US agency launches initiative on better prescribing for hypertension.
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ABSTRACT:
SUBMITTER: Lenzer J
PROVIDER: S-EPMC1370992 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Training in procedures has been identified as the top priority for core medical trainees (GMC trainee survey 2011). Current practice relies on each trainee being lucky enough to encounter each procedure during clinical rotations and during on-calls. Where trainees are not lucky enough, they are entering their registrar years without the skills to efficiently lead the medical 'on-take'.(1) This can lead to delays in patient diagnosis or treatment. Because a single delay can easily burgeon into a lengthy series of multiple delays, this can lead to an associated prolongation of patient stay.(3) Both confidence and competence in practical procedures can be increased with a procedure bleep system. A dedicated procedure bleep, carried on a rotational basis alerts the bleep holder when a medical procedure is planned. The bleep holder then attends to observe, assist, perform, or teach the relevant procedure. This scheme shares the opportunities for procedure exposure amongst all trainees and ensures that a good breadth of experience has been gained independent of current placement. Formal evaluation revealed that 95% (19/20) of junior trainees felt more confident and competent as a result of participation. Furthermore, consultants felt this initiative reduced the burden on the medical registrars on-call. By ensuring our diagnostic and therapeutic interventions are conducted efficiently, we are actively reducing length of hospital stay and improving the standard of healthcare provided.
| S-EPMC4663826 | biostudies-other
Project description: Not available
| S-EPMC1557943 | biostudies-literature
Project description:AimsThe question of whether new medical graduates are adequately prepared for the challenge of prescribing has been raised. Although broad outcomes for prescribing competency have been agreed, clarity is needed on the detailed outcomes expected of new graduates. This study aimed to create a consensus on the required competencies for new graduates in the area of prescribing.MethodsWe used a modified Delphi approach based on the findings of a systematic review of educational interventions for improved prescribing. Panellists were asked to rank the importance of a list of 53 possible learning outcomes and to add any additional outcomes felt to be missing.ResultsOf the 48 experts who were invited to participate, 28 agreed (58%). Forty-five learning outcomes were included from the original list of 53. A further nine outcomes were suggested by panellists, of which five were included. The wording of three outcomes was changed in line with suggestions from the panellists. Many of the agreed outcomes relate to improving patient safety through medication review, checking appropriateness of the drug for the patient, recognizing the prescriber's limitations and seeking advice when needed. Enhanced communication with the patient and healthcare team, better documentation in the notes and discharge letters were key areas featured in this Delphi exercise.DiscussionThis study has identified 50 learning outcomes for teaching prescribing. These build on the existing British Pharmacological Society document by focusing specifically on prescribing, with greater emphasis on avoiding medication errors and better communication.
| S-EPMC2950995 | biostudies-literature
Project description:BackgroundResearch literature consistently documents that scientifically based therapeutic recommendations are not always followed in the hospital or in the primary care setting. Currently, there is evidence that some general practitioners in Australia are not prescribing appropriately for patients diagnosed with 1) hypertension (HT) and 2) chronic heart failure (CHF). The objectives of this study were to improve general practitioner's drug treatment management of these patients through feedback on their own prescribing and small group discussions with peers and a trained group facilitator. The impact evaluation includes quantitative assessment of prescribing changes at 6, 9, 12 and 18 months after the intervention.MethodsA pragmatic multi site cluster RCT began recruiting practices in October 2009 to evaluate the effects of a multi-faceted quality improvement (QI) intervention on prescribing practice among Australian general practitioners (GP) in relation to patients with CHF and HT. General practices were recruited nationally through General Practice Networks across Australia. Participating practices were randomly allocated to one of three groups: two groups received the QI intervention (the prescribing indicator feedback reports and small group discussion) with each group undertaking the clinical topics (CHF and HT) in reverse order to the other. The third group was waitlisted to receive the intervention 6 months later and acted as a "control" for the other two groups.De-identified data on practice, doctor and patient characteristics and their treatment for CHF and HT are extracted at six-monthly intervals before and after the intervention. Post-test comparisons will be conducted between the intervention and control arms using intention to treat analysis and models that account for clustering of practices in a Network and clustering of patients within practices and GPs.DiscussionThis paper describes the study protocol for a project that will contribute to the development of acceptable and sustainable methods to promote QI activities within routine general practice, enhance prescribing practices and improve patient outcomes in the context of CHF and HT.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR), Trial # 320870.
| S-EPMC3515472 | biostudies-literature
Project description:BackgroundFluoroquinolones are antibiotics prescribed in the outpatient setting, though they have serious side effects. This study evaluates the impact of stewardship interventions on total and inappropriate prescribing of fluoroquinolones in outpatient settings in a large county hospital and health system.MethodsIn an effort to decrease inappropriate outpatient fluoroquinolone usage, a multimodal antimicrobial stewardship initiative was implemented in November 2016. Education regarding the risks, benefits, and appropriate uses of fluoroquinolones was provided to providers in different outpatient settings, Food and Drug Administration warnings were added to all oral fluoroquinolone orders, an outpatient order set for cystitis treatment was created, and fluoroquinolone susceptibilities were suppressed when appropriate. Charts from October 2016, 2017, and 2018 were retrospectively reviewed if the patient encounter occurred in primary care clinics, emergency departments, or urgent care centers within Parkland Health & Hospital System and a fluoroquinolone was prescribed. Inappropriate use was defined as a fluoroquinolone prescription for cystitis, bronchitis, or sinusitis in a patient without a history of Pseudomonas aeruginosa or multidrug-resistant organisms and without drug allergies that precluded use of other oral antibiotics.ResultsTotal fluoroquinolone prescriptions per 1000 patient visits decreased significantly by 39% (P?<?.01), and inappropriate fluoroquinolone use decreased from 53% to 34% (P?<?.01). More than 90% of inappropriate fluoroquinolone prescriptions were given for cystitis, while bronchitis and sinusitis accounted for only 4.4% and 1.6% of inappropriate indications, respectively.ConclusionA multimodal stewardship initiative appears to effectively reduce both total and inappropriate outpatient fluoroquinolone prescriptions.
| S-EPMC7284006 | biostudies-literature
Project description:OBJECTIVE:To assess whether a multiphase, departmental quality improvement effort decreases opioid prescribing and increases multimodal analgesic use after cesarean delivery. METHODS:This is a prospective quality improvement study. In phase 1 of the protocol, discharge providers implemented counseling regarding expectations for pain, typical need for opioids, and importance of multimodal nonopioid analgesic use and used shared decision-making to determine the number of opioids prescribed. Patients could select up to a maximum of 30 tablets of 5 mg oxycodone (or equivalent opioid), lower than the previous routine discharge prescription of 40 opioid tablets. The primary outcome was the mean (SD) number of opioid tablets prescribed on discharge with secondary outcomes including opioid refill rate within 30 days of discharge and rates of nonopioid analgesic prescriptions on discharge. In phase 2, using these results, we adjusted the protocol's maximum opioid prescription to 25 opioid tablets, but no other aspects of the protocol were changed. All data were analyzed with t test and ? analyses. RESULTS:Data from 624 women who underwent cesarean deliveries were analyzed. Opioids, most commonly oxycodone, were prescribed after 95% of all cesarean deliveries. The mean (SD) number of opioid tablets prescribed decreased from 33.2 (9.3) to 26.5 (6.7; P<.01) with the implementation of phase 1 having no effect on the opioid refill rate, 8.9% vs 8.1% (P=.79). These results allowed adjustment of the maximum recommended prescription to 25 opioid tablets, introducing phase 2 of the study, during which the mean (SD) number of opioid tablets prescribed further decreased from 24.9 (7.5) to 21.5 (6.3; P<.01) with no effect on the opioid refill rate, 6.3% vs 5.1% (P=.72). Overall, this represents a 35% decrease in opioid prescribing (P<.01). Rates of ibuprofen prescribing were 98% or higher throughout the study, but rates of acetaminophen prescribing increased from 32.6% before phase 1 to 92.0% after phase 2 (P<.001). CONCLUSION:Implementation of a multiphase quality improvement protocol to decrease opioid prescribing, combined with iterative review of discharge data, resulted in a significant decrease in the number of opioid tablets prescribed after cesarean delivery.
| S-EPMC6105442 | biostudies-literature
Project description:Objective:Use an established quality improvement method, Lean A3, to improve the process of opioid prescribing in an academic rheumatology ambulatory clinic. Methods:This retrospective pre-postintervention analysis of rheumatology records included patients prescribed opioids at least once during the study period. Lean A3 was used to develop a Controlled Substance Visit Protocol to standardize eight recommended elements of the opioid prescribing workflow. Analyses included changes in the recommended workflow elements and changes in opioid prescribing volume. Results:Improvements were observed in seven of the eight recommended elements. Patient education, including treatment agreements and consent forms (39% completion for both preimplementation) increased to 78% and 80%, respectively (P < 0.001 for both). Risk assessment, as measured by the Current Opioid Misuse Measure, increased from 0.5% to 76% (P < 0.001). Best practices in prescribing, including prescribing in multiples of seven to avoid weekend refill requests, increased from 1% to 79% (P < 0.001). Monitoring parameters, including standardized functional assessment (0% vs. 86%), prescription drug monitoring program queries (49% vs. 84%), and urine testing (1% vs. 32%) all increased (P < 0.001). Visits scheduled at least quarterly for patients on chronic opioids did not change (P = 0.18). Overall, the number of patients prescribed opioids (185 vs. 160; P < 0.001) and annual prescription opioid morphine milligram equivalents (MMEs) (1 933 585 MME vs. 1 386 368 MME; P < 0.001) decreased. Conclusion:The Lean A3 method is a successful quality improvement tool for improving and sustaining opioid prescribing within a single academic rheumatology clinic. This method has potential applicability to similar clinics interested in improving opioid prescribing.
| S-EPMC6857975 | biostudies-literature
Project description:IntroductionAnalyses of off-label use of acetylcholinesterase inhibitors (AChEIs) in mild cognitive impairment (MCI) has produced mixed results. Post hoc analyses of observational cohorts, such as the Alzheimer's Disease Neuroimaging Initiative (ADNI), have reported deleterious effects in AChEI-treated subjects (AChEI+). Here, we used neuroimaging biomarkers to determine whether AChEI+ subjects had a greater rate of neurodegeneration than untreated (AChEI-) subjects while accounting for baseline differences.MethodsWe selected 121 ADNI MCI AChEI+ subjects and 151 AChEI- subjects with a magnetic resonance imaging (MRI) scan; 82 AChEI+ and 110 AChEI- also had a fluorodeoxyglucose (FDG) scan. A subset (83 AChEI+ and 98 AChEI-) had cerebrospinal fluid (CSF) or amyloid positron emission tomography (PET) assessment for amyloid positivity. Linear regression models were used to compare the effect of treatment on changes in Mini-Mental State Examination and Clinical Dementia Rating-Sum of Boxes scores. We used standard regression in SPM (for baseline) and the SPM toolbox sandwich estimator, SwE (for longitudinal) for comparisons of AChEI+ and AChEI- FDG PET and MRI data.ResultsAt baseline, the AChEI+ group had significantly reduced cortical gray matter density (GMD) and more hypometabolism than AChEI- subjects. The greater rate of atrophy and hypometabolic changes over time in AChEI+ compared to AChEI- subjects did not survive correction for baseline differences. AChEI+ participants were more likely to be amyloid-positive and have lower GMD and FDG standardized uptake value ratio than AChEI- at baseline. AChEI+ subjects showed greater atrophy over time, which remained significant after controlling for amyloid status.DiscussionOur data suggest that the observed differences in rates of cognitive decline, atrophy, and hypometabolism are likely the result of significant baseline differences between the groups. Furthermore, the data indicate no treatment effect of AChEI (positive of negative), rather that physicians prescribe AChEI to subjects who present with more severe clinical impairment. This alone may account for the negative effect seen previously in the ADNI population of AChEI use among MCI subjects.
| S-EPMC8719350 | biostudies-literature
Project description:BackgroundA range of first-line similarly effective medications ranging in price are recommended for treating uncomplicated hypertension. Considering drug costs alone, thiazides and thiazide-like diuretics are the most cost-efficient option. We determined incident prescribing of thiazides for newly diagnosed hypertension as first-line treatment in Alberta, factors that predicted receiving thiazides vs more costly medications, and how much could be saved if more patients were prescribed thiazides.MethodsUsing a retrospective cohort design, factors predicting receiving thiazides vs other agents were determined using mixed effects logistic regression. Cost savings were simulated by shifting patients from other antihypertensive medications to thiazides and calculating the difference.ResultsWithin our cohort of 89,548 adults, only 12% received thiazides as first-line treatment whereas 44% received angiotensin converting enzyme inhibitors, 17% received angiotensin receptor blockers, 16% received calcium channel blockers, and 10% received β-blockers. Antihypertensive medications were typically prescribed by office-based, general practitioners (88%). Being male and receiving a prescription from a physician with ≥ 20 years of practice and a high clinical workload were associated with increased odds of receiving nonthiazides. In the extreme case that all patients received thiazides as their first prescription, spending would have been reduced by a maximum of 95% (CAD$1.8 million).ConclusionsOnly 12% of Albertan adults with incident, uncomplicated hypertension were prescribed thiazides as first-line treatment. With the opportunity for drug cost savings, future research should evaluate the risk of adverse events and side effects across the drug classes and whether the costs associated with managing those risks could offset the savings achieved through increased thiazide use.
| S-EPMC8209399 | biostudies-literature
Project description:Thousands of fungal species use surface energy to power the launch of their ballistospores. The surface energy is released when a spherical Buller's drop at the spore's hilar appendix merges with a flattened drop on the adaxial side of the spore. The launching mechanism is primarily understood in terms of energetic models, and crucial features such as launching directionality are unexplained. Integrating experiments and simulations, we advance a mechanistic model based on the capillary-inertial coalescence between the Buller's drop and the adaxial drop, a pair that is asymmetric in size, shape and relative position. The asymmetric coalescence is surprisingly effective and robust, producing a launching momentum governed by the Buller's drop and a launching direction along the adaxial plane of the spore. These key functions of momentum generation and directional control are elucidated by numerical simulations, demonstrated on spore-mimicking particles, and corroborated by published ballistospore kinematics. Our work places the morphological and kinematic diversity of ballistospores into a general mechanical framework, and points to a generic catapulting mechanism of colloidal particles with implications for both biology and engineering.
| S-EPMC5550963 | biostudies-literature