Potentially Inappropriate Medication Dispensing in Outpatients: Comparison of Different Measurement Approaches.

Purpose of the Research: This paper aims at comparing different approaches to measure potentially inappropriate medication (PIM) with routinely collected data on prescriptions, patient age institutionalization status (ie in nursing home or in the community). A secondary objective is to measure the rate and prevalence of PIM dispensing and to identify problematic practices in Switzerland. Material and Methods: The studied population includes about 90,000 insured over 17 years old from a Swiss health maintenance organization in 2019 and 2020. We computed and compared the number of PIM per patient for Beers criteria, Priscus list, Laroche, NORGEP and Prescrire approaches. We also created a composite indicator that accounts for the specificities of the Swiss context (adaptation to the Swiss drugs' market, recommendations in force related to sleeping pills, anxiolytics and NSAIDs). We also stratified the analysis per physician, including initiation and cessation of PIM prescription. Results: Our comparison revealed similarities between the approaches, but also that each of them had specific gaps that provides further motivation for the development of a composite approach. PIM rate was particularly high for sleeping pills, anxiolytics, NSAIDs, even when analyses were limited to chronic use. Drugs with anticholinergic effect were also frequently prescribed. Based on our composite indicator, 27% of insured over 64 years old received at least one PIM in 2020, and 8% received more than one. Our analyses also reveal that for sleeping pills and anxiolytics, half of the volume (or prevalence?) occurs in the <65 population. We observed strong variations between physicians and a significant proportion of new users among patients with PIM. Conclusion: Our results show that PIMs prescribing is very frequent in Switzerland and is driven mostly by a few drug categories. There is important physician variation in PIM prescribing that warrants the development of intervention targeted at high PIM-prescribers.

Physician Assessment and Feedback During Quality Circle to Reduce Low-Value Services in Outpatients: a Pre-Post Quality Improvement Study.

BACKGROUND: The impact of the Choosing Wisely (CW) campaign is debated as recommendations alone may not modify physician behavior. OBJECTIVE: The aim of this study was to assess whether behavioral interventions with physician assessment and feedback during quality circles (QCs) could reduce low-value services. DESIGN AND PARTICIPANTS: Pre-post quality improvement intervention with a parallel comparison group involving outpatients followed in a Swiss-managed care network, including 700 general physicians (GPs) and 150,000 adult patients. INTERVENTIONS: Interventions included performance feedback about low-value activities and comparison with peers during QCs. We assessed individual physician behavior and healthcare use from laboratory and insurance claims files between August 1, 2016, and October 31, 2018. MAIN MEASURES: Main outcomes were the change in prescription of three low-value services 6 months before and 6 months after each intervention: measurement of prostate-specific antigen (PSA) and prescription rates of proton pump inhibitors (PPIs) and statins. KEY RESULTS: Among primary care practices, a QC intervention with physician feedback and peer comparison resulted in lower rates of PPI prescription (pre-post mean prescriptions per GP 25.5 ± 23.7 vs 22.9 ± 21.4, p value<0.01; coefficient of variation (Cov) 93.0% vs 91.0%, p=0.49), PSA measurement (6.5 ± 8.7 vs 5.3 ± 6.9 tests per GP, p<0.01; Cov 133.5% vs 130.7%, p=0.84), as well as statins (6.1 ± 6.8 vs 5.6 ± 5.4 prescriptions per GP, p<0.01; Cov 111.5% vs 96.4%, p=0.21). Changes in prescription of low-value services among GPs who did not attend QCs were not statistically significant over this time period. CONCLUSION: Our results demonstrate a modest but statistically significant effect of QCs with educative feedback in reducing low-value services in outpatients with low impact on coefficient of variation. Limiting overuse in medicine is very challenging and dedicated discussion and real-time review of actionable data may help.

[Vitamin D dosage : is it for everyone ?] / Dosage de la vitamine D : vraiment utile pour tous ?

In recent years, the topic of vitamin D has been the subject of numerous publications covering a wide range of fields, with the corollary effect of overusing its routine dosage. However, substitution benefits only a small part of the population and systematic dosing of vitamin D outside risk situations is not recommended. This dosage of vitamin D is only useful if it results in effective treatment in case of deficiency. The purpose of this article is to provide a synthesis of current knowledge about vitamin D, in particular about the indications for its dosage in clinical practice.

Ces dernières années, le thème de la vitamine D a nourri de très nombreuses publications couvrant des domaines très variés avec comme effet corollaire une surutilisation de son dosage de routine. Toutefois, la substitution ne bénéficie qu'à une petite partie de la population et le dosage systématique de la vitamine D en dehors de situation à risque n'est pas recommandé. Ce dosage de la vitamine D n'a d'intérêt que s'il débouche sur un traitement efficace en cas de déficit. Le but de cet article est de proposer une synthèse des connaissances actuelles sur la vitamine D, en particulier au sujet des indications retenues pour son dosage en pratique clinique.

Developing clinical skills using a virtual patient simulator in a resource-limited setting.

OBJECTIVE: to measure the effect of training with a virtual patient (VP) simulation system on clinical skills of healthcare professionals in Africa. METHODS: A randomized controlled intervention was carried out at Yaounde Central Hospital (Cameroon). The intervention consisted of two groups training on one of the two clinical vignettes implemented in the VP simulator. Four actors were trained to play standardized patient (SP) roles. The clinical skills (performance score) of participants were assessed on both clinical vignettes using these SPs. RESULTS: Twenty medical students from FMSB were recruited. The difference in overall score was observed between participants who received training from the VP system (higher average) and those who did not receive the training (lower average). This difference is statistically significant, especially when the focus is on participants' scores in the relevant items for proper management of the case. CONCLUSION: This study suggests that the training with a medical consultation VP simulator can develop the operational clinical skills of the user.

Virtual patient simulation: a comparison of two approaches for capacity building in Sub-Saharan Africa.

BACKGROUND: given the diversity of virtual patient simulation systems, this study provides a comparison of two different tools, in the perspective of deploying them for supporting initial and continuing medical education in Sub-Saharan Africa. METHOD: the evaluation was based on existing documentation, analysis of the data models, usage of implemented of virtual patient cases, and interviews with the domain experts. RESULTS: despite some shared similarities in their contents, there are many differences between the two applications especially in respect to their pedagogic models, technical architecture, types of interactions, feedback, and the learner's performance evaluations. DISCUSSION AND CONCLUSION: the implementation of learning activity based on virtual patient in a given context should consider these differences. According to their respective approaches, this study suggests that MVP is more suitable for novice learners whereas VIPS is more suitable for experienced learners.

Relevance and usability of a computerized patient simulator for continuous medical education of isolated care professionals in sub-saharan Africa.

OBJECTIVE: to explore the relevance and usability of using a computerized patient simulator as a tool for continuous medical education and decision support for health professionals in district hospitals in Sub-Saharan Africa. METHODS: based on the diagnosis pathway and decision analysis in uncertainty context, interactive clinical vignettes are developed using VIPS, a computerized patient simulator, taking into account clinical problem situations whose relevance was identified. Vignettes were adapted to take into account local epidemiology, availability of diagnostic and therapeutic resources, and local socio-cultural constraints. The evaluation on VIPS software was made by care professionals and students. RESULTS: a computerized patient simulator can be used to provide initial and continuing medical education in Sub-Saharan Africa. But many challenges exist. CONCLUSION: further research is needed to measure potential improvements in knowledge, skills, decision-making abilities as well as patient outcome.

[Chronic diseases and integrated health care delivery system: the example of Kaiser Permanente]. / Maladies chroniques et réseaux de soins: l'exemple de Kaiser Permanente.

Kaiser Permanente (California, Etats-Unis) is an integrated health care delivery system, particularly in what is related to the management of chronic conditions. This article describes the strategies developed by this organization in order to improve the quality of care of patients suffering from chronic diseases, through coordination of care, enhancement of a team based approach, self-management education programs, and patient involvement and empowerment.