Patterns and Behavioural Outcomes of Antipsychotic Use among Nursing Home Residents: a Canadian and Swiss Comparison

Background. Although antipsychotic medications are primarily intended to treat schizophrenia and psychotic symptoms in adults, they are commonly administered to nursing home residents as pharmacotherapy for "off-label" indications such as disruptive behaviour. However, clinical trials have demonstrated limited efficacy and serious side-effects of antipsychotics among the elderly. As previous studies have reported inappropriate use in several countries, their use in nursing home residents ought to be monitored to detect and reduce inappropriate administration. Objectives. The aim of this study was a) to determine and compare prevalence rates of antipsychotic use in Ontario and Swiss nursing homes, b) to identify determinants of antipsychotics use in these two countries, by means of a cross-sectional design, and c) to investigate the impact of antipsychotic use on behaviours over time in Ontario and Swiss residents, by means of a longitudinal design. Methods. This study involved secondary data analysis of 1932 residents from 24 nursing homes in the province of Ontario in Canada and 1536 residents from 4 nursing homes in a German-speaking canton in Switzerland. Residents were assessed with the Minimum Data Set (MDS) tool. Resident characteristics and prevalence rates were compared internationally with the chi-square test. Demographic and clinical determinants of antipsychotic use, as well as behavioural change associated with antipsychotics, were analyzed using logistic regression. Results. Although Ontario nursing home residents had an overall heavier-care profile than Swiss residents, antipsychotics were administered to 25% of the Ontario residents compared to 29. 5% of the Swiss residents. The adjusted rate among residents without appropriate conditions was also lower in Ontario (14%) than in Switzerland (24. 5%). Apart from schizophrenia, bipolar disorder and cognitive impairment, antipsychotic use was determined by a different range of characteristics in these two countries. Antipsychotic use was not predictive of behavioural improvement. Conclusion. The high adjusted rates of antipsychotic use in Ontario and Swiss nursing home residents, as well as the presence of "inappropriate indications" and "facility" as determinants of their use, raise concerns about the appropriateness of their administration in both countries. Their lack of effectiveness to improve behaviours also questions their use as long-term treatment for behaviour disturbances. Changes in practice patterns and implementation of policies are warranted to reduce inappropriate prescribing practices to enhance the quality of care provided to residents in nursing homes

Les enquêtes SCAPE en Suisse. Recueillir l’opinion des patient∙es : pourquoi et comment ?

Les opinions des patient∙es sont cruciales pour personnaliser les soins, favoriser la prise de décisions partagée et encourager l’engagement des patient∙es. La collecte systématique et à large échelle de ces opinions permettent d’évaluer l’impact des soins sur la santé (PROMs) et l’expérience des patient∙es avec le système de soins (PREMs). Les enquêtes SCAPE visent à recueillir et analyser systématiquement l’expérience des patient·es atteint·es de cancer, fournissant des données essentielles pour améliorer la qualité des soins en oncologie

How are "teaching the teachers" courses in evidence based medicine evaluated? A systematic review

Background Teaching of evidence-based medicine (EBM) has become widespread in medical education. Teaching the teachers (TTT) courses address the increased teaching demand and the need to improve effectiveness of EBM teaching. We conducted a systematic review of assessment tools for EBM TTT courses. To summarise and appraise existing assessment methods for teaching the teachers courses in EBM by a systematic review. Methods We searched PubMed, BioMed, EmBase, Cochrane and Eric databases without language restrictions and included articles that assessed its participants. Study selection and data extraction were conducted independently by two reviewers. Results Of 1230 potentially relevant studies, five papers met the selection criteria. There were no specific assessment tools for evaluating effectiveness of EBM TTT courses. Some of the material available might be useful in initiating the development of such an assessment tool. Conclusion There is a need for the development of educationally sound assessment tools for teaching the teachers courses in EBM, without which it would be impossible to ascertain if such courses have the desired effect

Responsiveness of cancer care in Switzerland through patients’ eyes: a study of patient-reported experiences of care (PREMs)

Patients’ perspectives on the care they receive have become central to health services research, as well as performance measurement and quality improvement. These perspectives, termed patient- reported experience measures (PREMs) when collected with patient experience surveys, are essential to evaluate responsiveness of care, one of the core dimensions of the quality of health services. As there were no information nor research on PREMs in cancer care in Switzerland, the objectives of this thesis were 1) to evaluate responsiveness of cancer care by collecting and analyzing PREMs with the Swiss CAncer Patient Experiences (SCAPE) study, 2) to study the added-value of free-text comments written at the end of the questionnaire, 3) to examine the association between experiences of care and type of cancer and patient characteristics, and 4) to develop policy recommendations for further actions related to the collection and use of cancer PREMs in a policy brief. First, we observed from the 2755 participants of the cross-sectional SCAPE study diagnosed with one of the six most frequent cancers (breast, prostate, lung, colon, skin and blood) that overall rating of cancer care was fairly high, with an average score of 8.5 on a 0 (worst) to 10 (best) scale. While the rates of positive experiences of care were high for nurse consultations, diagnostic tests and inpatient care, they were lower for experiences related to communication, information and supportive care issues. Second, the computer-assisted textual analyses of the free-text comments showed that they provided additional understandings on the personal experience of living with cancer that complemented the quantitative information collected with PREMs. Third, we observed from multiple logistic regressions that experiences of care differed by type of cancer, without being systematically more positive (or negative) for one type of cancer. In addition, poor self-reported health, low health literacy, and financial hardship were three characteristics associated with lower overall rating of care and less positive experiences of care. Finally, we provided two recommendations in the policy brief, discussed and approved by eleven stakeholders during a dialogue: i) develop a position statement on the importance and value of patients’ experiences of cancer care, and ii) collect patients’ experiences of cancer care on a large scale by implementing a national survey. The SCAPE study was the first investigation of patient-reported experiences of cancer care that went beyond institutional and monocentric surveys in Switzerland. It contributed to giving cancer patients a voice and allowed to evaluate whether current cancer care was responding to their needs. This thesis generated new knowledge about PREMs in cancer care and their determinants, while offering guidance for improvement initiatives in clinical care and guidance for policymakers. This work has also led to changes in clinical practice in participating hospitals and to further research on the responsiveness of cancer care, with the SCAPE-2 and SCAPE-CH surveys. -- Les points de vue des patient∙e∙s sur les soins qu'ils/elles reçoivent sont devenus un élément central de la recherche sur les services de santé, ainsi que de la mesure de leur performance et de l'amélioration de la qualité. Ces points de vue, appelés mesures d’expériences de soins rapportées par les patient∙e∙s (PREMs en anglais) lorsqu’ils sont recueillis au moyen d'enquêtes, sont essentiels pour évaluer si les soins répondent aux besoins des patient∙e∙s, l'une des dimensions fondamentales de la qualité des services de santé. En raison du manque d'information et de recherche sur les PREMs en oncologie en Suisse, les objectifs de cette thèse étaient 1) d’évaluer si les soins oncologiques répondent aux besoins des patient∙e∙s en collectant et analysant les PREMs recueillies avec l'enquête Swiss CAncer Patient Experiences (SCAPE), 2) d'étudier l’apport des commentaires libres notés à la fin du questionnaire, 3) d'examiner l'association entre les expériences de soins et le type de cancer et les caractéristiques des patient∙e∙s, et 4) de développer des recommandations d’actions liées à la collecte et l'utilisation des PREMs en oncologie dans une note d’orientation (policy brief en anglais). Premièrement, nous avons observé à partir des 2755 participant∙e∙s à l’étude transversale SCAPE atteint∙e∙s d’un des six cancers les plus fréquents (sein, prostate, poumon, colon, peau et sang) que l'évaluation globale des soins contre le cancer était assez élevée, avec un score moyen de 8.5 sur une échelle de 0 (pire) à 10 (meilleur). Si les proportions d'expériences positives étaient élevées pour les consultations infirmières, les tests diagnostiques et les soins durant l’hospitalisation, elle étaient plus faibles pour les expériences liées aux questions de communication, d'information et de soins de support. Deuxièmement, l’analyse textuelle assistée par ordinateur des commentaires libres a montré que ces derniers apportaient une compréhension additionnelle sur l'expérience de la vie avec le cancer qui complétaient les informations quantitatives recueillies avec les PREMs. Troisièmement, les régressions logistiques multiples ont révélé que les expériences de soins différaient selon le type de cancer, sans être systématiquement plus positives (ou négatives) pour un type de cancer. En outre, un mauvais état de santé, une faible littératie en santé et une précarité financière étaient trois caractéristiques fréquemment associées à une moins bonne évaluation globale des soins et à des expériences spécifiques de soins moins positives. Enfin, nous avons émis deux recommandations dans la note d'orientation, discutées et approuvées par onze parties prenantes lors d'un dialogue : i) élaborer une prise de position sur l'importance et la valeur des expériences de soins des personnes atteintes de cancer, et ii) recueillir ces expériences de soins oncologiques à large échelle par le biais d’une enquête nationale. L'étude SCAPE a été la première enquête sur les PREMs en oncologie à aller au-delà des enquêtes institutionnelles et monocentriques en Suisse. Elle a contribué à donner la parole aux patient∙e∙s atteint∙e∙s de cancer et d'évaluer si les soins actuels contre le cancer répondaient à leurs besoins. La thèse a généré de nouvelles connaissances sur les PREMs en oncologie et leurs déterminants, tout en suggérant des pistes d'amélioration des soins oncologiques et des conseils pour les décideur∙se∙s politiques. Ce travail a également conduit à des changements de pratique clinique dans les hôpitaux participants et à d'autres recherches sur les PREMs en oncologie, avec les enquête SCAPE-2 et SCAPE-CH

Patterns and Behavioural Outcomes of Antipsychotic Use among Nursing Home Residents: a Canadian and Swiss Comparison

I hereby declare that I am the sole author of this thesis. This is a true copy of the thesis, including any required final revisions, as accepted by my examiners. I understand that my thesis may be made electronically available to the public. ii Background. Although antipsychotic medications are primarily intended to treat schizophrenia and psychotic symptoms in adults, they are commonly administered to nursing home residents as pharmacotherapy for “off-label ” indications such as disruptive behaviour. However, clinical trials have demonstrated limited efficacy and serious side-effects of antipsychotics among the elderly. As previous studies have reported inappropriate use in several countries, their use in nursing home residents ought to be monitored to detect and reduce inappropriate administration. Objectives. The aim of this study was a) to determine and compare prevalence rates of antipsychotic use in Ontario and Swiss nursing homes, b) to identify determinants of antipsychotics use in these two countries, by means of a cross-sectional design, and c) to investigate the impact of antipsychotic use on behaviours over time in Ontario and Swiss residents, by means of a longitudinal design