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

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Dalton, Kieran
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University College Cork
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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.
Prescribing , Medication , Aged , Hospital , Pharmacist
Dalton, K. 2019. Factors affecting prescriber implementation of medication appropriateness recommendations in hospitalised older adults. PhD Thesis, University College Cork.