How to ... be a reflective practitioner.

ContextDevelopers of health care software have attributed improvements in patient
care to these applications. As with any health care intervention, such claims
require confirmation in clinical trials.ObjectivesTo review controlled trials assessing the effects of computerized clinical
decision support systems (CDSSs) and to identify study characteristics predicting
benefit.Data SourcesWe updated our earlier reviews by searching the MEDLINE, EMBASE, Cochrane
Library, Inspec, and ISI databases and consulting reference lists through
September 2004. Authors of 64 primary studies confirmed data or provided additional
information.Study SelectionWe included randomized and nonrandomized controlled trials that evaluated
the effect of a CDSS compared with care provided without a CDSS on practitioner
performance or patient outcomes.Data ExtractionTeams of 2 reviewers independently abstracted data on methods, setting,
CDSS and patient characteristics, and outcomes.Data SynthesisOne hundred studies met our inclusion criteria. The number and methodologic
quality of studies improved over time. The CDSS improved practitioner performance
in 62 (64%) of the 97 studies assessing this outcome, including 4 (40%) of
10 diagnostic systems, 16 (76%) of 21 reminder systems, 23 (62%) of 37 disease
management systems, and 19 (66%) of 29 drug-dosing or prescribing systems.
Fifty-two trials assessed 1 or more patient outcomes, of which 7 trials (13%)
reported improvements. Improved practitioner performance was associated with
CDSSs that automatically prompted users compared with requiring users to activate
the system (success in 73% of trials vs 47%; P = .02)
and studies in which the authors also developed the CDSS software compared
with studies in which the authors were not the developers (74% success vs
28%; respectively, P = .001).ConclusionsMany CDSSs improve practitioner performance. To date, the effects on
patient outcomes remain understudied and, when studied, inconsistent.

Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review.

ContextCurrent assessment formats for physicians and trainees reliably test
core knowledge and basic skills. However, they may underemphasize some important
domains of professional medical practice, including interpersonal skills,
lifelong learning, professionalism, and integration of core knowledge into
clinical practice.ObjectivesTo propose a definition of professional competence, to review current
means for assessing it, and to suggest new approaches to assessment.Data SourcesWe searched the MEDLINE database from 1966 to 2001 and reference lists
of relevant articles for English-language studies of reliability or validity
of measures of competence of physicians, medical students, and residents.Study SelectionWe excluded articles of a purely descriptive nature, duplicate reports,
reviews, and opinions and position statements, which yielded 195 relevant
citations.Data ExtractionData were abstracted by 1 of us (R.M.E.). Quality criteria for inclusion
were broad, given the heterogeneity of interventions, complexity of outcome
measures, and paucity of randomized or longitudinal study designs.Data SynthesisWe generated an inclusive definition of competence: the habitual and
judicious use of communication, knowledge, technical skills, clinical reasoning,
emotions, values, and reflection in daily practice for the benefit of the
individual and the community being served. Aside from protecting the public
and limiting access to advanced training, assessments should foster habits
of learning and self-reflection and drive institutional change. Subjective,
multiple-choice, and standardized patient assessments, although reliable,
underemphasize important domains of professional competence: integration of
knowledge and skills, context of care, information management, teamwork, health
systems, and patient-physician relationships. Few assessments observe trainees
in real-life situations, incorporate the perspectives of peers and patients,
or use measures that predict clinical outcomes.ConclusionsIn addition to assessments of basic skills, new formats that assess
clinical reasoning, expert judgment, management of ambiguity, professionalism,
time management, learning strategies, and teamwork promise a multidimensional
assessment while maintaining adequate reliability and validity. Institutional
support, reflection, and mentoring must accompany the development of assessment
programs.

/pdf/defining-and-assessing-professional-competence-1sy606vpxu.pdf

Defining and Assessing Professional Competence

Background Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States. Methods This study used a modified Delphi method, a set of procedures and methods for formulating a group judgment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of statements: (1) medications or medication classes thatshould generally be avoidedin persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to havespecific medical conditions. Results This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity. Conclusions This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/757456/ioi20821.pdf

Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts.

Objective: The objective of this study was to evaluate the impact of medication adherence on healthcare utilization and cost for 4 chronic conditions that are major drivers of drug spending: diabetes, hypertension, hypercholesterolemia, and congestive heart failure. Research Design: The authors conducted a retrospective cohort observation of patients who were continuously enrolled in medical and prescription benefit plans from June 1997 through May 1999. Patients were identified for disease-specific analysis based on claims for outpatient, emergency room, or inpatient services during the first 12 months of the study. Using an integrated analysis of administrative claims data, medical and drug utilization were measured during the 12-month period after patient identification. Medication adherence was defined by days’ supply of maintenance medications for each condition. Patients: The study consisted of a population-based sample of 137,277 patients under age 65. Measures: Disease-related and all-cause medical costs, drug costs, and hospitalization risk were measured. Using regression analysis, these measures were modeled at varying levels of medication adherence. Results: For diabetes and hypercholesterolemia, a high level of medication adherence was associated with lower disease-related medical costs. For these conditions, higher medication costs were more than offset by medical cost reductions, producing a net reduction in overall healthcare costs. For diabetes, hypercholesterolemia, and hypertension, cost offsets were observed for all-cause medical costs at high levels of medication adherence. For all 4 conditions, hospitalization rates were significantly lower for patients with high medication adherence. Conclusions: For some chronic conditions, increased drug utilization can provide a net economic return when it is driven by improved adherence with guidelines-based therapy.

http://innovamedicaldesign.com/studies/Impact_of_Medication_Adherence.pdf

Impact of medication adherence on hospitalization risk and healthcare cost.

ContextRising costs of medications and inequities in access have sparked calls
for drug policy reform in the United States and Canada. Control of drug expenditures
by prescription cost-sharing for elderly persons and poor persons is a contentious
issue because little is known about the health impact in these subgroups.ObjectivesTo determine (1) the impact of introducing prescription drug cost-sharing
on use of essential and less essential drugs among elderly persons and welfare
recipients and (2) rates of emergency department (ED) visits and serious adverse
events associated with reductions in drug use before and after policy implementation.Design and SettingInterrupted time-series analysis of data from 32 months before and 17
months after introduction of a prescription coinsurance and deductible cost-sharing
policy in Quebec in 1996. Separate 10-month prepolicy control and postpolicy
cohort studies were conducted to estimate the impact of the drug reform on
adverse events.ParticipantsA random sample of 93 950 elderly persons and 55 333 adult
welfare medication recipients.Main Outcome MeasuresMean daily number of essential and less essential drugs used per month,
ED visits, and serious adverse events (hospitalization, nursing home admission,
and mortality) before and after policy introduction.ResultsAfter cost-sharing was introduced, use of essential drugs decreased
by 9.12% (95% confidence interval [CI], 8.7%-9.6%) in elderly persons and
by 14.42% (95% CI, 13.3%-15.6%) in welfare recipients; use of less essential
drugs decreased by 15.14% (95% CI, 14.4%-15.9%) and 22.39% (95% CI, 20.9%-23.9%),
respectively. The rate (per 10 000 person-months) of serious adverse
events associated with reductions in use of essential drugs increased from
5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly
persons (a net increase of 6.8 [95% CI, 5.6-8.0]) and from 14.7 to 27.6 in
welfare recipients (a net increase of 12.9 [95% CI, 10.2-15.5]). Emergency
department visit rates related to reductions in the use of essential drugs
also increased by 14.2 (95% CI, 8.5-19.9) per 10 000 person-months in
elderly persons (prepolicy control cohort, 32.9; postpolicy cohort, 47.1)
and by 54.2 (95% CI, 33.5-74.8) among welfare recipients (prepolicy control
cohort, 69.6; postpolicy cohort, 123.8). These increases were primarily due
to an increase in the proportion of recipients who reduced their use of essential
drugs. Reductions in the use of less essential drugs were not associated with
an increase in risk of adverse events or ED visits.ConclusionsIn our study, increased cost-sharing for prescription drugs in elderly
persons and welfare recipients was followed by reductions in use of essential
drugs and a higher rate of serious adverse events and ED visits associated
with these reductions.

https://jamanetwork.com/journals/jama/articlepdf/1108322/JOC00341.pdf

Adverse Events Associated With Prescription Drug Cost-Sharing Among Poor and Elderly Persons

OBJECTIVE: To develop a consensus-based list of inappropriate practices in prescribing for elderly people. DESIGN: Mail survey of a 32-member national panel. SETTING: Academic medical centres across Canada. PARTICIPANTS: Thirty-two specialists selected arbitrarily, including 7 clinical pharmacologists, 9 geriatricians, 8 family practitioners and 8 pharmacists. OUTCOME MEASURES: Consensus that the practice would introduce a substantial and significant increase in the risk of serious adverse effect and is common enough that its curtailment would decrease morbidity among elderly people, ranking of clinical importance of the risk, and availability of equally or more effective and less risky alternative therapy. RESULTS: The 32-member national panel developed a list of 71 practices in prescribing for elderly people and rated the clinical significance of each on a scale of 1 (not significant) to 4 (highly significant). The practices in prescribing identified fell into 3 categories: drugs generally contraindicated for elderly people, drug-disease interactions and drug-drug interactions. The mean significance rating was greater than 3 for 39 practices. For each practice, alternative therapies were recommended. There was surprising congruence among the specialists on the significance rating and the suggested alternative therapies. CONCLUSION: The authors have developed a valid, relevant list of inappropriate practices in prescribing for elderly people, to be used in a practice-based intervention study.

/pdf/defining-inappropriate-practices-in-prescribing-for-elderly-4m46bvqy4s.pdf

Defining inappropriate practices in prescribing for elderly people: a national consensus panel

Background: Adverse drug-related events are common in the elderly, and inappropriate prescribing is a preventable risk factor. Our objective was to determine whether inappropriate prescribing could be reduced when primary care physicians had computer-based access to information on all prescriptions dispensed and automated alerts for potential prescribing problems. Methods: We randomly assigned 107 primary care physicians with at least 100 patients aged 66 years and older (total 12 560) to a group receiving computerized decision-making support (CDS) or a control group. Physicians in the CDS group had access to information on current and past prescriptions through a dedicated computer link to the provincial seniors9 drug-insurance program. When any of 159 clinically relevant prescribing problems were identified by the CDS software, the physician received an alert that identified the nature of the problem, possible consequences and alternative therapy. The rate of initiation and discontinuation of potentially inappropriate prescriptions was assessed over a 13-month period. Results: In the 2 months before the study, 31.8% of the patients in the CDS group and 33.3% of those in the control group had at least 1 potentially inappropriate prescription. During the study the number of new potentially inappropriate prescriptions per 1000 visits was significantly lower (18%) in the CDS group than in the control group (relative rate [RR] 0.82, 95% confidence interval [CI] 0.69–0.98), but differences between the groups in the rate of discontinuation of potentially inappropriate prescriptions were significant only for therapeutic duplication by the study physician and another physician (RR 1.66, 95% CI 0.99–2.79) and drug interactions caused by prescriptions written by the study physician (RR 2.15, 95% CI 0.98–4.70). Interpretation: Computer-based access to complete drug profiles and alerts about potential prescribing problems reduces the rate of initiation of potentially inappropriate prescriptions but has a more selective effect on the discontinuation of such prescriptions.

/pdf/the-medical-office-of-the-21st-century-moxxi-effectiveness-54mkupnwuj.pdf

The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care

OBJECTIVES: To determine (a) whether the risk of a potentially inappropriate drug combination (PIDC) increases with the number of physicians involved in the medical management of an elderly patient and (b) whether the risk of a PIDC is reduced if a patient has a single primary care physician or a single dispensing pharmacy, or both. DESIGN: Cross-sectional retrospective provincial database study. PARTICIPANTS: A regionally stratified random sample of 51,587 elderly medicare registrants in Quebec who (a) visited at least one physician in 1990, (b) were not living in a health care institution for the entire year and (c) had been dispensed at least one prescription for a cardiovascular drug, a psychotropic drug or a nonsteroidal anti-inflammatory drug (NSAID). OUTCOME MEASURES: Information on all physician visits and drugs dispensed during 1990. Physician claims were used to identify the number of physicians involved in a patient9s management and whether the patient had one primary care physician. Prescription claims were used to identify the number of PIDCs, prescribing physicians and dispensing pharmacies. RESULTS: The prevalence of PIDCs ranged from 4.0% (among those in the NSAID group) to 20.3% (among those in the psychotropic drug group). Of the PIDCs identified, 17.6% to 25.8% resulted from contemporaneous prescribing by different physicians. The number of prescribing physicians was the most important risk factor for a PIDC in all drug groups (odds ratio [OR] 1.44 to 1.71). The presence of a single primary care physician lowered the risk for cardiovascular and psychotropic PIDCs (OR 0.70 and 0.79 respectively) but not for NSAID PIDCs (OR 0.94). The use of a single dispensing pharmacy lowered the risk of a PIDC in all drug groups (OR 0.68 to 0.79). CONCLUSION: The greater the number of physicians prescribing medications for an elderly patient, the greater is the risk that the patient will receive a PIDC. A single primary care physician and a single dispensing pharmacy may be "protective" factors in preventing PIDCs.

Do too many cooks spoil the broth? Multiple physician involvement in medical management of elderly patients and potentially inappropriate drug combinations.

Background: Use of nonsteroidal anti-inflammatory drugs (NSAIDs) increases the risk for hospitalization and death from gastrointestinal bleeding and perforation. Objectives: To 1) estimate the exte...

Peter J. McLeod

Papers

Adverse Events Associated With Prescription Drug Cost-Sharing Among Poor and Elderly Persons

Defining inappropriate practices in prescribing for elderly people: a national consensus panel

The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care

Do too many cooks spoil the broth? Multiple physician involvement in medical management of elderly patients and potentially inappropriate drug combinations.

Unnecessary Prescribing of NSAIDs and the Management of NSAID-Related Gastropathy in Medical Practice