Using sociotechnical theory to understand medication safety work in primary care and prescribers' use of clinical decision support: a qualitative study.

OBJECTIVES: The concept of safety work draws attention to the intentional work of ensuring safety within care systems. Clinical decision support (CDS) has been designed to enhance medication safety in primary care by providing decision-making support to prescribers. Sociotechnical theory understands that healthcare settings are complex and dynamically connected systems of fluid networks, human agents, changing relationships and social processes. This study aimed to understand the relationship between safety work and the use of CDS. DESIGN AND SETTING: This qualitative study took place across nine different general practices in England. Stakeholders included general practitioners (GPs) and general practice-based pharmacists and nurse prescribers. Semi-structured interviews were conducted to illicit how the system was used by the participants in the context of medication safety work. Data analysis conducted alongside data collection was thematic and drew on socio-technical theory. PARTICIPANTS: Twenty-three interviews were conducted with 14 GPs, three nurse prescribers and three practice pharmacists between February 2018 and June 2020. RESULTS: Safety work was contextually situated in a complex network of relationships. Three interconnected themes were interpreted from the data: (1) the use of CDS within organisational and social practices and workflows; (2) safety work and the use of CDS within the interplay between prescribers, patients and populations; and (3) the affordances embedded in CDS systems. CONCLUSION: The use of sociotechnical theory here extends current thinking in patient safety particularly in the ways that safety work was co-constituted with the use of CDS alerts. This has implications for implementation and use to ensure that the contexts into which such CDS systems are implemented are taken into account. Understanding how alerts can adapt safety culture will help improve the efficacy of CDS systems, enhance prescribing safety and help to further understand how safety work is achieved in primary care.

Understanding factors that could influence patient acceptability of the use of the PINCER intervention in primary care: A qualitative exploration using the Theoretical Framework of Acceptability.

INTRODUCTION: Medication errors are an important cause of morbidity and mortality. The pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) intervention was shown to reduce medication errors when tested in a cluster randomised controlled trial and when implemented across one region of England. Now that it has been rolled out nationally, and to enhance findings from evaluations with staff and stakeholders, this paper is the first to report patients' perceived acceptability on the use of PINCER in primary care and proposes suggestions on how delivery of PINCER related care could be delivered in a way that is acceptable and not unnecessarily burdensome. METHODS: A total of 46 participants living with long-term health conditions who had experience of medication reviews and/or monitoring were recruited through patient participant groups and social media. Semi-structured, qualitative interviews and focus groups were conducted face-to-face or via telephone. A thematic analysis was conducted and findings mapped to the constructs of the Theoretical Framework of Acceptability (TFA). RESULTS: Two themes were identified and interpreted within the most relevant TFA construct: Perceptions on the purpose and components of PINCER (Affective Attitude and Intervention Coherence) and Perceived patient implications (Burden and Self-efficacy). Overall perceptions on PINCER were positive with participants showing good understanding of the components. Access to medication reviews, which PINCER related care can involve, was reported to be limited and a lack of consistency in practitioners delivering reviews was considered challenging, as was lack of communication between primary care and other health-care providers. Patients thought it would be helpful if medication reviews and prescription renewal times were synchronised. Remote medication review consultations were more convenient for some but viewed as a barrier to communication by others. It was acknowledged that some patients may be more resistant to change and more willing to accept changes initiated by general practitioners. CONCLUSIONS: Participants found the concept of PINCER acceptable; however, acceptability could be improved if awareness on the role of primary care pharmacists is raised and patient-pharmacist relationships enhanced. Being transparent with communication and delivering streamlined and consistent but flexible PINCER related care is recommended.

Understanding factors influencing uptake and sustainable use of the PINCER intervention at scale: A qualitative evaluation using Normalisation Process Theory.

INTRODUCTION: Medication errors are an important cause of morbidity and mortality. The pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) has demonstrated improvements in primary care medication safety, and whilst now the subject of national roll-out its optimal and sustainable use across health contexts has not been fully explored. As part of a qualitative evaluation we aimed to identify factors influencing successful adoption, embedding and sustainable use of PINCER across primary care settings in England, UK. METHODS: Semi-structured face-to-face or telephone interviews, including follow-up interviews and an online survey were conducted with professionals knowledgeable of PINCER. Interview recruitment targeted four early adopter regions; the survey was distributed nationally. Initial data analysis was inductive, followed by analysis using a coding framework. A deductive matrix approach was taken to map the framework to the Normalisation Process Theory (NPT). Themes were then identified. RESULTS: Fifty participants were interviewed, 18 participated in a follow-up interview. Eighty-one general practices and three Clinical Commissioning Groups completed the survey. Four themes were identified and interpreted within the relevant NPT construct: Awareness & Perceptions (Coherence), Receptivity to PINCER (Cognitive Participation), Engagement [Collective Action] and Reflections & Adaptations (Reflexive Monitoring). Variability was identified in how PINCER awareness was raised and how staff worked to operationalise the intervention. Facilitators for use included stakeholder investment, favourable evidence, inclusion in policy, incentives, fit with individual and organisational goals and positive experiences. Barriers included lack of understanding, capacity concerns, operational difficulties and the impact of COVID-19. System changes such as adding alerts on clinical systems were indicative of embedding and continued use. CONCLUSIONS: The NPT helped understand motives behind engagement and the barriers and facilitators towards sustainable use. Optimising troubleshooting support and encouraging establishments to adopt an inclusive approach to intervention adoption and utilisation could help accelerate uptake and help establish ongoing sustainable use.

Strategies supporting sustainable prescribing safety improvement interventions in English primary care: a qualitative study.

BACKGROUND: While the use of prescribing safety indicators (PSI) can reduce potentially hazardous prescribing, there is a need to identify actionable strategies for the successful implementation and sustainable delivery of PSI-based interventions in general practice. AIM: To identify strategies for the successful implementation and sustainable use of PSI-based interventions in routine primary care. DESIGN & SETTING: Qualitative study in primary care settings across England. METHOD: Anchoring on a complex pharmacist-led IT-based intervention (PINCER) and clinical decision support (CDS) for prescribing and medicines management, a qualitative study was conducted using sequential, multiple methods. The methods comprised documentary analysis, semi-structured interviews, and online workshops to identify challenges and possible solutions to the longer-term sustainability of PINCER and CDS. Thematic analysis was used for the documentary analysis and stakeholder workshops, while template analysis was used for the semi-structured interviews. Findings across the three methods were synthesised using the RE-AIM (reach, efficacy, adoption, implementation, and maintenance) framework. RESULTS: Forty-eight documents were analysed, and 27 interviews and two workshops involving 20 participants were undertaken. Five main issues were identified, which aligned with the adoption and maintenance dimensions of RE-AIM: fitting into current context (adoption); engaging hearts and minds (maintenance); building resilience (maintenance); achieving engagement with secondary care (maintenance); and emphasising complementarity (maintenance). CONCLUSION: Extending ownership of prescribing safety beyond primary care-based pharmacists, and achieving greater alignment between general practice and hospital prescribing safety initiatives, is fundamental to achieve sustained impact of PSI-based interventions in primary care.

Current COVID-19 treatments: Rapid review of the literature.

BACKGROUND: As SARS-CoV-2 continues to spread worldwide, it has already resulted in over 110 million cases and 2.5 million deaths. Currently, there are no effective COVID-19 treatments, although numerous studies are under way. SARS-CoV-2, however, is not the first coronavirus to cause serious outbreaks. COVID-19 can be compared with previous human coronavirus diseases, such as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), to better understand the development of treatments. METHODS: Databases Medline, Embase and WHO COVID-19 was systematically searched on 9 February 2021 for studies reporting on therapeutic effect of COVID-19 treatments. Clinical trials, case reports, observational studies and systematic reviews in the English language were eligible. RESULTS: 1416 studies were identified and 40 studies were included in this review. Therapies included are: remdesivir, convalescent plasma, hydroxychloroquine, lopinavir/ ritonavir, interferon, corticosteroids, cytokine storm inhibitors and monoclonal antibodies. Remdesivir, convalescent plasma and interferon seems to provide some clinical benefits such as faster recovery time and reduced mortality, but these effects are not clinically significant. Some corticosteroids are effective in reducing mortality in severe COVID-19 patients. Hydroxychloroquine do not convey any beneficial, and therapies such as cytokine storm inhibitors and monoclonal antibodies were also not effective and require further investigation. CONCLUSIONS: There is no single therapy effective against COVID-19. However, a combination of therapies administered at different stages of infection may provide some benefit. This conclusion is reflected in the limited effects of these treatments in previous human coronaviruses.

The implementation, use and sustainability of a clinical decision support system for medication optimisation in primary care: A qualitative evaluation.

BACKGROUND: The quality and safety of prescribing in general practice is important, Clinical decision support (CDS) systems can be used which present alerts to health professionals when prescribing in order to identify patients at risk of potentially hazardous prescribing. It is known that such computerised alerts may improve the safety of prescribing in hospitals but their implementation and sustainable use in general practice is less well understood. We aimed to understand the factors that influenced the successful implementation and sustained use in primary care of a CDS system. METHODS: Participants were purposively recruited from Clinical Commissioning Groups (CCGs) and general practices in the North West and East Midlands regions of England and from the CDS developers. We conducted face-to-face and telephone-based semi-structured qualitative interviews with staff stakeholders. A selection of participants was interviewed longitudinally to explore the further sustainability 1-2 years after implementation of the CDS system. The analysis, informed by Normalisation Process Theory (NPT), was thematic, iterative and conducted alongside data collection. RESULTS: Thirty-nine interviews were conducted either individually or in groups, with 33 stakeholders, including 11 follow-up interviews. Eight themes were interpreted in alignment with the four NPT constructs: Coherence (The purpose of the CDS: Enhancing medication safety and improving cost effectiveness; Relationship of users to the technology; Engagement and communication between different stakeholders); Cognitive Participation (Management of the profile of alerts); Collective Action (Prescribing in general practice, patient and population characteristics and engagement with patients; Knowledge);and Reflexive Monitoring (Sustaining the use of the CDS through maintenance and customisation; Learning and behaviour change. Participants saw that the CDS could have a role in enhancing medication safety and in the quality of care. Engagement through communication and support for local primary care providers and management leaders was considered important for successful implementation. Management of prescribing alert profiles for general practices was a dynamic process evolving over time. At regional management levels, work was required to adapt, and modify the system to optimise its use in practice and fulfil local priorities. Contextual factors, including patient and population characteristics, could impact upon the decision-making processes of prescribers influencing the response to alerts. The CDS could operate as a knowledge base allowing prescribers access to evidence-based information that they otherwise would not have. CONCLUSIONS: This qualitative evaluation utilised NPT to understand the implementation, use and sustainability of a widely deployed CDS system offering prescribing alerts in general practice. The system was understood as having a role in medication safety in providing relevant patient specific information to prescribers in a timely manner. Engagement between stakeholders was considered important for the intervention in ensuring prescribers continued to utilise its functionality. Sustained implementation might be enhanced by careful profile management of the suite of alerts in the system. Our findings suggest that the use and sustainability of the CDS was related to prescribers' perceptions of the relevance of alerts. Shared understanding of the purpose of the CDS between CCGS and general practices particularly in balancing cost saving and safety messages could be beneficial.

Risk factors for poor outcomes in hospitalised COVID-19 patients: A systematic review and meta-analysis.

BACKGROUND: Understanding the risk factors for poor outcomes among COVID-19 patients could help identify vulnerable populations who would need prioritisation in prevention and treatment for COVID-19. We aimed to critically appraise and synthesise published evidence on the risk factors for poor outcomes in hospitalised COVID-19 patients. METHODS: We searched PubMed, medRxiv and the WHO COVID-19 literature database for studies that reported characteristics of COVID-19 patients who required hospitalisation. We included studies published between January and May 2020 that reported adjusted effect size of any demographic and/or clinical factors for any of the three poor outcomes: mortality, intensive care unit (ICU) admission, and invasive mechanical ventilation. We appraised the quality of the included studies using Joanna Briggs Institute appraisal tools and quantitatively synthesised the evidence through a series of random-effect meta-analyses. To aid data interpretation, we further developed an interpretation framework that indicated strength of the evidence, informed by both quantity and quality of the evidence. RESULTS: We included a total of 40 studies in our review. Most of the included studies (29/40, 73%) were assessed as "good quality", with assessment scores of 80 or more. We found that male sex (pooled odds ratio (OR) = 1.32 (95% confidence interval (CI) = 1.18-1.48; 20 studies), older age (OR = 1.05, 95% CI = 1.04-1.07, per one year of age increase; 10 studies), obesity (OR = 1.59, 95% CI = 1.02-2.48; 4 studies), diabetes (OR = 1.25, 95% CI = 1.11-1.40; 11 studies) and chronic kidney diseases (6 studies; OR = 1.57, 95% CI = 1.27-1.93) were associated with increased risks for mortality with the greatest strength of evidence based on our interpretation framework. We did not find increased risk of mortality for several factors including chronic obstructive pulmonary diseases (5 studies), cancer (4 studies), or current smoker (5 studies); however, this does not indicate absence of risk due to limited data on each of these factors. CONCLUSION: Male sex, older age, obesity, diabetes and chronic kidney diseases are important risk factors of COVID-19 poor outcomes. Our review provides not only an appraisal and synthesis of evidence on the risk factors of COVID-19 poor outcomes, but also a data interpretation framework that could be adopted by relevant future research.