The use of an electronic clinical rule to discontinue chronically used benzodiazepines and related Z drugs.

PURPOSE: The chronic use of benzodiazepines and benzodiazepine-related drugs (BZ/Z) in older people is common and not without risks. The objective of this study was to evaluate whether the implementation of a clinical rule promotes the discontinuation of chronically used BZ/Z for insomnia. METHODS: A clinical rule, generating an alert in case of chronic BZ/Z use, was created and applied to the nursing home (NH) setting. The clinical rule was a one-off intervention, and alerts did not occur over time. Reports of the generated alerts were digitally sent to NH physicians with the advice to phase out and eventually stop the BZ/Z. In cases where the advice was adopted, a follow-up period of 4 months on the use of BZ/Z was taken into account in order to determine whether the clinical rule alert led to a successful discontinuation of BZ/Z. RESULTS: In all, 808 NH patients were screened. In 161 (19.1%) of the patients, BZ/Z use resulted in a clinical rule alert. From these, the advice to phase out and stop the BZ/Z was adopted for 27 patients (16.8%). Reasons for not following the advice consisted of an unsuccessful attempt in the past (38 patients), patients family and/or patient resistance (37 patients), the non-continuous use of BZ/Z (32 patients) and indication still present (27 patients). Of the 12 NH physicians, seven adopted the advice. CONCLUSIONS: The success rate of a clinical rule for discontinuation of chronically used BZ/Z for insomnia was low, as reported in the present study. Actions should be taken to help caregivers, patients and family members understand the importance of limiting BZ/Z use to achieve higher discontinuation rates.

Medication-related hospital admissions and readmissions in older patients: an overview of literature.

Background The number of medication related hospital admissions and readmissions are increasing over the years due to the ageing population. Medication related hospital admissions and readmissions lead to decreased quality of life and high healthcare costs. Aim of the review To assess what is currently known about medication related hospital admissions, medication related hospital readmissions, their risk factors, and possible interventions which reduce medication related hospital readmissions. Method We searched PubMed for articles about the topic medication related hospital admissions and readmissions. Overall 54 studies were selected for the overview of literature. Results Between the different selected studies there was much heterogeneity in definitions for medication related admission and readmissions, in study population and the way studies were performed. Multiple risk factors are found in the studies for example: polypharmacy, comorbidities, therapy non adherence, cognitive impairment, depending living situation, high risk medications and higher age. Different interventions are studied to reduce the number of medication related readmission, some of these interventions may reduce the readmissions like the participation of a pharmacist, education programmes and transition-of-care interventions and the use of digital assistance in the form of Clinical Decision Support Systems. However the methods and the results of these interventions show heterogeneity in the different researches. Conclusion There is much heterogeneity in incidence and definitions for both medication related hospital admissions and readmissions. Some risk factors are known for medication related admissions and readmissions such as polypharmacy, older age and additional diseases. Known interventions that could possibly lead to a decrease in medication related hospital readmissions are spare being the involvement of a pharmacist, education programs and transition-care interventions the most mentioned ones although controversial results have been reported. More research is needed to gather more information on this topic.

Usually Available Clinical and Laboratory Data Are Insufficient for a Valid Medication Review: A Crossover Study.

OBJECTIVES: To establish the quality of medication reviews performed by nursing home physicians, general practitioners and pharmacists. DESIGN AND SETTING: 15 Pharmacists, 13 general practitioners and 18 nursing home physicians performed a medication review for three cases (A, B and C), at three evaluation moments. First, they received the medication list. Secondly, they also received laboratory results and reason for admission and finally, we added medical history. Remarks were divided into 6 categories, i.e. indication without medication, medication without indication, contraindications/ interactions, dosage problems, double medication and wrong medication. Remarks were compared to the remarks made by our expert panel and scored according to our grading model as appropriate (0 to +3) or missed or potentially harmful (-1). For each medication error category, the percentage of participants who made this error was computed. RESULTS: After the first evaluation moment, the overall estimated mean percentage score was -1.7% for case A, 3.9% for case B, and 8.7% for case C. After the second review, this score was 15.0% for case A, 19.8% for case B, and 22.2% for case C. This further increased to 30.0% for case A, 36.7% for case B and 44% for case C at the final evaluation. The absence of medication where there was an indication (indication without medication) was frequently missed and did not improve after adding the extra information regarding laboratory results, reason for admission and finally medical history. CONCLUSION: Increasing clinical information helps physicians and pharmacists to improve their medication reviews, however, additional information was still related with a high margin of error. Detection of certain errors becomes easier with additional information, whereas other errors remain undetected. To achieve a high standard of medication review, we have to change the way medication reviews should be performed.