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Intervention protocol: OPtimising thERapy to prevent avoidable hospital Admission in the Multi-morbid elderly (OPERAM): a structured medication review with support of a computerised decision support system.

ABSTRACT: BACKGROUND:Several approaches to medication optimisation by identifying drug-related problems in older people have been described. Although some interventions have shown reductions in drug-related problems (DRPs), evidence supporting the effectiveness of medication reviews on clinical and economic outcomes is lacking. Application of the STOPP/START (version 2) explicit screening tool for inappropriate prescribing has decreased inappropriate prescribing and significantly reduced adverse drug reactions (ADRs) and associated healthcare costs in older patients with multi-morbidity and polypharmacy. Therefore, application of STOPP/START criteria during a medication review is likely to be beneficial. Incorporation of explicit screening tools into clinical decision support systems (CDSS) has gained traction as a means to improve both quality and efficiency in the rather time-consuming medication review process. Although CDSS can generate more potential inappropriate medication recommendations, some of these have been shown to be less clinically relevant, resulting in alert fatigue. Moreover, explicit tools such as STOPP/START do not cover all relevant DRPs on an individual patient level. The OPERAM study aims to assess the impact of a structured drug review on the quality of pharmacotherapy in older people with multi-morbidity and polypharmacy. The aim of this paper is to describe the structured, multi-component intervention of the OPERAM trial and compare it with the approach in the comparator arm. METHOD:This paper describes a multi-component intervention, integrating interventions that have demonstrated effectiveness in defining DRPs. The intervention involves a structured history-taking of medication (SHiM), a medication review according to the systemic tool to reduce inappropriate prescribing (STRIP) method, assisted by a clinical decision support system (STRIP Assistant, STRIPA) with integrated STOPP/START criteria (version 2), followed by shared decision-making with both patient and attending physician. The developed method integrates patient input, patient data, involvement from other healthcare professionals and CDSS-assistance into one structured intervention. DISCUSSION:The clinical and economical effectiveness of this experimental intervention will be evaluated in a cohort of hospitalised, older patients with multi-morbidity and polypharmacy in the multicentre, randomized controlled OPERAM trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multi-morbid elderly), which will be completed in the last quarter of 2019. TRIAL REGISTRATION:Universal Trial Number: U1111-1181-9400 Clinicaltrials.gov: NCT02986425, Registered 08 December 2016. FOPH (Swiss national portal): SNCTP000002183. Netherlands Trial Register: NTR6012 (07-10-2016).

SUBMITTER: Crowley EK

PROVIDER: S-EPMC7076919 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Intervention protocol: OPtimising thERapy to prevent avoidable hospital Admission in the Multi-morbid elderly (OPERAM): a structured medication review with support of a computerised decision support system.

Crowley Erin K EK Sallevelt Bastiaan T G M BTGM Huibers Corlina J A CJA Murphy Kevin D KD Spruit Marco M Shen Zhengru Z Boland Benoît B Spinewine Anne A Dalleur Olivia O Moutzouri Elisavet E Löwe Axel A Feller Martin M Schwab Nathalie N Adam Luise L Wilting Ingeborg I Knol Wilma W Rodondi Nicolas N Byrne Stephen S O'Mahony Denis D

BMC health services research 20200317 1

<h4>Background</h4>Several approaches to medication optimisation by identifying drug-related problems in older people have been described. Although some interventions have shown reductions in drug-related problems (DRPs), evidence supporting the effectiveness of medication reviews on clinical and economic outcomes is lacking. Application of the STOPP/START (version 2) explicit screening tool for inappropriate prescribing has decreased inappropriate prescribing and significantly reduced adverse d ...[more]

PMID: 32183810

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Project description:BackgroundMedication for attention deficit hyperactivity disorder (ADHD) should be closely monitored to ensure optimisation. There is growing interest in using computerised assessments of ADHD symptoms to support medication monitoring. The aim of this study was to assess the feasibility and acceptability of a randomised controlled trial (RCT) to evaluate the efficacy of one such computerised assessment, the Quantified Behavior (Qb) Test, as part of medication management for ADHD.MethodsThis feasibility multi-site RCT conducted in child and adolescent mental health and community paediatric settings recruited participants aged 6-15 years diagnosed with ADHD starting stimulant medication. Participants were randomised into one of two arms: experimental (QbTest protocol) where participants completed a QbTest at baseline and two follow-up QbTests on medication (2-4 weeks and 8-10 weeks later) and control where participants received treatment as usual, including at least two follow-up consultations. Measures of parent, teacher, and clinician-rated symptoms and global functioning were completed at each time point. Clinicians recorded treatment decision-making and health economic measures were obtained. Data were analysed using multi-level modelling and participants (children and parents) and clinicians were interviewed about their experiences, resulting data were thematically analysed.ResultsForty-four children and young people were randomised. Completion of study outcome measures by care-givers and teachers ranged from 52 to 78% at baseline to 47-65% at follow-up. Participants reported the questionnaires to be useful to complete. SNAP-IV inattention scores showed greater reduction in the intervention than the control group (- 5.85, 95% CI - 10.33, - 1.36,). Engagement with the intervention ranged from 100% at baseline, to 78% follow-up 1 and 57% follow-up 2. However, only 37% of QbTests were conducted in the correct time period. Interview data highlighted that the objectivity of the QbTest was appreciated by clinicians and parents. Clinicians commented that the additional time and resources required meant that it is not feasible to use QbTest for all cases.ConclusionThe trial design and protocol appear to be feasible and acceptable but could be improved by modifying QbTest time periods and the method of data collection. With these changes, the protocol may be appropriate for a full trial. Adding QbTest may improve symptom outcome as measured by SNAP-IV.Trial registrationClinicalTrials.gov, NCT03368573 , prospectively registered, 11th December 2017, and ISRCTN, ISRCTN69461593 , retrospectively registered, 10th April 2018.

Project description:IntroductionMultimorbidity and polypharmacy are important risk factors for drug-related hospital admissions (DRAs). DRAs are often linked to prescribing problems (overprescribing and underprescribing), as well as non-adherence with drug regimens for different reasons. In this trial, we aim to assess whether a structured medication review compared with standard care can reduce DRAs in multimorbid older patients with polypharmacy.Methods and analysisOPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people is a European multicentre, cluster randomised, controlled trial. Hospitalised patients ≥70 years with ≥3 chronic medical conditions and concurrent use of ≥5 chronic medications are included in the four participating study centres of Bern (Switzerland), Utrecht (The Netherlands), Brussels (Belgium) and Cork (Ireland). Patients treated by the same prescribing physician constitute a cluster, and clusters are randomised 1:1 to either standard care or Systematic Tool to Reduce Inappropriate Prescribing (STRIP) intervention with the help of a clinical decision support system, the STRIP Assistant. STRIP is a structured method performing customised medication reviews, based on Screening Tool of Older People's Prescriptions/Screening Tool to Alert to Right Treatment criteria to detect potentially inappropriate prescribing. The primary endpoint is any DRA where the main reason or a contributory reason for the patient's admission is caused by overtreatment or undertreatment, and/or inappropriate treatment. Secondary endpoints include number of any hospitalisations, all-cause mortality, number of falls, quality of life, degree of polypharmacy, activities of daily living, patient's drug compliance, the number of significant drug-drug interactions, drug overuse and underuse and potentially inappropriate medication.Ethics and disseminationThe local Ethics Committees in Switzerland, Ireland, The Netherlands and Belgium approved this trial protocol. We will publish the results of this trial in a peer-reviewed journal.Main fundingEuropean Union's Horizon 2020 programme.Trial registration numberNCT02986425 , SNCTP000002183 , NTR6012, U1111-1181-9400.

Project description:INTRODUCTION:Multimorbidity and polypharmacy are major risk factors for potentially inappropriate prescribing (eg, overprescribing and underprescribing), and systematic medication reviews are complex and time consuming. In this trial, the investigators aim to determine if a systematic software-based medication review improves medication appropriateness more than standard care in older, multimorbid patients with polypharmacy. METHODS AND ANALYSIS:Optimising PharmacoTherapy In the multimorbid elderly in primary CAre is a cluster randomised controlled trial that will include outpatients from the Swiss primary care setting, aged ?65 years with ?three chronic medical conditions and concurrent use of ?five chronic medications. Patients treated by the same general practitioner (GP) constitute a cluster, and clusters are randomised 1:1 to either a standard care sham intervention, in which the GP discusses with the patient if the medication list is complete, or a systematic medication review intervention based on the use of the 'Systematic Tool to Reduce Inappropriate Prescribing'-Assistant (STRIPA). STRIPA is a web-based clinical decision support system that helps customise medication reviews. It is based on the validated 'Screening Tool of Older Person's Prescriptions' (STOPP) and 'Screening Tool to Alert doctors to Right Treatment' (START) criteria to detect potentially inappropriate prescribing. The trial's follow-up period is 12 months. Outcomes will be assessed at baseline, 6 and 12 months. The primary endpoint is medication appropriateness, as measured jointly by the change in the Medication Appropriateness Index (MAI) and Assessment of Underutilisation (AOU). Secondary endpoints include the degree of polypharmacy, overprescribing and underprescribing, the number of falls and fractures, quality of life, the amount of formal and informal care received by patients, survival, patients' quality adjusted life years, patients' medical costs, cost-effectiveness of the intervention, percentage of recommendations accepted by GPs, percentage of recommendation rejected by GPs and patients' willingness to have medications deprescribed. ETHICS AND DISSEMINATION:The ethics committee of the canton of Bern in Switzerland approved the trial protocol. The results of this trial will be published in a peer-reviewed journal. MAIN FUNDING:Swiss National Science Foundation, National Research Programme (NRP 74) 'Smarter Healthcare'. TRIAL REGISTRATION NUMBERS:Clinicaltrials.gov (NCT03724539), KOFAM (Swiss national portal) (SNCTP000003060), Universal Trial Number (U1111-1226-8013).

Project description:BackgroundThe demand for healthcare is increasing due to an aging population, more people living with chronic diseases and medical comorbidities. To manage this demand, political institutions call for action to reduce the potentially avoidable hospitalizations. Quantitative and qualitative aspects should be considered to understand how and why interventions work, and for whom. The aim of this mixed methods systematic review was to identify and synthesize evidence on interventions targeting avoidable hospitalizations from the perspectives of the citizens and the healthcare professionals to improve the preventive healthcare services.Methods and resultsA mixed methods systematic review was conducted following the JBI methodology using a convergent integrated approach to synthesis. The review protocol was registered in PROSPERO, reg. no. CRD42020134652. A systematic search was undertaken in six databases. In total, 45 articles matched the eligibility criteria, and 25 of these (five qualitative studies and 20 quantitative studies) were found to be of acceptable methodological quality. From the 25 articles, 99 meaning units were extracted. The combined evidence revealed four categories, which were synthesized into two integrated findings: (1) Addressing individual needs through care continuity and coordination prevent avoidable hospitalizations and (2) Recognizing preventive care as an integrated part of the healthcare work to prevent avoidable hospitalizations.ConclusionsThe syntheses highlight the importance of addressing individual needs through continuous and coordinated care practices to prevent avoidable hospitalizations. Engaging healthcare professionals in preventive care work and considering implications for patient safety may be given higher priority. Healthcare administers and policy-makers could support the delivery of preventive care through targeted educational material aimed at healthcare professionals and simple web-based IT platforms for information-sharing across healthcare settings. The findings are an important resource in the development and implementation of interventions to prevent avoidable hospitalizations, and may serve to improve patient safety and quality in preventive healthcare services.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=134652, identifier: CRD42020134652.

Project description:Stat medications are regularly prescribed on hospital wards as part of the ongoing care for patients. Because they are prescribed at variable times that do not coincide with regular nursing drug administration times, they rely on good communication and vigilance on staff to ensure they are administered in a timely manner. Delays in drug administration can lengthen patient recovery times, prolong admission, and can lead to avoidable patient harm and suffering. While working on a geriatrics ward I noticed that there were often significant delays in administration of stat medications which occurred on a regular basis. I therefore investigated this by collecting data over a two week period to assess the situation based on our current practice. After root cause analysis (figure 1), it became clear that communication between staff was a significant factor in delayed administration. A solution was implemented in the form of "ward bay wall charts" to aid documentation and communication of stat medication requirements between nursing and medical staff with the intention to reduce delays by improving communication. After gaining support of medical and nursing staff, a trial was undertaken and a further two weeks of data collected to see the effect of the intervention. The results showed that there was an increase in the median time delay (1 hour 34 minutes to 2 hours 26 minutes, a 55% increase in median time delay) after the implementation of the my intervention, suggesting that it actually made communication worse, creating more delays. Subsequent feedback and analysis showed that this was due to a number of factors that led to worsened communication between staff and therefore an increase in medication delays. Early recognition allowed the intervention to be promptly withdrawn and a re-assessment of the nature of the initial problem. This project highlights the importance of measurement in determining if an intervention actually works and is an improvement on current practice.

Dataset Information

Intervention protocol: OPtimising thERapy to prevent avoidable hospital Admission in the Multi-morbid elderly (OPERAM): a structured medication review with support of a computerised decision support system.

Publications

Intervention protocol: OPtimising thERapy to prevent avoidable hospital Admission in the Multi-morbid elderly (OPERAM): a structured medication review with support of a computerised decision support system.

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