Task sharing in an interprofessional medication management program – a survey of general practitioners and community pharmacists

Background Pharmacist-led medication review and medication management programs (MMP) are well-known strategies to improve medication safety and effectiveness. If performed interprofessionally, outcomes might even improve. However, little is known about task sharing in interprofessional MMP, in which general practitioners (GPs) and community pharmacists (CPs) collaboratively perform medication reviews and continuously follow-up on patients with designated medical and pharmaceutical tasks, respectively. In 2016, ARMIN (Arzneimittelinitiative Sachsen-Thüringen) an interprofessional MMP was launched in two German federal states, Saxony and Thuringia. The aim of this study was to understand how GPs and CPs share tasks in MMP when reviewing the patients’ medication. Methods This was a cross-sectional postal survey among GPs and CPs who participated in the MMP. Participants were asked who completed which MMP tasks, e.g., checking drug-drug interactions, dosing, and side effects. In total, 15 MMP tasks were surveyed using a 5-point Likert scale ranging from “I complete this task alone” to “GP/CP completes this task alone”. The study was conducted between 11/2020 and 04/2021. Data was analyzed using descriptive statistics. Results In total, 114/165 (69.1%) GPs and 166/243 (68.3%) CPs returned a questionnaire. The majority of GPs and CPs reported (i) checking clinical parameters and medication overuse and underuse to be completed by GPs, (ii) checking storage conditions of drugs and initial compilation of the patient’s medication including brown bag review being mostly performed by CPs, and (iii) checking side-effects, non-adherence, and continuous updating of the medication list were carried out jointly. The responses differed most for problems with self-medication and adding and removing over-the-counter medicines from the medication list. In addition, the responses revealed that some MMP tasks were not sufficiently performed by either GPs or CPs. Conclusions Both GPs’ and CPs’ expertise are needed to perform MMP as comprehensively as possible. Future studies should explore how GPs and CPs can complement each other in MMP most efficiently

Good Agreement Between Modeled and Measured Sulfur and Nitrogen Deposition in Europe, in Spite of Marked Differences in Some Sites

Atmospheric nitrogen and sulfur deposition is an important effect of atmospheric pollution and may affect forest ecosystems positively, for example enhancing tree growth, or negatively, for example causing acidification, eutrophication, cation depletion in soil or nutritional imbalances in trees. To assess and design measures to reduce the negative impacts of deposition, a good estimate of the deposition amount is needed, either by direct measurement or by modeling. In order to evaluate the precision of both approaches and to identify possible improvements, we compared the deposition estimates obtained using an Eulerian model with the measurements performed by two large independent networks covering most of Europe. The results are in good agreement (bias <25%) for sulfate and nitrate open field deposition, while larger differences are more evident for ammonium deposition, likely due to the greater influence of local ammonia sources. Modeled sulfur total deposition compares well with throughfall deposition measured in forest plots, while the estimate of nitrogen deposition is affected by the tree canopy. The geographical distribution of pollutant deposition and of outlier sites where model and measurements show larger differences are discussed

On the alert: future priorities for alerts in clinical decision support for computerized physician order entry identified from a European workshop

Background: Clinical decision support (CDS) for electronic prescribing systems (computerized physician order entry) should help prescribers in the safe and rational use of medicines. However, the best ways to alert users to unsafe or irrational prescribing are uncertain. Specifically, CDS systems may generate too many alerts, producing unwelcome distractions for prescribers, or too few alerts running the risk of overlooking possible harms. Obtaining the right balance of alerting to adequately improve patient safety should be a priority. Methods: A workshop funded through the European Regional Development Fund was convened by the University Hospitals Birmingham NHS Foundation Trust to assess current knowledge on alerts in CDS and to reach a consensus on a future research agenda on this topic. Leading European researchers in CDS and alerts in electronic prescribing systems were invited to the workshop. Results: We identified important knowledge gaps and suggest research priorities including (1) the need to determine the optimal sensitivity and specificity of alerts; (2) whether adaptation to the environment or characteristics of the user may improve alerts; and (3) whether modifying the timing and number of alerts will lead to improvements. We have also discussed the challenges and benefits of using naturalistic or experimental studies in the evaluation of alerts and suggested appropriate outcome measures. Conclusions: We have identified critical problems in CDS, which should help to guide priorities in research to evaluate alerts. It is hoped that this will spark the next generation of novel research from which practical steps can be taken to implement changes to CDS systems that will ultimately reduce alert fatigue and improve the design of future systems

Homogenisation of climate time series from ICP Forests Level II monitoring sites in Germany based on interpolated climate data

• The aim of our work was to homogenise the meteorological dataset of German ICP Forests Level II sites (n = 73) by the aid of interpolations based on climate data from the German meteorological network (DWD). • For each site daily values of climate variables (temperature, precipitation, solar radiation, relative humidity and wind speed) were interpolated by ordinary kriging after the removal of global trends for each day over a period of 11 y. The quality of the method was estimated by cross validation. The standard normal homogeneity test for single shifts was applied repetitively to detect inhomogenities in all time series (n = 594) using the interpolated dataset as reference. • Our results indicate that: the accuracy of the interpolation method was highest for maximum air temperature and lowest for wind speed; homogenisation improved the quality of the climate time series and had the largest impact on solar radiation and wind speed; the correlation of interpolated and measured climate was stronger within the DWD network than within the ICP Forests Level II network, due to a generally higher variance (precipitation) or a systematic deviation (wind speed, minimum air temperature). • We suggest the use of external climate data for homogenisation procedures within the quality assurance/quality control of the ICP Forests Level II programme. The high prediction errors of precipitation and wind speed demonstrate the need for the on – site survey within the monitoring programme

50 years of succession of an old-growth oak stand in eastern Hesse

In einem um 1788 aufgeforsteten 0,2 ha großen Eichen-Bestand auf einem Luzulo-Fagetum-Stand­ort wurde mittels einer 355 m2 großen Dauerbeobachtungsfläche die Vegetationsentwicklung von 1951 bis 1998 beobachtet. Der noch wüchsige Eichen-Bestand konnte aufgrund fehlender Eingriffe eine deutlich über den Ertragstafelwerten liegende Derbholzmasse bilden. Die zweite Baumschicht wird im wesentlichen von Buche sowie etwas Hainbuche und Berg-Ahorn aufgebaut; die Eiche konnte sich nicht verjüngen. Die Baumartenzusammensetzung blieb während 50 Jahren nahezu stabil, lediglich in der Strauch- und Krautschicht ergab sich vor allem in den 50er Jahren hinsichtlich der Gehölzartenzusammensetzung eine etwas höhere Dynamik. Die Krautschicht war in den Anfangsjahren üppig entwickelt, was vor allem die Folge eines erhöh­ten Seitenlichtgenusses aufgrund einer benachbarten Schlagfläche gewesen sein dürfte. Das Aufwachsen des angrenzenden Bestandes dürfte die starken Rückgänge der Deckungsgrade von Arten der Kraut- und Strauchschicht verursacht haben, was schließlich zum Ausfall ganzer Artengruppen (Molinio-Arrhenatheretea- , Epilobietea-, Quercetalia-Arten) führte. Als weitere Gründe für die Verarmung der Krautschicht, insbesondere für das Verschwinden der Arten oligotropher Wälder, werden neben der Abnahme des Lichtgenusses diskutiert: atmogene Stoff-, insbesondere N-Einträge, endogene Anreicherung von Basen im Oberboden durch den Baumbestand und das langfristige Ausbleiben früher üblicher Nebennutzungen wie Streuentnahme oder Waldweide.Succession was studied from 1951 to 1998 on a permanent plot (355 m2) within an 0.2 ha stand of oak derived from a 1788 afforestation on former agricultural land. The oak stand growing well up to now has achieved a dendromass far beyond values of the “Ertrags­tafel” (standardized values of regularly managed forest stands). The second tree layer is mainly com­posed of beech. Oaks are not regenerating. The composition of woody species has almost been stable over the last 50 years, apart from somewhat higher dynamics during the 1950s. The gound-layer vegetation reached high degrees of coverage during the beginning of the observa­tions, caused perhaps by high light levels due to an adjacent clear-cut. With growth of the neighbouring stand, radiation and ground vegetation were both reduced. Especially, species of the phytosociological categories Molinio-Arrhenatheretea, Epilobietea, and Quercetalia vanished entirely in the course of the succession. As further reasons especially for the decline of species of oligotrophic woods (Quercetalia), the following are discussed: air-borne inputs of basic cations and nitrogen, enrichment of bases and therefore better conditions for N mineralisation as a result of endogenous processes, and the long ab­sence of the former practices of pasturing and hay-making

Improving eye-drop administration skills of patients - A multicenter parallel-group cluster-randomized controlled trial.

BackgroundEye-drop administration errors occur in the majority of patients and increase the risk for treatment failure or systemic adverse events. While lacking knowledge is the principal error cause, most patients overestimate their skills and are unaware of often substantial knowledge gaps. Therefore, the impact of including motivational patient education on long-term eye-drop administration skills of patients was investigated.MethodsThis is a cluster-randomized controlled trial in German community pharmacies. Patient education in both groups comprised observation of the patient during eye-drop administration to identify individual errors, pharmaceutical counseling, and teach-back evaluation of the training. In the intervention group, motivational communication techniques were included to increase error awareness and readiness for patient education. In addition, intervention patients were trained on repeated errors until administration was performed correctly. In contrast, patients in the control group only received feedback on erroneous administration steps without another assessment and reinforced training.ResultsIn total, 152 adult patients were eligible to the study and 91 patients (intervention group N = 46) agreed to participate in a 1-month, 6-month, and 12-month follow-up. Patient education significantly increased the proportion of patients correctly administering eye-drops from 6% (7 out of 56 intervention patients, 1 out of 82 control patients) at baseline to 35% (12 out of 30 intervention patients, 12 out of 39 control patients, p ≤ 0.001) at the 1-month follow-up, and 64% (11 out of 15 intervention patients, 17 out of 29 control patients, p ≤ 0.001) at the 6-month follow-up irrespective of group allocation. In some patients previously resolved errors recurred during follow-up visits. This emphasizes the need for periodical reevaluation of patient administration skills and the provision of prevention strategies besides education.ConclusionPatient education that included demonstration of administration skills and verbal and written counseling on observed errors improved eye-drop administration skills irrespective of the communication technique applied. Whereof, high drop-out rates limited the power to detect a difference between groups. In particular, periodic demonstration of administration skills seemed important for sustainable improvement of administration skills. However, further error prevention strategies such as additional education materials or support by a caregiver may be necessary in some patients