on behalf of the Erasmus+ consortia European Prescribing Exam, European Open Platform of Prescribing Education and Clinical Pharmacology and Therapeutics Teach the Teacher program, and the EACPT Education Working Group

Utrecht University Repository

Vol.:(0123456789) European Journal of Clinical Pharmacology (2023) 79:571–574 https://doi.org/10.1007/s00228-023-03465-9BRIEF COMMUNICATIONEducational value of international and intercultural differences in prescribing: the international and interprofessional student‑run clinic projectMichiel J. Bakkum1,2 · Erik M. Donker1,2 · Pietro Spitaleri Timpone3 · Charlotte A. M. Hagen1 · Milan C. Richir1,2,4 · Michiel A. van Agtmael1,2 · Fabrizio De Ponti3 · Jelle Tichelaar1,2 · on behalf of the Erasmus+ consortia European Prescribing Exam, European Open Platform of Prescribing Education and Clinical Pharmacology and Therapeutics Teach the Teacher program, and the EACPT Education Working GroupReceived: 7 December 2022 / Accepted: 14 December 2022 / Published online: 7 February 2023 © The Author(s) 2023Keywords Clinical pharmacology · Education · Interprofessional · UndergraduateTreatment guidelines differ significantly, not only between Europe and North America but also among European coun-tries [1–4]. Reasons for these differences include antimi-crobial resistance patterns, accessibility to and reimburse-ment policies for medicines, and culturally and historically determined prescribing attitudes. The European Associa-tion of Clinical Pharmacology and Therapeutics’ Education Working Group has launched several initiatives to improve and harmonize European pharmacotherapy education, but international differences have proven to be a major barrier to these efforts [5–7]. While we have taken steps to chart these differences [6, 8], it will probably not be possible to fully resolve them. Rather than viewing these differences as a barrier, we should perhaps see them as an opportunity for intercultural learning by providing students and teach-ers a valuable lesson in the context-dependent nature of prescribing medication and the different interpretations of evidence-based medicine. Here, we extend our experience with interprofessional student-run clinics [9, 10], to report on our first experiences with the “International and Inter-professional Student-run Clinic.”We organized three successful video meetings with medi-cal and pharmacy students of the Amsterdam UMC, loca-tion VU University (the Netherlands), and the University of Bologna (Italy). During these meetings, one of the students presented a real-life case of a patient on polypharmacy. Then, in a 45-min session, the students split into smaller groups (break-out rooms) to review the patient’s medica-tion, using the prescribing optimization method and STOPP/START criteria [11, 12]. The teachers rotated between the different rooms and assisted the students when necessary. Teachers and students reconvened for 60 min for debriefing, with students presenting their findings and suggestions to revise the medication list and teachers stimulating discus-sion and indicating how they would alter the medication list. Participation was voluntary, and the meetings were held in the evenings to accommodate students in clinical rotations.Third-to-final-year medical and pharmacy students par-ticipated in the three meetings (n = 17, n = 20, n = 12, respec-tively). They reported learning a lot from each other, gaining an international and interprofessional perspective. Moreover, they learned to always consider the patient’s perspective, that evidence-based medicine is context-dependent, and that guidelines should be adapted to the patient’s situation.There were marked differences in prescribing guidelines and the use and accessibility of medicines (Table 1). In both countries, national societies develop guidelines based on international standards, but in the Netherlands, most Michiel J. Bakkum and Erik M. Donker contributed equally as first authors. * Erik M. Donker  e.donker@amsterdamumc.nl1 Department of Internal Medicine, Amsterdam UMC, Unit Pharmacotherapy, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands2 Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands3 Department of Medical and Surgical Sciences, Alma Mater Studiorum, Pharmacology Unit, University of Bologna, Bologna, Italy4 Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands572 European Journal of Clinical Pharmacology (2023) 79:571–5741 3Table 1  Examples of differences between clinical practice guidelines and the use of medicines in the Netherlands and ItalyDDD defined daily dose, PPI proton pump inhibitor, SU sulfonylurea, SGLT2 sodium/glucose cotransporter-2, GLP glucagon-like peptide-1a  Data based on figures of the Dutch National Health Care Institute [18]b  Data based on figures of OSMED report - Italian Medicines Agency (AIFA) [19]c  No data about over-the-counter use availabled  Apixaban, rivaroxaban, edoxaban, dabigatrane  Omeprazole, pantoprazole, lansoprazole, rabeprazole, esomeprazolef  Macrogol, lactuloseg  Glibenclamide, tolbutamide, gliclazide, glimepirideSubjectDutch situationaItalian situationbAcetylsalicylic acidAlmost exclusively used in low dosages as anti-platelet therapy (41.7 DDD/1000 inhabitants/day)Commonly used as over-the-counter nonsteroidal anti-inflammatory  drugc  and as anti-platelet therapy (46.1 user DDD/1000 inhabitants/day)Direct oral  anticoagulantsdCommonly prescribed by medical specialists and general practitioners (18.6 DDD/1000 inhabitants/day) [16]Almost exclusively prescribed by medical specialists due to prescribing restrictions that were lifted only recently (15.2 DDD/1000 inhabitants/day) [17]Vitamin D supplementsAdvised as primary prevention for osteoporosis in postmenopausal women and men aged 70 years or older (65.3 DDD/1000 inhabitants/day). Selective reimbursement since 2019, possibly leads to increase of over-the-counter  usec. Per 2023 no reimbursement at all (over-the-counter use promoted)In adults, reimbursement was recently restricted to selected conditions because of its potentially inappropriate use (142.9 DDD/1000 inhabitants/day)Gastric ulcer  prophylaxiseVery directive guidelines intended to avoid under- and overuse of PPIs (126.8 DDD/1000 inhabitants/day)Guidelines aimed at preventing gastric ulcers/bleeding, but not at reducing overuse (79.8 DDD/1000 inhabitants/day)Osmotic laxatives with  opioidsfProphylactic treatment with laxatives is advised when opioids are started (18.9 DDD/1000 inhabitants/day)Laxatives are reactively given when constipation develops (2.2 DDD/1000 inhabitants/day)Type II diabetes mellitusSU  derivatesg  remain second-line treatment (for patients without prior  cardiovascular or renal disease) (24.6 DDD/1000 inhabitants/day)SU derivates virtually abandoned since the introduction of SGLT2-inhibitors and GLP1-agonists (7.1 DDD/1000 inhabitants/day)Angina pectoris prophylaxisLong-acting nitrates usually administered orallyLong-acting nitrates usually administered either via skin patches or oral tablets573European Journal of Clinical Pharmacology (2023) 79:571–574 1 3hospitals have their own local guidelines as well, resulting in different prescribing preferences (e.g., use of different low-molecular-weight heparins). Differences in prescrib-ing preferences exist in Italy, but are based on regional, not local, formularies. For instance, the Emilia-Romagna region has a periodically revised formulary, whereas the Lombardy region does not. Moreover, while in the Netherlands, physi-cians are allowed to prescribe almost all marketed drugs, even if their costs are not always reimbursed; in Italy, cer-tain drugs may only be prescribed by a specialist (e.g., new glucose-lowering drugs, until January 2022) [13].These first experiences with international and interprofes-sional case discussions during the COVID pandemic have taught us that geographical distance no longer needs to be an obstacle to organizing educational events. This, together with the earlier finding that an interprofessional student-run medication review program could optimize pharma-cotherapy and reduce adverse drug events, is a promising development [14, 15]. We intend to expand the scope of these case discussions by including different universities and larger (intra-curricular) assignments. Five other European universities monitored the last two meetings and want to par-ticipate in future meetings. The European Open Platform of Prescribing Education  (EurOP2E) provides a meeting place for international teachers wishing to organize such meetings and helps to facilitate them. Interested teachers can apply via www. presc ribin geduc ation. eu.Erasmus+ consortia European Prescribing Exam, European Open Plat‑form of Prescribing Education and Clinical Pharmacology and Thera‑peutics Teach the Teacher program, and the EACPT Education Working Group Robert Likic, Unit of Clinical Pharmacology, Department of Internal Medicine, University Hospital Centre Zagreb and Univer-sity of Zagreb School of Medicine, Zagreb, Croatia; Ylva Böttiger, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden; Thierry Christiaens, Department of Clinical Pharmacology, Ghent University, Ghent, Belgium; Cornelis Kramers, Department of Pharmacology-Toxicology, Radboud University Medi-cal Center, Nijmegen, The Netherlands; João N. Costa, Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Uni-versity of Lisbon, Lisbon, Portugal; Emilio J Sanz, School of Health Science, Universidad de La Laguna, Tenerife, Spain And Hospital Universitario de Canarias. La Laguna. Tenerife. Spain; Paraskevi Papaioannidou, 1st Department of Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thes-saloniki, Greece; Joost Piët, Department of Internal Medicine, Unit Pharmacotherapy, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands, Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands; Lorena Dima, Transilvania University of Brașov, Faculty of Medicine, Brașov, Romania; Jeroen van Smeden, Division of education, Centre for Human Drug Research, Leiden, The Netherland; Jitka Rychlícková, Department of Anesthesiology and Intensive Care, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University; Floor van Rosse, Department of Hos-pital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands; Susanna M. Wallerstedt, Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Markus Schwaninger, Institute for Experimen-tal and Clinical Pharmacology and Toxicology, University of Lübeck, Lübeck, Germany; Yves-Marie Pers, RMB, University of Montpel-lier, Inserm U1183, CHU Montpellier, Montpellier, France; David J. Brinkman, Department of Internal Medicine, Unit Pharmacotherapy, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands, Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Nether-lands; Carla Sans-Pola, Department of Clinical Pharmacology, Vall d'Hebron Hospital Universitari, Barcelona, Spain; Jamie J. Coleman, University of Birmingham, Institute of Clinical Sciences, Birmingham, UK; Romaldas Maciulaitis, Lithuanian University of Health Sciences, Institute of Physiology and Pharmacology, Kaunas, Lithuania; Bogdan Ionel Tamba, Department of Pharmacology, Clinical Pharmacology and Algesiology, Grigore T. Popa University of Medicine and Phar-macy, Iasi, Romania.Author contribution All authors contributed to the study’s concep-tion and design. Material preparation, data collection, and analysis were performed by MB, ED, CAMH, and PST. The first draft of the manuscript was written by MB and ED, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.Funding This work was supported by Erasmus+ , grant numbers 2019‐1 ‐ NL01 ‐ KA203‐060492, 2020–1-NL01-KA203-083098, and 2022–1-NL01-KA220-HED-000088069.Data availability Not applicable.Code availability Not applicable.Declarations Ethics approval Not applicable.Consent to participate Not applicable.Consent for publication Not applicable.Conflict of interest The authors declare no competing interests.Open Access This article is licensed under a Creative Commons Attri-bution 4.0 International License, which permits use, sharing, adapta-tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.References 1. van der Meer P, Gaggin HK, Dec GW (2019) ACC/AHA versus ESC guidelines on heart failure: JACC guideline comparison. J Am Coll Cardiol 73(21):2756–2768. https:// doi. org/ 10. 1016/j. jacc. 2019. 03. 478 2. Youssef A, Vermeulen N, Lashley EELO, Goddijn M, van der Hoorn MLP (2019) Comparison and appraisal of (inter)national 574 European Journal of Clinical Pharmacology (2023) 79:571–5741 3recurrent pregnancy loss guidelines. Reprod Biomed Online 39(3):497–503. https:// doi. org/ 10. 1016/j. rbmo. 2019. 04. 008 3. Mohan GC, Lio PA (2015) Comparison of dermatology and allergy guidelines for atopic dermatitis management. JAMA Der-matol 151(9):1009–1013. https:// doi. org/ 10. 1001/ jamad ermat ol. 2015. 0250 4. Becker M, Breuing J, Nothacker M, Deckert S, Brombach M, Schmitt J, Neugebauer E, Pieper D (2019) Guideline-based quality indicators—a systematic comparison of German and international clinical practice guidelines. Implement Sci 14(1):71. https:// doi. org/ 10. 1186/ s13012- 019- 0918-y 5. Bakkum MJ, Richir MC, Papaioannidou P, Likic R, Sanz EJ, Christiaens T, Costa JN, Mačiulaitis R, Dima L, Coleman J, Tichelaar J, van Agtmael MA (2021) EurOP(2)E - the European Open Platform for Prescribing Education, a consensus study among clinical pharmacology and therapeutics teachers. Eur J Clin Pharmacol 77(8):1209–1218. https:// doi. org/ 10. 1007/ s00228- 021- 03101-4 6. Brinkman DJ, Tichelaar J, Mokkink LB, Christiaens T, Likic R, Maciulaitis R, Costa J, Sanz EJ, Maxwell SR, Richir MC, van Agtmael MA, Education working group of the European Associa-tion for Clinical P, Therapeutics, its affiliated Network of Teachers in P (2018) Key learning outcomes for clinical pharmacology and therapeutics education in Europe: a modified Delphi study. Clin Pharmacol Ther 104(2):317–325. https:// doi. org/ 10. 1002/ cpt. 962 7. Donker EM, Brinkman DJ, Richir MC, Papaioannidou P, Likic R, Sanz EJ, Christiaens T, Costa JN, De Ponti F, Böttiger Y, Kramers C, van Agtmael MA, Tichelaar J (2022) The European Prescribing Exam: assessing whether European medical students can prescribe rationally and safely. Eur J Clin Pharmacol 78(6):1049–1051. https:// doi. org/ 10. 1007/ s00228- 022- 03301-6 8. Donker E, Brinkman D, Richir M, Papaioannidou P, Likic R, Sanz EJ, Christiaens T, Costa J, De Ponti F, Gatti M, Böttiger Y, Kramers C, Garner S, Pandit R, van Agtmael M, Tichelaar J (2021) European list of essential medicines for medical edu-cation: a protocol for a modified Delphi study. BMJ Open 11(5):e045635. https:// doi. org/ 10. 1136/ bmjop en- 2020- 045635 9. Schutte T, Tichelaar J, van Agtmael M (2016) Learning to pre-scribe in a student-run clinic. Med Teach 38(4):425. https:// doi. org/ 10. 3109/ 01421 59x. 2015. 10721 45 10. Dekker RS, Schutte T, Tichelaar J, Thijs A, van Agtmael MA, de Vries TP, Richir MC (2015) A novel approach to teaching pharmacotherapeutics–feasibility of the learner-centered student-run clinic. Eur J Clin Pharmacol 71(11):1381–1387. https:// doi. org/ 10. 1007/ s00228- 015- 1916-x 11. Drenth-van Maanen AC, van Marum RJ, Knol W, van der Linden CMJ, Jansen PAF (2009) Prescribing optimization method for improving prescribing in elderly patients receiving polypharmacy. Drugs Aging 26(8):687–701. https:// doi. org/ 10. 2165/ 11316 400- 00000 0000- 00000 12. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P (2014) STOPP/START criteria for potentially inap-propriate prescribing in older people: version 2. Age Ageing 44(2):213–218. https:// doi. org/ 10. 1093/ ageing/ afu145 13. Agenzia Italiana del Farmaco (2022) NOTA 100. In: ed. https:// www. aifa. gov. it/ docum ents/ 20142/ 17281 25/ nota- 100. pdf 14. Sultan R, van den Beukel TO, Reumerman MO, Daelmans HEM, Springer H, Grijmans E, Muller M, Richir MC, van Agtmael MA, Tichelaar J (2022) An interprofessional student-run medication review program: the clinical STOPP/START-based outcomes of a controlled clinical trial in a geriatric outpatient clinic. Clin Phar-macol Ther 111(4):931–938. https:// doi. org/ 10. 1002/ cpt. 2475 15. Reumerman MO, Richir MC, Sultan R, Daelmans HEM, Springer H, Grijmans E, Muller M, van Agtmael MA, Tichelaar J (2022) An inter-professional student-run medication review programme. Reducing adverse drug reactions in a memory outpatient clinic: a controlled clinical trial. Expert Opin Drug Saf 1–10. https:// doi. org/ 10. 1080/ 14740 338. 2022. 20697 48 16. de Jong LA, Koops M, Gout-Zwart JJ, Beinema MJ, Hemels MEW, Postma MJ, Brouwers J (2018) Trends in direct oral anti-coagulant (DOAC) use: health benefits and patient preference. Neth J Med 76(10):426–430 17. Agenzia Italiana del Farmaco (2020) NOTA 97. https:// www. aifa. gov. it/ docum ents/ 20142/ 17281 16/ nota- 97. pdf 18. Zorginstituut Nederland / GIPdatabank. https:// www. gipda tabank. nl/. Accessed Dec 2022 19. Italian Medicines Agency (2022) The medicines utilisation moni-toring centre. National Report on Medicines use in Italy. 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Educational value of international and intercultural differences in prescribing: the international and interprofessional student-run clinic project

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Educational value of international and intercultural differences in prescribing: the international and interprofessional student-run clinic project

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