E-learning in order to improve drug prescription for hospitalized older patients: a cluster-randomized controlled study

Using a mobile application to reduce potentially inappropriate prescribing for older Brazilian adults in primary care: a triple-blind randomised clinical trial

BACKGOUND

Potentially inappropriate prescribing (PIP) has been evaluated in several countries, and several strategies have been devised for deprescribing drugs in older adults. The aim of this study was to evaluate the efficacy of a mobile application in reducing PIP for older adults in primary care facilities in Brazil.

METHODS

This randomised, triple-blind, parallel-group trial was conducted in 22 public primary care facilities in Brazil. During the intervention phase, the general practitioners (GPs) were randomly allocated to the intervention (MPI Brasil app provides information about PIP, therapeutic alternatives and deprescribing) or control (MedSUS app provides general information about medications) group. All GPs were trained on the Clinical Decision-Making Process and how to access an Evidence-Based Health website. The GPs received an Android tablet with an installed mobile application depending on their allocated group, which they used when caring for older patients over at least 3 months. At the end of this period, a sample of older patients aged ≥ 60 years who had been awaiting medical consultation by the participating GPs were interviewed and their prescriptions analysed. The primary outcome was the frequency of PIP in and between the groups.

RESULTS

Among 53 GPs who were administered the baseline survey, 14 were included in the clinical trial. At baseline, 146 prescriptions were analysed: the PIP overall was 37.7% (55/146), in the intervention group was 40.6% (28/69), and in the control group was 35.1% (27/77). After the intervention, 284 prescriptions were analysed: the PIP overall was 31.7% (90/284), in the intervention group was 32.2% (46/143), and in the control group was 31.2% (44/141) (RR: 1.16; 95% CI, 0.76-1.76). In the within-group analysis, the PIP reduced from before to after the intervention in both groups-more significantly in the intervention than in the control group (p < 0.001). In the stratified analysis of PIP frequency by GPs, there was a relative risk reduction in 86% (6/7) of GPs in the intervention group compared to 71% (5/7) in the control group.

CONCLUSION

We found that the MPI Brasil app effectively reduced PIP, suggesting that it may be useful to incorporate this tool into clinical practice.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (NCT02918643). First registration on 22/09/2016.

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, so that many medicines may be used to achieve better clinical outcomes for patients. This is the third update of this Cochrane Review.

OBJECTIVES

To assess the effects of interventions, alone or in combination, in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 13 January 2021, together with handsearching of reference lists to identify additional studies. We ran updated searches in February 2023 and have added potentially eligible studies to 'Characteristics of studies awaiting classification'.

SELECTION CRITERIA

For this update, we included randomised trials only. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy (four or more medicines) in people aged 65 years and older, which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).

DATA COLLECTION AND ANALYSIS

Four review authors independently reviewed abstracts of eligible studies, and two authors extracted data and assessed the risk of bias of the included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We identified 38 studies, which includes an additional 10 in this update. The included studies consisted of 24 randomised trials and 14 cluster-randomised trials. Thirty-six studies examined complex, multi-faceted interventions of pharmaceutical care (i.e. the responsible provision of medicines to improve patients' outcomes), in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists, nurses and geriatricians, and most were conducted in high-income countries. Assessments using the Cochrane risk of bias tool found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low. It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool) (mean difference (MD) -5.66, 95% confidence interval (CI) -9.26 to -2.06; I2 = 97%; 8 studies, 947 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs) (standardised mean difference (SMD) -0.19, 95% CI -0.34 to -0.05; I2 = 67%; 9 studies, 2404 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIM (risk ratio (RR) 0.81, 95% CI 0.68 to 0.98; I2 = 84%; 13 studies, 4534 participants; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.48, 95% CI -1.05 to 0.09; I2 = 92%; 3 studies, 691 participants; low-certainty evidence), however it must be noted that this effect estimate is based on only three studies, which had serious limitations in terms of risk of bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPO (RR 0.50, 95% CI 0.27 to 0.91; I2 = 95%; 7 studies, 2765 participants; very low-certainty evidence). Pharmaceutical care may make little or no difference to hospital admissions (data not pooled; 14 studies, 4797 participants; low-certainty evidence). Pharmaceutical care may make little or no difference to quality of life (data not pooled; 16 studies, 7458 participants; low-certainty evidence). Medication-related problems were reported in 10 studies (6740 participants) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies. This also applied to studies examining adherence to medication (nine studies, 3848 participants).

AUTHORS' CONCLUSIONS

It is unclear whether interventions to improve appropriate polypharmacy resulted in clinically significant improvement. Since the last update of this review in 2018, there appears to have been an increase in the number of studies seeking to address potential prescribing omissions and more interventions being delivered by multidisciplinary teams.

Effectiveness of de-implementation strategies for low-value prescribing in secondary care: a systematic review

BACKGROUND/AIMS

Considerable efforts have been made to improve guideline adherence in healthcare through de-implementation, such as decreasing the prescription of inappropriate medicines. However, we have limited knowledge about the effectiveness, barriers, facilitators and consequences of de-implementation strategies targeting inappropriate medication prescribing in secondary care settings. This review was conducted to understand these factors to contribute to better replication and optimisation of future de-implementation efforts to reduce low-value care.

METHODS

A systematic review of randomised control trials was conducted. Papers were identified through CINAHL, EMBASE, MEDLINE and Cochrane register of controlled trials to February 2021. Eligible studies were randomised control trials evaluating behavioural strategies to de-implement inappropriate prescribing in secondary healthcare. Risk of bias was assessed using the Cochrane Risk of Bias tool. Intervention characteristics, effectiveness, barriers, facilitators and consequences were identified in the study text and tabulated.

RESULTS

Eleven studies were included, of which seven were reported as effectively de-implementing low-value prescribing. Included studies were judged to be mainly at low to moderate risk for selection biases and generally high risk for performance and reporting biases. The majority of these strategies were clinical decision support at the 'point of care'. Clinical decision support tools were the most common and effective. They were found to be a low-cost and simple strategy. However, barriers such as clinician's reluctance to accept recommendations, or the clinical setting were potential barriers to their success. Educational strategies were the second most reported intervention type however the utility of educational strategies for de-implementation remains varied. Multiple barriers and facilitators relating to the environmental context, resources and knowledge were identified across studies as potentially influencing de-implementation. Various consequences were identified; however, few measured the impact of de-implementation on usual appropriate practice.

CONCLUSION

This review offers insight into the intervention strategies, potential barriers, facilitators and consequences that may affect the de-implementation of low-value prescribing in secondary care. Identification of these key features helps understand how and why these strategies are effective and the wider (desirable or undesirable) impact of de-implementation. These findings can contribute to the successful replication or optimisation of strategies used to de-implement low-value prescribing practices in future.

TRIAL REGISTRATION

The review protocol was registered at PROSPERO (ID: CRD42021243944).

A comparison of the clinical pharmacotherapy knowledge of medical and surgical residents and consultants

PURPOSE

Knowledge of clinical pharmacotherapy is essential for all who prescribe medication. The aims of this study were to investigate differences in the pharmacotherapy and polypharmacy knowledge of medical and surgical residents and consultants and whether this knowledge can be improved by following an online course.

METHODS

Design: A before-and-after-measurement.

SETTING

An online course available for Dutch residents and consultants working in hospitals.

STUDY POPULATION

Dutch residents and consultants from different disciplines who voluntarily followed an online course on geriatric care.

INTERVENTION

An online 6-week course on geriatric care, with 1 week dedicated to clinical pharmacotherapy and polypharmacy. Variables, such as medical vs surgical specialty, consultant vs resident, age, and sex, that could predict the level of knowledge. The effects of the online course were studied using repeated measures ANOVA. The study was approved by the National Ethics Review Board of Medical Education (NERB dossier number 996).

RESULTS

A total of 394 residents and 270 consultants, 220 from surgical and 444 from medical specialties, completed the online course in 2016 and 2017. Residents had higher test scores than consultants for pharmacotherapy (73% vs 70%, p < 0.02) and polypharmacy (75% vs 72%, p < 0.02). The learning effect did not differ. Medical residents/consultants had a better knowledge of pharmacotherapy (74% vs 68%, p < 0.001) and polypharmacy (77% vs 66%, p < 0.001) than surgical residents/consultants, but the learning effect was the same.

CONCLUSIONS

Residents and consultants had a similar learning curve for acquiring knowledge, but residents outperformed consultants on all measures. In addition, surgical and medical residents/consultants had similar learning curves, but medical residents/consultants had higher test scores on all measures.

Medication review in hospitalised patients to reduce morbidity and mortality

BACKGROUND

A medication review can be defined as a structured evaluation of a patient's medication conducted by healthcare professionals with the aim of optimising medication use and improving health outcomes. Optimising medication therapy though medication reviews may benefit hospitalised patients.

OBJECTIVES

We examined the effects of medication review interventions in hospitalised adult patients compared to standard care or to other types of medication reviews on all-cause mortality, hospital readmissions, emergency department contacts and health-related quality of life.

SEARCH METHODS

In this Cochrane Review update, we searched for new published and unpublished trials using the following electronic databases from 1 January 2014 to 17 January 2022 without language restrictions: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). To identify additional trials, we searched the reference lists of included trials and other publications by lead trial authors, and contacted experts.

SELECTION CRITERIA

We included randomised trials of medication reviews delivered by healthcare professionals for hospitalised adult patients. We excluded trials including outpatients and paediatric patients.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed risk of bias. We contacted trial authors for data clarification and relevant unpublished data. We calculated risk ratios (RRs) for dichotomous data and mean differences (MDs) or standardised mean differences (SMDs) for continuous data (with 95% confidence intervals (CIs)). We used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach to assess the overall certainty of the evidence.

MAIN RESULTS

In this updated review, we included a total of 25 trials (15,076 participants), of which 15 were new trials (11,501 participants). Follow-up ranged from 1 to 20 months. We found that medication reviews in hospitalised adults may have little to no effect on mortality (RR 0.96, 95% CI 0.87 to 1.05; 18 trials, 10,108 participants; low-certainty evidence); likely reduce hospital readmissions (RR 0.93, 95% CI 0.89 to 0.98; 17 trials, 9561 participants; moderate-certainty evidence); may reduce emergency department contacts (RR 0.84, 95% CI 0.68 to 1.03; 8 trials, 3527 participants; low-certainty evidence) and have very uncertain effects on health-related quality of life (SMD 0.10, 95% CI -0.10 to 0.30; 4 trials, 392 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Medication reviews in hospitalised adult patients likely reduce hospital readmissions and may reduce emergency department contacts. The evidence suggests that mediation reviews may have little to no effect on mortality, while the effect on health-related quality of life is very uncertain. Almost all trials included elderly polypharmacy patients, which limits the generalisability of the results beyond this population.

Prescription Appropriateness of Drugs for Peptic Ulcer and Gastro-Esophageal Reflux Disease: Baseline Assessment in the LAPTOP-PPI Cluster Randomized Trial

Background: Drugs for peptic ulcer and gastro-esophageal reflux disease (GERD) are among the most widely prescribed, frequently without appropriate indications. This represents an important issue, as it leads to risk of adverse events for patients and unnecessary costs for National Health Service.

Aim: To assess the prescription appropriateness of drugs for GERD, in the frame of the “Evaluation of the effectiveness of a Low-cost informative intervention to improve the Appropriate PrescripTiOn of Proton PumP Inhibitors in older people in primary care: a cluster-randomized controlled study” (LAPTOP-PPI) (Clinicaltrial.gov: NCT04637750).

Methods: The appropriateness of drug prescription was assessed on data collected in administrative databases, by integrating information on concomitant medications, outpatient medical and laboratory procedures and hospital discharge diagnoses, according to the reimbursement criteria provided by the Italian Medicine Agency. We analyzed data of community-dwelling people aged 65 years and over, living in the areas of Bergamo (Northern Italy) and Caserta (Southern Italy), from July 1 to 31 December 2019.

Results: Among 380,218 patients, 175,342 (46.1%) received at least one prescription of drugs for GERD. All in all, we found that only 41.2% of patients received appropriate prescriptions.

Conclusion: Given the potential risk of adverse drug reactions, especially in older people, educational interventions should be prompted for physicians, in order to improve the quality of prescription of drugs for GERD and, in turn, avoid unfavorable health outcomes and unnecessary costs.

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].

A narrative review of evidence to guide deprescribing among older adults

Potentially inappropriate prescription and polypharmacy are well‐known risk factors for morbidity and mortality among older adults. However, recent systematic reviews have failed to demonstrate the overall survival benefits of deprescribing. Thus, it is necessary to synthesize the current evidence to provide a practical direction for future research and clinical practice. This review summarizes the existing body of evidence regarding deprescribing to identify useful intervention elements. There is evidence that even simple interventions, such as direct deprescribing targeted at risky medications and explicit criteria‐based approaches, effectively reduce inappropriate prescribing. On the other hand, if the goal is to improve clinical outcomes such as hospitalization and emergency department visits, patient‐centered multimodal interventions such as a combination of medication review, multidisciplinary collaboration, and patient education are likely to be more effective. We also consider the opportunities and challenges for deprescribing within the Japanese healthcare system.

The evaluation of an e-learning prescribing course for general practice

Prescribed medication may lead to significant morbidity or mortality as a result of these medications causing adverse events, or because of a prescribing error. E-learning is a common tool used in supporting training in prescribing. This paper describes the development of an e-learning course and the subsequent evaluation undertaken by the users with the aim of obtaining an effective e-learning course for prescribing. The e-learning course was developed by general practitioners and pharmacists and focussed on the principles of good prescribing, examined the common reasons for prescribing errors, and was evaluated using self-reported quantitative and qualitative measures. Scores significantly increased on an assessment given before and after the course. The majority of respondents reported that the e-learning course had a positive impact on prescribing knowledge, skills and attitudes, with medication reviews the top area where a change in prescribing practice was reported. Over 90% of the respondents agreed that the e-learning course was easy to use and a useful part of their continuing professional education. This study shows that clinicians recognise the on-going need for training in prescribing, but the lack of training is one of the factors contributing to errors, which suggests that more education is needed, not just for GPs in training, but for qualified GPs as well.

Deprescribing perceptions and practice: Reported by multidisciplinary hospital clinicians after, and by medical students before and after, viewing an e-learning module

BACKGROUND

There are many barriers to deprescribing in the routine care of older inpatients with polypharmacy. Implementation is limited by factors related to clinicians, patients, and the acute care setting. A short (11 min) e-learning module for multidisciplinary hospital clinicians was developed to address two commonly reported barriers: awareness of polypharmacy and self-efficacy in deprescribing.

OBJECTIVES

1) Describe the level of awareness of polypharmacy and self-efficacy of deprescribing in multi-disciplinary hospital clinicians following completion of an online e-learning module; and 2) describe the immediate impact of an online educational module in awareness and self-efficacy of polypharmacy and deprescribing in senior medical students.

METHODS

A questionnaire was developed and administered to hospital clinicians following completion of the e-learning module. Senior medical students undertook the questionnaire pre- and post-module.

RESULTS

Overall, 99 hospital clinicians with diverse clinical roles, experience, and ages, and 30 medical students completed the questionnaire. Although most (≥80%) hospital clinicians reported a general awareness of polypharmacy and deprescribing, there was moderate to low current activity in medication review and deprescribing, a perceived lack of role in medication review by junior doctors, and minimal knowledge of deprescribing tools. Use of a previously validated self-efficacy questionnaire showed lowest self-efficacy in domains related to developing deprescribing plans and implementing them. Pre-post analysis of medical student responses found a small statistically significant improvement following viewing the module in awareness of polypharmacy, deprescribing and deprescribing tools, perception of their role in deprescribing, and self-efficacy in planning and implementation of deprescribing decisions.

CONCLUSIONS

Hospital clinicians and senior medical students had limited self-efficacy in deprescribing and hospital clinicians reported they did not deprescribe frequently. Targets for educational and behavioral interventions were identified. A short e-learning module on polypharmacy and deprescribing may be a useful component of a multi-strategic intervention to implement deprescribing into routine inpatient care.

Drug-Drug Interactions in Elderly Patients with Potentially Inappropriate Medications in Primary Care, Nursing Home and Hospital Settings: A Systematic Review and a Preliminary Study

Drug–drug interactions (DDI) occurring with potentially inappropriate medications (PIM) are additional risk factors that may increase the inappropriate character of PIM. The aim of this study was (1) to describe the prevalence and severity of DDI in patients with PIM and (2) to evaluate the DDI specifically regarding PIM. This systematic review is based on a search carried out on PubMed and Web-of-Science from inception to June 30, 2020. We extracted data of original studies that assessed the prevalence of both DDI and PIM in elderly patients in primary care, nursing home and hospital settings. Four hundred and forty unique studies were identified: 91 were included in the qualitative analysis and 66 were included in the quantitative analysis. The prevalence of PIM in primary care, nursing home and hospital were 19.1% (95% confidence intervals (CI): 15.1–23.0%), 29.7% (95% CI: 27.8–31.6%) and 44.6% (95% CI: 28.3–60.9%), respectively. Clinically significant severe risk-rated DDI averaged 28.9% (95% CI: 17.2–40.6), in a hospital setting; and were approximately 7-to-9 lower in primary care and nursing home, respectively. Surprisingly, only four of these studies investigated DDI involving specifically PIM. Hence, given the high prevalence of severe DDI in patients with PIM, further investigations should be carried out on DDI involving specifically PIM which may increase their inappropriate character, and the risk of adverse drug reactions.

Effectiveness and sustainability of deprescribing for hospitalized older patients near end of life: a systematic review

Introduction: Polypharmacy is prevalent in hospitals and deprescribing strategies for older people are strongly promoted. However, evidence of their feasibility and sustainability among patients receiving end of life care is lacking. The objective of this review was to ascertain effectiveness and post-discharge sustainability of hospital-initiated deprescribing strategies in older people near the end of life. Areas covered: The authors searched for controlled trials, with low risk of bias and measures of effectiveness post-discharge. Intervention description, duration, and healthcare provider engagement were investigated for their impact on reduction of number of medications, proportions of patients prescribed inappropriate medications, returns to emergency, hospital admission and adverse events. Expert opinion: Limited evidence suggests hospital-initiated deprescribing interventions may reduce prescribing inappropriateness among older terminal patients in the short term, but evidence beyond 3 months is lacking for significant prevention of adverse events or health service utilization. Heterogeneity precluded meta-analysis, and short follow-up periods precluded quantitative assessment of sustainability. Trials of older people with terminal conditions with larger sample sizes and longer follow-up periods are needed to confirm the effectiveness and sustainability of deprescribing at the end of life. Objective tools to reliably identify near end-of-life status would be useful in selecting target groups for these interventions.

Application of the intervention Complexity Assessment Tool for Systematic Reviews within a Cochrane review: an illustrative case study

Background: The intervention Complexity Assessment Tool for Systematic Reviews (iCAT_SR) has been developed to facilitate detailed assessments of intervention complexity in systematic reviews. Worked examples of the tool’s application are needed to promote its use and refinement. The aim of this case study was to apply the iCAT_SR to a subset of 20 studies included in a Cochrane review of interventions aimed at improving appropriate polypharmacy in older people.

Methods: Interventions were assessed independently by two authors using the six core iCAT_SR dimensions: (1) ‘Target organisational levels/categories’; (2) ‘Target behaviour/actions’; (3) ‘Active intervention components’; (4) ‘Degree of tailoring’; (5) ‘Level of skill required by intervention deliverers’; (6) ‘Level of skill required by intervention recipients’. Attempts were made to apply four optional dimensions: ‘Interaction between intervention components’; ‘Context/setting’; ‘Recipient/provider factors’; ‘Nature of causal pathway’. Inter-rater reliability was assessed using Cohen’s Kappa coefficient. Disagreements were resolved by consensus discussion. The findings are presented narratively.

Results: Assessments involving the core iCAT_SR dimensions showed limited consistency in intervention complexity across included studies, even when categorised according to clinical setting. Interventions were delivered across various organisational levels and categories (i.e. healthcare professionals and patients) and typically comprised multiple components. Intermediate skill levels were required by those delivering and receiving the interventions across all studies. A lack of detail in study reports precluded application of the iCAT_SR’s optional dimensions. The inter-rater reliability was substantial (Cohen's Kappa = 0.75)

Conclusions: This study describes the application of the iCAT_SR to studies included in a Cochrane systematic review. Future intervention studies need to ensure more detailed reporting of interventions, context and the causal pathways underlying intervention effects to allow a more holistic understanding of intervention complexity and facilitate replication in other settings. The experience gained has helped to refine the original guidance document relating to the application of iCAT_SR.

Use and prescription appropriateness of drugs for peptic ulcer and gastrooesophageal reflux disease in hospitalized older people

PURPOSE

The aims of this study were to assess the prevalence of use and prescription appropriateness of drugs for peptic ulcer and gastrooesophageal reflux disease (GERD) at hospital admission and discharge.

METHODS

Patients aged 65 years or more hospitalized from 2010 to 2016 in 101 Italian internal medicine and geriatric wards in the context of the REPOSI register were scrutinized to assess if they were prescribed with drugs for peptic ulcer and GERD at hospital admission and discharge. Appropriateness of prescription was assessed considering the presence of specific conditions (i.e., history of peptic ulcer or gastrointestinal hemorrhages, advanced age, Helicobacter Pylori) or gastro-toxic drug combinations, according to the criteria provided by the reimbursement rules of the Agenzia Italiana del Farmaco (NOTA 1 and 48).

RESULTS

Among 4715 enrolled patients, 3899 were discharged alive. At hospital discharge, 2412 (61.9%, 95%CI: 60.3-63.4%) patients were prescribed with drugs for peptic ulcer and GERD, a 12% of increase from hospital admission. Almost half of the patients (N = 1776, 45.6%, 95%CI: 44.0-47.1%) were inappropriately prescribed or not prescribed: among the drugs for peptic ulcer and GERD users, about 60% (1444/2412) were overprescribed, and among nonusers, 22% (332/1487) were underprescribed. Among patients newly prescribed at hospital discharge, 60% (392/668) were inappropriately prescribed. The appropriateness of drugs for peptic ulcer and GERD therapy decreased by 3% from hospital admission to discharge.

CONCLUSIONS

Hospitalization missed the opportunity to improve the quality of prescription of this class of drug.

Simulation-Based Education for Physicians to Increase Oral Anticoagulants in Hospitalized Elderly Patients with Atrial Fibrillation

PURPOSE

This study was intended to determine whether a simulation-based education addressed to physicians was able to increase the proportion of hospitalized elderly with atrial fibrillation prescribed with oral anticoagulants (OACs) compared with the usual practice.

METHODS

We conducted a cluster randomized trial (from April 2015 to September 2018) on 32 Italian internal medicine and geriatric wards randomized 1:1 to intervention or control arms. The physicians of wards randomized to intervention received a computer-based e-learning tool with clinical scenarios (Dr Sim), and those of wards randomized to control received no formal educational intervention. The primary outcome was the OAC prescription rate at hospital discharge in the intervention and control arms.

RESULTS

Of 452 patients scrutinized, 247 were included in the analysis. Of them, 186 (75.3%) were prescribed with OACs at hospital discharge. No difference was found between the intervention and control arms in the post-intervention phase (odds ratio, 1.46; 95% confidence interval [CI], 0.81-2.64). The differences from the pre- to post-intervention phases in the proportions of patients prescribed with OACs (15.1%; 95% CI, 0%-31.5%) and with direct oral anticoagulants (DOACs) (20%; 95% CI, 0%-39.8%) increased more in the intervention than in the control arm.

CONCLUSIONS

This simulation-based course did not succeed in increasing the rate of elderly patients prescribed with OACs at hospital discharge compared with the usual practice. Notwithstanding, over time there was a greater increase in the intervention than in the control arm in the proportion of patients prescribed with OACs and DOACs.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03188211.

Digital Learning to Improve Safe and Effective Prescribing: A Systematic Review

With the aim to modernize and harmonize prescribing education, the European Association for Clinical Pharmacology and Therapeutics (EACPT) Working Group on education recommended the extensive use and distribution of digital learning resources (DLRs). However, it is unclear whether the complex task of prescribing medicine can be taught digitally. Therefore, the aim of this review was to investigate the effect of diverse DLRs in clinical pharmacology and therapeutics education. Databases PubMed, EMBASE, CINAHL, ERIC, and CENTRAL were systematically searched. Sixty-five articles were included in the analyses. Direct effects on patients were studied, but not detected, in six articles. Skills and behavior were studied in 11 articles, 8 of which reported positive effects. Knowledge acquisition was investigated in 19 articles, all with positive effects. Qualitative analyses yielded 10 recommendations for the future development of DLRs. Digital learning is effective in teaching knowledge, attitudes, and skills associated with safe and effective prescribing.

Appropriateness of prescription of oral anticoagulant therapy in acutely hospitalized older people with atrial fibrillation. Secondary analysis of the SIM-AF cluster randomized clinical trial

AIMS

To assess the appropriateness of oral anticoagulant (OAC) prescription and its associated factors in acutely hospitalized elderly patients.

METHODS

Data were obtained from the prospective phase of SIM-AF (SIMulation-based technologies to improve the appropriate use of oral anticoagulants in hospitalized elderly patients with Atrial Fibrillation) randomized controlled trial, aimed to test whether an educational intervention improved OAC prescription, compared to current clinical practice, in internal medicine wards. In this secondary analysis, appropriateness of OAC prescription was assessed at hospital admission and discharge.

RESULTS

For 246 patients, no significant differences were found between arms (odds ratio 1.38, 95% confidence interval [CI] 0.84-2.28) in terms of appropriateness of OAC prescription. Globally, 92 patients (37.4%, 95% CI = 31.6-43.6%) were inappropriately prescribed or not prescribed at hospital discharge. Among 51 patients inappropriately prescribed, 82% showed errors on dosage, being mainly under-dosed (n = 29, 56.9%), and among 41 inappropriately not prescribed, 98% were taking an antiplatelet drug. Factors independently associated with a lower probability of appropriateness at discharge were those related to a higher risk of bleeding (older age, higher levels of aspartate aminotransferase, history of falls, alcohol consumption) and antiplatelet prescription at admission. The prescription of OACs at admission was the strongest predictor of appropriateness at discharge (odds ratio = 7.43, 95% CI = 4.04-13.73).

CONCLUSIONS

A high proportion of hospitalized older patients with AF remains inappropriately prescribed or nonprescribed with OACs. The management of these patients at hospital admission is the strongest predictor of prescription appropriateness at discharge.

Effect of an educational intervention on the number potential drug-drug interactions

Background

The objective of this study was to evaluate effect of an Educational intervention on the number Potential Drug-Drug Interactions in the Emergency Hospital.

Methods

The prevalence and structure of Major Drug-Drug Interactions at Emergency care Hospitals of Aktobe, Uralsk, Atyrau cities (Kazakhstan) were studied (pharmacoepidemiological, cross-sectional study). Educational interventions were developed and implemented to improve pharmacotherapy in the Cardiology Department of the Aktobe Emergency Hospital, followed by an assessment of their effect.

Results

The effect of educational interventions was revealed, which led to a significant decrease in the indicators of drug interactions of the Major Drug-Drug Interactions by 18.2% (OR: 0.45; 95% CI, 0.25-to-0.82) in the cardiological patients of the Emergency Care Hospital of Aktobe city compared to the Regional Cardiology Center of Uralsk.

Conclusion

The implementation of educational pharmacotherapy programs decreased the number of clinically significant drug interactions in the Cardiology Department of Emergency Hospitals.

Online Digital Education for Postregistration Training of Medical Doctors: Systematic Review by the Digital Health Education Collaboration

Background

Globally, online and local area network–based (LAN) digital education (ODE) has grown in popularity. Blended learning is used by ODE along with traditional learning. Studies have shown the increasing potential of these technologies in training medical doctors; however, the evidence for its effectiveness and cost-effectiveness is unclear.

Objective

This systematic review evaluated the effectiveness of online and LAN-based ODE in improving practicing medical doctors’ knowledge, skills, attitude, satisfaction (primary outcomes), practice or behavior change, patient outcomes, and cost-effectiveness (secondary outcomes).

Methods

We searched seven electronic databased for randomized controlled trials, cluster-randomized trials, and quasi-randomized trials from January 1990 to March 2017. Two review authors independently extracted data and assessed the risk of bias. We have presented the findings narratively. We mainly compared ODE with self-directed/face-to-face learning and blended learning with self-directed/face-to-face learning.

Results

A total of 93 studies (N=16,895) were included, of which 76 compared ODE (including blended) and self-directed/face-to-face learning. Overall, the effect of ODE (including blended) on postintervention knowledge, skills, attitude, satisfaction, practice or behavior change, and patient outcomes was inconsistent and ranged mostly from no difference between the groups to higher postintervention score in the intervention group (small to large effect size, very low to low quality evidence). Twenty-one studies reported higher knowledge scores (small to large effect size and very low quality) for the intervention, while 20 studies reported no difference in knowledge between the groups. Seven studies reported higher skill score in the intervention (large effect size and low quality), while 13 studies reported no difference in the skill scores between the groups. One study reported a higher attitude score for the intervention (very low quality), while four studies reported no difference in the attitude score between the groups. Four studies reported higher postintervention physician satisfaction with the intervention (large effect size and low quality), while six studies reported no difference in satisfaction between the groups. Eight studies reported higher postintervention practice or behavior change for the ODE group (small to moderate effect size and low quality), while five studies reported no difference in practice or behavior change between the groups. One study reported higher improvement in patient outcome, while three others reported no difference in patient outcome between the groups. None of the included studies reported any unintended/adverse effects or cost-effectiveness of the interventions.

Conclusions

Empiric evidence showed that ODE and blended learning may be equivalent to self-directed/face-to-face learning for training practicing physicians. Few other studies demonstrated that ODE and blended learning may significantly improve learning outcomes compared to self-directed/face-to-face learning. The quality of the evidence in these studies was found to be very low for knowledge. Further high-quality randomized controlled trials are required to confirm these findings.

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. This is the second update of this Cochrane Review.

OBJECTIVES

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

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 7 February 2018, together with handsearching of reference lists to identify additional studies.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older, prescribed polypharmacy (four or more medicines), which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We identified 32 studies, 20 from this update. Included studies consisted of 18 randomised trials, 10 cluster randomised trials (one of which was a stepped-wedge design), two non-randomised trials and two controlled before-after studies. One intervention consisted of computerised decision support (CDS); and 31 were complex, multi-faceted pharmaceutical-care based approaches (i.e. the responsible provision of medicines to improve patient's outcomes), one of which incorporated a CDS component as part of their multi-faceted intervention. Interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists and geriatricians, and all were conducted in high-income countries. Assessments using the Cochrane 'Risk of bias' tool, found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low.It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool), mean difference (MD) -4.76, 95% CI -9.20 to -0.33; 5 studies, N = 517; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs), (standardised mean difference (SMD) -0.22, 95% CI -0.38 to -0.05; 7 studies; N = 1832; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIMs, (risk ratio (RR) 0.79, 95% CI 0.61 to 1.02; 11 studies; N = 3079; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.81, 95% CI -0.98 to -0.64; 2 studies; N = 569; low-certainty evidence), however it must be noted that this effect estimate is based on only two studies, which had serious limitations in terms of risk bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPOs (RR 0.40, 95% CI 0.18 to 0.85; 5 studies; N = 1310; very low-certainty evidence). Pharmaceutical care may make little or no difference in hospital admissions (data not pooled; 12 studies; N = 4052; low-certainty evidence). Pharmaceutical care may make little or no difference in quality of life (data not pooled; 12 studies; N = 3211; low-certainty evidence). Medication-related problems were reported in eight studies (N = 10,087) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies.

AUTHORS' CONCLUSIONS

It is unclear whether interventions to improve appropriate polypharmacy, such as reviews of patients' prescriptions, resulted in clinically significant improvement; however, they may be slightly beneficial in terms of reducing potential prescribing omissions (PPOs); but this effect estimate is based on only two studies, which had serious limitations in terms of risk bias.

Medication review versus usual care to improve drug therapies in older inpatients not admitted to geriatric wards: a quasi-experimental study (RASP-IGCT)

Background

Interdisciplinary geriatric consultation teams (IGCT) are regularly requested to provide comprehensive geriatric assessments in older inpatients. Our primary aim was to evaluate whether medication reviews increased the number of IGCT-provided drug-related recommendations. Secondary aims were to reduce the number of potentially inappropriate medications (PIMs), and to identify the acceptance rate of and determinants for the number of recommendations.

Methods

A before-after study was performed in older inpatients not admitted to acute geriatric wards. The before cohort received usual care (UC); the after cohort was subjected to the intervention (I), consisting of a systematic medication review, based on but not limited to the RASP (Rationalization of Home Medication by an Adjusted STOPP in Older Patients) list. The primary outcome measure was the number of IGCT-provided drug-related recommendations. Age, sex, Charlson Comorbidity Index, creatinine clearance and serum creatinine were ascertained upon enrolment. Following variables were determined on admission and at discharge: number of drugs and number as well as type of RASP-identified PIMs. Acceptance by ward-based physicians was also determined. Poisson regression was performed to identify determinants for the primary outcome measure.

Results

Fifty-nine participants were enrolled (n_UC = 29; n_I = 30). The intervention increased the number of drug-related recommendations from a median of 0 (IQR: 0–1) to 8 (IQR: 6.75–10) (p < 0.001). The median number of accepted recommendations differed significantly as well (UC vs. I: 0.0 (0.0–0.5) vs. 3.0 (0.0–5.3); p < 0.001). In the intervention cohort, patients were discharged with fewer drugs compared to admission (UC vs. I: 108.5%, IQR: 100.0–135.8% vs. 92%, IQR: 80.5–103.5%; p = 0.002). More RASP PIMs were discontinued in the intervention cohort, with a mean difference of 1.49 RASP PIMs (95% confidence interval (CI): 0.70, 2.23; p < 0.001). Regression analysis identified two determinants: allocation to the intervention cohort with an incidence rate ratio (IRR) of 14.1 (95% CI: 8.30, 23.8) and the number of preadmission drugs with an IRR of 1.06 (95% CI: 1.03, 1.09).

Conclusions

A structured medication review as part of usual IGCT care may contribute to an increased detection of drug-related problems and help to further reduce polypharmacy in older inpatients, not admitted to acute geriatric care wards.

Trial registration

NCT02165618, retrospectively registered June 17, 2014.

E-learning for health professionals

BACKGROUND

The use of e-learning, defined as any educational intervention mediated electronically via the Internet, has steadily increased among health professionals worldwide. Several studies have attempted to measure the effects of e-learning in medical practice, which has often been associated with large positive effects when compared to no intervention and with small positive effects when compared with traditional learning (without access to e-learning). However, results are not conclusive.

OBJECTIVES

To assess the effects of e-learning programmes versus traditional learning in licensed health professionals for improving patient outcomes or health professionals' behaviours, skills and knowledge.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and three trial registers up to July 2016, without any restrictions based on language or status of publication. We examined the reference lists of the included studies and other relevant reviews. If necessary, we contacted the study authors to collect additional information on studies.

SELECTION CRITERIA

Randomised trials assessing the effectiveness of e-learning versus traditional learning for health professionals. We excluded non-randomised trials and trials involving undergraduate health professionals.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data and assessed risk of bias. We graded the certainty of evidence for each outcome using the GRADE approach and standardised the outcome effects using relative risks (risk ratio (RR) or odds ratio (OR)) or standardised mean difference (SMD) when possible.

MAIN RESULTS

We included 16 randomised trials involving 5679 licensed health professionals (4759 mixed health professionals, 587 nurses, 300 doctors and 33 childcare health consultants).When compared with traditional learning at 12-month follow-up, low-certainty evidence suggests that e-learning may make little or no difference for the following patient outcomes: the proportion of patients with low-density lipoprotein (LDL) cholesterol of less than 100 mg/dL (adjusted difference 4.0%, 95% confidence interval (CI) -0.3 to 7.9, N = 6399 patients, 1 study) and the proportion with glycated haemoglobin level of less than 8% (adjusted difference 4.6%, 95% CI -1.5 to 9.8, 3114 patients, 1 study). At 3- to 12-month follow-up, low-certainty evidence indicates that e-learning may make little or no difference on the following behaviours in health professionals: screening for dyslipidaemia (OR 0.90, 95% CI 0.77 to 1.06, 6027 patients, 2 studies) and treatment for dyslipidaemia (OR 1.15, 95% CI 0.89 to 1.48, 5491 patients, 2 studies). It is uncertain whether e-learning improves or reduces health professionals' skills (2912 health professionals; 6 studies; very low-certainty evidence), and it may make little or no difference in health professionals' knowledge (3236 participants; 11 studies; low-certainty evidence).Due to the paucity of studies and data, we were unable to explore differences in effects across different subgroups. Owing to poor reporting, we were unable to collect sufficient information to complete a meaningful 'Risk of bias' assessment for most of the quality criteria. We evaluated the risk of bias as unclear for most studies, but we classified the largest trial as being at low risk of bias. Missing data represented a potential source of bias in several studies.

AUTHORS' CONCLUSIONS

When compared to traditional learning, e-learning may make little or no difference in patient outcomes or health professionals' behaviours, skills or knowledge. Even if e-learning could be more successful than traditional learning in particular medical education settings, general claims of it as inherently more effective than traditional learning may be misleading.

The effect of prescriber education on medication-related patient harm in the hospital: a systematic review

AIMS

Educating prescribers is a strategy to reduce prescription errors in hospitals. The present systematic review gives an overview of original research papers on the education of prescribers and reporting outcomes on (potential) patient harm.

METHODS

A search of the databases Embase and Medline, using the Ovid interface, was performed. Research on the effect of physician education in order to prevent medication-related problems in inpatients, and on reporting original data and outcomes on prescribing errors and/or (potential) patient harm, was included. The assessment of methodological quality and risk of bias was performed using the Methodological Index for Non-Randomized studies (MINORS) checklist and the suggested risk of bias criteria for Effective Practice and Organization of Care (EPOC) reviews.

RESULTS

Eight studies investigated an intervention on education alone, and in seven studies education was the main part of a multifaceted intervention. All studies were small and had short follow-up periods. The educational programmes varied and were given to physicians of different specialties and levels of experience. Most studies reported intermediate process parameters as the outcome. The risk of performance and reporting bias were high.

CONCLUSION

All included studies suffered from poor methodology. The majority, especially studies in which education was part of a multifaceted intervention, reported effectiveness on intermediate outcome markers as prescription errors and potential adverse drug events. However, we found no firm evidence that educating prescribers in the hospital leads to a decrease in patient harm. Further work is needed to develop educational programmes, accompanied by more high-quality research with outcomes on the improvement of patient care.

E-learning in order to improve drug prescription for hospitalized older patients: a cluster-randomized controlled study

AIMS

The aim of the study was to evaluate the effect of an e-learning educational program meant to foster the quality of drug prescription in hospitalized elderly patients.

METHODS

Twenty geriatric and internal medicine wards were randomized to intervention (e-learning educational program) or control (basic geriatric pharmacology notions). Logistic regression analysis was used in order to assess the effect of the intervention on the use of potentially inappropriate medication (PIM, primary outcome) at hospital discharge. Secondary outcomes were a reduced prevalence of at least one potential drug-drug interaction (DDI) and potentially severe DDI at discharge. Mortality rate and incidence of re-hospitalizations were other secondary outcomes assessed at the 12-month follow-up.

RESULTS

A total of 697 patients (347 in the intervention and 350 in the control arms) were enrolled. No difference in the prevalence of PIM at discharge was found between arms (OR 1.29 95%CI 0.87-1.91). We also found no decrease in the prevalence of DDI (OR 0.67 95%CI 0.34-1.28) and potentially severe DDI (OR 0.86 95%CI 0.63-1.15) at discharge, nor in mortality rates and incidence of re-hospitalization at 12-month follow-up.

CONCLUSIONS

This e-learning educational program had no clear effect on the quality of drug prescription and clinical outcomes in hospitalized elderly patients. Given the high prevalence of PIMs and potential DDIs recorded in the frame of this study, other approaches should be developed in order to improve the quality of drug prescription in this population.