Factors affecting prescriber implementation of medication appropriateness recommendations in hospitalised older adults

Introduction: Despite the well-documented association between potentially inappropriate prescribing (PIP) and adverse outcomes for hospitalised older adults, the prevalence of PIP remains unacceptably high. Recommendations to improve medication appropriateness in hospital often come from sources external to the attending prescribing team, such as pharmacists and computerised system alerts. However, these recommendations to minimise PIP are not always implemented by prescribers, meaning that PIP can continue, thereby increasing the risk of adverse drug reactions (ADRs), rehospitalisation, and higher healthcare costs. Interventions with sufficiently high rates of adherence to medication appropriateness recommendations among prescribers are more likely to result in significantly improved patient outcomes in comparison to those interventions with lower implementation rates, which often show non-significant effects on key outcomes. Thus, it is imperative that prescribing optimisation interventions achieve sufficiently high prescriber implementation rates for these recommendations to be clinically effective. However, it is not always clear which specific intervention components are essential to high implementation rates of prescribing recommendations. Therefore, the overarching aim of this thesis was to identify the key factors affecting prescriber implementation of recommendations to improve medication appropriateness in hospitalised older adults, focusing on the factors affecting implementation of i) computer-generated recommendations and ii) pharmacist recommendations. Methods: Initially, a systematic review and meta-analysis were undertaken to ascertain the effectiveness of computerised interventions in minimising PIP in hospitalised older adults. Secondly, a semi-structured qualitative interview study was conducted alongside the Software ENgine for the Assessment & optimization of drug and non-drug Therapy in Older peRsons (SENATOR) trial to determine the key factors affecting prescriber implementation of the SENATOR software-generated recommendations, which aimed to reduce PIP and ADRs in hospitalised older adults. Based on these qualitative findings, an evaluation of the clinical relevance of SENATOR’s computer-generated recommendations based on Screening Tool of Older People's Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) criteria (version 2) was performed. Subsequently, the association between the clinical relevance of the recommendations and their implementation by prescribers was assessed. Thereafter, the prescriber implementation rates of STOPP/START recommendations from a physician approach and a pharmacist approach were compared. Finally, a further semi-structured qualitative interview study was conducted to identify the key factors affecting physician prescriber implementation of pharmacist recommendations aimed at optimising medication appropriateness in hospitalised older adults. Results: The systematic review and meta-analysis showed that computerised interventions can significantly reduce PIP in hospitalised older adults (p < 0.05). Of the nine included studies, five reported prescriber implementation rates for the computer-generated recommendations, ranging from 22.5% – 95%, but none of the included studies comprehensively explored the underlying reasons for non-implementation. The qualitative study conducted alongside the SENATOR trial identified four key factors affecting prescriber implementation of the computer-generated recommendations: i) Computerised output: the clinical relevance and method of provision for the recommendations. ii) Acute hospital environment: the timing and location of recommendations in a busy and often pressurised clinical setting. iii) Prescriber role and identity: the responsibility, experience, and specialty of prescribers, as well as their attitude towards research studies. iv) Patient-specific details: knowing the patient, patient preferences, and their acutely ill status in hospital. The study evaluating the clinical relevance of the computer-generated SENATOR recommendations showed that nearly three quarters of the 925 computer-generated STOPP/START recommendations generated were judged to be clinically relevant (73.6%), whilst the remainder were judged to be of ‘no clinical relevance’ (21.5%) or of potential ‘adverse significance’ if implemented (4.9%). Recommendations judged to be of higher clinical relevance were significantly more likely to be implemented than those of lower clinical relevance (p < 0.05), substantiating the findings from the preceding qualitative study that clinical relevance was a key factor affecting implementation. In the study comparing the implementation of pharmacist-provided and physician-provided STOPP/START recommendations, prescribers implemented a significantly greater proportion of physician recommendations in comparison to pharmacist recommendations (83.4% versus 37.8%; p < 0.0001). The final qualitative interview study found that the key factors affecting prescriber implementation of pharmacists' medication appropriateness recommendations for hospitalised older adults were: i) Clinical relevance and complexity of the recommendation. ii) Interprofessional communication. iii) Prescriber role and identity. iv) Knowing each other and developing trusting relationships. v) Hospital environment. Conclusion: This thesis has made a significant contribution to the understanding of the key factors affecting prescriber implementation of recommendations to improve medication appropriateness in hospitalised older adults. Prescriber non-implementation of these recommendations is not attributable to one easily identifiable cause, and it is likely that a multi-faceted approach will be required in future interventions. The novel studies conducted in this thesis will facilitate the development of theoretically-informed interventions that result in enhanced prescriber implementation of these recommendations, ultimately with the aims of substantially reducing PIP and improving health outcomes for hospitalised older adults

Pharmacy students' views and experiences regarding an online video-recorded objective structured clinical examination.

Objective structured clinical examinations (OSCEs) are considered gold standard in the assessment of pharmacy students' clinical skills. The COVID-19 pandemic, however, necessitated for minimising in-person interactions and therefore more innovative approaches to OSCE delivery. The objective of this study was to provide pharmacy students the opportunity to participate in an online video-recorded OSCE with pharmacist feedback, and thereafter assess their views and experiences regarding this initiative and reviewing the recording. Ethics approval was obtained prior to study commencement. All 3rd year pharmacy students in University College Cork, Ireland (n=68) were invited to participate in a formative video-recorded OSCE station online via Microsoft® Teams in April 2021, comprising one minute of reading time and five minutes of interaction time, followed by an individualised feedback session with a pharmacist facilitator. Participants were sent two surveys: one on the day of the OSCE and the other after receiving the video recording 7 days later. Closed-ended questions were analysed using Microsoft® Excel and free text comments underwent content analysis. Twenty-three students participated (34% of total), with 20 respondents to the first survey and 15 respondents to the second. Nearly all students enjoyed this OSCE experience (94%). Half of the students agreed that conducting the OSCE online (rather than in person) had no significant impact on their performance, whilst 75% agreed that knowing they were being recorded had no significant impact either. While most students (80%) agreed that this OSCE has prepared them for telepharmacy interactions in future, 25% found it difficult to get a personal connection with the simulated patient in this virtual environment. All students were satisfied with the quality of pharmacist facilitator feedback; however, 79% agreed that reviewing the recording had a significantly greater impact on them compared to receiving the facilitator feedback alone, and allowed them to become more aware of their body language during patient interactions. Whilst some students found it uncomfortable to watch the recording, 93% agreed (i) that reviewing their performance on video made them more self-aware of what clinical skills need development, and (ii) that they would review the video to help prepare for OSCEs in future. To our knowledge, this is the first study to evaluate pharmacy students' views and experiences with a formative online video-recorded OSCE with individualised feedback. This research has shown that conducting a formative OSCE online is acceptable, enjoyable, and beneficial for pharmacy students, and should be considered where in-person interactions are not possible. Furthermore, this has emphasised the added value of providing a video recording after the OSCE to heighten pharmacy students' awareness of their non-verbal communication and enhance their clinical skills. Future studies with larger sample sizes should explore how student characteristics impact on their views with such video-recorded OSCEs

Role of the pharmacist in reducing healthcare costs: current insights

Global healthcare expenditure is escalating at an unsustainable rate. Money spent on medicines and managing medication-related problems continues to grow. The high prevalence of medication errors and inappropriate prescribing is a major issue within healthcare systems, and can often contribute to adverse drug events, many of which are preventable. As a result, there is a huge opportunity for pharmacists to have a significant impact on reducing healthcare costs, as they have the expertise to detect, resolve, and prevent medication errors and medication-related problems. The development of clinical pharmacy practice in recent decades has resulted in an increased number of pharmacists working in clinically advanced roles worldwide. Pharmacist-provided services and clinical interventions have been shown to reduce the risk of potential adverse drug events and improve patient outcomes, and the majority of published studies show that these pharmacist activities are cost-effective or have a good cost:benefit ratio. This review demonstrates that pharmacists can contribute to substantial healthcare savings across a variety of settings. However, there is a paucity of evidence in the literature highlighting the specific aspects of pharmacists' work which are the most effective and cost-effective. Future high-quality economic evaluations with robust methodologies and study design are required to investigate what pharmacist services have significant clinical benefits to patients and substantiate the greatest cost savings for healthcare budgets

Interventions to improve reporting of medication errors in hospitals: a systematic review and narrative synthesis

Background: In 2017, the World Health Organisation pledged to halve medication errors by 2022. In order to learn from medication errors and prevent their recurrence, it is essential that medication errors are reported when they occur. Objectives: The aim of this systematic review was to identify studies in which interventions were carried out in hospitals to improve medication error reporting, to summarise the findings of these studies, and to make recommendations for future investigations. Methods: A comprehensive search of five electronic databases (PubMed, Medline (OVID), Embase (OVID), Web of Science, and CINAHL) was conducted from inception up to and including December 2018. Studies were included if they described an intervention aiming to increase the reporting of medication errors by healthcare providers in hospitals and excluded if there was no full-text English language version available, or if the reporting rate in the hospital prior to the intervention was not available. Data extracted from included studies were described using narrative synthesis. Results: Of 12,025 identified studies, seventeen were included in this review - fifteen uncontrolled before versus after studies, one survey and one non-equivalent group controlled trial. Five studies carried out a single intervention and twelve studies conducted multifaceted interventions. The most common intervention types were critical incident reporting, implemented in fifteen studies, and audit and feedback, implemented in seven studies. Other intervention types included educational materials, educational meetings, and role expansion and task shifting. As only one study compared a control and intervention group, the effectiveness of the different intervention types could not be evaluated. Conclusion: This is the first review to address the evidence on medication error reporting in hospitals on a global scale. The review has identified interventions to improve medication error reporting that were implemented without evidence of their effectiveness. Due to the essential role played by incident reporting in learning from and preventing the recurrence of medication errors more research needs to be done in this area

Factors affecting prescriber implementation of computer-generated medication recommendations in the SENATOR trial: A qualitative study

Background: The SENATOR trial intervention included the provision of computer-generated medication recommendations to physician prescribers caring for hospitalised older adults (≥ 65 years), with the aim of reducing in-hospital adverse drug reactions. Interim data analysis during the trial revealed that the prescriber implementation rates of the computer-generated STOPP/START recommendations were lower than expected across all six trial sites. Aim: The aim of this qualitative study was to identify the factors affecting prescriber implementation of the medication recommendations in the SENATOR trial. Methods: Semi-structured interviews were conducted with trial researchers and physician prescribers who were provided with SENATOR recommendations. Content analysis was used to identify the most relevant domains from the Theoretical Domains Framework (TDF) that affected recommendation uptake. Results: Ten trial researchers and fourteen prescribers were interviewed across the six trial sites. Eight TDF domains were found to be most relevant in affecting prescriber implementation: ‘environmental context and resources’, ‘goals’, ‘intentions’, ‘knowledge’, ‘beliefs about consequences’, ‘memory, attention and decision processes’, ‘social/professional role and identity’, and ‘social influences’. Interviewees felt that there was often a disconnect between the time prescribers were reviewing the patient and the point at which the recommendations were provided. However, when recommendations were reviewed, prescriber inertia was highly pervasive, with a particular reluctance to make pharmacotherapy changes outside their own specialty. Implementation was facilitated by recommendations reaching a ‘decision-maker’, but this was often not possible as the software could not evaluate the entire clinical context of patients, and thus frequently produced recommendations of low clinical relevance. Conclusion: This study has demonstrated that the clinical relevance of the SENATOR prescribing recommendations was a significant factor affecting their implementation. Whilst software refinement will be necessary to improve the quality of recommendations, future interventions will need to be multifaceted to overcome the complex prescriber specialty culture within the acute hospital environment

Computerised interventions designed to reduce potentially inappropriate prescribing in hospitalised older adults: a systematic review and meta-analysis

Background: computerised interventions have been suggested as an effective strategy to reduce potentially inappropriate prescribing (PIP) for hospitalised older adults. This systematic review and meta-analysis examined the evidence for efficacy of computerised interventions designed to reduce PIP in this patient group. Methods: an electronic literature search was conducted using eight databases up to October 2017. Included studies were controlled trials of computerised interventions aiming to reduce PIP in hospitalised older adults (≥65 years). Risk of bias was assessed using Cochrane’s Effective Practice and Organisation of Care criteria. Results: of 653 records identified, eight studies were included—two randomised controlled trials, two interrupted time series analysis studies and four controlled before–after studies. Included studies were mostly at a low risk of bias. Overall, seven studies showed either a statistically significant reduction in the proportion of patients prescribed a potentially inappropriate medicine (PIM) (absolute risk reduction {ARR} 1.3–30.1%), or in PIMs ordered (ARR 2–5.9%). However, there is insufficient evidence thus far to suggest that these interventions can routinely improve patient-related outcomes. It was only possible to include three studies in the meta-analysis—which demonstrated that intervention patients were less likely to be prescribed a PIM (odds ratio 0.6; 95% CI 0.38, 0.93). No computerised intervention targeting potential prescribing omissions (PPOs) was identified. Conclusions: this systematic review concludes that computerised interventions are capable of statistically significantly reducing PIMs in hospitalised older adults. Future interventions should strive to target both PIMs and PPOs, ideally demonstrating both cost-effectiveness data and clinically significant improvements in patient-related outcomes

Pharmacists' views on the impact of the falsified medicines directive on community pharmacies: A cross-sectional survey

Background: The Falsified Medicines Directive (FMD) was implemented to minimise the circulation of falsified medicines in the legal pharmaceutical supply chain. Whilst pharmacists are involved in the final step of the FMD requirements with the decommissioning of medicines at the point of supply to patients, limited research has been conducted to investigate the impact of fulfilling these requirements on the relevant stakeholders. Objective: To examine community pharmacists' views on how the FMD has affected their practice. Methods: An online survey was disseminated via email in June 2020 to pharmacists in Ireland (n = 4727), who were invited to participate if practising full time or part time in community pharmacies. Quantitative data were captured through multiple option and Likert-scale questions, and analysed using descriptive and inferential statistics. Qualitative data were captured by use of a free-text box, with the open comments analysed thematically. Results: In total, 618 valid responses were received (13.1% response rate). Most perceived that FMD requirements increased waiting times for patients (82%) and reduced time interacting with patients (65%). Only 28% agreed/strongly agreed that the introduction of the FMD legislation improves patient safety. In the open comments, the need for medicine authentication was acknowledged, but it was believed that this should be the wholesalers' responsibility, not pharmacists' responsibility. The additional step of medicines decommissioning was viewed as a time-consuming distraction to clinical checks that increased the risk for error. Pharmacists complained that they were not remunerated for the lost staff productivity or the additional software and equipment costs. Many pharmacists felt that the increased workload was disproportionate to the small risk of patients receiving falsified medicines. Conclusions: Key stakeholder engagement is required to optimise the implementation and integration of the FMD procedures into community pharmacy practice with minimal impact on dispensing and without compromising patient care

Prescriber implementation of STOPP/START recommendations for hospitalised older adults: a comparison of a pharmacist approach and a physician approach

Background: Two randomised controlled trials (RCTs) conducted simultaneously in the same Irish university teaching hospital have shown that provision of Screening Tool of Older Persons’ Prescriptions (STOPP)/Screening Tool to Alert doctors to Right Treatment (START) recommendations to attending prescribers by a physician or a pharmacist can reduce in-hospital adverse drug reactions (ADRs) in older adults (≥ 65 years). The aims of this study were to compare the prescriber implementation rates of STOPP/START recommendations between the physician approach and the pharmacist approach in these two RCTs and to provide a narrative summary of the comparable clinical outcomes. Methods: Data were extracted from the two RCT published papers and their associated computerised databases to calculate the percentage prescriber implementation rates for the STOPP/START recommendations. The Chi-square test was used to quantify the differences in prescriber implementation rates, with differences considered statistically significant where p < 0.05. Results: Prescriber implementation rates of the STOPP and START recommendations made by the physician were 81.2% and 87.4% respectively, significantly higher than those made by the pharmacist (39.2% and 29.5% respectively), p < 0.0001. A greater absolute risk reduction in patients with ADRs was shown with the physician’s intervention compared to the pharmacist’s intervention (9.3% vs 6.8%). Conclusion: This study shows that the methods of communication and the medium through which the STOPP/START recommendations are delivered significantly affect their implementation. Non-implementation of some pharmacist-delivered recommendations may be contributing to preventable ADRs in older adults. Thus, future research should aim to identify the factors influencing prescriber implementation of pharmacist recommendations in order to inform the design of more effective pharmacist interventions in optimising older patients’ pharmacotherapy

Variational quantum chemistry requires gate-error probabilities below the fault-tolerance threshold

The variational quantum eigensolver (VQE) is a leading contender for useful quantum advantage in the NISQ era. The interplay between quantum processors and classical optimisers is believed to make the VQE noise resilient. Here, we probe this hypothesis. We use full density-matrix simulations to rank the noise resilience of leading gate-based VQE algorithms in ground-state computations on a range of molecules. We find that, in the presence of noise: (i) ADAPT-VQEs that construct ansatz circuits iteratively outperform VQEs that use "fixed" ansatz circuits; and (ii) ADAPT-VQEs perform better when circuits are constructed from gate-efficient elements rather than physically-motivated ones. Our results show that, for a wide range of molecules, even the best-performing VQE algorithms require gate-error probabilities on the order of $10^{-6}$ to $10^{-4}$ to reach chemical accuracy. This is significantly below the fault-tolerance thresholds of most error-correction protocols. Further, we estimate that the maximum allowed gate-error probability scales inversely with the number of noisy (two-qubit) gates. Our results indicate that useful chemistry calculations with current gate-based VQEs are unlikely to be successful on near-term hardware without error correction.Comment: 17 pages, 8 figure

Integrated methodologies of economics and socio-economics assessments in ocean renewable energy : private and public perspectives

This paper offers a holistic approach to the evaluation of an ocean renewable energy (ORE) technology type or specific project in order to provide a comprehensive assessment of both narrow economic and broader socio-economic performance. This assessment incorporates methods from three pillars areas: Economic - financial returns and efficient use of resources, Social - employment, social and community cohesion and identity, and Environmental - including the physical environment and pollution. These three pillars are then considered in the broader context of governance. In order to structure this evaluation, a novel parameter space model was created, defined by the three pillars and by the scale of the system under assessment. The scale of the system ranged from individual components of an ORE project; to projects comprising of a number of devices; through to a geographic regions in which multiple farms may be deployed. The parameter space consists of an inner circle representing the boundary of interest for a private investor, or a firm, developing an ORE project. The outer circle is characterised by assessment tools typically employed at the broader stakeholder level including economic, social, and environmental methods that can be employed at local, regional or national scale and which are typically employed to inform policy and decision making regarding ORE. Governance sets the stage within which management occurs. Wider impacts to the firm undertaking the project will take into account “externalities” of the project across the three fields. In this model, key methods identified are mapped onto this parameter space and the connectivity explored. The paper demonstrates that the three pillars are inter-connected and each must be considered in any meaningful assessment of ORE sustainability. An integrated assessment approach has the ability to address both the private and the public aspects of an ORE development,. This analysis provides insights on existing best practice, but also reveals the potential for disconnect between an ORE project’s commercial viability and its contribution to environmental and social goals