Quality of prescribing: a study of guideline adherence of medication in patients with diabetes mellitus

Medication assessment tool to detect care issues from routine data: a pilot study in primary care

BACKGROUND

Medication assessment tools (MATs) may be implemented in routine electronic data sources in order to identify patients with opportunities for optimisation of medication therapy management (MTM) and follow-up by a multi-disciplinary team.

OBJECTIVE

(1) To demonstrate the use of a MAT for cardiovascular conditions (MAT CVC) as a means of profiling potential opportunities for MTM optimisation in primary care and (2) to assess the performance of MAT CVC in identifying actual opportunities for better care.

SETTING

Members of a pharmacotherapy discussion group, i.e. two single-handed general practitioners (GPs), three GP partners, and community pharmacists (CPs) from each of two community pharmacies, in a rural part of the Netherlands.

METHODS

MAT CVC comprises 21 medication assessment criteria, each of which is designed to detect a specific care issue and to check whether it is 'addressed' by provision of guideline recommended care or 'open' in the presence ('open explained') or absence ('open unexplained') of pre-specified explanations for guideline deviations. (1) Relevant data was extracted from linked GP and CP electronic records and MAT CVC assessment was conducted to profile the population of CVC patients registered with both, participating CPs and GPs, in terms of 'open unexplained' care issues. (2) A purposive sample of patients with 'open unexplained' care issues was reviewed by each patient's GP.

MAIN OUTCOME MEASURES

Number and proportion of 'open unexplained' care issues per MAT CVC criterion and per patient. The number of patients with MAT CVC detected 'open unexplained' care issues to be reviewed (NNR) in order to identify one that requires changes in MTM.

RESULTS

In 1,876 target group patients, MAT CVC identified 6,915 care issues, of which 2,770 (40.1 %) were 'open unexplained'. At population level, ten MAT CVC criteria had particularly high potential for quality improvement. At patient level, 1,277 (68.1 %) target group patients had at least one 'open unexplained' care issue. For patients with four or more 'open unexplained' care issues, the NNR was 2 (95 % CI 2-2).

CONCLUSION

The study demonstrates potential ways of using MA TCVC as a key component of a collaborative MTM system. Strategies that promote documentation and sharing of explanations for deviating from guideline recommendations may enhance the utility of the approach.

MAT-CAP: a novel medication assessment tool to explore adherence to clinical practice guidelines in community-acquired pneumonia

BACKGROUND/PURPOSE

Community-acquired pneumonia (CAP) is a disease with high morbidity and mortality. Adherence to clinical practice guidelines (CPGs) in treatment of CAP is associated with favourable outcome. We aimed to develop and validate a medication assessment tool (MAT) to explore adherence to CPG recommendations in patients with CAP admitted to a Norwegian hospital. The tool is named MAT-CAP.

METHOD

Sixteen quality indicators (QIs) based on local and international CPGs were developed. Content validity was explored in an expert panel using a two-round modified Delphi technique. QIs demonstrating content valdity were reformulated into review criteria forming the MAT-CAP. Feasibility and adherence to MAT-CAP were explored in a retrospective study using data from electronic patient records of CAP patients admitted to the University Hospital of North Norway Tromso during 2008. Reliability was explored using Cohen's kappa (ĸ) statistics for inter- and intra-observer agreements.

RESULTS

Content validity was demonstrated for 15 QIs covering areas as initial empirical treatment, microbiological diagnostics, pathogen specific treatment, dose adjustment according to renal function, switch from intravenous to oral treatment and treatment duration. Overall reliability was excellent with ĸ-values of 0.88 and 0.95 for inter-observer and intra-observer agreements, respectively. Overall applicability was 37.2%, and mean application times were 3.1 and 3.8 min for the two observers. Overall adherence to 812 criteria applied was 59% (range 0-100).

CONCLUSIONS

We have demonstrated content validity, feasibility and reliability of a 15-criterion MAT-CAP. Adherence results from applying MAT-CAP criteria pinpointed areas with good clinical performance and areas with improvement potentials.

Kidney dysfunction and related cardiovascular risk factors among patients with type 2 diabetes

BACKGROUND

Kidney dysfunction is a strong predictor of end-stage renal disease and cardiovascular (CV) events. The main goal was to study the clinical correlates of diabetic kidney disease in a large cohort of patients with type 2 diabetes mellitus (T2DM) attending 236 Diabetes Clinics in Italy.

METHODS

Clinical data of 120 903 patients were extracted from electronic medical records by means of an ad hoc-developed software. Estimated glomerular filtration rate (GFR) and increased urinary albumin excretion were considered. Factors associated with the presence of albuminuria only, GFR < 60 mL/min/1.73 m(2) only or both conditions were evaluated through multivariate analysis.

RESULTS

Mean age of the patients was 66.6 ± 11.0 years, 58.1% were male and mean duration of diabetes was 11.1 ± 9.4 years. The frequency of albuminuria, low GFR and both albuminuria and low GFR was 36.0, 23.5 and 12.2%, respectively. Glycaemic control was related to albuminuria more than to low GFR, while systolic and pulse pressure showed a trend towards higher values in patients with normal kidney function compared with those with both albuminuria and low GFR. Multivariate logistic analysis showed that age and duration of disease influenced both features of kidney dysfunction. Male gender was associated with an increased risk of albuminuria. Higher systolic blood pressure levels were associated with albuminuria, with a 4% increased risk of simultaneously having albuminuria and low GFR for each 5 mmHg increase.

CONCLUSIONS

In this large cohort of patients with T2DM, reduced GFR and increased albuminuria showed, at least in part, different clinical correlates. A worse CV risk profile is associated with albuminuria more than with isolated low GFR.

Sex-specific-differences in cardiometabolic risk in type 1 diabetes: a cross-sectional study

Background

Little is known about the impact of sex-specific differences in the management of type 1 diabetes (T1DM).

Thus, we evaluated the influence of gender on risk factors, complications, clinical care and adherence in patients with T1DM.

Methods

In a cross-sectional study, sex-specific disparities in glycaemic control, cardiovascular risk factors, diabetic complications, concomitant medication use and adherence to treatment recommendations were evaluated in 225 consecutive patients (45.3% women) who were comparable with respect to age, diabetes duration, and body mass index.

Results

Although women with T1DM had a higher total cholesterol than men, triglycerides were higher in obese men and males with HbA1c>7% than in their female counterparts. No sex differences were observed in glycaemic control and in micro- or macrovascular complications. However, the subgroup analysis showed that nephropathy was more common in obese men, hyperlipidaemic women and all hypertensive patients, whereas peripheral neuropathy was more common in hyperlipidaemic women. Retinopathy was found more frequently in women with HbA1c>7%, obese men and in both sexes with a long duration of diabetes. The multivariate analysis revealed that microvascular complications were associated with the duration of disease and BMI in both sexes and with hyperlipidaemia in males. The overall adherence to interventions according to the guidelines was higher in men than in women. This adherence was concerned particularly with co-medication in patients diagnosed with hypertension, aspirin prescription in elderly patients and the achievement of target lipid levels following the prescription of statins.

Conclusions

Our data showed sex differences in lipids and overweight in patients with T1DM. Although glycaemic control and the frequency of diabetic complications were comparable between the sexes, the overall adherence to guidelines, particularly with respect to the prescription of statins and aspirin, was lower in women than in men.

Adherence to clinical guidelines in management of diabetes and prevention of cardiovascular disease in Qatar

INTRODUCTION

The prevalence of diabetes mellitus (DM) in the UK increased in 2009 to 4 %, of which type-2 diabetes accounts for 85-95 % of all cases. In Qatar the prevalence of DM among the adult Qatari population in 2008 was 16.7 %; around four times higher than the prevalence in the UK. The aim of the study was to design and to apply a medication assessment tool (MAT) to determine the level of adherence to internationally recognised guideline recommendations in type-2 diabetes management and in primary prevention of cardiovascular disease (CVD) among type-2 diabetes patients, to quantify any gaps in guideline implementation.

MATERIALS AND METHODS

305 patients were included in this study; all diagnosed with type-2 diabetes with no history of CVD. A 38 criteria MAT was designed from published guideline recommendations on the management of type-2 diabetes and combined with recommendations relevant to primary prevention of cardiovascular disease. The MAT comprised 21 criteria assessing control of blood glucose, 5 criteria assessing management of diabetes complications and 12 criteria assessing preventive medication use in CVD. The MAT was validated by a group of practitioners and researchers and field tested in the diabetes outpatient clinic within Hamad General Hospital, Qatar, with electronic and manual access to patients' medical records. Levels of applicability and adherence to each criterion were calculated individually and the overall adherence was determined.

RESULTS

The MAT was applied to the whole study sample (11,590 assessed criteria in 305 patients). Application of the MAT identified 19/38 criteria with high levels of adherence (≥80 %), 9/38 criteria with intermediate levels of adherence (≥50 %; <80 %) and 10/38 criteria with low levels of adherence (<50 %). The overall adherence in 305 patients was 68.1 % (95 % CI: 67, 69) in 6,657 applicable criteria. Total non-adherences, both justified and unjustified, were found in 30.8 % (95 % CI: 30, 32) in 2,049 of the applicable criteria in which only 5.8 % (95 % CI: 5, 7) in 118 criteria had a documented justification. Consequently 94.2 % of all non-adherences (95 % CI: 93, 95) in 1,931 criteria had unjustified non-adherence and indicated a need for inclusion in treatment review through an appropriate pharmaceutical care plan.

DISCUSSION AND CONCLUSION

The study identifies levels of adherence to guideline recommendations, the need for additional documentation and criteria with low adherence that might be a focus for an educational intervention and a starting point for targeted pharmaceutical care.

Application of the MAT-CHDSP to assess guideline adherence and therapy goal achievement in secondary prevention of coronary heart disease after percutaneous coronary intervention

PURPOSE

Numerous studies have documented suboptimal adherence to guideline recommendations in secondary prevention of coronary heart disease (CHD(SP)). Clinical practice guidelines (CPGs) are continuously developed to define appropriate patient care, aiming to reduce risk of morbidity and death. The Medication Assessment Tool for CHD(SP) (MAT-CHD(SP)) was developed to assess adherence to CPGs concerning medication therapy and follow-up of patients with CHD(SP). The aim of this study was to explore whether the MAT-CHD(SP) could be applied retrospectively to assess guideline adherence and therapy goal achievement in secondary prevention of CHD.

METHODS

We collected data from electronic medical records of all patients who underwent percutaneous coronary intervention with stent implantation from January to March 2008 (n = 300) and applied the MAT-CHD(SP). We measured time for data collection and MAT application and tested reproducibility by calculating Cohen's kappa (κ) value for inter and intraobserver agreement.

RESULTS

A total of 247 MAT applications were analyzed, showing overall applicability of 66 % of the 4,446 MAT-CHD(SP) criteria and a high reproducibility of MAT-CHD(SP) application (κ values 0.93 and 0.95 for intra- and interobserver agreement, respectively). Mean time for data collection and MAT-CHD(SP) application was 11 min. Adherence to criteria concerning prescription was high (>75 %), but achievement of therapy goals for cholesterol and blood pressure was low (<50 %). Documentation of lifestyle advice achieved intermediate (50-75 %) or low adherence, as did therapy amendments in patients in whom therapy goals were unachieved at hospital admission.

CONCLUSIONS

The MAT-CHD(SP) offers a means to identify both adherence and nonadherence to CPGs concerning CHD(SP) is applicable in retrospective assessment of CHD(SP), and identifies potentials for improved patient care.

Evaluation of educational needs in patients with diabetes mellitus in respect of medication use in Austria

BACKGROUND

Effective control of diabetes mellitus type 1 (DM1) and type 2 (DM2) can reduce the development and progression of diabetic complications. Therefore, patient education should be considered as an integral part of diabetes management.

OBJECTIVE

The aim of the study was to assess DM patients' perception of knowledge for their medication and attitude towards self-management and pharmacist's role.

SETTING

The study was conducted at the diabetes out-patient clinic at the Vienna General Hospital (AKH), Division of Endocrinology and Metabolism, Department of Internal Medicine III, Austria.

METHOD

The study was a cross sectional survey using patient data from a validated patient questionnaire and medical records. Medical records were evaluated by applying a medication assessment tool.

MAIN OUTCOME MEASURE

To assess the quality of diabetes self management the following outcome measures are considered: HbA1c levels, pre- and post-prandial blood glucose levels, prevention of acute episodes of hypo- and hyperglycaemia, reduction of macrovascular risk factors, short term quality of life, adverse effects and treatment tolerance.

RESULTS

The present study comprised 225 patients with DM1 and 201 patients with DM2, respectively. In comparison to DM2 patients, cardio- and cerebrovascular diseases were diagnosed very rarely in patients with DM1. The risk for these diseases was higher in patients with other factors of the metabolic syndrome, in addition. Overall, 118 of these patients participated in the questionnaire. The level of positive response on diabetes self-care and knowledge with respect to medication for the prevention of diabetes complications, glycaemic control, and treatment goals in diabetes was 81.8 %. The comparison of patients' perceptions of diabetes self-care and knowledge showed differences among subgroups. Higher perceived knowledge and self-care apparently was associated with DM1. Additional findings of this study indicate that patients do not expect community pharmacists to be integrated in a multidisciplinary diabetes care team.

CONCLUSION

Although the level of positive response was found to be high there is still a minority of patients whose level of comprehension appears to be insufficient. Intense pharmaceutical care including patients' education within a multidisciplinary team could contribute to improvements in those patients.

Sex-specific differences in metabolic control, cardiovascular risk, and interventions in patients with type 2 diabetes mellitus

BACKGROUND

Sex-specific differences appear particularly relevant in the management of type 2 diabetes mellitus (T2DM), with women experiencing greater increases in cardiovascular morbidity and mortality than do men.

OBJECTIVE

The aim of this article was to investigate the influence of biological sex on clinical care and microvascular and macrovascular complications in patients with T2DM in a Central European university diabetes clinic.

METHODS

In a cross-sectional study, sex-specific disparities in metabolic control, cardiovascular risk factors, and diabetic complications, as well as concomitant medication use and adherence to treatment recommendations, were evaluated in 350 consecutive patients who were comparable for age, diabetes duration, and body mass index. Study inclusion criteria included age ≤75 years, T2DM, a documented history of presence or absence of coronary heart disease (CHD), and informed consent. Patients were followed in the diabetes outpatient clinic between November 2007 and March 2008.

RESULTS

Two hundred and one patients with T2DM met inclusion criteria (93 [46.3%] women, 108 [53.7%] men). Women with T2DM had higher mean (SE) systolic blood pressure (155.4 [22.5] vs 141.0 [19.8] mm Hg for men; P < 0.001) and total cholesterol (TC) (5.28 [1.34] vs 4.86 [1.29] mmol/L for men; P < 0.05), but a lower TC:HDL-C ratio (4.1 [1.19] vs 4.5 [1.2] for men; P < 0.05). Slightly more men (32.4%) than women (26.9%) reached the therapeutic goal of <7.0% for glycosylated hemoglobin. Women with shorter diabetes duration (<10 years) received oral antihyperglycemic therapy less frequently (P < 0.05). Women with longer disease duration had hypertension more frequently than did their male counterparts (100% vs 86.0%, respectively; P < 0.01). Despite a similar rate of CHD, men were twice as likely as women to have had coronary interventions (percutaneous transluminal coronary angioplasty/coronary artery bypass graft, 25.0% vs 12.9%, respectively; P < 0.05). Women with CHD also had a higher rate of cerebral ischemia than did men (27.6% vs 5.4%, respectively; P < 0.05) and received aspirin less frequently for secondary prevention (P < 0.001). Men had greater overall adherence to diabetes and cardiovascular risk guidelines than did women (66.4% vs 58.9%, respectively; P < 0.01).

CONCLUSIONS

In this study of diabetes clinic outpatients, women with T2DM had a worse cardiovascular risk profile and achieved therapeutic goals less frequently than did men. Treatment strategies should be improved in both sexes, but women with diabetes may be in need of more aggressive treatment, especially when cardiovascular disease is present.

Clinical characteristics, modalities and complications of diabetic patients with migration background at a Central European University Clinic

The objective of the present study was to assess (i) the effects of immigration on the outcome of 200 consecutive singleton pregnancies in women with overt diabetes as well as (ii) gender-specific differences in cardiovascular risk factor profile and the achievement of therapeutic targets in type 2 diabetic subjects with migration background (n = 50). In pregnant subjects, baseline characteristics at admission, pregnancy outcome and the rate of obstetrical complications were similar in immigrant and non-immigrant women. Type 2 diabetes and also preconceptionally undiagnosed diabetes were significantly more frequent in women with migration background. Following delivery, immigrants presented with a worse metabolic profile, including higher triglyceride and nonHDL levels, than the indigenous population. Furthermore, within diabetic subjects with a migration background, non-pregnant women feature a more adverse cardiovascular risk factor profile than men. However, no gender-specific differences in the total adherence to clinical recommendations according to clinical recommendations have been found.

MAT-CHDSP, a novel medication assessment tool for evaluation of secondary prevention of coronary heart disease

BACKGROUND

Quality of health performance is of increasing international importance. The potential value of the implementation of a guideline-based medication assessment tool (MAT) has been evaluated in order to measure and improve adherence to guideline recommendations in secondary prevention of coronary heart disease (CHD).

METHOD

An existing MAT developed in the UK based on internationally recognised clinical evidence has been further developed [with criteria extended to secondary prevention of CHD only] for application in Norway. Content validity was demonstrated using a two round Delphi process among an expert group (12 reviewers, consensus threshold 75%). Inter- and intra-observer reliability testing was conducted with agreement expressed by Cohen's kappa (κ). The designed MAT was applied in a pilot study and application time was measured to inform clinical utility of the tool in real world settings. A total of 85 patients (69% male) undergoing coronary angiography were included. Mean age was 65.4 years (SD 11.6).

RESULTS

The new MAT is named MAT-CHDSP and comprises 21 review criteria. Consensus among the expert group (n = 12) was obtained for all final criteria. Reliability testing showed κ in the range (0.79-0.90). Applicability in the pilot study was 63% (n = 1106) and adherence was 65%, 95% CI (64-66) (n = 791). The mean application time for the experienced user was 1.5 minutes (SD 0.3).

CONCLUSION

MAT methodology might merge the increasing demand for continuous assessment of quality of health performance with the clinical pharmacist's need for a standardised and explicit working tool.

Adherence to clinical guidelines in the prevention of coronary heart disease in type II diabetes mellitus

OBJECTIVE

The study aimed to assess adherence of prescribed medication in primary care to nationally recognised guideline criteria using case note review applying a previously developed medication assessment tool for coronary heart disease (MAT-CHD). Setting Primary care medical centre serving 17,991 patients. A sample of 208 from 463 patients with type 2 diabetes aged 20-75 years with or without a history of ischaemic heart disease (IHD).

METHOD

Patients' records were accessed via medical and pharmacy databases. The criteria of the 23-item audit tool were applied to medical records from case notes in order to quantify adherence to individual guideline criteria.

MAIN OUTCOME MEASURE

Frequency of adherence to agreed definitions of medication use quality criteria.

RESULTS

A total of 1,433 guideline criteria were applied and 1,107 (77.2%, CI: 75.0, 79.4) criteria standards were met with 326 (22.7%, CI: 20.6, 25.0) non-adherences. The overall adherence to guideline criteria was significantly lower for secondary prevention than for primary prevention (74.4 vs. 80.1%, P<0.05; Chi square). Justification recorded in the case notes was identified for 54 (17%, CI: 13, 21) of those non-adherences.

CONCLUSION

The MAT-CHD highlighted areas for review and possible improvement. The tool can be used in primary care from case record examination and offers a means of co-operation between community pharmacists and general practitioners in clinical guideline implementation.

Design and validation of a medication assessment tool for cancer pain management

OBJECTIVE

A clinical tool to examine prescribing in cancer pain management may provide a means to help establish acceptable standards of adherence to treatment guidelines. The study aim was to design and validate a Medication Assessment Tool for Cancer Pain Management (MAT-CP).

SETTING

Hospitals in Northern Norway

METHOD

The MAT-CP was designed from guideline criteria based on a previously developed method. The tool was validated by peer review before and during field-testing on a study sample of cancer patients experiencing pain.

MAIN OUTCOME MEASURE

Perceived relevance, utility, and clarity of individual criteria, and reliability of their application to clinical documentation. Frequency of adherence to agreed definitions of guideline criteria.

RESULTS

The final tool comprised 36 criteria covering six different aspects of cancer pain management: (1) pain assessment and information transfer, (2) start of strong opioid therapy; (3) current continuous analgesia; (4) current intermittent analgesia; (5) follow-up of therapy, and; (6) other care issues. The tool was tested on 109 cancer patients experiencing pain (57 males), mean (SD) age 60.8 (11.5) years. Guideline adherence overall was 61% (n=1704 applicable criteria). The field-testing informed the modification of the MAT-CP to optimise its clarity and utility when applied to patients' clinical documentation. Good inter- and intra-rater reliability (Cohen's kappa kappa=0.86 and kappa=0.95, respectively) were demonstrated in the application. The preliminary application of the tool during field-testing has highlighted the following for further study: (a) Low adherence <50%) to 14 standards concerning start of opioid treatment and pain therapy follow-up, clinical assessment of risk of gastro-intestinal adverse effects among patients on non-steroidal anti-inflammatory drugs (NSAID), current treatment of breakthrough pain, management of nausea/vomiting; (b) High adherence (>75%) to standards of prescribing of continuous analgesia.

CONCLUSION

A clinical tool to examine prescribing in cancer pain management has been designed. Face and content validity have been informed by field-testing. The tool requires further study among palliative care specialists as part of the validation required before it can be recommended for clinical use.