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CMAJ : Canadian Medical Association... Feb 2022Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of...
BACKGROUND
Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada.
METHODS
We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level.
RESULTS
We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%-56.6%). Underuse (median 43.9%, IQR 23.8%-66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%-30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%-85.7%, = 9) and thyroid-stimulating hormone (overused, range 3.0%-35.1%, = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%-71.0%, = 6) and potentially inappropriate medications (overused, range 13.5%-97.3%, = 9).
INTERPRETATION
We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.
Topics: Canada; Humans; Inappropriate Prescribing; Medical Overuse; Overtreatment; Patient Satisfaction; Quality of Health Care
PubMed: 35228321
DOI: 10.1503/cmaj.211416 -
Biomedicines Feb 2022Optimal delivery of medication via dry powder inhalers, the most commonly prescribed inhaler type, is dependent on a patient achieving a minimum level of inspiratory... (Review)
Review
Optimal delivery of medication via dry powder inhalers, the most commonly prescribed inhaler type, is dependent on a patient achieving a minimum level of inspiratory flow during inhalation. However, measurement of peak inspiratory flow (PIF) against the simulated resistance of a dry powder inhaler is not frequently performed in clinical practice due to time or equipment limitations. Therefore, defining which patient characteristics are associated with lower PIF is critically important to help clinicians optimize their inhaler choice through a more personalized approach to prescribing. The objective of this scoping review was to systematically evaluate patient and disease characteristics determining PIF in patients with chronic obstructive pulmonary disease (COPD). Medline, Cochrane and Embase databases were systematically searched for relevant studies on PIF in patients with COPD published in English between January 2000 and May 2021. The quality of evidence was assessed using a modified Grading of Recommendations Assessment, Development and Evaluation checklist. Of 3382 citations retrieved, 35 publications were included in the review (nine scored as high quality, 13 as moderate, nine as low, and four as very low). Factors correlating with PIF in >70% of papers included both patient characteristics (lower PIF correlated with increased age, female gender, shorter height, decreased handgrip and inspiratory muscle strength, and certain comorbidities) and disease characteristics (lower PIF correlated with markers of lung hyperinflation, lower peak expiratory flow [PEF] and increased disease severity). Other factors correlating with adequate/optimal or improved PIF included education/counseling and exercise/inspiratory muscle training; impaired physical function and errors in inhalation technique/non-adherence were associated with low/suboptimal PIF. In conclusion, clinicians should measure PIF against the simulated resistance of a particular device wherever possible. However, as this often cannot be done due to lack of resources or time, the patient and disease characteristics that influence PIF, as identified in this review, can help clinicians to choose the most appropriate inhaler type for their patients.
PubMed: 35203667
DOI: 10.3390/biomedicines10020458 -
BJGP Open Sep 2022Tablet splitting can provide dose flexibility and cost savings; however, pharmaceutical representatives typically discourage the practice.
BACKGROUND
Tablet splitting can provide dose flexibility and cost savings; however, pharmaceutical representatives typically discourage the practice.
AIM
To identify and summarise all published concerns related to tablet splitting and to present the experimental evidence that investigates those concerns.
DESIGN & SETTING
Systematic review and qualitative synthesis of tablet-splitting concerns and evidence.
METHOD
Medline and EMBASE databases were searched over all years of publication for articles in English discussing the splitting of tablets. Eligible articles included original research, narrative reviews, systematic reviews, and expert opinion.
RESULTS
After removing duplicates, 1837 potentially relevant articles underwent dual review, whereupon 1612 articles were excluded based on title and abstract. After examination of 225 full texts, 138 articles were included (one systematic review, four narrative reviews, 101 original research articles, and 32 opinion articles). The described concerns included difficulty breaking tablets, loss of mass, weight variability, chemical instability, overly rapid dosing if sustained-release medications are split, non-compliance, and patient confusion resulting in medication errors. No substantive evidence was found to support concerns regarding loss of mass, weight variability, chemical instability, or non-compliance. Evidence does support some older adults struggling to split tablets without tablet splitters, and the inappropriateness of splitting sustained-release preparations, given the potential for alteration of the rate of drug release for some products.
CONCLUSION
With the exception of sustained-release tablets, which should not be split, and excepting those older people who may struggle to split tablets based on physical limitations, there is little evidence to support tablet-splitting concerns.
PubMed: 35193886
DOI: 10.3399/BJGPO.2022.0001 -
Journal of Clinical Medicine Jan 2022Pharmacotherapy in older adults is one of the most challenging aspects of patient care. Older people are prone to drug-related problems such as adverse effects,... (Review)
Review
BACKGROUND
Pharmacotherapy in older adults is one of the most challenging aspects of patient care. Older people are prone to drug-related problems such as adverse effects, ineffectiveness, underdosage, overdosage, and drug interactions. Anticholinergic medications are associated with poor outcomes in older patients, and there is no specific intervention strategy for reducing drug burden from anticholinergic activity medications. Little is known about the effectiveness of current interventions that may likely improve the anticholinergic prescribing practice in older adults.
AIMS
This review seeks to document all types of interventions aiming to reduce anticholinergic prescribing among older adults and assess the current evidence and quality of existing single and combined interventions.
METHODS
We systematically searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO from January 1990 to August 2021. Only studies that examined the effect of interventions in older people focused on improving compliance with anticholinergic prescribing guidelines with quantifiable data were included. The primary outcome of interest was to find the effectiveness of interventions that enhance the anticholinergic prescribing practice in older adults.
RESULTS
We screened 3168 records and ended up in 23 studies that met the inclusion criteria. We found only single-component interventions to reduce anticholinergic prescribing errors in older people. Pharmacists implemented interventions without collaboration in nearly half of the studies ( = 11). Medication review (43%) and education provision (26%) to healthcare practitioners were the most common interventions. Sixteen studies (70%) reported significant reductions in anticholinergic prescribing errors, whereas seven studies (30%) showed no significant effect.
CONCLUSION
This systematic review suggests that healthcare practitioner-oriented interventions have the potential to reduce the occurrence of anticholinergic prescribing errors in older people. Interventions were primarily effective in reducing the burden of anticholinergic medications and assisting with deprescribing anticholinergic medications in older adults.
PubMed: 35160166
DOI: 10.3390/jcm11030714 -
Brain Imaging and Behavior Oct 2022Medication overuse headache (MOH) is a prevalent secondary headache, bringing heavy economic burden and neuropsychological damage. Neuroimaging studies on the disease... (Meta-Analysis)
Meta-Analysis Review
Medication overuse headache (MOH) is a prevalent secondary headache, bringing heavy economic burden and neuropsychological damage. Neuroimaging studies on the disease reported divergent results. To merge the reported neuroimaging alterations in MOH patients and explore a pathophysiological mechanism of this disorder. A meta-analytic activation likelihood estimation (ALE) analysis method was used. We systematically searched English and Chinese databases for both morphological and functional neuroimaging studies published before Nov 18, 2021. Reported altered brain regions and the stereotactic coordinates of their peaks were extracted and pooled by GingerALE using Gaussian probability distribution into brain maps, illustrating converged regions of alteration among studies. We identified 927 articles, of which five studies on gray matter changes, using voxel-based morphometry (VBM) were eventually included for ALE analysis, with 344 subjects and 54 coordinates put into GingerALE. No functional magnetic resonance imaging (fMRI) or positron emission topography (PET) studies were included for pooling. Compared with healthy controls (HCs), MOH featured increased gray matter density in midbrain, striatum, cingulate, inferior parietal cortex and cerebellum (P < 0.001 uncorrected), whereas decreased gray matter density in orbitofrontal cortex (P < 0.05, family-wise error), frontal, insular and parietal cortices (P < 0.001 uncorrected). Withdrawal of analgesics led to decreased gray matter density in superior temporal gyrus, cuneus, midbrain and cerebellum (P < 0.001 uncorrected). This meta-analysis confirmed that medication overuse headache is associated with morphologic alteration in the reward system, the prefrontal cortex and a reversible modification in the pain network. Further functional imaging paradigms and longitudinal studies are required for a more definite conclusion and a causal mechanism.
Topics: Humans; Gray Matter; Likelihood Functions; Magnetic Resonance Imaging; Headache Disorders, Secondary; Brain; Headache
PubMed: 35143020
DOI: 10.1007/s11682-022-00634-9 -
BMC Geriatrics Feb 2022Z-drugs are usually prescribed as first line pharmacological therapy for insomnia. However, the benefits and risks of Z-drugs may differ for older adults. This... (Review)
Review
Efficacy and safety of Z-substances in the management of insomnia in older adults: a systematic review for the development of recommendations to reduce potentially inappropriate prescribing.
BACKGROUND
Z-drugs are usually prescribed as first line pharmacological therapy for insomnia. However, the benefits and risks of Z-drugs may differ for older adults. This systematic review investigated the available evidence on the efficacy and safety of Z-drugs in the management of insomnia in older adults.
METHODS
The Cochrane database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE and EMBASE were searched for systematic reviews, meta-analyses, controlled interventional and observational studies using a pre-formulated search term. The target population was older adults (≥65 years old) with insomnia. Studies were included if they reported efficacy and/or safety outcomes of the use of Z-drugs for the management of insomnia compared to placebo, usual or no treatment, or other pharmacological agents.
RESULTS
Eighteen studies were included (8 interventional and 10 observational studies). In short-term interventional studies, Z-drugs were similarly or better efficacious in improving both sleep and daytime parameters than placebo or other pharmacological treatments, while showing good results on measures of safety. However, in longer-term observational studies, Z-drugs significantly increased the risk for falls and fractures in comparison to no treatment or melatonin agonists.
CONCLUSIONS
Analyzing the evidence from short-term interventional studies, Z-drugs appear effective and safe for treatment of insomnia in older adults, but they may have unfavorable side effects when used for longer periods of time. We, therefore, recommend discontinuing Z-drugs, principally because of the high risk for falls and fractures. Nonetheless, quality and quantity of evidence are low. Due to the scarcity of data, especially concerning drug dependence after longer periods of treatment and due to the significantly increased risk for falls and fractures, further studies are needed to evaluate the benefit-risk profile of Z-drugs use in older patients, particularly for long-term use.
Topics: Aged; Humans; Hypnotics and Sedatives; Inappropriate Prescribing; Sleep; Sleep Initiation and Maintenance Disorders
PubMed: 35100976
DOI: 10.1186/s12877-022-02757-6 -
BMJ Quality & Safety Aug 2022Patients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. Structured handover... (Meta-Analysis)
Meta-Analysis
Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis.
BACKGROUND
Patients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. Structured handover recommendations often underestimate the challenges and complexity of ICU patient transitions. For adult ICU patients transitioning to a hospital ward, it is currently unclear what interventions reduce the risks of medication errors.The aims were to examine the impact of medication-related interventions on medication and patient outcomes on transition from adult ICU settings and identify barriers and facilitators to implementation.
METHODS
The systematic review protocol was preregistered on PROSPERO. Six electronic databases were searched until October 2020 for controlled and uncontrolled study designs that reported medication-related (ie, de-prescribing; medication errors) or patient-related outcomes (ie, mortality; length of stay). Risk of bias (RoB) assessment used V.2.0 and ROBINS-I Cochrane tools. Where feasible, random-effects meta-analysis was used for pooling the OR across studies. The quality of evidence was assessed by Grading of Recommendations, Assessment, Development and Evaluations.
RESULTS
Seventeen studies were eligible, 15 (88%) were uncontrolled before-after studies. The intervention components included education of staff (n=8 studies), medication review (n=7), guidelines (n=6), electronic transfer/handover tool or letter (n=4) and medicines reconciliation (n=4). Overall, pooled analysis of all interventions reduced risk of inappropriate medication continuation at ICU discharge (OR=0.45 (95% CI 0.31 to 0.63), I=55%, n=9) and hospital discharge (OR=0.39 (95% CI 0.2 to 0.76), I=75%, n=9). Multicomponent interventions, based on education of staff and guidelines, demonstrated no significant difference in inappropriate medication continuation at the ICU discharge point (OR 0.5 (95% CI 0.22 to 1.11), I=62%, n=4), but were very effective in increasing de-prescribing outcomes on hospital discharge (OR 0.26 (95% CI 0.13 to 0.55), I=67%, n=6)). Facilitators to intervention delivery included ICU clinical pharmacist availability and participation in multiprofessional ward rounds, while barriers included increased workload associated with the discharge intervention process.
CONCLUSIONS
Multicomponent interventions based on education of staff and guidelines were effective at achieving almost four times more de-prescribing of inappropriate medication by the time of patient hospital discharge. Based on the findings, practice and policy recommendations are made and guidance is provided on the need for, and design of theory informed interventions in this area, including the requirement for process and economic evaluations.
Topics: Adult; Critical Care; Humans; Intensive Care Units; Medication Errors; Patient Discharge; Pharmacists
PubMed: 35042765
DOI: 10.1136/bmjqs-2021-013760 -
F1000Research 2021Electronic medical records (EMRs) refer to the digital copies of paper notes prepared in the physician's office, outpatient clinics and other departments in health care...
Electronic medical records (EMRs) refer to the digital copies of paper notes prepared in the physician's office, outpatient clinics and other departments in health care institutes. EMRs are considered to be significant and preferable to paper records because they allow providers to keep accurate track of patient data and monitoring over time, thus reducing errors, and enhance overall health care quality. The aim of this systematic review was to highlight the significance of EMRs and the effectiveness of implementation regarding reducing documentation errors and waiting time for patients in outpatient clinics. PubMed, Central, Ovid, Scopus, Science Direct, Elsevier, Cochrane , WHO website and the McMaster University Health Evidence website from 2005-2020 were searched to identify studies that investigated the association between the EMR implementation and documentation error and waiting time for patients. A reviewer screened identified citations and extracted data according to the PRISMA guidelines and data was synthesized in a narrative manner. After full text examination of the articles selected for this literature review, the major themes of relevance that were identified in the context of reducing documentation errors and waiting time for patients in outpatient clinic include: reduction of medical errors because of fewer documentation errors resulting from EMR implementation and reduction of waiting time for patients due to overall improvement of system workflow after use of EMRs. In summary of the reviewed evidence from published material, the implementation of an EMR system in any outpatient setting appears to reduce documentation errors (medication dose errors, issues of prescription errors). It was also seen that in many settings, waiting time for patients in outpatient clinics was reduced with EMR use, while in other settings it was not possible to determine if any significant improvement was seen in this aspect after EMR implementation.
Topics: Ambulatory Care Facilities; Documentation; Electronic Health Records; Humans; Waiting Lists; Workflow
PubMed: 35035887
DOI: 10.12688/f1000research.45039.2 -
Journal of Pharmacy Practice Jun 2023Transitions of care (ToC) aim to provide continuity while preventing loss of information that may result in poor outcomes such as hospital readmission. Readmissions not...
Transitions of care (ToC) aim to provide continuity while preventing loss of information that may result in poor outcomes such as hospital readmission. Readmissions not only burden patients, they also increase costs. Given the high prevalence of coronary artery diseases (CAD) in the United States (US), patients with CAD often make up a significant portion of hospital readmissions. To conduct a systematic review evaluating the impact of pharmacist-driven ToC interventions on post-hospital outcomes for patients with CAD. MEDLINE, Scopus, and CINAHL were searched from database inception through 03/2020 using key words for CAD and pharmacists. Studies were included if they: (1) identified adults with CAD at US hospitals, (2) evaluated pharmacist-driven ToC interventions, and (3) assessed post-discharge outcomes. Outcomes were summarized qualitatively. Of the 1612 citations identified, 11 met criteria for inclusion. Pharmacist-driven ToC interventions were multifaceted and frequently included medication reconciliation, medication counseling, post-discharge follow-up and initiatives to improve medication adherence. Hospital readmission and emergency room visits were numerically lower among patients receiving vs not receiving pharmacist-driven interventions, with statistically significant differences observed in 1 study. Secondary prevention measures and adherence tended to be more favorable in the pharmacist-driven intervention groups. Eleven studies of multifaceted, ToC interventions led by pharmacists were identified. Readmissions were numerically lower and secondary prevention measures and adherence were more favorable among patients receiving pharmacist-driven interventions. However, sufficiently powered studies are still required to confirm these benefits.
Topics: Adult; Humans; United States; Patient Discharge; Pharmacists; Coronary Artery Disease; Aftercare; Patient Readmission; Hospitals; Medication Reconciliation
PubMed: 34962844
DOI: 10.1177/08971900211064155 -
European Journal of Clinical... Apr 2022This study aimed to estimate the prevalence, contributory factors, and severity of medication errors associated with direct acting oral anticoagulants (DOACs). (Meta-Analysis)
Meta-Analysis
Prevalence, contributory factors and severity of medication errors associated with direct-acting oral anticoagulants in adult patients: a systematic review and meta-analysis.
PURPOSE
This study aimed to estimate the prevalence, contributory factors, and severity of medication errors associated with direct acting oral anticoagulants (DOACs).
METHODS
A systematic review and meta-analysis were undertaken by searching 11 databases including Medline, Embase, and CINHAL between January 2008 and September 2020. The pooled prevalence of errors and predictive intervals were estimated using random-effects models using Stata software. Data related to error causation were synthesised according to Reason's accident causation model.
RESULTS
From the 5205 titles screened, 32 studies were included which were mostly based in hospitals and included DOAC treatment for thromboembolism and atrial fibrillation. The proportion of study population who experienced either prescription, administration, or dispensing error ranged from 5.3 to 37.3%. The pooled percentage of patients experiencing prescribing error was 20% (95% CI 15-25%; I = 96%; 95% PrI 4-43%). Prescribing error constituted the majority of all error types with a pooled estimate of 78% (95%CI 73-82%; I = 0) of all errors. The common reported causes were active failures including wrong drug, and dose for the indication. Mistakes such as non-consideration of renal function, and error-provoking conditions such as lack of knowledge were common contributing factors. Adverse events such as potentially fatal intracranial haemorrhage or patient deaths were linked to the errors but causality assessments were often missing.
CONCLUSIONS
Despite their favourable safety profile, DOAC medication errors are common. There is a need to promote multidisciplinary working, guideline-adherence, training, and education of healthcare professionals, and the use of theory-based and technology-facilitated interventions to minimise errors and maximise the benefits of DOACs usage in all settings.
PROTOCOL
A protocol developed as per PRISMA-P guideline is registered under PROSPERO ID = CRD42019122996.
Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Factor Xa Inhibitors; Humans; Medication Errors
PubMed: 34935068
DOI: 10.1007/s00228-021-03212-y