Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: an overview of reviews

BACKGROUND

This review aimed to assess the existing evidence regarding the clinical effectiveness and safety of pharmacological and non-pharmacological interventions in adults with insomnia and identify where research or policy development is needed.

METHODS

MEDLINE, Embase, PsycINFO, The Cochrane Library, and PubMed were searched from inception until June 14, 2017, along with relevant gray literature sites. Two reviewers independently screened titles/abstracts and full-text articles, and a single reviewer with an independent verifier completed charting, data abstraction, and quality appraisal.

RESULTS

A total of 64 systematic reviews (35 with meta-analysis) were included after screening 5024 titles and abstracts and 525 full-text articles. Eight of the included reviews were rated as high quality using the Assessment of Multiple Systematic Reviews 2 (AMSTAR2) tool, and over half of the included articles (n = 40) were rated as low or critically low quality. Consistent evidence of effectiveness across multiple outcomes based on more than one high- or moderate quality review with meta-analysis was found for zolpidem, suvorexant, doxepin, melatonin, and cognitive behavioral therapy (CBT), and evidence of effectiveness across multiple outcomes based on one high-quality review with meta-analysis was found for temazepam, triazolam, zopiclone, trazodone, and behavioral interventions. These interventions were mostly evaluated in the short term (< 16 weeks), and there was very little harms data available for the pharmacological interventions making it difficult to evaluate their risk-benefit ratio.

CONCLUSIONS

Assuming non-pharmacological interventions are preferable from a safety perspective CBT can be considered an effective first-line therapy for adults with insomnia followed by other behavioral interventions. Short courses of pharmacological interventions can be supplements to CBT or behavioral therapy; however, no evidence regarding the appropriate duration of pharmacological therapy is available from these reviews.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017072527.

The use of smartphones on General Internal Medicine wards: a mixed methods study

OBJECTIVE

To describe the uses of institutional and personal smartphones on General Internal Medicine wards and highlight potential consequences from their use.

METHODS

A mixed methods study consisting of both quantitative and qualitative research methods was conducted in General Internal Medicine wards across four academic teaching hospitals in Toronto, Ontario. Participants included medical students, residents, attending physicians and allied health professionals. Data collection consisted of work shadowing observations, semi-structured interviews and surveys.

RESULTS

Personal smartphones were used for both clinical communication and non-work-related activities. Clinicians used their personal devices to communicate with their medical teams and with other medical specialties and healthcare professionals. Participants understood the risks associated with communicating confidential health information via their personal smartphones, but appear to favor efficiency over privacy issues. From survey responses, 9 of 23 residents (39%) reported using their personal cell phones to email or text patient information that may have contained patient identifiers. Although some residents were observed using their personal smartphones for non-work-related activities, personal use was infrequent and most residents did not engage in this activity.

CONCLUSION

Clinicians are using personal smartphones for work-related purposes on the wards. With the increasing popularity of smartphone devices, it is anticipated that an increasing number of clinicians will use their personal smartphones for clinical work. This trend poses risks to the secure transfer of confidential personal health information and may lead to increased distractions for clinicians.

Perceptions of urgency: defining the gap between what physicians and nurses perceive to be an urgent issue

INTRODUCTION

Through our research into the design and evaluation of technology systems to improve the quality and safety of clinical communication, we have discovered that physicians and nurses differ in perspective regarding clinical prioritization and desirable response times. This has a number of important consequences including unnecessary interruptions, escalating conflict and deterioration in interprofessional relationships. Understanding the differing perspectives on clinical prioritization, or the gap in perceived urgency, may improve interprofessional relationships.

METHODS

We conducted a mixed-methods study utilizing both qualitative (semi-structured interviews) and quantitative (surveys) methods to determine the gap between perceived urgency among physicians and nurses. The survey comprised of real messages extracted from the clinical communication system that was implemented. Physicians and nurses reviewed the messages and assigned an urgency level to each. The semi-structured interviews used open-ended questions to act as a guide to highlight key themes of interest. Thematic analysis, frequency tabulation, and triangulation were used to analyze the data.

RESULTS

Although the surveys demonstrated concordance between physicians and nurses when independently ranking the urgency of clinical messages (kappa=0.66 SE 0.15), agreement was only fair in comparison to the urgency identified by the original nurse who sent the message (kappa=0.22 SE 0.18). We hypothesize that clinical context has a major role in defining urgency and may explain this finding. The survey data was triangulated with the semi-structured interview data and it was determined that the desired response time significantly impacted the sender's message prioritization. For example, shift changes and anxious family members were associated with discordant prioritizations.

DISCUSSION

This study demonstrated that the perceived communication urgency gap between sending nurses and receiving physicians was primarily related to timeframe and context, not clinical condition. Most disagreement occurred when nurses used urgent messaging for time sensitive but not clinically urgent issues in an effort to expedite the resolution of their issue by the physicians. These results indicate the need for clinical communication systems to incorporate decision support around both clinical prioritization and expected response time in their design. Effective interprofessional communication is essential to the provision of safe, quality-based healthcare; these results highlight some of the sociotechnical aspects of health information technology implementation that must be considered.

Understanding interprofessional communication: a content analysis of email communications between doctors and nurses

BACKGROUND

Clinical communication is recognized as a major source of errors in hospitals. The lack of documentation of communication, especially among verbal interactions, often creates hindrances and impedes improvement efforts. By providing smartphones to residents and encouraging nurses to communicate with residents by email shifted much of the communication to emails which permitted analysis of content.

OBJECTIVE

Description on the interprofessional email communication between doctors and nurses occurring on the general internal medicine wards at two academic hospitals.

DESIGN

A prospective analysis of email communications between doctors and nurses.

SETTING

34 out of the 67 residents who were on the general medicine clinical teaching units consented to allow analysis of their emails over a 6 month period.

MAIN MEASURES

Statistical tabulations were performed on the volume and frequency of communications as well the response time of messages. Two physicians coded the content of randomly selected emails for urgency, emotion, language, type of interaction, and subject content.

KEY RESULTS

A total of 13,717 emails were available for analysis. Among the emails from nurses, 39.1% were requests for a call back, 18.9% were requests for a response by email and the remaining 42.0% indicated no response was required from physicians. For the messages requesting a response by email, only 50% received an email response. Email responses had a median response time of 2.3 minutes. Content analysis revealed that messages were predominantly non-urgent. The two most frequent purposes for communications were to convey information (91%) and to request action by the physician (36%).

CONCLUSIONS

A smartphone-based email system facilitated the description and content analysis of a large amount of email communication between physicians and nurses. Our findings provide a picture of the communication between physicians, nurses and other healthcare professionals. This work may help inform the further development of information and communications technology that can improve clinical communication.

Using real-time alerts for clinical trials: Identifying potential study subjects

BACKGROUND

Clinical trials are widely accepted as a necessary step in evaluating the safety and efficacy of new pharmaceutical products. In order for a sufficiently powered study, a clinical trial depends on the effective and unbiased recruitment of eligible patients. Trials involving seasonal diseases like influenza pose additional challenges.

OBJECTIVE

This is a feasibility study of a mobile real-time alerting system to systematically identify potential study subjects for a randomized controlled trial evaluating the safety and efficacy of early intervention with interferon alfacon-1 for patients hospitalized for influenza virus infection.

METHODS

The alerting system was setup in a 471-bed acute care teaching hospital, enabled with computerized physician order entry (CPOE) and a rules-based alerting system. Patients were identified from the entire hospital using two alerts types: pharmacy prescription records for antiviral drugs, and positive influenza laboratory results. Email alerts were generated and sent to BlackBerry(®) devices carried by the study personnel for a 6 month period. The alerts were archived automatically on a secure server and were exported for analysis in Microsoft Access.

RESULTS

Over a period of 21 weeks, 779 total alerts were received. The study team was alerted to 241 patients, of whom 85 were potential study subjects. The alert system identified all but one of the patients independently identified by infection control.

CONCLUSIONS

Real-time identification of potential study subjects is possible with the integration of computerized physician order entry and BlackBerry(®) technology. It is a viable method for the systematic identification of patients throughout a hospital, particularly for trials investigating time-sensitive disease progression.