and over in the UK, many people in that age group still remain unimmunised. AIM: To investigate lay beliefs about influenza and influenza vaccine in older people to identify appropriate ways of promoting vaccine uptake. DESIGN: Qualitative study using narrative interviews. SETTING: Urban and rural communities in South Wales. METHOD: Participants were 54 people aged 65 years and over who were interviewed in their own home. Of these, 11 were regularly immunised, 18 had consistently refused immunisation (refusers), 15 had defaulted (defaulters), five had never been offered immunisation, and five had recently been immunised for the first time. RESULTS: There was an overwhelming consensus among immunised and unimmunised individuals that they were not at risk from influenza. Even if they did catch influenza, they would not suffer from any serious consequences. Refusers and defaulters were more likely to believe that the influenza vaccine had serious side-effects, while the regularly immunised group were more likely to perceive the vaccine as effective. Multiple prompts from family, friends, or primary care staff were important triggers for receiving immunisation. CONCLUSION: Many older people did not feel vulnerable to influenza, regardless of their age, and this influenced their views on the need for immunisation. Both refusers and defaulters overstated adverse effects from influenza vaccine so this is a potential target for an intervention. Individual prompts, particularly from GPs, seemed to be the most significant motivators to attend for immunisation.     

Identification of an updated set of prescribing-safety indicators for GPs

Background

Medication error is an important contributor to patient morbidity and mortality and is associated with inadequate patient safety measures. However, prescribing-safety tools specifically designed for use in general practice are lacking.

Aim

To identify and update a set of prescribing-safety indicators for assessing the safety of prescribing in general practice, and to estimate the risk of harm to patients associated with each indicator.

Design and setting

RAND/UCLA consensus development of indicators in UK general practice.

Method

Prescribing indicators were identified from a systematic review and previous consensus exercise. The RAND Appropriateness Method was used to further identify and develop the indicators with an electronic-Delphi method used to rate the risk associated with them. Twelve GPs from all the countries of the UK participated in the RAND exercise, with 11 GPs rating risk using the electronic-Delphi approach.

Results

Fifty-six prescribing-safety indicators were considered appropriate for inclusion (overall panel median rating of 7–9, with agreement). These indicators cover hazardous prescribing across a range of therapeutic indications, hazardous drug–drug combinations and inadequate laboratory test monitoring. Twenty-three (41%) of these indicators were considered high risk or extreme risk by 80% or more of the participants.

Conclusion

This study identified a set of 56 indicators that were considered, by a panel of GPs, to be appropriate for assessing the safety of GP prescribing. Twenty-three of these indicators were considered to be associated with high or extreme risk to patients and should be the focus of efforts to improve patient safety.     

GPs' approach to insulin prescribing in older patients: a qualitative study

BACKGROUND: Evidence suggests that insulin is under-prescribed in older people. Some reasons for this include physician's concerns about potential side-effects or patients' resistance to insulin. In general, however, little is known about how GPs make decisions related to insulin prescribing in older people. AIM: To explore the process and rationale for prescribing decisions of GPs when treating older patients with type 2 diabetes. DESIGN OF STUDY: Qualitative individual interviews using a grounded theory approach. SETTING: Primary care. METHOD: A thematic analysis was conducted to identify themes that reflected factors that influence the prescribing of insulin. RESULTS: Twenty-one GPs in active practice in Ontario completed interviews. Seven factors influencing the prescribing of insulin for older patients were identified: GPs' beliefs about older people; GPs' beliefs about diabetes and its management; gauging the intensity of therapy required; need for preparation for insulin therapy; presence of support from informal or formal healthcare provider; frustration with management complexity; and GPs' experience with insulin administration. Although GPs indicated that they would prescribe insulin allowing for the above factors, there was a mismatch in intended approach to prescribing and self-reported prescribing. CONCLUSION: GPs' rationale for prescribing (or not prescribing) insulin is mediated by both practitioner-related and patient-related factors. GPs intended and actual prescribing varied depending on their assessment of each patient's situation. In order to improve prescribing for increasing numbers of older people with type 2 diabetes, more education for GPs, specialist support, and use of allied health professionals is needed.     

Quality care provision for older people: an interview study with patients and primary healthcare professionals

Background

In recent years, primary health care for the ageing population has become increasingly complex.

Aim

This study sought to explore the views and needs of healthcare professionals and older patients relating to primary care in order to identify focal areas for improving primary health care for older people.

Design and setting

This research was structured as a mixed interview study with focus groups and individual interviews. Participants were made up of primary healthcare professionals and older patients. Patients were recruited from five elderly care homes in a small city in the southern part of the Netherlands.

Method

All interviews were transcribed verbatim and analysed by two individual researchers applying constant comparative analysis. Data collection proceeded until saturation was reached.

Results

Participants in the study agreed about the need for primary care for older patients, and showed sympathy with one another’s perspectives. They did note, however, a number of obstacles hindering good healthcare provision. The major themes that arose were: ‘autonomy and independence’, ‘organisational barriers’, and ‘professional expertise’. Participants generally noted that it is important to clarify differences in perspectives about good care between patients and healthcare professionals.

Conclusion

Effective primary care intervention for older patients requires mutual understanding of the expectations and goals of all parties involved. There are a number of important requirements, especially accessible patient information in the form of care plans; specialist training for nurses and GPs on complex care and multimorbidity; and training on discussing autonomy, goal setting, and shared care. Further improvement in health care for older people and its evaluation research should focus on these requirements.     

半胱氨酸蛋白酶抑制剂C与肾移植后尿路梗阻患者的肾功能

背景：半胱氨酸蛋白酶抑制剂C不被肾小管分泌和重吸收,近年来被认为是一种非常理想的评价肾小球滤过率的指标。 目的：探讨肾移植后输尿管狭窄患者血清半胱氨酸蛋白酶抑制剂C水平变化及其在肾功能损伤诊断中的价值。 方法：选取2007年4月至2011年4月于深圳市第二人民医院泌尿外科及广州华侨医院泌尿外科行肾移植并于移植后发生输尿管狭窄伴肾功能不全的患者18例作为病例组,同时纳入同期年龄性别与病例组相匹配的健康体检者63名作为对照组。分别于输尿管狭窄治疗前及治疗后1个月测定患者血清半胱氨酸蛋白酶抑制剂C、肌酐、尿素氮水平并分析其相关性。 结果与结论：与对照组比较,病例组输尿管狭窄治疗前半胱氨酸蛋白酶抑制剂C、血肌酐和尿素氮水平均显著增高(P < 0.01);治疗后1个月,病例组半胱氨酸蛋白酶抑制剂C、血肌酐和尿素氮水平较治疗前显著降低(P < 0.01)。相关分析结果显示,肾移植后输尿管狭窄患者血清半胱氨酸蛋白酶抑制剂C水平与血肌酐和尿素氮水平呈正相关。提示血清半胱氨酸蛋白酶抑制剂C可作为肾移植后肾功能恢复情况的监测指标。     

Prediction of complicated lower respiratory tract infections in older patients with diabetes

BACKGROUND: Patients with diabetes have an elevated risk of developing complicated lower respiratory tract infections (LRTIs). However, up until now, GPs have not had the tools to assess individual risks. AIM: To assess the applicability of an existing prediction rule for complicated LRTI among patients with diabetes. DESIGN OF STUDY: Retrospective cohort study. SETTING: The Utrecht GP Research Network. METHOD: An existing rule that was used estimates the risk of 30-day hospitalisation or death following an episode of LRTI. Predictors were exacerbation of chronic obstructive pulmonary disease, or pneumonia, increasing age, heart failure, number of hospitalisations in the previous year, use of antibiotics in the previous month, diabetes medication, and prednisone use. Discriminative capacity of the rule was estimated in patients with diabetes. Other potential predictors from the original study were examined, to test for a potentially improved model. RESULTS: Of 445 episodes of LRTI in patients with diabetes, 68 had an outcome of hospitalisation or death within 30 days of diagnosis of LRTI (15.3%). Results showed good reliability of the model (goodness of fit test P=0.16) and discriminative properties (area under the receiver operating characteristic curve: 0.79, 95% confidence interval=0.73 to 0.86). No other predictors could be added. Patients with a lower-risk assignment (scoreor=7) had a probability of 36.6% for the composite endpoint of hospitalisation or death within 30 days of diagnosis of LRTI. CONCLUSION: The use of a prediction rule may help GPs to assess the risk of hospitalisation or death in patients with diabetes who have an episode of LRTI.     

Depression indicators in a national sample of older community and care home patients: applying the Quality and Outcomes Framework

In a national primary care database sample of older people (≥65 years), 81% (83 588/103 821) of community and 58% (1702/2940) of care home residents with diabetes or heart disease had depression case finding recently recorded; 66% (1418/2145) of community and 22% (26/118) of care home residents with a new depression episode had a depression-severity assessment recorded. Age, sex, and higher care home dementia prevalence did not explain these differences. Case finding and assessment of depression need to be improved in older people, particularly care home residents.     

Determinants of health-related quality of life in older primary care patients: results of the longitudinal observational AgeCoDe Study

Background

In older patients with chronic diseases, focusing on subjective, patient-relevant outcomes, such as health-related quality of life (HRQoL), is more pertinent than pursuing clinical or laboratory target values.

Aim

To investigate factors influencing the course of HRQoL in older (aged ≥78 years) primary care patients and to derive non-pharmacological recommendations for improving their quality of life.

Design and setting

A population-based prospective longitudinal observational study featuring data analysis from waves 2 to 5 of the AgeCoDe study, which was conducted in six cities in Germany.

Method

The HRQoL of 1968 patients over the course of 4.5 years was observed. Patients were, on average, aged 82.6 (±3.4) years and their HRQoL was measured using the EQ-5D visual analogue scale in a face-to-face assessment. Fixed-effects regression models were calculated to examine impact of change in potential influencing factors. This method allows unobserved heterogeneity to be controlled.

Results

The course of the participants’ HRQoL declined with increasing age, walking and incident hearing impairment. Increasing the number of physical activities improved the HRQoL. These findings were modified by sex, education level, and depression. Especially in females and patients with rather low education levels, increased physical activity improved the subjects’ HRQoL, while hearing impairment decreased it. Moving to an institution only improved the HRQoL in patients without depression or those with a low level of education (primary education).

Conclusion

Motivating patients to increase their weekly physical activity and to focus on preserving their ability to walk are promising approaches to improving HRQoL in older age. Less-educated patients and those without depression can also benefit from moving into an institution (for example, a care or retirement home).     

Predicting blood pressure outcomes using single-item physician-administered measures: a retrospective pooled analysis of observational studies in Belgium

BackgroundPatient adherence is often not monitored because existing methods of evaluating adherence are either burdensome or do not accurately predict treatment outcomes.AimTo examine whether two simple, single-item physician-administered measures of patient adherence to antihypertensive medication are predictive of blood pressure outcomes.MethodUsing pooled data from five observational studies, a sample was identified of 9725 patients who were assessed using two single-item physician-administered measures of adherence to antihypertensive medication: the first item of the Basel Assessment of Adherence Scale (BAAS) and the Visual Analogue Scale (VAS). These two assessment tools were administered by GPs during regular appointments with patients. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and combined SBP/DBP were measured at baseline and at 90 days.ResultsBAAS-identified adherent patients achieved lower mean SBP and DBP compared with non-adherent patients at 90 days (P<0.001), and had odds ratios of achieving blood pressure control of 0.66 (95% confidence intervals (CI) = 0.61 to 0.73, P<0.001) for SBP, 0.69 (95% CI = 0.62 to 0.76, P<0.001) for DBP, and 0.65 (95% CI = 0.59 to 0.72, P<0.001) for combined SBP/DBP. For VAS-identified adherent patients, the odds ratios of achieving blood pressure control were 0.93 (95% CI = 0.86 to 1.00, P<0.001) for SBP, 0.79 (95% CI = 0.73 to 0.85, P<0.001) for DBP, and 0.91 (95% CI = 0.84 to 0.99, P<0.001) for combined SBP/DBP.ConclusionsThe first item of the BAAS and the VAS are independent predictors of blood pressure control. These methods can be integrated seamlessly into routine clinical practice by allowing GPs to quickly evaluate a patient’s adherence and tailor treatment recommendations accordingly.