Development of evidence-based Australian medication-related indicators of potentially preventable hospitalisations: a modified RAND appropriateness method

Potentially preventable medication-related hospitalisations with cardiovascular disease of Aboriginal and Torres Strait Islander people, Queensland, 2013-2017: a retrospective cohort study

OBJECTIVE

To identify the proportion of hospitalisations (inpatient admissions and emergency department presentations) of Aboriginal and Torres Strait Islander people in Queensland that were medication-related and potentially preventable for nine clinical indicators of cardiovascular disease (CVD).

STUDY DESIGN

Retrospective cohort study; analysis of linked hospitalisations and emergency department presentations data and administrative records of medical services, pharmaceuticals, and deaths.

SETTING, PARTICIPANTS

Aboriginal or Torres Strait Islander adults (18 years or older) admitted to Queensland public and private hospitals, 1 January 2013 - 31 December 2017.

MAIN OUTCOME MEASURES

Potentially preventable medication-related hospitalisations (PPMRHs), defined by a set of clinical indicators describing CVD; deaths within 30 days of PPMRHs; hospital costs.

RESULTS

We identified 31 472 CVD-related hospitalisations, of which 11 469 were of people with medical histories suggesting harm that was foreseeable and preventable with appropriate treatment. Of the 7886 hospitalisations with congestive heart failure, 4350 (55%) were of people with prior CVD diagnoses; 681 (16%) were associated with use of medicines known to exacerbate congestive heart failure, and 1488 (34%) were associated with underuse of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors. Of the 1089 hospitalisations with myocardial infarction of people who had previously experienced myocardial infarction or acute coronary syndrome events, 809 (74%) were not receiving recommended treatment at the time of hospitalisation. Of the 5417 hospitalisations with ischaemic events of people with histories including diabetes and earlier ischaemic events, 3343 (62%) were not receiving antiplatelet or lipid-lowering therapy. The median cost associated with PPMRHs for the time period (2013-2017) was $4352 (interquartile range, $8742), and 136 (3%) of CVD-related deaths within 30 days of hospital discharge followed PPMRH events.

CONCLUSIONS

Interventions supporting targeted and timely medication safety services for Aboriginal and Torres Strait Islander people need to be reviewed and improved to reduce the numbers of avoidable hospitalisations and deaths.

Selection of primary health care quality indicators in Europe: A Delphi study protocol

OBJECTIVE

To describe a protocol to achieve consensus on valid and important indicators to assess primary health care (PHC) quality regarding all clinical contexts of PHC in European health systems.

STUDY DESIGN

Qualitative study using the Delphi technique to gain consensus among European panels of experts comprising a heterogeneous professional background.

METHODS

Potential candidate indicators were extracted and translated according to a set of informative elements (i.e., name, description, formula, unit of analysis, and sources). This list was then independently reviewed, and duplicates were removed totaling 1726 indicators. To guarantee a good response rate, indicators were distributed across 57 Delphi panels organized by clinical context. Each panel is a Delphi process, assessing between 23 to 33 indicators. Experts' opinions on the validity and importance of the extracted indicators will be obtained through two rounds of online questionnaires, using a 9-point Likert scale and free-text boxes. To prevent biased responses, participation will be anonymous to other participants and to the team administrating panels. Consensus will be considered if at least 70% of ratings (≥7 assuming 10 participants) lie within the 7-9 range and less than 15% of ratings (<2 assuming 10 participants) are in the 1-3 range. Analysis of results will be streamlined and generalizable across panels using scripts.

CONCLUSIONS

This protocol will contribute to improve the quality of PHC in Europe by achieving a consensual and concise list of PHC quality indicators retrieved from the scientific literature that fit current clinical guidelines and populations' needs in countries from the European region according to the World Health Organization.

Development of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care-a modified e-Delphi study

BACKGROUND

Long-term opioid use is associated with dependency, addiction, and serious adverse events. Although a framework to reduce inappropriate opioid prescribing exists, there is no consensus on prescribing indicators for preventable opioid-related problems in patients with chronic pain in primary care in the UK. This study aimed to identify opioid prescription scenarios for developing indicators for prescribing opioids to patients with chronic pain in primary care.

METHODS

Scenarios of opioid prescribing indicators were identified from a literature review, guidelines, and government reports. Twenty-one indicators were identified and presented in various opioid scenarios concerning opioid-related harm and adverse effects, drug-drug interactions, and drug-disease interactions in certain disease conditions. After receiving ethics approval, two rounds of electronic Delphi panel technique surveys were conducted with 24 expert panellists from the UK (clinicians, pharmacists, and independent prescribers) from August 2020 to February 2021. Each indicator was rated on a 1-9 scale from inappropriate to appropriate. The score's median, 30th and 70th percentiles, and disagreement index were calculated.

RESULTS

The panel unanimously agreed that 15 out of the 21 opioid prescribing scenarios were inappropriate, primarily due to their potential for causing harm to patients. This consensus was reflected in the low appropriateness scores (median ranging from 1 to 3). There were no scenarios with a high consensus that prescribing was appropriate. The indicators were considered inappropriate due to drug-disease interactions (n = 8), drug-drug interactions (n = 2), adverse effects (n = 3), and prescribed dose and duration (n = 2). Examples included prescribing opioids during pregnancy, concurrently with benzodiazepines, long-term without a laxative prescription and prescribing > 120-mg morphine milligram equivalent per day or long-term duration over 3 months after surgery.

CONCLUSIONS

The high agreement on opioid prescribing indicators indicates that these potentially hazardous consequences are relevant and concerning to healthcare practitioners. Future research is needed to evaluate the feasibility and implementation of these indicators within primary care settings. This research will provide valuable insights and evidence to support opioid prescribing and deprescribing strategies. Moreover, the findings will be crucial in informing primary care practitioners and shaping quality outcome frameworks and other initiatives to enhance the safety and quality of care in primary care settings.

Fall-risk-increasing drugs in older patients: the role of guidelines and GP-centred health care in Germany

BACKGROUND

fall-risk-increasing drugs (FRIDs) are a ubiquitous issue, especially for older patients. As part of a German guideline for pharmacotherapy, from 2019, a new quality indicator for this patient group was developed to measure the percentage of patients receiving FRIDs.

METHODS

patients, aged at least 65 years in 2020, insured by the Allgemeine OrtsKrankenkasse statutory health insurance (Allgemeine Ortskrankenkasse, Baden-Wuerttemberg, Germany) with a particular general practitioner (GP) were observed from 1 January to 31 December 2020 cross-sectionally. The intervention group received GP-centred health care. Within GP-centred health care, GPs have the role of gatekeepers for patients within the health system and are-in contrast to regular care GPs in addition to other commitments-obliged to regularly attend training sessions on appropriate pharmacotherapy. The control group received regular GP care. For both groups, we measured the percentage of patients receiving FRIDs as well as the occurrence of (fall-related) fractures as the main outcomes. To test our hypotheses, we performed multivariable regression modelling.

RESULTS

a total of 634,317 patients were eligible for analysis. Within the intervention group (n = 422,364), we could observe a significantly reduced odds ratio (OR) for obtaining a FRID (OR = 0.842, confidence interval [CI]: [0.826, 0.859], P < 0.0001) in comparison to the control group (n = 211,953). Moreover, we could observe a significantly reduced chance for (fall-related) fractures in the intervention group (OR: 0.932, CI: [0.889, 0.975], P = 0.0071).

CONCLUSIONS

the findings point in the direction that the health care providers' awareness of the potential danger of FRIDs for older patients is higher in the GP-centred care group.

Planning and Reporting Effective Web-Based RAND/UCLA Appropriateness Method Panels: Literature Review and Preliminary Recommendations

BACKGROUND

The RAND/UCLA Appropriateness Method (RAM), a variant of the Delphi Method, was developed to synthesize existing evidence and elicit the clinical judgement of medical experts on the appropriate treatment of specific clinical presentations. Technological advances now allow researchers to conduct expert panels on the internet, offering a cost-effective and convenient alternative to the traditional RAM. For example, the Department of Veterans Affairs recently used a web-based RAM to validate clinical recommendations for de-intensifying routine primary care services. A substantial literature describes and tests various aspects of the traditional RAM in health research; yet we know comparatively less about how researchers implement web-based expert panels.

OBJECTIVE

The objectives of this study are twofold: (1) to understand how the web-based RAM process is currently used and reported in health research and (2) to provide preliminary reporting guidance for researchers to improve the transparency and reproducibility of reporting practices.

METHODS

The PubMed database was searched to identify studies published between 2009 and 2019 that used a web-based RAM to measure the appropriateness of medical care. Methodological data from each article were abstracted. The following categories were assessed: composition and characteristics of the web-based expert panels, characteristics of panel procedures, results, and panel satisfaction and engagement.

RESULTS

Of the 12 studies meeting the eligibility criteria and reviewed, only 42% (5/12) implemented the full RAM process with the remaining studies opting for a partial approach. Among those studies reporting, the median number of participants at first rating was 42. While 92% (11/12) of studies involved clinicians, 50% (6/12) involved multiple stakeholder types. Our review revealed that the studies failed to report on critical aspects of the RAM process. For example, no studies reported response rates with the denominator of previous rounds, 42% (5/12) did not provide panelists with feedback between rating periods, 50% (6/12) either did not have or did not report on the panel discussion period, and 25% (3/12) did not report on quality measures to assess aspects of the panel process (eg, satisfaction with the process).

CONCLUSIONS

Conducting web-based RAM panels will continue to be an appealing option for researchers seeking a safe, efficient, and democratic process of expert agreement. Our literature review uncovered inconsistent reporting frameworks and insufficient detail to evaluate study outcomes. We provide preliminary recommendations for reporting that are both timely and important for producing replicable, high-quality findings. The need for reporting standards is especially critical given that more people may prefer to participate in web-based rather than in-person panels due to the ongoing COVID-19 pandemic.

Quality and safety indicators for home care recipients in Australia: development and cross-sectional analyses

Objectives

To develop and examine the prevalence of quality and safety indicators to monitor care of older Australians receiving home care packages (HCPs), a government-funded aged care programme to support individuals to live at home independently.

Design

Cross-sectional.

Setting

Home care recipients, Australia.

Participants

90 650 older individuals (aged ≥65 years old and ≥50 years old for people of Aboriginal or Torres Strait Islander descent) who received a HCP between 1 January 2016 and 31 December 2016 nationally were included.

Primary and secondary outcome measures

The Registry of Senior Australians developed 15 quality and safety indicators: antipsychotic use, high sedative load, chronic opioid use, antimicrobial use, premature mortality, home medicines reviews, chronic disease management plan, wait-time for HCP, falls, fractures, medication-related adverse events, weight loss/malnutrition, delirium/dementia-related hospitalisations, emergency department (ED) presentations and pressure injuries. Risk adjusted prevalence (%, 95% CI) and geographical area (statistical level 3) variation during 2016 were examined.

Results

In 2016, a total of 102 590 HCP episodes were included for 90 650 individuals, with 66.9% (n=68 598) level 1–2 HCP episodes (ie, for basic care needs) and 33.1% (n=33 992) level 3–4 HCP (ie, higher care needs). The most prevalent indicators included: antibiotic use (52.4%, 95% CI 52.0 to 52.7), chronic disease management plans (38.1%, 95% CI 37.8 to 38.4), high sedative load (29.1%, 95% CI 28.8 to 29.4) and ED presentations (26.4%, 95% CI 25.9 to 26.9). HCP median wait time was 134 days (IQR 41–406). Geographical variation was highest in chronic disease management plans and ED presentations (20.7% of areas outside expected range).

Conclusion

A comprehensive outcome monitoring system to monitor the quality and safety of care and variation for HCP recipients was developed. It provides a pragmatic, efficient and low burden tool to support evidence-based quality and safety improvement initiatives for the aged care sector.

Identifying patterns of potentially preventable hospitalisations in people living with dementia

BACKGROUND

Older Australians make up 46% of all potentially preventable hospitalisations (PPHs) and people living with dementia are at significantly greater risk. While policy reforms aim to reduce PPHs, there is currently little evidence available on what drives this, especially for people living with dementia. This study examines patterns of PPHs in people living with dementia to inform service delivery and the development of evidence-based interventions.

METHODS

We used the Victorian Admitted Episodes Dataset from Victoria, Australia, to extract data for people aged 50 and over with a diagnosis of dementia between 2015 and 2016. Potentially avoidable admissions, known as ambulatory care sensitive conditions (ACSCs), were identified. The chi-square test was used to detect differences between admissions for ACSCs and non-ACSCs by demographic, geographical, and administrative factors. Predictors of ACSCs admissions were analysed using univariate and multiple logistic regression.

RESULTS

Of the 8156 hospital records, there were 3884 (48%) ACSCs admissions, of which admissions for urinary tract infections accounted for 31%, followed by diabetes complications (21%). Mean bed-days were 8.26 for non-ACSCs compared with 9.74 for ACSCs (p ≤ 0.001). There were no differences between admissions for ACSCs and non-ACSCs by sex, marital status, region (rural vs metro), and admission source (private accommodation vs residential facility). Culture and language predicted ASCS admission rates in the univariate regression analyses, with ACSC admission rates increasing by 20 and 29% if English was not the preferred language or if an interpreter was required, respectively. Results from the multiple regression analysis confirmed that language was a significant predictor of ACSC admission rates.

CONCLUSIONS

Improved primary health care may help to reduce the most common causes of PPHs for people living with dementia, particularly for those from culturally and linguistically diverse backgrounds.

Medication-related hospital admissions in aged care residents

OBJECTIVE

To determine the prevalence of medication-related hospitalisations preceded by potentially suboptimal processes of care in aged care residents.

METHOD

We conducted a retrospective analysis of administrative claims data from the Australian Government Department of Veterans' Affairs (DVA). We identified all hospital admissions for aged care residents between 1 July 2014 and 30 June 2019. The proportion of hospital admissions preceded by potentially suboptimal medication-related processes of care was determined.

RESULTS

A total of 18 874 hospitalisations were included, and 46% were preceded by potentially suboptimal medication-related care. One-quarter of fracture admissions occurred in residents at risk of fracture who were not using a medicine to prevent fracture, and 87% occurred in residents using falls-risk medicines. Thirty per cent of heart failure admissions occurred in patients who were not using an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker.

CONCLUSION

Nearly half of hospital admissions were preceded by potentially suboptimal medication-related processes of care. Interventions to improve use of medicines for aged care residents in these areas are warranted.

The Registry of Senior Australians outcome monitoring system: quality and safety indicators for residential aged care

Objectives

To introduce the Registry of Senior Australians (ROSA) Outcome Monitoring System, which can monitor the quality and safety of care provided to individuals accessing residential aged care. Development and examination of 12 quality and safety indicators of care and their 2016 prevalence estimates are presented.

Design

Retrospective.

Setting

2690 national and 254 South Australian (SA) aged care facilities.

Participants

208 355 unique residents nationally and 18 956 in SA.

Main Outcome Measures

Risk-adjusted prevalence of high sedative load, antipsychotic use, chronic opioid use, antibiotic use, premature mortality, falls, fractures, medication-related adverse events, weight loss/malnutrition, delirium and/or dementia hospitalisations, emergency department presentations, and pressure injuries.

Results

Five indicators were estimated nationally; antibiotic use (67.5%, 95% confidence interval (CI): 67.3–67.7%) had the highest prevalence, followed by high sedative load (48.1%, 95% CI: 47.9–48.3%), chronic opioid use (26.8%, 95% CI: 26.6–26.9%), antipsychotic use (23.5%, 95% CI: 23.4–23.7%) and premature mortality (0.6%, 95% CI: 0.6–0.7%). Seven indicators were estimated in SA; emergency department presentations (19.1%, 95% CI: 18.3–20.0%) had the highest prevalence, followed by falls (10.1%, 95% CI: 9.7–10.4%), fractures (4.8%, 95% CI: 4.6–5.1%), pressure injuries (2.9%, 95% CI: 2.7–3.1%), delirium and/or dementia related hospitalisations (2.3%, 95% CI: 2.1–2.6%), weight loss/malnutrition (0.7%, 95% CI: 0.6–0.8%) and medication-related events (0.6%, 95% CI: 0.5–0.7%).

Conclusions

Twelve quality and safety indicators were developed to monitor aged care provided to older Australians based on the synthesis of existing literature and expert advisory input. These indicators rely on existing data within the aged care and healthcare sectors, therefore creating a pragmatic tool to examine quality and unwarranted care variation.

The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study

Background

Serious mental illness, including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with serious mental illness are treated in primary care by general practitioners, who are financially incentivised to meet quality targets for patients with chronic conditions, including serious mental illness, under the Quality and Outcomes Framework. The Quality and Outcomes Framework, however, omits important aspects of quality.

Objectives

We examined whether or not better quality of primary care for people with serious mental illness improved a range of outcomes.

Design and setting

We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, accident and emergency attendances, Office for National Statistics mortality data and community mental health records in the Mental Health Minimum Data Set. We used survival analysis to estimate whether or not selected quality indicators affect the time until patients experience an outcome.

Participants

Four cohorts of people with serious mental illness, depending on the outcomes examined and inclusion criteria.

Interventions

Quality of care was measured with (1) Quality and Outcomes Framework indicators (care plans and annual physical reviews) and (2) non-Quality and Outcomes Framework indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by general practitioners).

Main outcome measures

Several outcomes were examined: emergency admissions for serious mental illness and ambulatory care sensitive conditions; all unplanned admissions; accident and emergency attendances; mortality; re-entry into specialist mental health services; and costs attributed to primary, secondary and community mental health care.

Results

Care plans were associated with lower risk of accident and emergency attendance (hazard ratio 0.74, 95% confidence interval 0.69 to 0.80), serious mental illness admission (hazard ratio 0.67, 95% confidence interval 0.59 to 0.75), ambulatory care sensitive condition admission (hazard ratio 0.73, 95% confidence interval 0.64 to 0.83), and lower overall health-care (£53), primary care (£9), hospital (£26) and mental health-care costs (£12). Annual reviews were associated with reduced risk of accident and emergency attendance (hazard ratio 0.80, 95% confidence interval 0.76 to 0.85), serious mental illness admission (hazard ratio 0.75, 95% confidence interval 0.67 to 0.84), ambulatory care sensitive condition admission (hazard ratio 0.76, 95% confidence interval 0.67 to 0.87), and lower overall health-care (£34), primary care (£9) and mental health-care costs (£30). Higher general practitioner continuity was associated with lower risk of accident and emergency presentation (hazard ratio 0.89, 95% confidence interval 0.83 to 0.97) and ambulatory care sensitive condition admission (hazard ratio 0.77, 95% confidence interval 0.65 to 0.92), but not with serious mental illness admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or accident and emergency presentation. None of the quality measures was statistically significantly associated with risk of re-entry into specialist mental health care.

Limitations

There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences.

Conclusions

Better performance on Quality and Outcomes Framework measures and continuity of care are associated with better outcomes and lower resource utilisation, and could generate moderate cost savings.

Future work

Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 25. See the NIHR Journals Library website for further project information.

Adaptation of potentially preventable medication-related hospitalisation indicators for Indigenous populations in Australia using a modified Delphi technique

OBJECTIVES

One of the outcomes of a medication review service is to identify and manage medication-related problems (MRPs). The most serious MRPs may result in hospitalisation, which could be preventable if appropriate processes of care were adopted. The aim of this study was to update and adapt a previously published set of clinical indicators for use in assessing the effectiveness of a medication review service tailored to meet the needs of Indigenous people, who experience some of the worst health outcomes of all Australians.

DESIGN

A modified Delphi technique was used to: (i) identify additional indicators for consideration, (ii) assess whether the original indicators were relevant in the context of Indigenous health and (iii) reach consensus on a final set of indicators. Three rounds of rating were used via an anonymous online survey, with 70% agreement required for indicator inclusion.

SETTING

The indicators were designed for use in Indigenous primary care in Australia.

PARTICIPANTS

Thirteen panellists participated including medical specialists, general practice doctors, pharmacists and epidemiologists experienced in working with Indigenous patients.

RESULTS

Panellists rated 101 indicators (45 from the original set and 57 newly identified). Of these, 41 were accepted unchanged, seven were rejected and the remainder were either modified before acceptance or merged with other indicators. A final set of 81 indicators was agreed. Conclusions This study provides a set of clinical indicators to be used as a primary outcome measure for medication review services for Indigenous people in Australia and as a prompt for pharmacists and doctors conducting medication reviews.

TRIAL REGISTRATION NUMBER

The trial registration for the Indigenous Medication Review Service feasibility study is ACTRN12618000188235.

Primary health care quality indicators: An umbrella review

Nowadays, evaluating the quality of health services, especially in primary health care (PHC), is increasingly important. In a historical perspective, the Department of Health (United Kingdom) developed and proposed a range of indicators in 1998, and lately several health, social and political organizations have defined and implemented different sets of PHC quality indicators. Some systematic reviews in PHC quality indicators are reported but only in specific contexts and conditions. The aim of this study is to characterize and provide a list of indicators discussed in the literature to support managers and clinicians in decision-making processes, through an umbrella review on PHC quality indicators. The methodology was performed according to PRISMA Statement. Indicators from 33 eligible systematic reviews were categorized according to the dimensions of care, function, type of care, domains and condition contexts. Of a total of 727 indicators or groups of indicators, 74.5% (n = 542) were classified in process category and 89.5% (n = 537) with chronic type of care (n = 428; 58.8%) and effective domain (n = 423; 58.1%) with the most frequent values in categorizations by dimensions. The results of this overview of reviews are valuable and imply the need for future research and practice regarding primary health care quality indicators in the most varied conditions and contexts to generate new discussions about their use, comparison and implementation.

Identifying potential prescribing safety indicators related to mental health disorders and medications: A systematic review

BACKGROUND

Prescribing errors and medication related harm may be common in patients with mental illness. However, there has been limited research focusing on the development and application of prescribing safety indicators (PSIs) for this population.

OBJECTIVE

Identify potential PSIs related to mental health (MH) medications and conditions.

METHODS

Seven electronic databases were searched (from 1990 to February 2019), including the bibliographies of included studies and of relevant review articles. Studies that developed, validated or updated a set of explicit medication-specific indicators or criteria that measured prescribing safety or quality were included, irrespective of whether they contained MH indicators or not. Studies were screened to extract all MH related indicators before two MH clinical pharmacists screened them to select potential PSIs based on established criteria. All indicators were categorised into prescribing problems and medication categories.

RESULTS

79 unique studies were included, 70 of which contained at least one MH related indicator. No studies were identified that focused on development of PSIs for patients with mental illness. A total of 1386 MH indicators were identified (average 20 (SD = 25.1) per study); 245 of these were considered potential PSIs. Among PSIs the most common prescribing problem was 'Potentially inappropriate prescribing considering diagnoses or conditions' (n = 91, 37.1%) and the lowest was 'omission' (n = 5, 2.0%). 'Antidepressant' was the most common PSI medication category (n = 85, 34.7%).

CONCLUSION

This is the first systematic review to identify a comprehensive list of MH related potential PSIs. This list should undergo further validation and could be used as a foundation for the development of new suites of PSIs applicable to patients with mental illness.

Protocol for a feasibility study of an Indigenous Medication Review Service (IMeRSe) in Australia

INTRODUCTION

The age-adjusted rate of potentially preventable hospitalisations for Aboriginal and Torres Strait Islander people is almost five times the rate of other Australians. Quality use of medicines has an important role in alleviating these differences. This requires strengthening existing medication reviewing services through collaboration between community pharmacists and health workers, and ensuring services are culturally appropriate. This Indigenous Medication Review Service (IMeRSe) study aims to develop and evaluate the feasibility of a culturally appropriate medication management service delivered by community pharmacists in collaboration with Aboriginal health workers.

METHODS AND ANALYSIS

This study will be conducted in nine Aboriginal health services (AHSs) and their associated community pharmacies in three Australian states over 12 months. Community pharmacists will be trained to improve their awareness and understanding of Indigenous health and cultural issues, to communicate the quality use of medicines effectively, and to strengthen interprofessional relationships with AHSs and their staff. Sixty consumers (with a chronic condition/pregnant/within 2 years post partum and at risk of medication-related problems (MRPs) per site will be recruited, with data collection at baseline and 6 months. The primary outcome is the difference in cumulative incidence of serious MRPs in the 6 months after IMeRSe introduction compared with the 6 months prior. Secondary outcomes include potentially preventable medication-related hospitalisations, medication adherence, total MRPs, psychological and social empowerment, beliefs about medication, treatment satisfaction and health expenditure.

ETHICS AND DISSEMINATION

The protocol received approval from Griffith University (HREC/2018/251), Queensland Health Metro South (HREC/18/QPAH/109), Aboriginal Health and Medical Research Council of New South Wales (1381/18), Far North Queensland (HREC/18/QCH/86-1256) and the Central Australian HREC (CA-18-3090). Dissemination to Indigenous people and communities will be a priority. Results will be available on the Australian Sixth Community Pharmacy Agreement website and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12618000188235; Pre-results.

Quality indicators for responsible use of medicines: a systematic review

OBJECTIVE

All healthcare systems require valid ways to evaluate service delivery. The objective of this study was to identify existing content validated quality indicators (QIs) for responsible use of medicines (RUM) and classify them using multiple frameworks to identify gaps in current quality measurements.

DESIGN

Systematic review without meta-analysis.

SETTING

All care settings.

SEARCH STRATEGY

CINAHL, Embase, Global Health, International Pharmaceutical Abstract, MEDLINE, PubMed and Web of Science databases were searched up to April 2018. An internet search was also conducted. Articles were included if they described medication-related QIs developed using consensus methods. Government agency websites listing QIs for RUM were also included.

ANALYSIS

Several multidimensional frameworks were selected to assess the scope of QI coverage. These included Donabedian's framework (structure, process and outcome), the Anatomical Therapeutic Chemical (ATC) classification system and a validated classification for causes of drug-related problems (c-DRPs; drug selection, drug form, dose selection, treatment duration, drug use process, logistics, monitoring, adverse drug reactions and others).

RESULTS

2431 content validated QIs were identified from 131 articles and 5 websites. Using Donabedian's framework, the majority of QIs were process indicators. Based on the ATC code, the largest number of QIs pertained to medicines for nervous system (ATC code: N), followed by anti-infectives for systemic use (J) and cardiovascular system (C). The most common c-DRPs pertained to 'drug selection', followed by 'monitoring' and 'drug use process'.

CONCLUSIONS

This study was the first systematic review classifying QIs for RUM using multiple frameworks. The list of the identified QIs can be used as a database for evaluating the achievement of RUM. Although many QIs were identified, this approach allowed for the identification of gaps in quality measurement of RUM. In order to more effectively evaluate the extent to which RUM has been achieved, further development of QIs may be required.

Developing a measure of polypharmacy appropriateness in primary care: systematic review and expert consensus study

BACKGROUND

Polypharmacy is an increasing challenge for primary care. Although sometimes clinically justified, polypharmacy can be inappropriate, leading to undesirable outcomes. Optimising care for polypharmacy necessitates effective targeting and monitoring of interventions. This requires a valid, reliable measure of polypharmacy, relevant for all patients, that considers clinical appropriateness and generic prescribing issues applicable across all medications. Whilst there are several existing measures of potentially inappropriate prescribing, these are not specifically designed with polypharmacy in mind, can require extensive clinical input to complete, and often cover a limited number of drugs. The aim of this study was to identify what experts consider to be the key elements of a measure of prescribing appropriateness in the context of polypharmacy.

METHODS

Firstly, we conducted a systematic review to identify generic (not drug specific) prescribing indicators relevant to polypharmacy appropriateness. Indicators were subject to content analysis to enable categorisation. Secondly, we convened a panel of 10 clinical experts to review the identified indicators and assess their relative clinical importance. For each indicator category, a brief evidence summary was developed, based on relevant clinical and indicator literature, clinical guidance, and opinions obtained from a separate patient discussion panel. A two-stage RAND/UCLA Appropriateness Method was used to reach consensus amongst the panel on a core set of indicators of polypharmacy appropriateness.

RESULTS

We identified 20,879 papers for title/abstract screening, obtaining 273 full papers. We extracted 189 generic indicators, and presented 160 to the panel grouped into 18 classifications (e.g. adherence, dosage, clinical efficacy). After two stages, during which the panel introduced 18 additional indicators, there was consensus that 134 indicators were of clinical importance. Following the application of decision rules and further panel consultation, 12 indicators were placed into the final selection. Panel members particularly valued indicators concerned with adverse drug reactions, contraindications, drug-drug interactions, and the conduct of medication reviews.

CONCLUSIONS

We have identified a set of 12 indicators of clinical importance considered relevant to polypharmacy appropriateness. Use of these indicators in clinical practice and informatics systems is dependent on their operationalisation and their utility (e.g. risk stratification, targeting and monitoring polypharmacy interventions) requires subsequent evaluation.

TRIAL REGISTRATION

Registration number: PROSPERO ( CRD42016049176 ).

Identifying primary care quality indicators for people with serious mental illness: a systematic review

Background

Serious mental illness (SMI) — which comprises long-term conditions such as schizophrenia, bipolar disorder, and other psychoses — has enormous costs for patients and society. In many countries, people with SMI are treated solely in primary care, and have particular needs for physical care.

Aim

The objective of this study was to systematically review the literature to create a list of quality indicators relevant to patients with SMI that could be captured using routine data, and which could be used to monitor or incentivise better-quality primary care.

Design and setting

A systematic literature review, combined with a search of quality indicator databases and guidelines.

Method

The authors assessed whether indicators could be measured from routine data and the quality of the evidence.

Results

Out of 1847 papers and quality indicator databases identified, 27 were included, from which 59 quality indicators were identified, covering six domains. Of the 59 indicators, 52 could be assessed using routine data. The evidence base underpinning these indicators was relatively weak, and was primarily based on expert opinion rather than trial evidence.

Conclusion

With appropriate adaptation for different contexts, and in line with the relative responsibilities of primary and secondary care, use of the quality indicators has the potential to improve care and to improve the physical and mental health of people with SMI. However, before the indicators can be used to monitor or incentivise primary care quality, more robust links need to be established, with improved patient outcomes.

Quality indicators for pharmaceutical care: a comprehensive set with national scores for Dutch community pharmacies

Background The quality of pharmaceutical care in community pharmacies in the Netherlands has been assessed annually since 2008. The initial set has been further developed with pharmacists and patient organizations, the healthcare inspectorate, the government and health insurance companies. The set over 2012 was the first set of quality indicators for community pharmacies which was validated and supported by all major stakeholders. The aims of this study were to describe the validated set of quality indicators for community pharmacies and to report their scores over 2012. In subanalyses the score development over 5 years was described for those indicators, that have been surveyed before and remained unchanged. Methods Community pharmacists in the Netherlands were invited in 2013 to provide information for the set of 2012. Quality indicators were mapped by categories relevant for pharmaceutical care and defined for structures, processes and dispensing outcomes. Scores for categorically-measured quality indicators were presented as the percentage of pharmacies reporting the presence of a quality aspect. For numerical quality indicators, the mean of all reported scores was expressed. In subanalyses for those indicators that had been questioned previously, scores were collected from earlier measurements for pharmacies providing their scores in 2012. Multilevel analysis was used to assess the consistency of scores within one pharmacy over time by the intra-class correlation coefficient (ICC). Results For the set in 2012, 1739 Dutch community pharmacies (88 % of the total) provided information for 66 quality indicators in 10 categories. Indicator scores on the presence of quality structures showed relatively high quality levels. Scores for processes and dispensing outcomes were lower. Subanalyses showed that overall indicators scores improved within pharmacies, but this development differed between pharmacies. Conclusions A set of validated quality indicators provided insight into the quality of pharmaceutical care in the Netherlands. The quality of pharmaceutical care improved over time. As of 2012 quality structures were present in at least 80 % of the community pharmacies. Variation in scores on care processes and outcomes between individual pharmacies and over time can initiate future research to better understand and facilitate quality improvement in community pharmacies.

Suboptimal medication-related quality of care preceding hospitalisation of older patients

OBJECTIVE

To examine the prevalence of suboptimal medication-related processes of care before the hospitalisation of older patients.

DESIGN AND SETTING

We conducted a retrospective cohort study using a clinical indicator set related to medication management that has been validated by an expert panel as consisting of suboptimal aspects of medication use that clinicians should be able to foresee and avoid. Australian Government Department of Veterans' Affairs administrative claims data between 1 July 2007 and 30 June 2012 were analysed according to these clinical indicators to assess medication-related processes of care preceding hospitalisation.

PARTICIPANTS

Veterans with one or more hospitalisations in Australia for a condition defined by the clinical indicator set.

MAIN OUTCOME MEASURE

Prevalence of suboptimal medication-related processes of care before hospitalisation as a proportion of all hospitalisations defined by diagnoses in the clinical indicator set.

RESULTS

During the 5-year study period, there were 164,813 hospitalisations with primary diagnoses for conditions included in the clinical indicator set, encompassing 83,430 patients. The overall proportion of hospitalisations that were preceded by suboptimal medication-related processes of care was 25.2% (41,546 hospitalisations); 34.5% of patients (28,807 patients) had at least one hospitalisation and 10.4% (8640 patients) had two or more hospitalisations preceded by suboptimal medication-related processes of care. At least one in 10 hospitalisations for chronic heart failure, ischaemic stroke, asthma, gastrointestinal ulcer or bleeding, fracture, renal failure or nephropathy, hyperglycaemia or hypoglycaemia were preceded by suboptimal medication-related processes of care.

CONCLUSIONS

This study highlights conditions for which there are evidence-practice gaps in medication management in the older population. Routine prospective monitoring of these evidence-based, validated, medication-related clinical indicators provides a means for quality improvement in the management of common chronic conditions.

Sociodemographic and health characteristics, rather than primary care supply, are major drivers of geographic variation in preventable hospitalizations in Australia

Supplemental Digital Content is available in the text.

Background:

Geographic rates of preventable hospitalization are used internationally as an indicator of accessibility and quality of primary care. Much research has correlated the indicator with the supply of primary care services, yet multiple other factors may influence these admissions.

Objective:

To quantify the relative contributions of the supply of general practitioners (GPs) and personal sociodemographic and health characteristics, to geographic variation in preventable hospitalization.

Methods:

Self-reported questionnaire data for 267,091 participants in the 45 and Up Study, Australia, were linked with administrative hospital data to identify preventable hospitalizations. Multilevel Poisson models, with participants clustered in their geographic area of residence, were used to explore factors that explain geographic variation in hospitalization.

Results:

GP supply, measured as full-time workload equivalents, was not a significant predictor of preventable hospitalization, and explained only a small amount (2.9%) of the geographic variation in hospitalization rates. Conversely, more than one-third (36.9%) of variation was driven by the sociodemographic composition, health, and behaviors of the population. These personal characteristics explained a greater amount of the variation for chronic conditions (37.5%) than acute (15.5%) or vaccine-preventable conditions (2.4%).

Conclusions:

Personal sociodemographic and health characteristics, rather than GP supply, are major drivers of preventable hospitalization. Their contribution varies according to condition, and if used for performance comparison purposes, geographic rates of preventable hospitalization should be reported according to individual condition or potential pathways for intervention.