Remo Ostini

Systematic Review of Interventions to Improve Prescribing

Objective: To update 2 comprehensive reviews of systematic reviews on prescribing interventions and identify the latest evidence about the effectiveness of the interventions. Data Sources: Systematic searches for English-language reports of experimental and quasi-experimental research were conducted in PubMed(1951–May 2007). EMBASE (1974–March 2008), International Pharmaceutical Abstracts (1970–March 2008), and 11 other bibliographic databases of medical, social science, and business research. Following an initial title screening process and after selecting 6 specific intervention categories (identified from the previous reviews) in community settings, 2 reviewers independently assessed abstracts and then full studies for relevance and quality and extracted relevant data using formal assessment and data extraction tools. Results were then methodically incorporated into the findings of the 2 earlier reviews of systematic reviews. Data Selection And Synthesis: Twenty-nine of 26,314 articles reviewed were assessed to be of relevant, high-quality research. Audit and feedback, together with educational outreach visits, were the focus of the majority of recent, high-quality research into prescribing interventions. These interventions were also the most effective in improving prescribing practice. A smaller number of studies included a patient-mediated intervention; this intervention was not consistently effective. There is insufficient recent research into manual reminders to confidently update earlier reviews and there remains insufficient evidence to draw conclusions regarding the effectiveness of local consensus processes or multidisciplinary teams. Conclusions: Educational outreach as well as audit and feedback continue to dominate research into prescribing interventions. These 2 prescribing interventions also most consistently show positive results. Much less research is conducted into other types of interventions and there is still very little effort to systematically test why interventions do or do not work.

Validation of a measure of knowledge about human papillomavirus (HPV) using item response theory and classical test theory

OBJECTIVE Public understanding of HPV is important to ensure informed participation in cervical cancer prevention programmes. While many studies have measured HPV knowledge, none has developed a validated measure for use across countries. We aimed to develop and validate such a measure. METHOD Items tapping knowledge of HPV, HPV testing and HPV vaccination were developed from previous literature and with expert consultation. The 29-item measure was administered via the internet to 2409 adults in the UK, US and Australia in 2011. Classical test theory and item response theory were used to establish the measures psychometric properties. RESULTS Total scale reliability was very good (α = 0.838), as was internal consistency for a 16-item general HPV knowledge subset (α = 0.849). Subsets of HPV testing and vaccination items showed reasonable test-retest reliability (r(test-retest) = 0.62 and 0.69) but moderate internal consistency (α = 0.52 and 0.56). Dimensionality analyses suggested that one item was not measuring the same construct as the remainder of the questionnaire. A 2-parameter logistic item response theory (IRT) model was fitted to the remaining 28 scale items. CONCLUSIONS A structurally coherent set of items covering a range of important HPV knowledge was developed. Responses indicated a reliable questionnaire, which allowed the fitting of an IRT model.

How is medication prescribing ceased? A systematic review

Background:Medication prescribing is a complex process where the focus tends to be on starting new medication, changing a drug regimen, and continuing a drug regimen. On occasion, a prudent approach to prescribing may necessitate ending an ongoing course of medication, either because it should not have been started in the first place; because its continued use would cause harm; or because the medication is no longer effective. Objective:To identify effective strategies for stopping pre-existing prescribing in situations where continued prescribing may no longer be clinically warranted. Research design:Systematic searches for English-language reports of experimental and quasi-experimental research were conducted in PubMed (1951–November 2009), EMBASE (1966–September 2008), and International Pharmaceutical Abstract b (1970–September 2008). A manual search for relevant review articles and a keyword search of a local database produced by a previous systematic search for prescribing influence and intervention research were also conducted. Study selection and data extraction:Following initial title screening for relevance 2 reviewers, using formal assessment and data extraction tools, independently assessed abstracts for relevance and full studies for quality before extracting data from studies selected for inclusion. Results:Of 1306 articles reviewed, 12 were assessed to be of relevant, high-quality research. A variety of drugs were examined in the included studies with benzodiazepines the most common. Studies included in the review tested 9 different types of interventions. Effective interventions included patient-mediated interventions, manual reminders to prescribers, educational materials given to patients, a face-to-face intervention with prescribers, and a case of regulatory intervention. Partially effective interventions included audit and feedback, electronic reminders, educational materials alone sent to prescribers, and distance communication combined with educational materials sent to prescribers. Conclusions:It appears possible to stop the prescribing of a variety of medications with a range of interventions. A common theme in effective interventions is the involvement of patients in the stopping process. However, prescribing at the level of individual patients was rarely reported, with data often aggregated to number of doses or number of drugs per unit population, attributing any reduction to cessation. Such studies are not measuring the actual required outcome (stopping prescribing), and this may reflect the broader ambiguity about when or why it might be important to end a prescription. Much more research is required into the process of stopping pre-existing prescribing, paying particular attention to improving the outcomes that are measured.

The ethics of experimental heroin maintenance.

In response to widespread concern about illegal drug use and the associated risk of the spread of HIV/AIDS, a study was undertaken to examine whether it was, in principle, feasible to conduct a trial providing heroin to dependent users in a controlled manner. Such a trial involves real ethical issues which are examined in this paper. The general issues examined are: should a trial be an experiment or an exercise in public policy?; acts and omissions; countermobilization; termination of a trial, and payment for drugs and for a trial. The specific issues examined are: selection of trial participants; privacy; issues for staff working on a trial; coupling the trial with other treatment, and issues for researchers. A number of alternative approaches to the various ethical issues are presented and discussed.

The Audit of Diabetes-Dependent Quality of Life 19 (ADDQoL): feasibility, reliability and validity in a population-based sample of Australian adults

PurposeThis study aims to analyse the psychometric properties of the most recent 19 item version of the Audit of Diabetes-Dependent Quality of Life (ADDQoL) in a large, population-based sample of adults living in Australia.MethodsA total of 3,951 people living with diabetes completed the ADDQoL as part of the Living With Diabetes Study. Data analysis investigated the feasibility of using the ADDQoL in a large, population-based survey; internal consistency; adherence to a single-factor structure; and convergent/discriminant validity.ResultsData support the feasibility of using the ADDQoL in population-based survey research. Although a strict single-factor structure for the ADDQoL was not demonstrated, the results overall support an interpretation of essential unidimensionality. A validation matrix provides support for the convergent and divergent validity of the measure, as does the ADDQoL’s ability to discriminate between respondents based on insulin dependence and complications.ConclusionsThe ADDQoL has good psychometric properties and provides clinicians and researchers with a useful tool for comprehensively assessing quality of life in adults with diabetes.

Further Evaluation of Merz's Psychological Reactance Scale:

Merzs Psychological Reactance Scale was evaluated on the basis of individual item analysis, factorial validity and reliability using responses of 379 Australian tertiary students. Several questionnaire items showed difficulties in readability, ambiguity and discriminatory power, possibly due to the effects of translation. The scale was factorially unstable, and the reliabilities of the present English version were .80 (α) and .77 (split-half) which are not as high as those for the original German version. A thorough refinement of questionnaire items was suggested to produce a more psychometrically acceptable scale.

Investigating the association between health literacy and non-adherence.

Background Low health literacy is expected to be associated with medication non-adherence and early research indicated that this might be the case. Further research suggested that the relationship may be more equivocal. Aim of the review The goal of this paper is initially to clarify whether there is a clear relationship between health literacy and non-adherence. Additionally, this review aims to identify factors that may influence that relationship and ultimately to better understand the mechanisms that may be at work in the relationship. Method English language original research or published reviews of health literacy and non-adherence to orally administered medications in adults were identified through a search of four bibliographic databases (PubMed, EMBASE, CINAHL, and EBSCO Health). Results The search protocol produced 78 potentially relevant articles, of which 16 articles addressed factors that contribute to non-adherence and 24 articles reported on the results of research into the relationship between non-adherence and health literacy. Factors that contribute to non-adherence can be categorised into patient related factors, including patient beliefs; medication related factors; logistical factors; and factors around the patient-provider relationship. Of the 23 original research articles that investigated the relationship between non-adherence and health literacy, only five reported finding clear evidence of a relationship, four reported mixed results and 15 articles reported not finding the expected relationship. Research on possible mechanisms relating health literacy to non-adherence suggest that disease and medication knowledge are not sufficient for addressing non-adherence while self-efficacy is an important factor. Other findings suggest a possible U-shaped relationship between non-adherence and health literacy where people with low health literacy are more often non-adherent, largely unintentionally; people with moderate health literacy are most adherent; and people with high health literacy are somewhat non-adherent, sometimes due to intentional non-adherence. Conclusion It is clear that relevant research generally fails to find a significant relationship between non-adherence and health literacy. A U-shaped relationship between these two conditions would explain why linear statistical tests fail to identify a relationship across all three levels of health literacy. It can also account for the conditions under which both positive and negative relationships may be found.

Quality Use of Medicines--medication safety issues in naming; look-alike, sound-alike medicine names.

Objective  To review current literature with the objective of developing strategies and recommendations to enhance patient safety and minimise clinical issues with look‐alike, sound‐alike medication names.

Knowledge of human papillomavirus (HPV) testing in the USA, the UK and Australia: an international survey.

Objective To measure knowledge and awareness of human papillomavirus (HPV) testing in the USA, the UK and Australia. Methods Participants in the USA, UK and Australia completed an anonymous web-based survey measuring awareness and knowledge of HPV (n=2409). We report analyses on a subsample of 1473 men and women in the USA (n=617), UK (n=404) and Australia (n=452) who had heard of HPV and completed questions about HPV testing. Results Overall, 50% of the sample (742/1473) had heard of HPV testing. Awareness of HPV testing was higher in the USA (62%) than in the UK (44%) and Australia (40%) (p<0.001). Among those who had heard of HPV testing, the mean knowledge score (out of 6) was 2.78 (SD: 1.49). No significant differences in knowledge score were found between the countries but, overall, women scored significantly higher than men (2.96 vs 2.52, p<0.001). Conclusions Awareness of HPV testing among people who have heard of HPV is higher in the USA than in the UK and Australia, but overall knowledge is low. This has important implications in those countries where HPV testing is being used in cervical screening. Increasing knowledge about the implications of HPV test results may help minimise any negative psychological consequences associated with HPV testing. Raising awareness in men could become increasingly important if HPV testing is introduced into the management of other cancers where HPV plays an aetiological role.

Why is the use of clopidogrel increasing rapidly in Australia? An exploration of geographical location, age, sex and cardiac stenting rates as possible influences on clopidogrel use.

To explore clopidogrel use within Australia, investigating geography, age, sex and cardiac stenting rates.