Appropriateness Of Drug Prescriptions Research Articles

Drug prescription appropriateness in hospitalized older patients: 15-year results and lessons from a countrywide register.

The global increase of aging with the related increase of multiple noncommunicable diseases is inevitably accompanied by the associated issue of multimorbidity and polypharmacy. The latter is not without peculiar consequences on health, because it has been shown to be associated with drug-related adverse events, mainly due to poor prescription appropriateness and drug-drug interactions. To contribute to tackle this gigantic problem, a registry of drug dispensation in hospitalized older patient has been initiated in Italy in 2008. Through the last 15years, data on nearly 11,000 older people have been accrued during their hospital stay in internal medicine and geriatric wards. This review article summarizes the main findings obtained, and how these data contribute to tackle the issue of appropriateness of drug prescription and the need of deprescribing in hospitalized older people affected by the most common noncommunicable diseases.

Prevalence of potentially inappropriate medications among elderly patients with diabetes – study based on STOPP/START criteria

Objective: The prevalence of drug-related problems in elderly patients is a concerning issue that can lead to elevated morbidity, mortality, and health care resource utilisation. This study focuses on the significance of addressing diabetes in the context of an ageing population, where elderly individuals face higher risks of comorbidities and mortality. The main objective of this study was to assess potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) among patients with diabetes in Bulgaria, using the explicit STOPP/START criteria, version 2. By evaluating the appropriateness of drug prescriptions in this specific patient population, this study aims to shed light on areas that require optimisation to enhance patient safety and treatment outcomes. Materials and methods: A national prospective questionnaire study was conducted in Bulgaria among patients aged over 65 years. The research was conducted in 25 randomly selected pharmacies. The study supports the use of the STOPP/START criteria based on the clinical information provided. A total of 133 patients with T1DM or T2DM participated in the study. The evaluation of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) was performed in 131 patients. sStatistical differences in demographics and medication numbers between patients with and without PIMs or PPOs were assessed using a Chi-square test, with a p-value of ≤ 0.05 considered statistically significant. Results: The pharmacotherapy of 131 patients with diabetes was assessed, and it was found that 57% of them had polypharmacy. Among the study population, 90 PIMs were identified, indicating that 66% of the patients had inappropriate prescribing. Notably, inappropriate prescribing concerning diabetes was associated with the use of long-acting sulfonylureas (n=10) and beta-blockers (n=13). Applying the START criteria revealed 67 PPOs among 67 patients, representing a prevalence of 50% in the study population. However, no PPOs were detected in the context of diabetes pharmacotherapy. Furthermore, a significant relationship was observed between the number of medications and PIMs, as evidenced by the chi-square test result with a p-value close to zero, indicating statistical significance. Conclusion: The study revealed a high prevalence of PIMs in elderly patients with diabetes in Bulgaria. Endocrine disorders contribute to 26% of PIMs. As Bulgaria’s ageing population faces increasing diabetes challenges, effective management strategies are crucial. These findings underscore the significance of addressing prescribing practises to enhance disease control and prevent complications.

Associations between polypharmacy and potentially inappropriate medications with risk of falls among the elderly in Saudi Arabia

BackgroundFalls are dangerous to the health of older adults and can impact their functional status leading to frailty. The use of potentially inappropriate medications (PIMs) among older adults may lead to adverse health outcomes and increase the risk of falls. Polypharmacy increases the incidence of falls. Beers criteria by the American Geriatric Society is one of the many criteria used to detect PIMs. It assesses the appropriateness of drug prescriptions (i.e., correct dose, duration, and indications) to ensure the safety of these drugs, reducing drug interactions and decreasing the hazards of side effects. This epidemiological study aims to explore the association between polypharmacy and Beers criteria with the risk of falls in the elderly.MethodA total of 387 outpatients aged 60 or older were interviewed in person. The patients were recruited from the University Hospital and the Family and Community Medicine Center in Khobar city, Saudi Arabia, between the period of November 2021 to March 2022. All patients were able to walk independently. The survey began by collecting patients’ demographics, gathering medication history, and asking three key questions to detect the risk of falls which was developed by the Center of Disease Control (CDC). Polypharmacy (defined as concurrent use of five or more medications) and PIMs (defined as use of one or more medications in the Beers list) were examined against risk of falls in the elderly. Multiple logistic regression analyses were used to estimate adjusted Odds Ratios (ORs).ResultA total of 387 patients participated in the study; 62% were male, and most participants belonged to the 60 < 65 years age category (47.80%). Among all patients, 55% had a high risk of falling, and 21% of patients had fell during the past year. Polypharmacy applied to 50.90% of all patients, while Beers criteria positive group applied to 51.42%. Risk of falls and prior falls were associated with polypharmacy both before and after adjustment.ConclusionThe results showed a significant association between risk of falls with polypharmacy and PIMs, and more than half of our study population had a high risk of falls. Of those at a higher risk, one out of five had indeed experienced a fall in the last 12 months. Higher rates of falls were associated with older aged patients, lower educational levels, female gender, and cardiovascular medications.

Appropriateness of drug prescriptions in patients with chronic kidney disease in primary care: a double-center retrospective study

BackgroundChronic kidney disease (CKD) is a highly prevalent disease worldwide. A basic pillar for the management of a patient with CKD is the safe use of drugs. Inadequate dosing of medication or contraindicated drugs in renal impairment can lead to negative outcomes. The primary objective was to analyse the drug prescriptions of patients with CKD from two primary care centres to see if they were optimally adapted to the patient's estimated glomerular filtration rate (eGFR).MethodsA retrospective observational study was conducted in two urban primary care centres. The study period was between September–October 2019. Patients over 18 years of age, with established CKD and with an eGFR less than 60 mL/min/1.73m2 for at least three months were included. Their demographic data (age and sex) and clinical variables such as associated comorbidities, eGFR value were retrospectively registered. Finally, their medication plans were reviewed in order to detect: inappropriate prescribing (IP), defined as an incorrect dose/frequency or contraindicated drug according to the renal function of the patient; nephrotoxic drugs and drugs with a high sodium content.ResultsA total of 273 patients were included. The most common patient profile was an elderly woman, polymedicated, with other concomitant diseases and with mild CKD. Two hundred and one IPs were detected, 13.9% of which were contraindicated drugs. Of all patients, 49.1% had been prescribed at least one IP on their medication plan, 93.8% had some potentially nephrotoxic drug and 8.4% had drugs with a high sodium content prescribed.ConclusionsPatients with CKD are at increased risk of medication-related problems. It is necessary to implement measures to improve the safety in the prescription of drugs in patients with CKD.

P697: PONATINIB IN A REAL-LIFE SETTING: A RETROSPECTIVE ANALYSIS FROM THE MONITORING REGISTRIES OF THE ITALIAN MEDICINES AGENCY (AIFA)

Background: The efficacy and safety of ponatinib, a third-generation tyrosine kinase inhibitor (TKI), are mainly reported in sponsored clinical trials. Aims: The aim of this study, based on a retrospective analysis from the monitoring Registries of the Italian Medicines Agency (AIFA wMRs), is to provide real-world data on daily practice management, treatment modifications and outcome of a large cohort of chronic myeloid leukemia (CML) patients treated with ponatinib. Methods: AIFA wMRs is an administrative database whose main scope is monitoring the appropriateness of drug prescription in Italy. Information collected through the wMRS included demographic (place of birth, age, and sex) and clinical data (BCR-ABL levels, mutations and chromosomal abnormalities if evaluated), drug prescription and administration data (date of prescription and administration, dose administered, dose changes, occurrence of adverse events as yes/no dichotomic variable, reasons for treatment interruption and/or discontinuation) and response to treatment (response assessment was requested every 90 days). Subjects who had not been administered ponatinib for ≥ 120 days were adjudicated as “discontinued” even in the absence of the “end of treatment form”. Time to treatment discontinuation (TTD) was defined as the time occurring between the date of first administration and the date of treatment discontinuation for any cause, including death. Results: Overall, 666 CML subjects were eligible for analysis: 515 patients had chronic phase (CP) CML, 50 accelerated phase (AP) and 101 blast phase (BP). Median age at baseline was 58.7 years, male prevalence (57.1%). Median time from diagnosis to start of ponatinib was 2.35 years: 259 (38.9%) subjects had received 2 lines of treatment, 260 (39.0%) 3 lines and 147 (22.1%) 4 or more lines. Mutational status was available for 58.3% of patients (n=388), with a T315I mutation reported in 46 (6.9%) patients and other mutations (the most represented being E255K, F317L, Y253H and V299L) in 99 (14.9%) subjects. At baseline, 181 patients (27.2%) had arterial hypertension, 33 (5.0%) a history of arterial and/or venous thromboses, 32 (4.8%) a pre-existing ischemic heart disease, and 13 (2.0%) a history of congestive heart failure. Overall, 593 patients (89.0%) were evaluable for best response. Ten cases (1.7%, 3 AP/BP and 7 CP) did not achieve molecular response, whereas 58 patients (8.7%, 26 AP/BP patients and 32 CP) reached a BCR/ABL1 ratio between 1% and 10% IS. A MR2 (less than 1%IS) was obtained by 82 subjects (12.3%, 20 AP/BP and 62 CP patients); 128 patients (19.2%, 12 AP/BP and 116 CP patients) achieved a molecular response ranged between MR3 (0.1%) and MR4 (0.01% IS) and 266 (39.9%, 44 AP/BP and 222 CP patients) a deeper molecular response (< 0.01% IS). With a median follow-up of 14.4 months, 136 subjects (20.4%) required at least one dose reduction due to adverse events; 309 patients (46.4%) had their dose decreased in the absence of any evidence of side effects. Treatment discontinuation occurred in 144 patients (21.6%): intolerance (7.4%), primary resistance (3.5%) and acquired resistance (5.6%). Kaplan-Meier estimated TTD was 47.2 months (CI 95% 39.3 – NA) and 7.3 months (CI 95% 4.6 – 11.8) for CP and AP/BP patients, respectively. The probability of treatment discontinuation did not significantly differ for ponatinib in second, third or subsequent line of therapy (p=0.58). Summary/Conclusion: This real-life investigation shows that ponatinib dose reductions were mainly performed in the absence of reported toxicity rather than owing to the occurrence of adverse reactions.

Prescription Appropriateness of Drugs for Peptic Ulcer and Gastro-Esophageal Reflux Disease: Baseline Assessment in the LAPTOP-PPI Cluster Randomized Trial.

Background: Drugs for peptic ulcer and gastro-esophageal reflux disease (GERD) are among the most widely prescribed, frequently without appropriate indications. This represents an important issue, as it leads to risk of adverse events for patients and unnecessary costs for National Health Service. Aim: To assess the prescription appropriateness of drugs for GERD, in the frame of the “Evaluation of the effectiveness of a Low-cost informative intervention to improve the Appropriate PrescripTiOn of Proton PumP Inhibitors in older people in primary care: a cluster-randomized controlled study” (LAPTOP-PPI) (Clinicaltrial.gov: NCT04637750). Methods: The appropriateness of drug prescription was assessed on data collected in administrative databases, by integrating information on concomitant medications, outpatient medical and laboratory procedures and hospital discharge diagnoses, according to the reimbursement criteria provided by the Italian Medicine Agency. We analyzed data of community-dwelling people aged 65 years and over, living in the areas of Bergamo (Northern Italy) and Caserta (Southern Italy), from July 1 to 31 December 2019. Results: Among 380,218 patients, 175,342 (46.1%) received at least one prescription of drugs for GERD. All in all, we found that only 41.2% of patients received appropriate prescriptions. Conclusion: Given the potential risk of adverse drug reactions, especially in older people, educational interventions should be prompted for physicians, in order to improve the quality of prescription of drugs for GERD and, in turn, avoid unfavorable health outcomes and unnecessary costs.

Renal Function, Cardiovascular Diseases, Appropriateness of Drug Prescription and Outcomes in Hospitalized Older Patients.

Reduced estimated creatinine clearance (eCrCl) is prevalent in older patients and impacts on drug prescription. In this study, the burden of eCrCl reduction and its associated factors and impact on outcomes were analyzed. Moreover, the rate of inappropriate drug prescription according to eCrCl and its impact on outcomes were described. Data were obtained from "REgistro POliterapie SIMI" (REPOSI), a prospective observational register enrolling hospitalized patients aged ≥65 years. Patients enrolled from 2010-2016 with available data to calculate eCrCl according to the Cockcroft-Gault formula were included in this analysis. A total of 5046 patients were available for analysis. Among these, we found an eCrCl of 45-59 mL/min in 1163 patients (23.0%), an eCrCl of 30-44 mL/min in 1128 (22.4%), an eCrCl of 15-29 mL/min in 702 (13.9%), and an eCrCl <15 mL/min in 152 (3.0%), with several clinical factors associated with decreasing eCrCl. During follow-up, a progressively higher risk for all-cause death, cardiovascular (CV) death, any death/re-hospitalization, and CV death/re-hospitalization was found across the renal function classes. Among patients with hypertension, diabetes mellitus, atrial fibrillation, coronary artery disease, and heart failure, 476 (10.9%) were inappropriately prescribed medications according to eCrCl. During follow-up, inappropriate prescription was associated with increased risk of all-cause death (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.13-1.97) and any death/re-hospitalization (OR 1.30, 95% CI 1.03-1.63). In older hospitalized patients, impaired eCrCl is prevalent and associated with several factors, polypharmacy in particular. Patients with reduced eCrCl have a higher risk of major clinical outcomes, and >10% of them are prescribed an inappropriate drug, with a higher risk for major clinical outcomes.

Integration between general practice and hospital specialty for drug prescription appropriateness: the Diabetes Project of the Local Health Service Tuscany Centre

According to standards of medical care in diabetes, sulphonylureas and glinides are suggested to be abolished in the treatment of type 2 diabetes, due to their long-term adverse effects. In 2019, the Local Health Service – ASL Toscana Centro (TC) – promoted a collaboration among diabetologists, general practitioners (GPs) and pharmacists. In detail, the prescription of hypoglycemic drugs was retrieved through codes (ATCA10). After the presentation of the relative data and the recommendation/training of the diabetologist, the GPs were urged to abolish sulphonylureas and glinides, replacing them with newly generation drugs. Comparison with data in 2020 showed a significant drop in prescription of such drugs. Moreover, this project has allowed an estimate of the diabetic population within ASL TC additionally tracking other drugs, such as statins, which generally should be co-prescribed with hypoglycemic agents in the care of the diabetic patients. In conclusion, this experience has increased the knowledge relating to the most recent standards of diabetic care in general practice, promoted the appropriateness in the use of newly drugs, generated epidemiological data, and helped in better planning the long-term pharmaceutical expenditure. KEY WORDS general practice; educational training; stardards of care; sulphonylureas and glinides; statins.

Drug-Drug Interactions and Prescription Appropriateness at Hospital Discharge: Experience with COVID-19 Patients.

BackgroundPatients with coronavirus disease 2019 (COVID-19) are often elderly, with comorbidities, and receiving polypharmacy, all of which are known factors for potentially severe drug–drug interactions (DDIs) and the prescription of potentially inappropriate medications (PIMs).ObjectiveThe aim of this study was to assess the risk of DDIs and PIMs in COVID-19 patients at hospital discharge.MethodPatients with a proven diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who were hospitalized between 21 February and 30 April 2020, treated with at least two drugs, and with available information regarding pharmacological treatments upon admission and at discharge were considered. The appropriateness of drug prescriptions was assessed using INTERcheck®.ResultsA significant increase in the prescription of proton pump inhibitors and heparins was found when comparing admission with hospital discharge (from 24 to 33% [p < 0.05] and from 1 to 17% [p < 0.01], respectively). The increased prescription of heparins at discharge resulted in a highly significant increase in the potentially severe DDIs mediated by this class of drugs. 51% of COVID-19 patients aged > 65 years had at least one PIM upon admission, with an insignificant increment at discharge (58%).ConclusionAn increased number of prescribed drugs was observed in COVID-19 patients discharged from our hospital. The addition of heparins is appropriate according to the current literature, while the use of proton pump inhibitors is more controversial. Particular attention should be paid to the risk of bleeding complications linked to heparin-based DDIs.

Relationship between frailty and drug use among nursing homes residents: results from the SHELTER study.

1.5-8% of older adults live in nursing homes (NHs), presenting a high prevalence of frailty and polypharmacy. To investigate the association of frailty with polypharmacy and drug prescription patterns in a sample of European Nursing Home (NH) residents. Cross-sectional study based on the data from the Services and Health for Elderly in Long TERm care (SHELTER) study. 4121 NH residents in Europe and Israel. Residents' clinical, cognitive, social, and physical status were evaluated with the InterRAI LTCF tool, which allows comprehensive, standardized evaluation of persons living in NH. Polypharmacy and hyperpolypharmacy were defined as the concurrent use of ≥ 5 and ≥ 10 medications. Frailty was defined according to the FRAIL-NH scale. Of 4121 participants, 46.6% were frail (mean age 84.6 ± 9.2years; 76.4% female). Polypharmacy and hyperpolypharmacy were associated with a lower likelihood of frailty (Odds Ratio = 0.72; 95% CI = 0.59-0.87 and OR = 0.75; 95% CI = 0.60-0.94, respectively). Patterns of drug prescriptions were different between frail and non-frail residents. Symptomatic drugs (laxatives, paracetamol, and opioids) were more frequently prescribed among frail residents, while preventive drugs (bisphosphonates, vitamin D, and acetylsalicylic acid) were more frequently prescribed among non-frail residents. Frailty is associated with less polypharmacy and with higher prevalence of symptomatic drugs use among NH residents. Further studies are needed to define appropriateness of drug prescription in frail individuals.

Community and hospital pharmacists in Europe: encroaching on medicine?

Pharmacy has been historically regarded as a discipline between health and chemistry devoted to drug development, production, and compounding. These tasks have been almost lost with the industrial manufacturing, and dispensing remains the main activity of pharmacists. Hospital pharmacists are usually employees in their workplace, while the professional framework of community pharmacists is very different, being pharmacies predominantly private shops in almost all European countries. In the last years pharmacists have strongly advocated that the focus of their services should switch from ‘product’ to ‘patient’. Clinical pharmacy and pharmaceutical care are the two most cited concepts to support this shift. Clinical pharmacy was originally defined as the area of pharmacy concerned with the science and practice of rational medication use, pharmaceutical care as the responsible provision of drug therapies to achieve definite outcomes. The practice of clinical pharmacy should embrace the philosophy of pharmaceutical care. The new wave of pharmacists’ patient-centered care in Europe still seems to be a reaction against the loss of their traditional professional role after the drug manufacturing revolution. To depict a realistic scenario for progress, it is worth differentiating between hospital and community. Hospital pharmacists should strengthen their pivotal role of medication gatekeepers to improve among clinicians the appropriateness of drug prescriptions and generate savings in expenditures. Any proposal for clinical services provided by community pharmacists is inevitably affected by the issue of their potential remuneration, especially in countries where the remuneration for reimbursable drugs is still a proportion of the retail price.

Quality of clinical direct oral anticoagulant prescribing and identification of risk factors for inappropriate prescriptions.

Even though the use of direct oral anticoagulants (DOACs) is safe based on clinical outcomes, drug safety also depends on appropriateness of drug prescription, which is challenging for DOACs since many patient factors need to be considered. The aim of this study was to assess the appropriateness of DOAC prescriptions and to identify risk factors of determinants for inappropriate DOAC prescriptions. A retrospective study in a nonuniversity teaching hospital was performed of hospitalized patients (≥18 years) who received an initial DOAC prescription between February and August 2018. Appropriateness of prescribing was evaluated on 8 criteria by using a modified version of the medication appropriateness index. A total of 770 initial DOAC prescriptions of inpatients were evaluated: 267 patients (34.6%) had at least met 1 inappropriate criterion for a DOAC prescription. The most frequent inappropriate criterion was dosage (17.4%). Of the 4 DOACs, dabigatran (21.6%) and apixaban (21.2%) were mostly inappropriate dosed. In a multivariable analysis, reduced renal function (estimated glomerular filtration rate <50 mL/min; odds ratio [OR] = 2.35; P < .001), a diagnosis of atrial fibrillation (OR = 1.87; P = .004), and 'prescribed by surgeons' (OR = 1.9; P = .013) were independently associated with inappropriateness of prescribing. This study has highlighted a high degree of inappropriate prescribing of DOACs. These results underline the need for targeted interventions to improve DOAC prescribing.

Prescription for psychiatric patients in a Brazilian public hospital: cross-sectional study

Background: The growing use of psychotropic drugs has been attributed to a higher frequency of psychiatric disorders diagnosed, interaction of new drugs on the pharmaceutical market, and new therapeutic indications of existing drugs. Given this scenario, the adequacy of the use of psychotropic drugs needs to be analyzed considering the scientific evidences. Objectives: To assess the appropriateness of drug prescriptions used by psychiatric patients in a public hospital in Sorocaba, according to the best available scientific evidence, and to describe the profile of this population. Methods: This cross-sectional study collected data from clinical records of patients with psychiatric disorders hospitalized in the psychiatric sector of the Sorocaba Hospital Complex, state of São Paulo, Brazil, between August 2015 and December 2016. The outcomes measured were: inappropriate use, presence of contraindication and serious or contraindicated drug interactions, according to the information available on the Dynamed® and Micromedex® 2.0 databases. Results: Patients were predominantly adults, and diagnosed with paranoid schizophrenia or bipolar affective disorder. Antipsychotics, benzodiazepines, and lithium accounted for 84.0% (n=2,938) of the 3,500 drugs prescribed for mental disorders. There were 2,157 (61.6%) inappropriate prescriptions, of which 81.9% corresponded to antipsychotics, benzodiazepines, and lithium. There were 1,712 prescriptions with drug combinations that risked causing drug interactions, predominantly involving antipsychotic use (67.0%). Conclusion: The study revealed a high number of inappropriate prescriptions, pointing to a need for greater prescription adequacy to ensure effective safe treatment for psychiatric patients.

Analysis of drug prescription appropriateness according to the STOPP/START criteria of the elderly patients with type 2 diabetes mellitus in the endocrinology department of a multi-speciality hospital

To assess the appropriateness of prescribed drugs according to the STOPP/START criteria of elderly patients with type 2 diabetes mellitus (T2DM) in the endocrinology department of a multi-speciality hospital.Medical records of 136 patients ≥65 years old with T2DM hospitalized in the endocrinology department of the multi-speciality hospital (Moscow, Russia) were analyzed according to the «STOPP/START» criteria.The analysis of prescription leaflets has identified 30 potentially not recommended drugs (46 patients [33,8%]), the use of which should be avoided in certain clinical situations. Also the analysis has identified 175 medications that should be considered for elderly patients with certain conditions (89 patients [65,4%]). The most frequent identified STOPP criteria were: «Glibenclamide or chlorpropamide or glimepiride with T2DM» (23,3%); «Non-steroidal anti-inflammatory drug (NSAID) with history of peptic ulcer disease or gastro-intestinal bleeding, unless with concurrent histamine H2 receptor antagonist, proton pump inhibitors or misoprostol» (13,3%) and «NSAID with estimated glomerular filtration rate 20–50 ml/min/1.73m2» (3%). The most frequent START criteria were: «Statin therapy with a documented history of coronary, cerebral or peripheral vascular disease, where the patient’s functional status remains independent for activities of daily living and life expectancy is &gt;5 years» (25,1%); «Сlopidogrel with a documented history of cerebral or peripheral vascular disease» (18,9%); «Aspirin with a documented history of atherosclerotic coronary disease in patients with sinus rhythm» (18,3%).In patients ≥ 65 years old with T2DM potentially not recommended drugs are often administrated and there are no prescriptions for some appropriate drugs required in certain clinical settings. The findings give evidence of the need to optimization of pharmacotherapy in elderly and senile patients with T2DM. This adaptation will improve the patients’ quality of life and avoid wasteful spending.

Co-prescription patterns of cardiovascular preventive treatments: a cross-sectional study in the Aragon worker’ health study (Spain)

ObjectivesTo identify cardiovascular disease (CVD) preventive treatments combinations, among them and with other drugs, and to determine their prevalence in a cohort of Spanish workers.DesignCross-sectional study.SettingAragon Workers’ Health Study (AWHS)...

Goal importance, use of performance measures, and knowledge exchange: An empirical study on general practitioners' performance.

In many health systems, general practitioners (GPs) exhibit high levels of isolation and, at the same time, low levels of organizational identification, which can hinder their individual performance. The extant health care literature suggests that the physicians' belief that organizational goals are important, the adoption of performance measurement systems, and knowledge-sharing practices affect their individual performance. Most research has investigated these constructs in isolation, however, rather than explored their collective impact on GPs' individual performance. The aim of this study was to explore how GPs' belief in goal importance, use of performance measures, and knowledge exchange affect their individual performance, here defined as their individual achievement of organizational goals. We developed five hypotheses regarding how GPs' belief in goal importance and use of performance measures may affect individual performance, as well as how knowledge exchange may moderate these relationships. We tested our theoretical conjectures using data collected in a community of GPs in the Italian National Health Service. A survey questionnaire was administered to gather information about the GPs' level of belief in goal importance, use of performance measures, and perception about knowledge exchange in their primary care units. We considered two measures of GPs' individual performance: efficiency and appropriateness of drug prescription. We tested our hypotheses using probit regressions. Our findings show that perceived importance of organizational goals and use of performance measures have a positive effect on GPs' individual performance. Meanwhile, GPs' use of performance measures moderates the relationship between their belief in goal importance and individual performance. Finally, perceived knowledge exchange moderates the relationships between belief in goal importance/use of performance measures and individual performance. Executives could improve GPs' individual performance through interventions that reinforce their belief that organizational goals are important, facilitate a more intensive use of performance measures, and encourage knowledge exchange practices.

Erratum: Drug prescription appropriateness in the elderly: an Italian study [Corrigendum

[This corrects the article on p. 325 in vol. 12, PMID: 28228653.].

Drug prescription appropriateness in the elderly: an Italian study.

PurposeCorrect drug prescription in the elderly is a difficult task that requires careful survey of the current pharmacological therapies. In this article, we reviewed the drug prescriptions provided to 860 persons aged 65 years or over, residing in a small city of Lombardy, Italy.MethodsSubjects were recruited from a local nursing home, the Pavia and Vigevano Neuropsychological Center for Alzheimer’s Disease, general practitioners’ offices, and the local University of the Third Age. For each patient, the amount of potentially inappropriate prescriptions (PIPs), sedative and anticholinergic load (SL and AL, respectively), and drug–drug interactions were evaluated.ResultsWidespread polypharmacy, giving rise to 10.06% of PIPs in the whole collection of prescriptions, was observed. In particular, PIPs mainly concern drugs acting at the central nervous system level, mostly benzodiazepines and antipsychotics. Moreover, approximately one-fourth of the subjects had an elevated SL and approximately one-tenth a high AL. Drug–drug interactions were frequent (266 requiring medical attention), up to five for each single patient. Of concern was the underuse of antidementia drugs: only 20 patients received a cholinesterase inhibitor or memantine, although 183 patients were potentially suitable for this treatment.ConclusionThese results demonstrate the need to develop novel strategies aimed at improving the quality of drug prescription.

Appropriateness of antithrombotic prophylaxis in the oldest old with non-valvular atrial fibrillation: ARAPACIS and REPOSI

In the frame of the Atrial Fibrillation Registry for Ankle–Brachial Index Prevalence Assessment-Collaborative Italian Study (ARAPACIS) involving 93 Internal Medicine wards, Pignatelli et al. [1] conducted a questionnaire survey that, in addition to other questions, asked on the drugs of choice for prophylaxis of cardioembolism in patients with non-valvular atrial fibrillation (AF). Aspirin was chosen by 9% of the respondents, whereas oral anticoagulants were chosen by asmany as 91% of the responders, 55% preferring vitamin K antagonists (VKAs) and 36% the non-vitamin K oral anticoagulants (NOACs) (of which dabigatran, rivaroxaban and apixaban are licensed in Italy). Unfortunately, we suspect that these indicators of excellent prescription appropriateness do not correspond to what happens in reallife in Italian internal medicinewards. REPOSI is a prospective and independent registry sponsored by the Italian Society of Internal Medicine, that starting in 2008 collects data on drug prescription in people older than 65 years acutely admitted to 90 Italian hospital wards of internal medicine [2]. One of the main purposes of the registry, that until now has data on 5386 cases (mean age 79 ± 7 years), is to evaluate the appropriateness of drug prescription in multimorbid elderly people, comparing medications recorded at the time of hospital admission (reflecting the prescription of family doctors as well as patient adherence) with those at discharge (reflecting the expert prescription of hospital internists and geriatricians). As it could be expected from the general features of these elderly patients, chronic AF was one of the most frequent diagnoses. In the first run of the registry conducted in 2008, the appropriateness of antithrombotic prophylaxis in AF was very poor [3]. At hospital admission, as many as 26% of the patients with this

Fluctuation of the renal function after discharge from hospital and its effects on drug dosing in elderly patients--study protocol.

BackgroundChronic kidney disease (CKD) is associated with an increased mortality rate, risk of cardiovascular events and morbidity. Impaired renal function is common in elderly patients, and their glomerular filtration rate (GFR) should be taken into account when prescribing renally excreted drugs. In a hospital care setting the GFR may fluctuate substantially, so that the renal function group and therefore the recommended dose, can change within a few days. The magnitude and prevalence of the fluctuation of renal function in daily clinical practice and its potential effects on appropriateness of drug prescriptions after discharge from the hospital is unknown.Methods/designThis is a prospective observational study. Patients ≥ 70 years with renal impairment (eGFR <60 ml/min/1.73 m2) admitted to a geriatric ward are eligible to participate. Participants undergo blood sample collection to measure serum creatinine level at three time points: at discharge from hospital, 14 days, and 2 months after discharge. At these time points the actual medication of the participants is assessed and the number of incorrect prescriptions according to the Dutch guidelines in relation to their estimated renal function is measured. In addition, for a hypothetical selection of drugs, the need for drug dose adaptation in relation to renal function is measured. The outcome of interest is the percentage of patients that changes from renal function group after discharge from hospital compared to the renal function at discharge. In addition, the percentages of patients whose actual medications are incorrectly prescribed and for the hypothetical selection of drugs that would have required dose adaptation will be determined at discharge, 14 days and 2 months after discharge. For each outcome, risk factors which may lead to increased risk for fluctuation of renal function and/or incorrect drug prescribing will also be identified and analysed.DiscussionThis study will provide data on changes in renal function in elderly patients after discharge from the hospital with a focus on the medications used. The benefits for healthcare professionals comprise of the creation, adjustment or confirmation of recommendations for the monitoring of the renal function after discharge from hospital of elderly patients.