Inappropriate Prescribing Clinical Trial
Official title:
Reducing Inappropriate Prescribing for Psychiatric Patients Using Nurse-led Medication Reviews - an Interventional Study
The purpose of this study is to investigate the effect of nurse-led medication reviews on the frequency, type and potential severity of PIP in psychiatric patients
Studies indicate that potential inappropriate prescribing (PIP) is associated with a higher
number of admissions, increased morbidity and mortality and that medication reviews might
decrease the prevalence of PIP. PIP has only been investigated in elderly populations and,
to our knowledge, never in a psychiatric, general population. There is a growing body of
evidence on the effect of medication reviews but very little research on the effect of
medication reviews in psychiatric populations. Medication reviews are a time consuming task
which requires an extensive clinical knowledge about the individual patient as well as
pharmacology. Healthcare systems across the world are looking to improve quality and safety
for the same or fewer economic resources and medication reviews are introduced as obligatory
in more and more hospitals and other institutions. This calls for alternative use of
existing resources.
Nurses have most of the direct patient contact but very few studies investigate the
potential role of nurses in improving medication quality and medication safety.
Administration af drugs and observation for effect and sideeffects of drugs are already
important aspects in nursing. Therefore the purpose of this study is to evaluate the effect
of nurse-led medication reviews in a controlled interventional study. Outcome measures
include prevalence, type and severity of the identified PIP as well as the proportion of
identified PIP which leads to a change in prescription by a physician.
Definitions
In this study PIP is defined as
- The use of drugs with a known risk of en adverse drug event or where evidence for a
less risky, equally or more effective drug treating the same condition exists.
- PIP includes the use of drugs with a higher frequency or longer duration than
indicated, concurrent use of drugs with known drug-drug interactions or interaction
between drug and the underlying disease.
- PIP also includes the omission of drugs which are clinically indicated and where no
contraindications are known.
Design
Prospective, controlled before- and after study where 2 acute psychiatric wards have been
selected for intervention and control. Ahead of the intervention the nurses have received
pharmacological training and instructions on performing medication reviews. The patients are
included consecutively.
Data
The nurses in the interventional ward will perform medication reviews after the patients
have been seen by the attending physician and thus have received usual care. This procedure
was chosen because most of the patients are admitted through one ward. With each medication
review the nurses fill out a structured paper form with their observations. The nurses also
register whether interventions by the physician were based - or in parts based - on the
nurses observations
Data analysis
Primary outcome is the difference in the proportion of patients receiving PIPs in the two
wards. Two senior clinical pharmacologists will also perform medication reviews on the
included patients. These medication reviews will serve as golden standard when the quality
of the nurse-led medication reviews is evaluated.
Secondary outcomes will be an analysis of the proportion of PIPs identified by nurses and
the proportion of PIPs ending in an intervention prescribed by a physician.
Power calculations
The investigators anticipate a prevalence of PIP on 30% among psychiatric patients and an
expectation of a reduction to 15% PIP due to nurse-led medication reviews. Based on these
assumptions there will be a need for 120 patients in each group in order to sufficiently
identify a difference (risk of type 1 error - 5% and a power of 80%)
;
Allocation: Non-Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Health Services Research
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