Perceptions and experiences of the implementation, management, use and optimisation of electronic prescribing systems in hospital settings:protocol for a systematic review of qualitative studies

Introduction: There is increasing evidence that electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of healthcare services. However, it has also become clear that their implementation is not straightforward and may create unintended or undesired consequences once in use. In this context, qualitative approaches have been particularly useful and their interpretative synthesis could make an important and timely contribution to the field. This review will aim to identify, appraise and synthesise qualitative studies on ePrescribing/CPOE in hospital settings, with or without clinical decision support. Methods and analysis: Data sources will include the following bibliographic databases: MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, Social Policy and Practice via Ovid, CINAHL via EBSCO, The Cochrane Library (CDSR, DARE and CENTRAL databases), Nursing and Allied Health Sources, Applied Social Sciences Index and Abstracts via ProQuest and SCOPUS. In addition, other sources will be searched for ongoing studies (ClinicalTrials.gov) and grey literature: Healthcare Management Information Consortium, Conference Proceedings Citation Index (Web of Science) and Sociological abstracts. Studies will be independently screened for eligibility by 2 reviewers. Qualitative studies, either standalone or in the context of mixed-methods designs, reporting the perspectives of any actors involved in the implementation, management and use of ePrescribing/CPOE systems in hospital-based care settings will be included. Data extraction will be conducted by 2 reviewers using a piloted form. Quality appraisal will be based on criteria from the Critical Appraisal Skills Programme checklist and Standards for Reporting Qualitative Research. Studies will not be excluded based on quality assessment. A postsynthesis sensitivity analysis will be undertaken. Data analysis will follow the thematic synthesis method. Ethics and dissemination: The study does not require ethical approval as primary data will not be collected. The results of the study will be published in a peer-reviewed journal and presented at relevant conferences.

Determinants of pharmaceutical innovation diffusion: social contagion and prescribing characteristics

This article studies the determinants of pharmaceutical innovation diffusion among specialists. To this end, it investigates the influences of six categories of factors—social embeddedness, socio-demography, scientific orientation, prescribing patterns, practice characteristics, and patient panel composition—on the use of new drugs for the treatment of type 2 diabetes mellitus in Hungary. Here, in line with international trends, 11 brands were introduced between April 2008 and April 2010, outperforming all other therapeutic classes. The Cox proportional hazards model identifies three determinants—social contagion (in the social embeddedness category) and prescribing portfolio and insulin prescribing ratio (in the prescribing pattern category). First, social contagion has a positive effect among geographically close colleagues—the higher the adoption ratio, the higher the likelihood of early adoption—but no influence among former classmates and scientific collaborators. Second, the wider the prescribing portfolio, the earlier the new drug uptake. Third, the lower the insulin prescribing ratio, the earlier the new drug uptake—physicians’ therapeutic convictions and patients’ socioeconomic statuses act as underlying influencers. However, this finding does not extend to opinion-leading physicians such as scientific leaders and hospital department and outpatient center managers. This article concludes by arguing that healthcare policy strategists and pharmaceutical companies may rely exclusively on practice location and prescription data to perfect interventions and optimize budgets.

UK prescribing practices as proxy markers of unmet need in allergic rhinitis : a retrospective observational study

Acknowledgements We thank Ruth B Murray for reviewing and editing this manuscript. We thank Joan B Soriano for his critical review and constructive comments. We thank Helga Mikkelsen and Alessandra Cifra for their assistance with manuscript editing and revision. Finally, we thank the Journal blind peer reviewers, whose suggestions and critical appraisal significantly improved our original submission. FUNDING This study was funded by Meda, Solna, Sweden. Data acquisition and analyses were funded by Meda. The study was conducted by Research in Real Life as an independent research organisation; Meda had no role in the conduct or reporting of the study.

An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice : The RAPiD Cluster Randomised Controlled Trial

Funding: This study was conducted as part of the TRiaDS programme of implementation research which is funded by NHS Education for Scotland (NES). The Health Services Research Unit which is funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates supported the study. The funder had no influence over the design, conduct, analysis and write up of the study.

Drug prescribing patterns in the General Medical Services Scheme in Ireland and projected costs to 2026

The primary objective is to investigate the main factors contributing to GMS expenditure on pharmaceutical prescribing and projecting this expenditure to 2026. This study is located in the area of pharmacoeconomic cost containment and projections literature. The thesis has five main aims: 1. To determine the main factors contributing to GMS expenditure on pharmaceutical prescribing. 2. To develop a model to project GMS prescribing expenditure in five year intervals to 2026, using 2006 Central Statistics Office (CSO) Census data and 2007 Health Service Executive{Primary Care Reimbursement Service (HSE{PCRS) sample data. 3. To develop a model to project GMS prescribing expenditure in five year intervals to 2026, using 2012 HSE{PCRS population data, incorporating cost containment measures, and 2011 CSO Census data. 4. To investigate the impact of demographic factors and the pharmacology of drugs (Anatomical Therapeutic Chemical (ATC)) on GMS expenditure. 5. To explore the consequences of GMS policy changes on prescribing expenditure and behaviour between 2008 and 2014. The thesis is centered around three published articles and is located between the end of a booming Irish economy in 2007, a recession from 2008{2013, to the beginning of a recovery in 2014. The literature identified a number of factors influencing pharmaceutical expenditure, including population growth, population aging, changes in drug utilisation and drug therapies, age, gender and location. The literature identified the methods previously used in predictive modelling and consequently, the Monte Carlo Simulation (MCS) model was used to simulate projected expenditures to 2026. Also, the literature guided the use of Ordinary Least Squares (OLS) regression in determining demographic and pharmacology factors influencing prescribing expenditure. The study commences against a backdrop of growing GMS prescribing costs, which has risen from e250 million in 1998 to over e1 billion by 2007. Using a sample 2007 HSE{PCRS prescribing data (n=192,000) and CSO population data from 2008, (Conway et al., 2014) estimated GMS prescribing expenditure could rise to e2 billion by2026. The cogency of these findings was impacted by the global economic crisis of 2008, which resulted in a sharp contraction in the Irish economy, mounting fiscal deficits resulting in Ireland's entry to a bailout programme. The sustainability of funding community drug schemes, such as the GMS, came under the spotlight of the EU, IMF, ECB (Trioka), who set stringent targets for reducing drug costs, as conditions of the bailout programme. Cost containment measures included: the introduction of income eligibility limits for GP visit cards and medical cards for those aged 70 and over, introduction of co{payments for prescription items, reductions in wholesale mark{up and pharmacy dispensing fees. Projections for GMS expenditure were reevaluated using 2012 HSE{PCRS prescribing population data and CSO population data based on Census 2011. Taking into account both cost containment measures and revised population predictions, GMS expenditure is estimated to increase by 64%, from e1.1 billion in 2016 to e1.8 billion by 2026, (ConwayLenihan and Woods, 2015). In the final paper, a cross{sectional study was carried out on HSE{PCRS population prescribing database (n=1.63 million claimants) to investigate the impact of demographic factors, and the pharmacology of the drugs, on GMS prescribing expenditure. Those aged over 75 (ẞ = 1:195) and cardiovascular prescribing (ẞ = 1:193) were the greatest contributors to annual GMS prescribing costs. Respiratory drugs (Montelukast) recorded the highest proportion and expenditure for GMS claimants under the age of 15. Drugs prescribed for the nervous system (Escitalopram, Olanzapine and Pregabalin) were highest for those between 16 and 64 years with cardiovascular drugs (Statins) were highest for those aged over 65. Females are more expensive than males and are prescribed more items across the four ATC groups, except among children under 11, (ConwayLenihan et al., 2016). This research indicates that growth in the proportion of the elderly claimants and associated levels of cardiovascular prescribing, particularly for statins, will present difficulties for Ireland in terms of cost containment. Whilst policies aimed at cost containment (co{payment charges, generic substitution, reference pricing, adjustments to GMS eligibility) can be used to curtail expenditure, health promotional programs and educational interventions should be given equal emphasis. Also policies intended to affect physicians prescribing behaviour include guidelines, information (about price and less expensive alternatives) and feedback, and the use of budgetary restrictions could yield savings.

The Antibiotic Resistance and Prescribing in European Children Project: A Neonatal and Pediatric Antimicrobial Web-based Point Prevalence Survey in 73 Hospitals Worldwide

BACKGROUND: The neonatal and pediatric antimicrobial point prevalence survey (PPS) of the Antibiotic Resistance and Prescribing in European Children project (http://www.arpecproject.eu/) aims to standardize a method for surveillance of antimicrobial use in children and neonates admitted to the hospital within Europe. This article describes the audit criteria used and reports overall country-specific proportions of antimicrobial use. An analytical review presents methodologies on antimicrobial use.

METHODS: A 1-day PPS on antimicrobial use in hospitalized children was organized in September 2011, using a previously validated and standardized method. The survey included all inpatient pediatric and neonatal beds and identified all children receiving an antimicrobial treatment on the day of survey. Mandatory data were age, gender, (birth) weight, underlying diagnosis, antimicrobial agent, dose and indication for treatment. Data were entered through a web-based system for data-entry and reporting, based on the WebPPS program developed for the European Surveillance of Antimicrobial Consumption project.

RESULTS: There were 2760 and 1565 pediatric versus 1154 and 589 neonatal inpatients reported among 50 European (n = 14 countries) and 23 non-European hospitals (n = 9 countries), respectively. Overall, antibiotic pediatric and neonatal use was significantly higher in non-European (43.8%; 95% confidence interval [CI]: 41.3-46.3% and 39.4%; 95% CI: 35.5-43.4%) compared with that in European hospitals (35.4; 95% CI: 33.6-37.2% and 21.8%; 95% CI: 19.4-24.2%). Proportions of antibiotic use were highest in hematology/oncology wards (61.3%; 95% CI: 56.2-66.4%) and pediatric intensive care units (55.8%; 95% CI: 50.3-61.3%).

CONCLUSIONS: An Antibiotic Resistance and Prescribing in European Children standardized web-based method for a 1-day PPS was successfully developed and conducted in 73 hospitals worldwide. It offers a simple, feasible and sustainable way of data collection that can be used globally.

Pharmaceutical strategies towards optimising polypharmacy in older people

This paper focuses on the issue of polypharmacy in older people and potential pharmaceutical strategies to optimize the use of multiple medicines. Although polypharmacy has long been viewed negatively, increasing emphasis is being placed on the difference between appropriate and inappropriate polypharmacy. This is largely being driven by the increasing prevalence of multimorbidity and the use of evidence-based guidelines. In this paper, we outline a number of key considerations that are pertinent to optimizing polypharmacy, notably prescribing appropriate polypharmacy, pharmaceutical formulations, the involvement of older people in clinical trials and patient adherence.

Prescribing of Psychoactive Drugs for Older People in Nursing Homes: An Analysis of Treatment Culture

Background There is increasing interest in how culture may affect the quality of healthcare services, and previous research has shown that ‘treatment culture’—of which there are three categories (resident centred, ambiguous and traditional)—in a nursing home may influence prescribing of psychoactive medications. Objective The objective of this study was to explore and understand treatment culture in prescribing of psychoactive medications for older people with dementia in nursing homes. Method Six nursing homes—two from each treatment culture category—participated in this study. Qualitative data were collected through semi-structured interviews with nursing home staff and general practitioners (GPs), which sought to determine participants’ views on prescribing and administration of psychoactive medication, and their understanding of treatment culture and its potential influence on prescribing of psychoactive drugs. Following verbatim transcription, the data were analysed and themes were identified, facilitated by NVivo and discussion within the research team. Results Interviews took place with five managers, seven nurses, 13 care assistants and two GPs. Four themes emerged: the characteristics of the setting, the characteristics of the individual, relationships and decision making. The characteristics of the setting were exemplified by views of the setting, daily routines and staff training. The characteristics of the individual were demonstrated by views on the personhood of residents and staff attitudes. Relationships varied between staff within and outside the home. These relationships appeared to influence decision making about prescribing of medications. The data analysis found that each home exhibited traits that were indicative of its respective assigned treatment culture. Conclusion Nursing home treatment culture appeared to be influenced by four main themes. Modification of these factors may lead to a shift in culture towards a more flexible, resident-centred culture and a reduction in prescribing and use of psychoactive medication. 

Does Inappropriate Quality Control Demotivate Workers

The construction industry requires quality control and regulation of its contingent,unpredictable environment. However, taking too much control from workers candisempower and demotivate. In the 1970s Deci and Ryan developed selfdeterminationtheory which states that in order to be intrinsically motivated, threecomponents are necessary - competence, autonomy and relatedness. This study aimsto examine the way in which the three ‘nutriments’ for intrinsic motivation may beundermined by heavy-handed quality control. A critical literature review analysesconstruction, psychological and management research regarding the control andmotivation of workers, using self-determination theory as a framework. Initialfindings show that quality management systems do not always work as designed.Workers perceive that unnecessary, wasteful and tedious counter checking of theirwork implies that they are not fully trusted by management to work without oversight.Control of workers and pressure for continual improvement may lead to resistanceand deception. Controlling mechanisms can break the link between performance andsatisfaction, reducing motivation and paradoxically reducing the likelihood of thequality they intend to promote. This study will lead to a greater understanding ofcontrol and motivation, facilitating further research into improvements in theapplication of quality control to maintain employee motivation.

Do GPs and psychiatrists recommend alternatives when prescribing anti-depressants?

This study explores whether a partial explanation for high antidepressant prescription rates is the failure of prescribers to recommend alternatives. 1,829 New Zealand adults were asked which of six non-pharmacological treatment approaches were recommended when prescribed anti-depressants. The majority (82%) received at least one recommendation and 32% received three or more, most commonly ‘Counsellor/Psychologist/Psychotherapist’ (74%) and Exercise Schedule (43%). It cannot, therefore, be concluded that failing to consider non-pharmacological treatments is a major cause of high prescribing rates. Being younger and more severely depressed were both positively related to number of recommendations. Psychiatrists made significantly more recommendations than GPs.

Statin Adherence, Utilisation, and Prescribing Patterns. Improving effectiveness of treatment

Statins are one of the most widely studied and evidence-based medications. Randomised controlled trials have provided convincing evidence on the benefits of statin therapy in preventing cardiovascular events. Despite proven benefits, low costs, and few adverse effects, everyday effectiveness of statins is limited, since adherence to statin therapy is poor. This thesis was conducted as four pharmacoepidemiological studies using register data on statin users in real clinical care. The main purpose of the study was to evaluate prescribing patterns and to discover the lifestyle factors predicting statin nonadherence and discontinuation. This knowledge is essential in order to help physicians to motivate the adherence of their patients to treatment. In Finland, from 1998 to 2004, the number of statin initiators nearly doubled. The discovered channelling of atorvastatin and simvastatin may have affected the treatment outcomes at the public health level. It is possible that money spent on statins in Finland in 1998‒2004 could have been used in a more cost-effective way. In 2015, the percentage of patients receiving reimbursement for statins was 12% of the total population. Thus, it is a major public health and economic challenge to improve statin effectiveness and allocate therapy correctly. Among the participants with cardiovascular comorbidities, risky alcohol use or clustering of lifestyle risks were predictors of nonadherence. In addition, the prevalence of nonadherence to statins increased after retirement among both men and women. This increase in post-retirement nonadherence was highest among those receiving statins for secondary prevention. Discontinuation of statin therapy was predicted by high patient co-payment, and in women, by risky alcohol use. Recognising the predictors of nonadherence to statins is important because nonadherence is associated with an increased risk of adverse cardiovascular outcomes and higher healthcare costs. In conclusion, optimal outcomes in medical therapy require both efficacious medications and adherence to those treatments. When prescribing statins to eligible patients, the physician’s clinical expertise in recognising patients at risk of statin discontinuation and nonadherence, as well as their ability to increase adherence, may have a great effect on public health.

Variations in chemoprophylaxis for meningococcal disease: a retrospective case note review, analysis of routine prescribing data and questionnaire of general practitioners

BACKGROUND: Invasive meningococcal disease is a significant cause of mortality and morbidity in the UK. Administration of chemoprophylaxis to close contacts reduces the risk of a secondary case. However, unnecessary chemoprophylaxis may be associated with adverse reactions, increased antibiotic resistance and removal of organisms, such as Neisseria lactamica, which help to protect against meningococcal disease. Limited evidence exists to suggest that overuse of chemoprophylaxis may occur. This study aimed to evaluate prescribing of chemoprophylaxis for contacts of meningococcal disease by general practitioners and hospital staff. METHODS: Retrospective case note review of cases of meningococcal disease was conducted in one health district from 1st September 1997 to 31st August 1999. Routine hospital and general practitioner prescribing data was searched for chemoprophylactic prescriptions of rifampicin and ciprofloxacin. A questionnaire of general practitioners was undertaken to obtain more detailed information. RESULTS: Prescribing by hospital doctors was in line with recommendations by the Consultant for Communicable Disease Control. General practitioners prescribed 118% more chemoprophylaxis than was recommended. Size of practice and training status did not affect the level of additional prescribing, but there were significant differences by geographical area. The highest levels of prescribing occurred in areas with high disease rates and associated publicity. However, some true close contacts did not appear to receive prophylaxis. CONCLUSIONS: Receipt of chemoprophylaxis is affected by a series of patient, doctor and community interactions. High publicity appears to increase demand for prophylaxis. Some true contacts do not receive appropriate chemoprophylaxis and are left at an unnecessarily increased risk