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Projects / Programmes source: ARIS

The effects of a web application and medical monitoring on the quality of medication, adverse drug events and adherence in the elderly living at home

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Research activity

Code Science Field Subfield
3.08.00  Medical sciences  Public health (occupational safety)   

Code Science Field
B680  Biomedical sciences  Public health, epidemiology 

Code Science Field
3.03  Medical and Health Sciences  Health sciences 
Keywords
patient, family medicine, elderly, chronic illness, multimorbidity, depression, drug- prescription, polypharmacy, adherence, ADE – adverse drug events
Evaluation (rules)
source: COBISS
Evaluation of bibliographic research performance indicators according to ARIS methodology
Citations Citations for bibliographic records in COBIB.SI that are linked to records in citation databases
source: WoS source: Scopus source: COBISS
Researchers (13)
no. Code Name and surname Research area Role Period No. of publications
1.  14715  PhD Mateja Bulc  Public health (occupational safety)  Researcher  2014 - 2017  318 
2.  18329  PhD Josip Car  Public health (occupational safety)  Head  2014 - 2017  244 
3.  33846  PhD Eva Cedilnik Gorup  Public health (occupational safety)  Researcher  2014 - 2017  108 
4.  37637  MSc Savin Gorup  Systems and cybernetics  Researcher  2014 - 2017  0 
5.  38365  PhD Vojislav Ivetić  Public health (occupational safety)  Researcher  2015 - 2017  173 
6.  18330  PhD Janko Kersnik  Public health (occupational safety)  Researcher  2014 - 2015  953 
7.  32520  PhD Zalika Klemenc Ketiš  Public health (occupational safety)  Researcher  2014 - 2017  768 
8.  27799  PhD Nena Kopčavar Guček  Public health (occupational safety)  Researcher  2014 - 2017  669 
9.  24488  PhD Janez Rifel  Public health (occupational safety)  Researcher  2014 - 2017  212 
10.  10937  PhD Polona Selič - Zupančič  Public health (occupational safety)  Researcher  2014 - 2017  464 
11.  26220  Barbara Toplek  Public health (occupational safety)  Researcher  2014 - 2017  8 
12.  33832  PhD Ksenija Tušek Bunc  Public health (occupational safety)  Researcher  2015 - 2017  396 
13.  38364  PhD Erika Zelko  Public health (occupational safety)  Researcher  2015 - 2017  310 
Organisations (3)
no. Code Research organisation City Registration number No. of publications
1.  0381  University of Ljubljana, Faculty of Medicine  Ljubljana  1627066  48,203 
2.  2334  University of Maribor, Faculty of Medicine  Maribor  5089638048  16,514 
3.  2677  Institute for development of Family Medicine  Ljubljana  1782592  220 
Abstract
Starting positions: In more than half of elderly chronically ill family clinic attendees, drug prescribing deviates from the internationally acknowledged STOPP/START recommendations, which increases the risk of adverse drug events. Prescribing inappropriate drugs for the elderly is the most common deviation. Factors associated with the quality of drug prescribing are connected with both patient (social environment, multimorbidity index, the number and regime of prescribed drugs), and GP (the knowledge of the indications for medication). So far, interventions have been either computerized warning systems, the involvement of a clinical pharmacist, or multidisciplinary approaches, with only a few studies including a prolonged assessment of trials. Aim and objectives: Our study will determine whether it is possible to improve the quality of drug prescribing in chronically ill elderly people living at home, by regularly monitoring the prescribed drugs according to STOPP/START criteria. Based on a specifically designed intervention for the improvement of drug prescribing in the form of a web application (WA) we will aim to reduce the incidence of inappropriate prescribing, the number of drugs prescribed and evaluate the quality of drug prescribing. We will aim to develop a model explaining the factors influencing the quality of drug prescriptions for the elderly living at home, and review its stability during the study. We will also aim to identify factors predicting poor adherence to medication. Methods: 40 GPs from across Slovenia will participate in a pragmatic randomized controlled trial. From the patient register, GPs will randomly select 20 people older than 65 years who regularly receive at least one drug and invite them to participate in the study. Patients with dementia and those with a terminal illness will be excluded. The WA will be designed and pre-tested to determine the adequacy of drug prescribing in the elderly according to the START/STOPP criteria. On initial examination of patients, demographic data will be collected, the multimorbidity (CIRS-G index), depression (Zung scale), adherence (Morisky 4-item questionnaire) and the quality of life index (EQ-5D) assessed and the doctor will enter all these data in the WA along with diagnoses and medications (strength and dosage). The WA will randomly place each patient into the test or control group. For test group patients, the WA will provide feedback regarding drug prescription violations and recommend changes. At control examination following Year 2 and Year 3, the initial data collection will be repeated and additional data provided: visits to GP, unplanned hospitalization/emergency department treatment, visits to clinical specialists or A&E. Patients in both groups will be compared according to gender, age, multimorbidity index, health-related quality of life and the number of drugs. At the start, GPs will fill out a questionnaire with basic demographic data of the family clinic, and at the annual data collection on the use and operation of the WA. Expected results: Originality: The use of WA will be the basis for the implementation of the application into the usual delivery of care, thereby reducing the problems of inappropriate prescribing, polypharmacy and adherence; we will identify the stability of the factors of drug prescribing in the elderly. By comparing the intervention and control group, it will be possible to distinguish which are related to the WA and which act independently. Relevance: The number of inappropriate drug prescriptions in the test group (year 2, 3) should be lower than in the control group with standard care, the average number of drugs per person in the test group should be equal or smaller, and adherence to medication should be better. Potential impact: The use of the WA will hopefully improve the quality of drug prescribing for GPs, the number of potentially inappropriate prescriptions the patient receives, and reduce patients’ need
Significance for science
We have demonstrated that the explicit STOPP/START criteria can be digitalised or transformed into simple logic statements, which are the basis for the development of software to support decision-making. We have developed original software to support prescription in family medicine practice. It may serve as the basis for using explicit criteria in electronic prescribing systems or electronic medical records, and allows for the development of further software. We established that the prevalence of potentially inappropriate prescribing in the elderly population (visitors attending family medicine practices) is high and results partly from an individualised, patient-oriented approach, within which explicit criteria alone cannot guide prescription. Therefore, the usefulness of the presence of explicit criteria as a quality indicator of prescribing is limited. We found that inappropriate prescription of medicines that an elderly person must receive according to the START criterion is influenced by multimorbidity rate rather than by the number of medicines prescribed. This important finding was published in a peer-reviewed journal with a high impact factor. We established a relatively low presence of anticholinergic drugs in the regular therapy of elderly people, which may indicate good quality prescription according to this indicator. The field of anticholinergic drugs, and specifically their potential effect on the development of dementia, is poorly studied. Our data may constitute the basis for further research into this field. Within the framework of STOPP/START criteria, version 2014, information regarding the influenza and pneumococcus vaccination coverage among the elderly in family medicine practices was obtained and found to be relatively low. Information was obtained about the adherence of elderly persons who attend family medicine practices and have at least one prescribed medicine as part of their regular therapy. The adherence in this population was found to be comparable with data from the literature. This confirmed the findings of prior researchers, saying that adherence in the treatment of chronic patients is problematic, as only 50% of the elderly multimorbid patients take medicines as prescribed. A randomised controlled study investigating the impact of software usage on prescribing showed that working with software resulted in a reduction of inappropriate prescriptions by doctors in all patients, even in those for whom the doctor had not been explicitly warned of the potentially inappropriate prescription. This supports the hypothesis that the use of software to support decision-making reduces the proportion of potentially inappropriate prescribing to the elderly, mostly through user learning, which will allow for the development or improvement of educational interventions aimed at reducing potentially inappropriate prescribing. Moreover, the inclusion of warning systems into e-prescribing programs or the short-term use of a warning system could improve prescribing even when the e-warning option is not used. An optional warning which could lead to increased awareness among doctors regarding the components of potentially inappropriate prescribing could contribute to better treatment. In the qualitative part of the study, we confirmed that the application was well accepted by users. We also learned how to adjust the application to better fit users. The next step is connection with software developers, which would integrate the application into existing software and offer it to users for routine practice. This is an important step, which would facilitate use the application by all doctors.
Significance for the country
We found that foreign explicit criteria regarding the appropriateness of prescribing could be adjusted or used in Slovenian family medicine practices. The presence of potentially inappropriate prescribing in the elderly according to the STOPP/START criteria in Slovenia is comparable with international rates. The presence of anticholinergic drugs in regular therapy of the elderly is low compared to the rest of the world, which could indicate a good quality of medicinal prescribing to the elderly in family medicine practices. During the dissemination of our results, presented at several doctors’ and nurses’ meetings, we raised the awareness of healthcare professionals regarding the importance of individual parameters of potentially inappropriate prescribing. Vaccination coverage among the elderly at family medicine practices in Slovenia is low, particularly for pneumococcal vaccination, though the recommended coverage of influenza vaccination has also not been achieved. One possible factor is a lower degree of commitment among the healthcare professionals to direct patients to vaccination. These results should be communicated to doctors and nurses, and the importance of vaccinating the elderly should be emphasised, even if they are not residents of a nursing institution. Our data constitute a basis for further development of public health measures focused on family medicine practices. In our population, the adherence of the elderly to medication was comparable with international data, with half of the elderly demonstrating adequate adherence. We believe it is important to caution doctors and nurses about the adherence issue and to encourage them to find solutions or ways to improve adherence through an individualised approach to patients. Slovenian doctors have well accepted the possibility to use the warning system for potentially inappropriate prescribing, so it would be reasonable to include this system into the emerging e-medical records. In order to find correlation between the self-assessment of depression, concurrent diseases and other psychosocial and behavioural characteristics of the elderly living at home, we checked the stability of correlations between depression, demographic data, lifestyle, number of concurrent diseases and severity of medical issues. The most common diseases included arterial hypertension and hyperlipidaemia, renal and urinary disorders, and gastrointestinal diseases; 4.7 ± 2.2 concurrent diseases. Depression showed a stable correlation with female gender, age, education, number of concurrent diseases and prescription medicines, as well as with health self-assessment, but not with marital status. Knowledge of factors associated with depression in the elderly can help with faster diagnosis and proper treatment, resulting in a higher quality of life in this group of visitors to family medicine practices. Because this was the first study conducted on a random sample of elderly visitors attending family medicine practices in Slovenia, new findings might be important for the development of guidelines and policies, as the proportion of the elderly aged above 60 in Slovenia will reach 30% within eight years (Eurostat population projections for Slovenia, 2008–2060, EUROPOP2008).
Most important scientific results Annual report 2014, 2015, final report
Most important socioeconomically and culturally relevant results Annual report 2015, final report
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