Implementation of interprofessional quality circles on deprescribing in Swiss nursing homes: an observational study.

BACKGROUND: Polypharmacy and potentially inappropriate medications (PIMs) are still frequent among older adults in nursing homes. Deprescribing is an intervention that has been shown to be effective in reducing their use. However, the implementation of deprescribing in clinical practice has not yet been widely evaluated. The Quality Circle Deprescribing Module (QC-DeMo) intervention has been trialled through an effectiveness-implementation hybrid type 2 design. The intervention consists of a quality circle workshop session between healthcare professionals HCPs (physicians, nurses, and pharmacists) within a nursing home, in which they define a consensus to deprescribe specific PIMs classes. The aim of this study was to evaluate the implementation of the QC-DeMo intervention in nursing homes. METHODS: This observational study focuses on the implementation part of the QC-DeMo trial. Implementation was based on the Framework for Implementation of Pharmacy Services (FISpH). Questionnaires at baseline and follow-up were used to evaluate reach, adoption, implementation effectiveness, fidelity, implementation, maintenance and the implementation strategies. Other data were collected from the QC-DeMo trial and routine data collected as part of the integrated pharmacy service where the QC-Demo trial was embedded. Implementation strategies included training of pharmacists, integration of the intervention into an existing quality circle dynamic and definition of tailored strategies to operationalise the consensus by each nursing home. RESULTS: The QC-DeMo intervention was successfully implemented in 26 nursing homes in terms of reach, fidelity, adoption, implementation and implementation effectiveness. However, the intervention was found to be implemented with low maintenance as none of the nursing homes repeated the intervention after the trial. Implementation strategies were well received by HCPs: training was adequate according to pharmacists. Pre-existing quality circle dynamic facilitated interprofessional collaboration as involvement and support of each HCP was rated as high. HCPs recognized a specific and important role for each HCP in the deprescribing process. The most relevant tailored strategies to implement the consensus defined by each nursing home were identification of the patients by the pharmacist and a systematic review of medication's patients. CONCLUSIONS: The implementation of a Quality Circle on Deprescribing is feasible but its maintenance in practice remains challenging. This study explores multiple implementation outcomes to better inform future implementation efforts of these types of interventions. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT03688542 ), registered on 26.09.2018.

Adaptation and validation of the revised Patients' Attitudes towards Deprescribing (rPATD) questionnaire for benzodiazepine receptor agonists.

BACKGROUND: The revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire explores older adults' views on deprescribing in general. Those views may differ, however, when the target is a specific drug such as benzodiazepine receptor agonists (BZRA). OBJECTIVE: This study aimed to adapt the 22-item French rPATD questionnaire to create a BZRA-specific instrument and to assess the psychometric properties of this new tool. METHODS: The adaptation of the questionnaire comprised 3 steps: 1) item transformation during group discussions with 8 healthcare providers and 8 BZRA users (aged ≥65 years), 2) pre-test of the questionnaire with 12 other older adults to ensure items understanding, 3) evaluation of the psychometric properties of the new questionnaire with 221 older BZRA users recruited in Belgium, France, and Switzerland. Construct validity was assessed using exploratory factor analysis (EFA), internal consistency with Cronbach's alpha, and test-retest reliability with intraclass correlation coefficient (ICC). RESULTS: After the pre-test, the questionnaire had 24 items (19 adapted from the French rPATD, 3 removed, and 5 added). The EFA, however, found that several items performed poorly. Eleven items were consequently removed, based on statistical performance and clinical relevance. Three factors were extracted from the EFA performed on the 11 retained items and were named "Concerns about stopping BZRA", "BZRA inappropriateness", and "Dependence on BZRA". The questionnaire also includes two global questions about willingness to reduce BZRA dosage and willingness to discontinue BZRA. All factors showed acceptable internal consistency (0.68 ≤ Cronbach's alpha ≤0.74). Two factors showed acceptable test-retest reliability. The "Concerns about stopping BZRA" factor was found to vary over time (ICC [95%CI]: 0.35[-0.02; 0.64]). CONCLUSIONS: We developed and validated a 13-item questionnaire to evaluate the attitudes of older people towards BZRA deprescribing. Despite some limitations, this questionnaire appears to be a useful tool for facilitating shared decision-making on BZRA deprescribing.

Medication Adherence Evaluated Through Electronic Monitors During the 2020 COVID-19 Pandemic Lockdown in Switzerland: A Longitudinal Analysis.

Background: During the 2020 COVID-19 lockdown, patients included in the Interprofessional Medication Adherence Program (IMAP) in Switzerland continued to use electronic monitors (EMs) that registered daily drug-dose intake. We aimed to understand to what extent patients' medication implementation (ie, the extent to which the patient took the prescribed medicine), measured with EMs, was impacted by the lockdown. Methods: Patients participating in the IMAP were diagnosed with diabetic kidney disease (DKD), solid cancer, human immunodeficiency virus (HIV) and miscellaneous long-term diseases (MLTD). Patient implementation was defined through a proxy: if all patient EMs were opened at least once daily, implementation was considered active (=1), and no implementation was considered (=0) otherwise. Implementation before (from December 2019 to March 2020), during (March to June 2020) and after (June to September 2020) the lockdown was compared. Subanalyses were performed according to the patients' diseases. Subanalyses were performed in patients who used at least one EM in 2018-2019 during the same periods (defined as winter, spring and summer). The logistic regression models used to estimate medication implementation according to the period were fitted using generalized estimating equations. Results: In 2020, patient implementation (n = 118) did not differ significantly before versus during (OR = 0.98, 95% CI: 0.84-1.15, p = 0.789) and before versus after (OR = 0.91, 95% CI: 0.79-1.06, p = 0.217) the lockdown. These findings remained stable when separately analyzing the implementation of patients with HIV (n = 61), DKD (n = 25) or MLTD (n = 22). Too few patients with cancer were included (n = 10) to interpret the results. In 2019, the implementation of 61/118 (51.7%) patients was significantly lower during summertime versus wintertime (OR = 0.73, 95% CI: 0.60-0.89, p = 0.002). Conclusion: Medication implementation remained steady before, during and after the lockdown in 2020. The IMAP before, during and after the lockdown may have supported the adherence of most patients, by ensuring continuity of care during periods of routine disturbances.

Attitudes and beliefs of older adults and caregivers towards deprescribing in French-speaking countries: a multicenter cross-sectional study.

PURPOSE: Successful deprescribing requires understanding the attitudes of older adults and caregivers towards this process. This study aimed to capture these attitudes in four French-speaking countries and to investigate associated factors. METHODS: A multicenter cross-sectional study was conducted by administrating the French version of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire in Belgium, Canada, France, and Switzerland. Community-dwelling or nursing home older adults ≥ 65 years taking ≥ 1 prescribed medications and caregivers of older adults with similar characteristics were included. Multivariate logistic regressions were carried out to examine factors associated with willingness to deprescribe. RESULTS: A total of 367 older adults (79.3 ± 8.7 years, 63% community-dwelling, 54% ≥ 5 medications) and 255 unrelated caregivers (64.4 ± 12.6 years) of care recipients (83.4 ± 7.9 years, 52% community-dwelling, 69% ≥ 5 medications) answered the questionnaire. Among them, 87.5% older adults and 75.6% caregivers would be willing to stop medications if the physician said it was possible. Reluctance to stop a medication taken for a long time was expressed by 46% of both older adults and caregivers. A low score for the factor "concerns about stopping" (older adults: aOR: 0.21; 95% CI: 0.07-0.59), and a high score for the factor "involvement" (older adults: aOR: 2.66; 95% CI: 1.01-7.07; caregivers: aOR: 11.28; 95% CI: 1.48-85.91) were associated with willingness to deprescribe. CONCLUSIONS: A significant proportion of older adults and caregivers of French-speaking countries are open to deprescribing. Despite this apparent willingness, deprescribing conversations in clinical practice remains marginal, emphasizing the importance of optimizing the integration of existing tools such as rPATD.

Response to the first wave of the COVID-19 pandemic in the community pharmacy of a University Center for Primary Care and Public Health.

BACKGROUND: Pharmacists played a key role during the coronavirus disease 2019 (COVID-19) pandemic: they contributed to preventing transmission and to maintaining continuity of primary care. OBJECTIVES: To present the contributions of a Swiss pharmacy of an academic outpatient care department (Unisanté) to the prevention of COVID-19 transmission and the precautionary measures plan implemented as well as to evaluate the impact of Swiss semicontainment on its pharmacy services. METHODS: Contributions to COVID-19 transmission prevention and the precautionary measures plan are described. The impact on pharmacy services was measured by quantitative comparison before, during and after semicontainment. RESULTS: The pharmacy supplied protective equipment to the population and to liberal healthcare professionals and provided COVID-19 recommendations to patients and community pharmacies. The precautionary measures plan implemented required a reorganization of the premises, facilities, staff operation and pharmacy services. Semicontainment had a strong impact on pharmacy services; however, clinical bonds with patients and other healthcare professionals were maintained. Unseen negative impacts may exist and need to be investigated. CONCLUSIONS: Although innovative solutions remain to be developed to guarantee continuous and secure remote communication with patients, this pandemic was an opportunity to demonstrate the versatility, benefit and importance of community pharmacy services.

Factors Influencing the Implementation of Antimicrobial Stewardship in Primary Care: A Narrative Review.

Antimicrobial resistance (AMR) is directly driven by inappropriate use of antibiotics. Although the majority of antibiotics (an estimated 80%) are consumed in primary care settings, antimicrobial stewardship (AMS) activities in primary care remain underdeveloped and factors influencing their implementation are poorly understood. This can result in promising stewardship activities having little-to-no real-world impact. With this narrative review, we aim to identify and summarize peer-reviewed literature reporting on (1) the nature and impact of AMS interventions in primary care and (2) the individual and contextual factors influencing their implementation. Reported activities included AMS at different contextual levels (individual, collective and policy). AMS activities being often combined, it is difficult to evaluate them as stand-alone interventions. While some important individual and contextual factors were reported (difficulty to reach physicians leading to a low uptake of interventions, tight workflow of physicians requiring implementation of flexible and brief interventions and AMS as a unique opportunity to strengthen physician-patients relationship), this review identified a paucity of information in the literature about the factors that support or hinder implementation of AMS in primary care settings. In conclusion, identifying multilevel barriers and facilitators for AMS uptake is an essential step to explore before implementing primary care AMS interventions.

Effects of an interprofessional deprescribing intervention in Swiss nursing homes: the Individual Deprescribing Intervention (IDeI) randomised controlled trial.

BACKGROUND: Deprescribing polypharmacy and potentially inappropriate medications (PIMs) has been shown to be beneficial to nursing home (NH) residents' health. Medication reviews are the most widely studied deprescribing intervention; in a previous trial, we showed that another intervention, a deprescribing-focused interprofessional quality circle, can reduce the use of inappropriate medications at the NH level. However, this intervention cannot account for the variety of the residents' clinical situations. Therefore, we trialled a subsequent intervention in NH that enacted the quality circle intervention in the previous year. METHODS: In 7 NHs, the most heavily medicated residents were recruited and randomised to receive usual care or the intervention. The intervention was a pharmacist-led, deprescribing-focused medication review, followed by the creation of an individualised treatment modification plan in collaboration with nurses and physicians. Intervention's effects were assessed after four months on the number and dose of PIMs used, quality of life, and safety outcomes (mortality, hospitalisations, falls, and use of physical restraints). Data were analysed using Poisson multivariate regression models. RESULTS: Sixty-two NH residents participated, falling short of the expected 100 participants; 4 died before initial data collection. Participants used a very high number of drugs (median 15, inter-quartile range [12-19]) and PIMs (median 5, IQR [3-7]) at baseline. The intervention did not reduce the number of PIMs prescribed to the participants; however, it significantly decreased their dose (incidence rate ratio 0.763, CI95 [0.594; 0.979]), in particular for chronic drugs (IRR 0.716, CI95 [0.546; 0.938]). No adverse effects were seen on mortality, hospitalisations, falls, and restraints use, but, in the intervention group, three participants experienced adverse events that required the reintroduction of withdrawn treatments, and a decrease in quality of life is possible. CONCLUSIONS: As it did not reach its recruitment target, this trial should be seen as exploratory. Results indicate that, following a NH-level deprescribing intervention, a resident-level intervention can further reduce some aspects of PIMs use. Great attention must be paid to residents' well-being when further developing such deprescribing interventions, as a possible reduction in quality of life was found in the intervention group, and some participants suffered adverse events following deprescribing. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03688542, https://clinicaltrials.gov/ct2/show/NCT03688542 ), registered on 31.08.2018.

Effects of an interprofessional Quality Circle-Deprescribing Module (QC-DeMo) in Swiss nursing homes: a randomised controlled trial.

BACKGROUND: Potentially inappropriate medications (PIMs) are common among nursing homes (NH) residents, as is polypharmacy. Deprescribing has emerged in the past decade as a safe and effective way to reduce the use of PIMs and improve patient outcomes. However, effective deprescribing interventions are expensive, as they require specialised staff and a great amount of time for each resident. The Quality Circle Deprescribing Module (QC-DeMo) intervention was designed to be less resource-intensive than medication reviews, the current deprescribing gold standard. It consists of a QC session in which physicians, nurses, and pharmacists define a local deprescribing consensus for specific PIMs classes, which is then implemented in the NH. The intervention was trialled in a RCT, with the NH as unit of analysis. METHODS: After randomisation, intervention NHs enacted the QC-DeMo at the start of the follow-up year. The primary outcomes were the proportion of PIM galenic units and number of PIM defined daily dose per average resident and per day (DDD/res). PIM status was assessed by a combination of the 2015 Beers list and the Norwegian General Practice-Nursing Home criteria. Secondary outcomes were the number of DDD/res to avoid and to reevaluate; safety outcomes were mortality, hospitalisations, falls, and use of physical restraints. Outcomes were evaluated at follow-up using linear regression models, adjusting for the outcome baseline values. RESULTS: Fifty-eight NHs took part in the trial; no individual residents were recruited. The intervention did not reduce the primary outcomes, but a strong trend towards reduction was seen for the number of PIM DDD/res, which accounts for the doses used. PIM DDD/res to reevaluate were significantly reduced, mostly through a reduction in the use of proton-pump inhibitors. Falls and use of physical restraints were not affected, but a statistical interaction between the mission of the NH (geriatric unit or specialised dementia unit) and the intervention group was seen for mortality and hospitalisations. CONCLUSIONS: The QC-DeMo intervention can reduce the use of some PIM classes, and could usefully complement other deprescribing interventions. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT03688542 ), registered on 26.09.2018, retrospectively registered.

Cross-cultural adaptation and psychometric validation of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire in French.

BACKGROUND: The revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire allows capture of the beliefs and attitudes of older adults and caregivers towards deprescribing. OBJECTIVES: To translate and validate the rPATD questionnaire into French. METHODS: The French rPATD was translated using forward-backward translation. Psychometric properties were evaluated in both older adults ≥65 years living in the community or in institutions and who were taking at least one chronic medication and in caregivers of older adults with similar characteristics. Participants were recruited in four French-speaking countries (Belgium, Canada, France and Switzerland). Face and content validity were assessed during the translation process. Construct validity (exploratory factor analysis (EFA)) and internal consistency (Cronbach's alpha) were investigated in questionnaires without missing data. Test-retest reliability was evaluated using intra-class correlation coefficient (ICC) in a sample of participants. RESULTS: In total, 320 questionnaires from older adults and 215 questionnaires from caregivers were included to evaluate construct validity and internal consistency. EFA extracted four factors in the older adults' and caregivers' versions of the questionnaire consistent with the English rPATD. The extracted factors related to the perceived burden of medication taking, the beliefs in appropriateness of medications, concerns about stopping medications and the level of involvement in making decisions and of knowledge of medications. Internal consistency was satisfactory for three factors for both versions (Cronbach's alpha >0.70), with lower internal consistency in the concerns about stopping factor. Test-retest reliability was overall good for all factors in the caregivers' version (ICC > 0.75) while for the older adults' version, moderate (ICC range: 0.75-0.50) to good ICC values were found. CONCLUSIONS: The French rPATD presents globally good psychometric properties and can be used to explore attitudes towards deprescribing in French-speaking older adults and caregivers.

Evolution of potentially inappropriate medication use in nursing homes: Retrospective analysis of drug consumption data.

BACKGROUND: The use of potentially inappropriate medication (PIMs) is frequent in nursing homes (NHs), and leads to worsened health outcomes for their residents. Numerous initiatives to curb their use have been launched. Most studies of PIMs use in NHs, however, focused on their prevalence, and provide few insights on the evolution of their use. OBJECTIVE: The objective of this analysis is to measure the evolution of PIMs use in the nursing NHs of western Switzerland taking part in an integrated pharmacy service (IPS). METHODS: Drug consumption data from 166 NHs were collected for 2014 to 2018, through the monitoring of the IPS. These data were cross-referenced with validated PIMs lists (Beers' list and Norwegian General Practice-Nursing Home, NORGEP-NH) to compute the number of potentially inappropriate defined daily doses per average resident (DDD/res) in each NH. Linear mixed-effects models were used to assess the evolution of PIMs use over time, following the NORGEP-NH classification of PIMs and the drug classes involved. RESULTS: In 2018, the number of DDD/res was 7.3 (SD 1.9); of those, 2.2 (SD 0.8) were potentially inappropriate. Psycholeptics, psychoanaleptics and antihypertenseives were the most-used PIMs. Between 2014 and 2018, the number of potentially inappropriate DDD/res decreased by 0.03 per year (CI95 [-0.05; -0.01]). CONCLUSIONS: This study complements others that focused on the prevalence of PIMs use in NHs. The statistically significant reduction in the use of PIMs is an encouraging sign, but is probably not clinically meaningful for NH residents. With the growing concerns of the potential harms of these drugs, more specific interventions and implementation strategies need to be developed to help clinicians further reduce their use in NHs.

Deprescribing in nursing homes: Protocol for nested, randomised controlled hybrid trials of deprescribing interventions.

INTRODUCTION: Polypharmacy and the use of potentially inappropriate medication (PIMs) are frequent among nursing home (NH) residents, and are associated with adverse health outcomes like falls, hospitalisation and death. Deprescribing has been proposed as a way to curtail both problems; however, the best way to implement deprescribing and its real impact are still unclear. This article describes nested trials of two consecutive deprescribing interventions, the first at the NH level, and the second at the resident level. METHODS AND ANALYSIS: The first intervention (QC-DeMo) will be a deprescribing module to be carried out in existing interprofessional quality circles in NHs, with the goal to develop a NH-wide deprescribing consensus. Its effects will be evaluated on the use of PIMs and on patient safety outcomes such as death, hospitalisation and falls. All NHs in the cantons of Vaud and Fribourg with an integrated pharmacy service will be eligible. The second intervention (IDeI), at the resident level, will be a deprescribing-focused medication review, resulting in the implementation of a deprescribing plan. Its effects will be evaluated on the use of PIMs and chronic medications, and on quality of life. This second trial will take place in the NHs allocated to the intervention group of the first trial. All residents of these NHs over 65 years old, living in the NH for at least 4 months, and taking 5 or more medications will be eligible to participate. Both trials will be hybrid effectiveness and implementation trials, aiming to understand the implementation process for the interventions, and to identify barriers and facilitators. ETHICS, REGISTRATION AND FUNDING: Both trials were approved by the relevant ethics committee, registered on ClinicalTrials.gov (QC-DeMo: NCT03688542; IDeI: NCT03655405), and funded by the Swiss National Fund for Scientific Research.

[Deprescribing in nursing homes: comparative views of residents, their relatives, and healthcare professionals]. / Déprescrire en EMS: regards croisés entre les résidents, leurs proches et les professionnels de la santé.

Deprescribing, in order to reduce both polypharmacy and the use of potentially inappropriate medications, remains a challenge, especially in nursing homes. Healthcare professionals perceive residents of these homes as wary of change and reluctant to take part in such endeavours. The results of two studies, one qualitative and the other quantitative, show that, on the contrary, nursing home residents and their relatives would be ready to consider a treatment reduction, provided that time is invested to explain the expected benefits of such changes.

Déprescrire pour réduire l'usage de médicaments inappropriés et, plus généralement, diminuer la polymédication reste un défi, en particulier chez les résidents d'établissements médico-sociaux. Les professionnels de la santé actifs en institution perçoivent cette population comme réticente au changement et peu encline à s'engager dans une telle démarche. Pourtant, les résultats de trois études, les deux premières qualitatives, la dernière quantitative, indiquent que ces résidents, ainsi que leurs proches, seraient prêts à tester une réduction de leur traitement, pour autant que l'on prenne le temps de discuter avec eux des bénéfices potentiels.

Physicians', Nurses' and Pharmacists' Perceptions of Determinants to Deprescribing in Nursing Homes Considering Three Levels of Action: A Qualitative Study.

Background: Polypharmacy and the use of potentially inappropriate medications are frequent safety issues among nursing home (NH) residents. Deprescribing can significantly reduce the number of drugs used, medication costs, and mortality. This qualitative study sought to understand and compare the perceptions and practices of nurses, pharmacists, and physicians regarding deprescribing in Swiss NHs, referring to an implementation approach on three levels of action: the individual, the institution, and the healthcare system. Methods: Two focus groups were held with 21 participants: one focus group with 11 pharmacists, another with 10 nurses and six semi-structured interviews with physicians were conducted and focused on their individual experience and practices. They were audiotaped and fully transcribed, and a content analysis was performed using to MAXQDA (Ver 12) software. Results: (1) At an individual level, physicians were concerned by consequences of deprescribing in terms of safety. Nurses were closest to residents and stressed the importance of finding the right time, creating a bond of trust before deprescribing and considering the purpose of the stay in the NH. Pharmacists relied on structured guides for deprescribing, which led their reflection and practice. All professionals saw the complexity of the clinical situations, as well as residents' and relatives' fears of interruption of care. (2) At an institutional level, the professionals stressed the lack of time to discuss patients' health and treatment, while pre-existing interprofessional collaboration, specifically, quality circles, seemed useful tools to create common knowledge. In order to reduce prescriptions, better coordination between physicians, nurses, pharmacists and specialists seemed crucial. (3) At the health system level, funding still needs to be provided to consolidate the process, go beyond organisational constraints and ensure deprescribing serves the patient's wellbeing above all. Conclusions: At the individual level of implementation, the different healthcare professionals expressed specific concerns about deprescribing, depending on their defined role in NHs. Their perspective about the different levers to promote deprescribing at institutional and healthcare system levels converge towards interprofessional collaboration supported by the healthcare system. Specific funding and incentives are therefore needed to support a sustainable interprofessional team.

Decrease in Antibacterial Use and Facility-Level Variability After the Introduction of Guidelines and Implementation of Physician-Pharmacist-Nurse Quality Circles in Swiss Long-term Care Facilities.

OBJECTIVES: The objective of this study is to describe antibacterial use in long-term care facilities and to investigate the determinants of use. DESIGN: This study is a quality improvement study conducted from January 2011 to December 2016. SETTING: Long-term care facilities in the canton of Vaud, Western Switzerland, were investigated. PARTICIPANTS: Twenty-three long-term care facilities were included in this study. INTERVENTION: The intervention included the publication of local guidelines on empirical antibacterial therapy and the implementation of physician-pharmacist-nurse quality circles. MEASURES: The main outcome was antibacterial use, expressed as defined daily doses (DDD) per 1000 beds per day. Statistical analyses were performed through a 1-level mixed model for repeated measurements. RESULTS: Antibacterial use decreased from 45.6 to 35.5 DDD per 1000 beds per day (-22%, P < .01) over the 6-year study period, which was mostly explained by reduced fluoroquinolone use (-59%, P < .001). A decrease in range of use among LTCFs was observed during the study period, and 27% of antibacterial use was related to the WATCH group (antibiotics with higher toxicity concerns and/or resistance potential) according to the AWaRe categorization of the WHO, decreasing from 17.3 DDD per 1000 beds per day to 9.5 (-45%) over the study period. The use of antibacterials from the RESERVE group ("last-resort" treatment options) was very low. CONCLUSION AND IMPLICATIONS: A reduction in facility-level antibacterial use and in variability across LTCFs was observed over the study period. The dissemination of empirical antibacterial prescription guidelines and the implementation of physician-pharmacist-nurse quality circles in all LTCFs of the canton of Vaud likely contributed to this reduction. Antibacterials from the WATCH group still represented 27% of the total use, providing targets for future antibiotic stewardship activities.

Immunosuppressive therapy after solid-organ transplantation: does the INTERMED identify patients at risk of poor adherence?

Background: Lack of adherence to medication is a trigger of graft rejection in solid-organ transplant (SOT) recipients. Objective: This exploratory study aimed to assess whether a biopsychosocial evaluation using the INTERMED instrument before transplantation could identify SOT recipients at risk of suboptimal post-transplantation adherence to immunosuppressant drugs. We hypothesized that complex patients (INTERMED>20) might have lower medication adherence than noncomplex patients (INTERMED≤20). Methods: Each patient eligible for transplantation at the University Hospital of Lausanne, Switzerland, has to undergo a pre-transplantation psychiatric evaluation. In this context the patient was asked to participate in our study. The INTERMED was completed pre-transplantation, and adherence to immunosuppressive medication was monitored post-transplantation by electronic monitors for 12 months. The main outcome measure was the implementation and persistence to two calcineurin inhibitors, cyclosporine and tacrolimus, according to the dichotomized INTERMED score (>20 or ≤20). Results: Among the 50 SOT recipients who completed the INTERMED, 32 entered the study. The complex (N=11) and noncomplex patients (N=21) were similar in terms of age, sex and transplanted organ. Implementation was 94.2% in noncomplex patients versus 87.8% in complex patients (non-significant p-value). Five patients were lost to follow-up: one was non-persistent, and four refused electronic monitoring. Of the four patients who refused monitoring, two were complex and withdrew early, and two were noncomplex and withdrew later in the study. Conclusion: Patients identified as complex pre-transplant by the INTERMED tended to deviate from their immunosuppressant regimen, but the findings were not statistically significant. Larger studies are needed to evaluate this association further, as well as the appropriateness of using a nonspecific biopsychosocial instrument such as INTERMED in highly morbid patients who have complex social and psychological characteristics (AU)

No disponible

[Antimicrobial stewardship in primary care setting]. / Antimicrobial stewardship en pratique communautaire.

Antibiotic overuse in primary care setting is a major contributor to the development of resistant bacteria. Antibiotic consumption is low in Switzerland compared to neighbour countries, but improvement is possible and has to be pursued. Antibiotic stewardship helps physician to better recognize patients who need antibiotic (guidelines implementation, electronic decision support and laboratory testing) and educate patients about the uselessness of antibiotics in a given situation (delayed prescription and shared decision making). Clinical studies demonstrated the efficacy of these interventions in reducing antibiotic consumption, mainly in acute respiratory infections, without affecting patients' clinical outcome.

Immunosuppressive therapy after solid-organ transplantation: does the INTERMED identify patients at risk of poor adherence?

BACKGROUND: Lack of adherence to medication is a trigger of graft rejection in solid-organ transplant (SOT) recipients. OBJECTIVE: This exploratory study aimed to assess whether a biopsychosocial evaluation using the INTERMED instrument before transplantation could identify SOT recipients at risk of suboptimal post-transplantation adherence to immunosuppressant drugs. We hypothesized that complex patients (INTERMED>20) might have lower medication adherence than noncomplex patients (INTERMED≤20). METHODS: Each patient eligible for transplantation at the University Hospital of Lausanne, Switzerland, has to undergo a pre-transplantation psychiatric evaluation. In this context the patient was asked to participate in our study. The INTERMED was completed pre-transplantation, and adherence to immunosuppressive medication was monitored post-transplantation by electronic monitors for 12 months. The main outcome measure was the implementation and persistence to two calcineurin inhibitors, cyclosporine and tacrolimus, according to the dichotomized INTERMED score (>20 or ≤20). RESULTS: Among the 50 SOT recipients who completed the INTERMED, 32 entered the study. The complex (N=11) and noncomplex patients (N=21) were similar in terms of age, sex and transplanted organ. Implementation was 94.2% in noncomplex patients versus 87.8% in complex patients (non-significant p-value). Five patients were lost to follow-up: one was non-persistent, and four refused electronic monitoring. Of the four patients who refused monitoring, two were complex and withdrew early, and two were noncomplex and withdrew later in the study. CONCLUSION: Patients identified as complex pre-transplant by the INTERMED tended to deviate from their immunosuppressant regimen, but the findings were not statistically significant. Larger studies are needed to evaluate this association further, as well as the appropriateness of using a nonspecific biopsychosocial instrument such as INTERMED in highly morbid patients who have complex social and psychological characteristics.

Relationship between drug-related problems and health outcomes: a cross-sectional study among cardiovascular patients.

OBJECTIVE: To describe drug-related problems (DRPs) and expense problems (EPs) identified by a standardised community pharmacist-based medication review (MR) program among Swiss cardiovascular outpatients (56-75 years old) and to evaluate the need for collaborative pharmacy practice to achieve economic, clinical and humanistic outcomes. SETTING: A pilot population of 85 cardiovascular outpatients who were customers of 14 community pharmacies (members of the pharmacieplus virtual chain) and insured with Groupe Mutuel health insurance. METHOD: Cross-sectional study of a structured medication review program, conducted by 11 pharmacists in collaboration with 61 general practitioners (GPs), with patient interviews and access to medical data. MAIN OUTCOME MEASURE: Numbers and types of DRPs and EPs within the study population and odds ratios between them, as well as economic, clinical and humanistic outcomes. RESULTS: Of the included patients, 91% had at least one DRP or EP. The odds ratios indicated that not being exposed to DRPs was associated with a higher chance of reaching the clinical target (OR: 3.4; IC95%:1.1-10.5; P = 0.01), of having a better physical quality of life than the median (OR: 2.5; IC95%: 0.9-7.3; P = 0.05) and having lower total health care costs (OR: 3.2; IC95%:1.1-9.8; P = 0.02). CONCLUSIONS: This cross-sectional study shows that the control of cardiovascular risk factors, quality of life and healthcare costs are statistically related to the presence of DRPs detected by a community pharmacist-based MR program.

The nine-year sustained cost-containment impact of swiss pilot physicians-pharmacists quality circles.

BACKGROUND: Six pioneer physicians-pharmacists quality circles (PPQCs) located in the Swiss canton of Fribourg (administratively corresponding to a state in the US) were under the responsibility of 6 trained community pharmacists moderating the prescribing process of 24 general practitioners (GPs). PPQCs are based on a multifaceted collaborative process mediated by community pharmacists for improving compliance with clinical guidelines within GPs' prescribing practices. OBJECTIVE: To assess, over a 9-year period (1999-2007), the cost-containment impact of the PPQCs. METHODS: The key elements of PPQCs are a structured continuous quality improvement and education process; local networking; feedback of comparative and detailed data regarding costs, drug choice, and frequency of prescribed drugs; and structured independent literature review for interdisciplinary continuing education. The data are issued from the community pharmacy invoices to the health insurance companies. The study analyzed the cost-containment impact of the PPQCs in comparison with GPs working in similar conditions of care without particular collaboration with pharmacists, the percentage of generic prescriptions for specific cardiovascular drug classes, and the percentage of drug costs or units prescribed for specific cardiovascular drugs. RESULTS: For the 9-year period, there was a 42% decrease in the drug costs in the PPQC group as compared to the control group, representing a $225,000 (USD) savings per GP only in 2007. These results are explained by better compliance with clinical and pharmacovigilance guidelines, larger distribution of generic drugs, a more balanced attitude toward marketing strategies, and interdisciplinary continuing education on the rational use of drugs. CONCLUSIONS: The PPQC work process has yielded sustainable results, such as significant cost savings, higher penetration of generics and reflection on patient safety, and the place of "new" drugs in therapy. The PPQCs may also constitute a solid basis for implementing more comprehensive collaborative programs, such as medication reviews, adherence-enhancing interventions, or disease management approaches.

Medication reviews led by community pharmacists in Switzerland: a qualitative survey to evaluate barriers and facilitators / Revisiones de medicación realizadas por farmacéuticos comunitarios en Suiza: estudio cualitativo para evaluar barreras y facilitadores

Objective: 1) To evaluate the participation rate and identify the practical barriers to implementing a community pharmacist-led medication review service in francophone Switzerland and, 2) To assess the effectiveness of external support. Methods: A qualitative survey was undertaken to identify barriers to patient inclusion and medication review delivery in daily practice among all contactable independent pharmacists working in francophone Switzerland (n=78) who were members of a virtual chain (pharmacieplus), regardless of their participation in a simultaneous cross-sectional study. This study analyzed the dissemination of a medication review service including a prescription and drug utilization review with access to clinical data, a patient interview and a pharmaceutical report to the physicians. In addition, we observed an exploratory and external coaching for pharmacists that we launched seven months after the beginning of the cross-sectional study. Results: Poor motivation on the part of pharmacists and difficulties communicating with physicians and patients were the primary obstacles identified. Lack of time and lack of self-confidence in administering the medication review process were the most commonly perceived practical barriers to the implementation of the new service. The main facilitators to overcome these issues may be well-planned workflow organization techniques, strengthened by an adequate remuneration scheme and a comprehensive and practice-based training course that includes skill-building in pharmacotherapy and communication. External support may partially compensate for a weak organizational framework. Conclusions: To facilitate the implementation of a medication review service, a strong local networking with physicians, an effective workflow management and a practice- and communications-focused training for pharmacists and their teams seem key elements required. External support can be useful to help some pharmacists improve their service management skills. Adequate remuneration seems necessary to encourage initial investments to provide such a service. Future research in this area may help improve the process and design of training programs, as well as the monitoring of implementation for each new pharmaceutical service (AU)

Objetivo: 1) Evaluar la tasa de participación e identificar las barreras para implantar un servicio de revisión de la medicación realizado por farmacéuticos comunitarios en la Suiza francófona y, 2) evaluar la efectividad del apoyo externo. Métodos: Todas las farmacias independientes contactables que trabajan en la Suiza francófona (n=78) que eran miembros de la cadena virtual (pharmacieplus), independientemente de su participación en un estudio transversal simultáneo que analizaba la diseminación del servicio de revisión de la medicación, que incluye la revisión de la prescripción y de la utilización de medicamentos con acceso a datos clínicos, entrevista a paciente y un informe de los farmacéuticos a los médicos. Se realizó un estudio cualitativo para identificar las barreras para la inclusión de pacientes y la provisión de revisión de la medicación en la práctica diaria. Además, analizamos un entrenador externo para farmacéutico que lanzamos siete meses después del estudio transversal. Resultados: La pobre motivación por parte de los farmacéuticos y las dificultades de comunicación con los médicos y los pacientes fueron los obstáculos principales identificados. La falta de tiempo y la falta de auto-confianza en la provisión del servicio de revisión de la medicación fueron las barreras prácticas más percibidas para la implantación del nuevo servicio. Los principales facilitadores para resolver estos problemas podrían ser las técnicas de organización de flujos de trabajo bien planeadas, el refuerzo por un esquema de remuneración adecuado, y cursos de entrenamiento intensivos y basados en la práctica que incluyesen creación de habilidades en farmacoterapia y comunicación. El apoyo externo puede compensar parcialmente una estructura organizacional débil. Conclusiones: Para facilitar la implantación de un servicio de revisión de la medicación parecen ser elementos clave necesarios un contacto fuerte con los médicos locales, una gestión efectiva y práctica del flujo de trabajos y una formación centrada en práctica y comunicación para los farmacéuticos. El apoyo externo puede ser útil para ayudar a algunos farmacéuticos a mejorar las habilidades de gestión del servicio. La remuneración adecuada parece ser necesaria para animar a las inversiones iniciales para proporcionar este servicio. La investigación futura podría ayudar a mejorar el proceso y el diseño de los programas de formación, así como monitorizar la implementación de cada nuevo servicio farmacéutico (AU)