Vet fastlegen hvilke medisiner hjemmesykepleien gir pasientene?

Artikkelen presenterer resultater fra en studie som avdekket dårlig informasjonsutveksling mellom fastlege og hjemmesykepleie, samt manglende samsvar mellom legemiddellistene de hadde for felles pasienter.Bakgrunn. Hjemmeboende, pleietrengende eldre må ofte overlate til hjemmesykepleien å administrere legemidlene sine. Lite er kjent om hvordan hjemmesykepleien og fastlegene samordner og oppdaterer medisinlister for felles pasienter. Materiale og metode. For 90 tilfeldig utvalgte pasienter som mottok medisiner fra hjemmesykepleien, ble hjemmesykepleiens lister over faste medisiner sammenliknet med fastlegenes tilsvarende lister. Rutiner og samarbeidsformer i forbindelse med legemiddelbruk hos felles pasienter ble kartlagt ved hjelp av et spørreskjema. Resultater. For over 60 % av pasientene var det ikke samsvar mellom fastlegenes lister over pasientenes faste medisiner og det som var anført på hjemmesykepleiens lister (antall medikamenter, døgndoser og antall doseringer per døgn for hver enkelt medisin). Avvik gjaldt hyppigst for medisiner mot hjerte- og karsykdommer og psykofarmaka. Legene oppgav generelt mindre tiltro til at pasientene mottok riktige medisiner enn hjemmesykepleierne. Mindre enn halvparten av legene hadde klare rutiner for oppdatering av medisinlistene ved mottak av epikriser fra andre leger. Fortolkning. Manglende samsvar mellom medisinlistene kan representere et potensielt folkehelseproblem. Kommunikasjonen mellom hjemmesykepleien og fastlegene bør bedres

The Norwegian General Practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients

Beskriver utvikling av en klinisk relevant liste med eksplisitte kriterier for farmakologisk uhensiktsmessige medikamentforeskrivinger for eldre ≥ 70 år i allmennpraksis.Objective. To establish a clinically relevant list with explicit criteria for pharmacologically inappropriate prescriptions in general practice for elderly people ]70 years. Design. A three-round Delphi process for validating the clinical relevance of suggested criteria (n 37) for inappropriate prescriptions to elderly patients. Setting. A postal consensus process undertaken by a panel of specialists in general practice, clinical pharmacology, and geriatrics. Main outcome measures. The Norwegian General Practice (NORGEP) criteria, a relevance-validated list of drugs, drug dosages, and drug combinations to be avoided in the elderly (570 years) patients. Results. Of the 140 invited panellists, 57 accepted to participate and 47 completed all three rounds of the Delphi process. The panellists reached consensus that 36 of the 37 suggested criteria were clinically relevant for general practice. Relevance of three of the criteria was rated significantly higher in Round 3 than in Round 1. At the end of the Delphi process, a significant difference between the different specialist groups’ scores was seen for only one of the 36 criteria. Conclusion. The NORGEP criteria may serve as rules of thumb for general practitioners (GPs) related to their prescribing practice for elderly patients, and as a tool for evaluating the quality of GPs’ prescribing in settings where access to clinical information for individual patients is limited, e.g. in prescription databases and quality improvement interventions

Can antibiotic prescriptions in respiratory tract infections be improved? A cluster-randomized educational intervention in general practice – The Prescription Peer Academic Detailing (Rx-PAD) Study [NCT00272155]

BACKGROUND: More than half of all antibiotic prescriptions in general practice are issued for respiratory tract infections (RTIs), despite convincing evidence that many of these infections are caused by viruses. Frequent misuse of antimicrobial agents is of great global health concern, as we face an emerging worldwide threat of bacterial antibiotic resistance. There is an increasing need to identify determinants and patterns of antibiotic prescribing, in order to identify where clinical practice can be improved. METHODS/DESIGN: Approximately 80 peer continuing medical education (CME) groups in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, evidence-based recommendations of antibiotic prescriptions for RTIs will be presented and software will be handed out for installation in participants PCs, enabling collection of prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Main outcomes are baseline proportion of inappropriate antibiotic prescriptions for RTIs and change in prescription patterns compared to baseline one year after the initiation of the tailored pedagogic intervention. DISCUSSION: Improvement of prescription patterns in medical practice is a challenging task. A thorough evaluation of guidelines for antibiotic treatment in RTIs may impose important benefits, whereas inappropriate prescribing entails substantial costs, as well as undesirable consequences like development of antibiotic resistance. Our hypothesis is that an educational intervention program will be effective in improving prescription patterns by reducing the total number of antibiotic prescriptions, as well as reducing the amount of broad-spectrum antibiotics, with special emphasis on macrolides

A cluster-randomized educational intervention to reduce inappropriate prescription patterns for elderly patients in general practice - The Prescription Peer Academic Detailing (Rx-PAD) study [NCT00281450]

Background Age-related alterations in metabolism and excretion of medications increase the risk of adverse drug events in the elderly. Inappropriate polypharmacy and prescription practice entails increased burdens of impaired quality of life and drug related morbidity and mortality. The main objective of this trial is to evaluate effects of a tailored educational intervention towards general practitioners (GPs) aimed at supporting the implementation of a safer drug prescribing practice for elderly patients ≥ 70 years. Methods/design Approximately 80 peer continuing medical education (CME) groups (about 600 GPs) in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. The control group will not receive any intervention towards prescription patterns in elderly, but will be the target of an educational intervention for prescription of antibiotics for respiratory tract infections. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, a set of quality indicators (QIs), i.e. explicit recommendations for safer prescribing for elderly patients, will be presented and discussed. Software will be handed out for installation in participants' practice computers to enable extraction of pre-defined prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Feedback reports will include QI-scores on individual- and group levels, before and after the intervention. The main outcome of this trial is the change in proportions of inappropriate prescriptions (QIs) for elderly patients ≥ 70 years following intervention, compared to baseline levels. Discussion Improvement of prescription patterns in medical practice is a challenging task. Evidence suggests that a thorough evaluation of diagnostic indications for drug treatment in the elderly and/or a reduction of potentially inappropriate drugs may impose significant clinical benefits. Our hypothesis is that an educational intervention program will be effective in improving prescribing patterns for elderly patients in GP settings

Prescription peer academic detailing to reduce inappropriate prescribing for older patients: a cluster randomised controlled trial

Artikkelen beskriver funn fra en studie som har undersøkt om en sammensatt pedagogisk intervensjon har effekt på allmennlegenes potensielt uhensiktsmessige legemiddelforskrivning for eldre pasienter.BACKGROUND: Older patients are at particular risk for adverse drug reactions. In older people, interventions targeting potentially inappropriate prescriptions (PIPs) are considered important measures to minimise drug-related harm, especially in the general practice setting where most prescriptions for older patients are issued. AIM: To study the effects of a multifaceted educational intervention on GPs' PIPs for older patients. DESIGN AND SETTING: This was a cluster randomised, educational intervention study in Norwegian general practice. Pre-study data were captured from January 2005 to December 2005 and post-study data from June 2006 to June 2007. The educational intervention was carried out from January 2006 to June 2006. METHOD: Eighty continuing medical education (CME) groups (465 GPs) were randomised to receive the educational intervention on GPs' PIPs for older patients (41 CME groups; 256 GPs) or another educational intervention (39 CME groups; 209 GPs); these two groups acted as controls for each other. GPs' prescription data from before and after the intervention were assessed against a list of 13 explicit PIP criteria for patients aged ≥70 years. In the CME groups, trained GPs carried out an educational programme, including an audit, focusing on the 13 criteria and their rationale. RESULTS: A total of 449 GPs (96.6%) completed the study; 250 in the intervention group and 199 in the control group. After adjusting for baseline differences and clustering effects, a reduction relative to baseline of 10.3% (95% confidence interval = 5.9 to 15.0) PIPs per 100 patients aged ≥70 years was obtained. CONCLUSION: Educational outreach visits with feedback and audit, using GPs as academic detailers in GPs' CME groups, reduced PIPs for older patients aged ≥70 years in general practice

Characteristics of GPs responding to an educational intervention to minimise inappropriate prescriptions: subgroup analyses of the Rx-PAD study

Background: Interventions aimed at improving GPs’ prescribing practice usually apply a 'one size fits all' when analysing intervention effects. Few studies explore intervention effects by variables related to the GPs’ age, sex, specialist status, practice type (single-handed versus group), practice setting (urban versus rural), and baseline performance regarding the target of an intervention. Aim: To explore the characteristics of the GPs responding to a comprehensive educational intervention. Design & setting: A secondary analysis of a cluster, randomised educational intervention in Norwegian general practice. Pre-intervention data were captured from January 2005 to December 2005, and post-intervention data from June 2006 to June 2007. The intervention was carried out from January to June 2006. Method: Eighty continuing medical education (CME) groups, including 449 GPs aged 27–68 years, were randomly allocated to either an education intervention arm (41 groups, 250 GPs) or a control arm (39 groups, 199 GPs). The primary outcome was GPs' change in potentially inappropriate prescriptions (PIPs) per 100 prescriptions issued to patients aged ≥70 years. The interaction between intervention outcome and variables related to the GPs and their practices were tested. Results: Improvements in prescribing were highest among GPs aged 57–68 years (incidence rate ratio [IRR] = 0.77 [95% confidence interval {CI} = 0.73 to 0.81]), those who were specialists (IRR = 0.80 [95% CI = 0.78 to 0.82]), and those who worked in single-handed practices (IRR = 0.75 [95% CI = 0.68 to 0.83]), among GPs with 2.4 to 2.9 PIPs per 100 prescriptions at baseline (IRR = 0.74 [95% CI = 0.70 to 0.78]), and GPs with ≥15 prescriptions per patient per year at baseline (IRR = 0.77 [95% CI = 0.73 to 0.80]). Conclusion: The GPs with the lowest adherence to recommended practice at baseline improved their practice most

A cluster-randomized educational intervention to reduce inappropriate prescription patterns for elderly patients in general practice – The Prescription Peer Academic Detailing (Rx-PAD) study [NCT00281450]

Abstract Background Age-related alterations in metabolism and excretion of medications increase the risk of adverse drug events in the elderly. Inappropriate polypharmacy and prescription practice entails increased burdens of impaired quality of life and drug related morbidity and mortality. The main objective of this trial is to evaluate effects of a tailored educational intervention towards general practitioners (GPs) aimed at supporting the implementation of a safer drug prescribing practice for elderly patients ≥ 70 years. Methods/design Approximately 80 peer continuing medical education (CME) groups (about 600 GPs) in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. The control group will not receive any intervention towards prescription patterns in elderly, but will be the target of an educational intervention for prescription of antibiotics for respiratory tract infections. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, a set of quality indicators (QIs), i.e. explicit recommendations for safer prescribing for elderly patients, will be presented and discussed. Software will be handed out for installation in participants' practice computers to enable extraction of pre-defined prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Feedback reports will include QI-scores on individual- and group levels, before and after the intervention. The main outcome of this trial is the change in proportions of inappropriate prescriptions (QIs) for elderly patients ≥ 70 years following intervention, compared to baseline levels. Discussion Improvement of prescription patterns in medical practice is a challenging task. Evidence suggests that a thorough evaluation of diagnostic indications for drug treatment in the elderly and/or a reduction of potentially inappropriate drugs may impose significant clinical benefits. Our hypothesis is that an educational intervention program will be effective in improving prescribing patterns for elderly patients in GP settings.</p

Helsepersonells oppfatninger om multidosepakkede legemidler

Beskriver en studie hvor hensikten var å undersøke hvordan leger, sykepleiere og hjelpepleiere oppfattet at innføring av multidosepakkede legemidler påvirket legemiddelhåndtering og informasjonsutveksling.Bakgrunn: maskinell dosepakking (multidose) av legemidler er i dag et satsingsområde for å gi mindre feilbruk av legemidler. Det er mangelfull kunnskap om hvordan multidosepakninger påvirker rutinene og kvaliteten av legemiddelhåndtering i åpen omsorg. Materiale og metode: vi gjennomførte en intervjuundersøkelse med strukturert spørreskjema hos 27 fastleger og 121 ansatte (sykepleiere og annet pleiepersonell) i fire pleiedistrikter i Fredrikstad kommune. Resultater: et flertall mente multidosepakkingen gjorde at de nå følte seg tryggere på at pasientene fikk riktige medisiner (hjemmetjenesten 73%, leger 78%), at rutinene i forbindelse med legemiddelhåndteringen var blitt bedre (hjemmetjenesten 84%, legene 52 %; p < 0,001) og at det var blitt enklere å ha oversikt over pasientenes medisiner (hjemmetjenesten 76%, legene 56 %; p = 0,03). 44% av legene mente at de måtte bruke mer tid på legemiddelordinering etter innføringen. Det var ulike rutiner for informasjonsflyt og koordinering av dokumentasjon i forhold til legene i de fire distriktene. Fortolkning: multidosesystemet ble opplevd som en forbedring fra tidligere situasjon med tanke på rutiner og kvalitet av legemiddelhåndteringen. At legene var mindre fornøyde med ordningen enn sykepleierne, kan skyldes at de måtte forholde seg til forskjellige distrikter med ulike informasjonsrutiner. Ved innføring av multidosepakkede legemidler er det viktig med klare ansvarsforhold og ensartede rutiner for samhandling mellom leger, hjemmetjeneste og apotek/pakkeprodusent

NorGeP kriterieliste

Liste over 36 eksplisitte kriterier over farmakologisk uhensiktsmessige forskrivninger til eldre pasienter (> 70 år) i allmennpraksis

Pharmacologically inappropriate prescriptions for elderly patients in general practice: how common?

Tverrsnittstudie, kartlegging av i hvor stor grad norske allmennleger (fastleger) foreskriver potensielt skadelige legemidler til eldre pasienter.Objective. To assess Norwegian general practitioners’ (GPs’) level of potentially harmful drug prescribing for elderly patients. Design. Prescription data for 12 months were retrospectively retrieved from the Norwegian Prescription Database (NorPD). Data were assessed in relation to 13 prescription quality indicators. Setting. General practice. Subjects. A total of 454 GPs attending continuous medical education (CME) groups in Southern Norway, 85 836 patients ]70 years who received any prescription from the GPs during the study period. Main outcome measures. Number of prescriptions assessed in relation to pharmacological inappropriateness based on a list of 13 explicit prescription quality indicators. Results. Some 18.4% of the patients (66% females with mean age 79.8 years, 34% males with mean age 78.7 years) received one or more inappropriate prescriptions from their GP. An NSAID in a potentially harmful combination with another drug (7%) and a long-acting benzodiazepine (4.6%) were the most frequent inappropriate prescriptions made. Doctor characteristics associated with more inappropriate prescribing practice were old age and working single-handed with many elderly patients. Conclusion. The study reveals areas where GPs’ prescribing practice for elderly patients can be improved and which can be targeted in educational interventions