Louise Forsetlund

Effect of interventions to reduce potentially inappropriate use of drugs in nursing homes: a systematic review of randomised controlled trials.

BackgroundStudies have shown that residents in nursing homes often are exposed to inappropriate medication. Particular concern has been raised about the consumption of psychoactive drugs, which are commonly prescribed for nursing home residents suffering from dementia. This review is an update of a Norwegian systematic review commissioned by the Norwegian Directorate of Health. The purpose of the review was to identify and summarise the effect of interventions aimed at reducing potentially inappropriate use or prescribing of drugs in nursing homes.MethodsWe searched for systematic reviews and randomised controlled trials in the Cochrane Library, MEDLINE, EMBASE, ISI Web of Knowledge, DARE and HTA, with the last update in April 2010. Two of the authors independently screened titles and abstracts for inclusion or exclusion. Data on interventions, participants, comparison intervention, and outcomes were extracted from the included studies. Risk of bias and quality of evidence were assessed using the Cochrane Risk of Bias Table and GRADE, respectively. Outcomes assessed were use of or prescribing of drugs (primary) and the health-related outcomes falls, physical limitation, hospitalisation and mortality (secondary).ResultsDue to heterogeneity in interventions and outcomes, we employed a narrative approach. Twenty randomised controlled trials were included from 1631 evaluated references. Ten studies tested different kinds of educational interventions while seven studies tested medication reviews by pharmacists. Only one study was found for each of the interventions geriatric care teams, early psychiatric intervening or activities for the residents combined with education of health care personnel. Several reviews were identified, but these either concerned elderly in general or did not satisfy all the requirements for systematic reviews.ConclusionsInterventions using educational outreach, on-site education given alone or as part of an intervention package and pharmacist medication review may under certain circumstances reduce inappropriate drug use, but the evidence is of low quality. Due to poor quality of the evidence, no conclusions may be drawn about the effect of the other three interventions on drug use, or of either intervention on health-related outcomes.

The potential for research-based information in public health: Identifying unrecognised information needs

ObjectiveTo explore whether there is a potential for greater use of research-based information in public health practice in a local setting. Secondly, if research-based information is relevant, to explore the extent to which this generates questioning behaviour.DesignQualitative study using focus group discussions, observation and interviews.SettingPublic health practices in Norway.Participants52 public health practitioners.ResultsIn general, the public health practitioners had a positive attitude towards research-based information, but believed that they had few cases requiring this type of information. They did say, however, that there might be a potential for greater use. During five focus groups and six observation days we identified 28 questions/cases where it would have been appropriate to seek out research evidence according to our definition. Three of the public health practitioners identified three of these 28 cases as questions for which research-based information could have been relevant. This gap is interpreted as representing unrecognised information needs.ConclusionsThere is an unrealised potential in public health practice for more frequent and extensive use of research-based information. The practitioners did not appear to reflect on the need for scientific information when faced with new cases and few questions of this type were generated.

Reducing hospital admissions from nursing homes: a systematic review

BackgroundThe geriatric nursing home population is vulnerable to acute and deteriorating illness due to advanced age, multiple chronic illnesses and high levels of dependency. Although the detriments of hospitalising the frail and old are widely recognised, hospital admissions from nursing homes remain common. Little is known about what alternatives exist to prevent and reduce hospital admissions from this setting. The objective of this study, therefore, is to summarise the effects of interventions to reduce acute hospitalisations from nursing homes.MethodsA systematic literature search was performed in Cochrane Library, PubMed, MEDLINE, EMBASE and ISI Web of Science in April 2013. Studies were eligible if they had a geriatric nursing home study population and were evaluating any type of intervention aiming at reducing acute hospital admission. Systematic reviews, randomised controlled trials, quasi randomised controlled trials, controlled before-after studies and interrupted time series were eligible study designs. The process of selecting studies, assessing them, extracting data and grading the total evidence was done by two researchers individually, with any disagreement solved by a third. We made use of meta-analyses from included systematic reviews, the remaining synthesis is descriptive. Based on the type of intervention, the included studies were categorised in: 1) Interventions to structure and standardise clinical practice, 2) Geriatric specialist services and 3) Influenza vaccination.ResultsFive systematic reviews and five primary studies were included, evaluating a total of 11 different interventions. Fewer hospital admissions were found in four out of seven evaluations of structuring and standardising clinical practice; in both evaluations of geriatric specialist services, and in influenza vaccination of residents. The quality of the evidence for all comparisons was of low or very low quality, using the GRADE approach.ConclusionsOverall, eleven interventions to reduce hospital admissions from nursing homes were identified. None of them were tested more than once and the quality of the evidence was low for every comparison. Still, several interventions had effects on reducing hospital admissions and may represent important aspects of nursing home care to reduce hospital admissions.

Identifying barriers to the use of research faced by public health physicians in Norway and developing an intervention to reduce them

Objectives: To explore why public health physicians seldom use research-based information and to develop an intervention to remedy this on the basis of this study, other research literature and suitable theories of information-seeking and professional behaviour change. Methods: A qualitative study was conducted using focus groups, observation of individuals and interviews. The setting was Norwegian public health practice; 52 public health physicians from all over Norway participated in the study. Results: We identified several barriers to the use of scientific literature that could be categorised as: psychological variables; environmental variables; and source characteristics. We developed an intervention that attempts to address these barriers, informed by previous research on the effectiveness of interventions to change professional practice and incorporating elements from social cognitive theories and the theory of innovation diffusion. Conclusions: The Norwegian public health physician works in an isolated environment which does not facilitate searching or obtaining scientific information, which does not ask for this information and far less encourages its use as a basis for decision-making. An intervention tailored to reduce some of the barriers to research use may lead to more frequent and extensive use of such information in public health decision-making.

Many a slip between cup and lip. Process evaluation of a program to promote and support evidence-based public health practice.

The main aims of this study are to document whether an intervention for promoting evidence-based public health practice had been delivered as intended and to explore the reasons for its lack of impact. Process data from the implementation of the program and data from interviews with 40 public health physicians are analyzed. Although they expressed satisfaction with the service, the doctors experienced the program as rather irrelevant for their daily work. They did not perceive that they dealt with many issues relevant for the use of research information, and if they did, referring to research would not make any difference to the way others perceived their advice. There is a need to develop more overlying strategies for integrating evidence into decision making than addressing the individual level.

When Was Random Allocation First Used To Generate Comparison Groups In Experiments To Assess The Effects Of Social Interventions

Random allocation is an important feature of experiments designed to assess the effects of interventions: it ensures that, in respect of measured and unmeasured factors of prognostic importance, the comparison groups generated will differ only by chance. It has been asserted that random allocation in experiments to assess the effects of social and educational interventions was introduced at least as early as the first quarter of the 20th century. However, because the term ‘experiment’ and words with the root ‘random-’ have not been adequately defined and kept apart in these accounts, there is still confusion regarding the studies that have been cited as examples on early randomisation. We examined these putative examples and found that they were not randomised trials. It seems that matching on prognostic variables was the predominant method used to generate comparison groups in social and education intervention studies. The earliest description of a random allocation procedure in a social or educational intervention study that we were able to identify, was published in 1928.

A comparison of two search methods for determining the scope of systematic reviews and health technology assessments.

OBJECTIVES This study aims to compare two different search methods for determining the scope of a requested systematic review or health technology assessment. The first method (called the Direct Search Method) included performing direct searches in the Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessments (HTA). Using the comparison method (called the NHS Search Engine) we performed searches by means of the search engine of the British National Health Service, NHS Evidence. METHODS We used an adapted cross-over design with a random allocation of fifty-five requests for systematic reviews. The main analyses were based on repeated measurements adjusted for the order in which the searches were conducted. RESULTS The Direct Search Method generated on average fewer hits (48 percent [95 percent confidence interval {CI} 6 percent to 72 percent], had a higher precision (0.22 [95 percent CI, 0.13 to 0.30]) and more unique hits than when searching by means of the NHS Search Engine (50 percent [95 percent CI, 7 percent to 110 percent]). On the other hand, the Direct Search Method took longer (14.58 minutes [95 percent CI, 7.20 to 21.97]) and was perceived as somewhat less user-friendly than the NHS Search Engine (-0.60 [95 percent CI, -1.11 to -0.09]). CONCLUSIONS Although the Direct Search Method had some drawbacks such as being more time-consuming and less user-friendly, it generated more unique hits than the NHS Search Engine, retrieved on average fewer references and fewer irrelevant results.