Robert Vander Stichele

European Surveillance of Antimicrobial Consumption (ESAC): quality indicators for outpatient antibiotic use in Europe

Background and objective: Indicators to measure the quality of healthcare are increasingly used by healthcare professionals and policy makers. In the context of increasing antimicrobial resistance, this study aimed to develop valid drug-specific quality indicators for outpatient antibiotic use in Europe, derived from European Surveillance of Antimicrobial Consumption (ESAC) data. Methods: 27 experts (15 countries), in a European Science Foundation workshop, built on the expertise within the European Drug Utilisation Research Group, the General Practice Respiratory Infections Network, the ESCMID Study Group on Primary Care Topics, the Belgian Antibiotic Policy Coordination Committee, the World Health Organization, ESAC, and other experts. A set of proposed indicators was developed using 1997–2003 ESAC data. Participants scored the relevance of each indicator to reducing antimicrobial resistance, patient health benefit, cost effectiveness and public health policy makers (scale: 1 (completely disagree) to 9 (completely agree)). The scores were processed according to the UCLA-RAND appropriateness method. Indicators were judged relevant if the median score was not in the 1–6 interval and if there was consensus (number of scores within the 1–3 interval was fewer than one third of the panel). From the relevant indicators providing overlapping information, the one with the highest scores was selected for the final set of quality indicators—values were updated with 2004 ESAC data. Results: 22 participants (12 countries) completed scoring of a set of 22 proposed indicators. Nine were rated as relevant antibiotic prescribing indicators on all four dimensions; five were rated as relevant if only relevance to reducing antimicrobial resistance and public health policy makers was taken into account. A final set of 12 indicators was selected. Conclusion: 12 of the proposed ESAC-based quality indicators for outpatient antibiotic use in Europe have face validity and are potentially applicable. These indicators could be used to better describe antibiotic use in ambulatory care and assess the quality of national antibiotic prescribing patterns in Europe.

Current and projected prevalence of arterial hypertension in sub-Saharan Africa by sex, age and habitat: an estimate from population studies

Introduction In sub-Saharan Africa (SSA), data on hypertension prevalence in terms of urban or rural and sex difference are lacking, heterogeneous or contradictory. In addition, there are no accurate estimates of hypertension burden. Objective To estimate the age-specific and sex-specific prevalence of arterial hypertension in SSA in urban and rural adult populations. Methods We searched for population studies, conducted from 1998 through 2008 in SSA. We extracted data from selected studies on available prevalences and used a logistic regression model to estimate all age/sex/habitat (urban/rural)/country-specific prevalences for SSA up to 2008 and 2025. On the basis of the United Nations Population Fund data for 2008 and predictions for 2025, we estimated the number of hypertensives in both years. Results Seventeen studies pertaining to 11 countries were analysed. The overall prevalence rate of hypertension in SSA for 2008 was estimated at 16.2% [95% confidence interval (CI) 14.1–20.3], ranging from 10.6% in Ethiopia to 26.9% in Ghana. The estimated prevalence was 13.7% in rural areas, 20.7% in urban areas, 16.8% in males, and 15.7% in women. The total number of hypertensives in SSA was estimated at 75 million (95% CI 65–93 million) in 2008 and at 125.5 million (95% CI 111.0–162.9 million) by 2025. Conclusion The estimated number of hypertensives in 2008 is nearly four times higher than the last (2005) estimate of the World Health Organization Regional Office for Africa. Prevalences were significantly higher in urban than in rural populations. Population data are lacking in many countries underlining the need for national surveys.

Systematic review of anticholinergic risk scales in older adults

BackgroundAnticholinergic drugs are often involved in explicit criteria for inappropriate prescribing in older adults. Several scales were developed for screening of anticholinergic drugs and estimation of the anticholinergic burden. However, variation exists in scale development, in the selection of anticholinergic drugs, and the evaluation of their anticholinergic load. This study aims to systematically review existing anticholinergic risk scales, and to develop a uniform list of anticholinergic drugs differentiating for anticholinergic potency.MethodsWe performed a systematic search in MEDLINE. Studies were included if provided (1) a finite list of anticholinergic drugs; (2) a grading score of anticholinergic potency and, (3) a validation in a clinical or experimental setting. We listed anticholinergic drugs for which there was agreement in the different scales. In case of discrepancies between scores we used a reputed reference source (Martindale: The Complete Drug Reference®) to take a final decision about the anticholinergic activity of the drug.ResultsWe included seven risk scales, and evaluated 225 different drugs. Hundred drugs were listed as having clinically relevant anticholinergic properties (47 high potency and 53 low potency), to be included in screening software for anticholinergic burden.ConclusionConsiderable variation exists among anticholinergic risk scales, in terms of selection of specific drugs, as well as of grading of anticholinergic potency. Our selection of 100 drugs with clinically relevant anticholinergic properties needs to be supplemented with validated information on dosing and route of administration for a full estimation of the anticholinergic burden in poly-medicated older adults.

Systematic review of clinical efficacy of topical treatments for head lice.

Abstract Objectives: To collect and evaluate all trials on clinical efficacy of topical treatments for head lice. Design: Systematic review of randomised trials identified from following data sources: Medline, International Pharmaceutical Abstracts, Science Citation Index, letters to key authors and companies, and hand search of journals. Setting: Trials in schools or communities. Subjects: Patients infested with lice. Main outcome measure: Cure rate (absence of live lice and viable nits) on day 14 after treatment. Results: Total of 28 trials were identified and evaluated according to eight general and 18 lice specific criteria. Of the 14 trials rated as having low to moderate risk of bias, seven were selected as they used the main outcome measure. These seven trials described 21 evaluations of eight different compounds and placebo (all but two evaluations were of single applications). Only permethrin 1% creme rinse showed efficacy in more than two studies with the lower 95% confidence limit of cure rate above 90%. Conclusions: Only for permethrin has sufficient evidence been published to show efficacy. Less expensive treatments such as malathion and carbaryl need more evidence of efficacy. Lindane and the natural pyrethrines are not sufficiently effective to justify their use.

Systematic appraisal of dementia guidelines for the management of behavioural and psychological symptoms

BACKGROUND Within the treatment of dementia, management of behavioural and psychological symptoms (BPSD) is a complex component. PURPOSE We wanted to offer a pragmatic synthesis of existing specific practice recommendations for managing BPSD, based on agreement among systematically appraised dementia guidelines. DATA SOURCES We conducted a systematic search in MEDLINE and guideline organisation databases, supplemented by a hand search of web sites. STUDY SELECTION Fifteen retrieved guidelines were eligible for quality appraisal by the Appraisal of Guidelines Research and Evaluation instrument (AGREE), performed by 2 independent reviewers. DATA EXTRACTION From the 5 included guidelines, 18 specific practice recommendations for BPSD were extracted and compared for their level of evidence and strength. DATA SYNTHESIS No agreement was found among dementia guidelines for the majority of specific practice recommendations with regard to non-pharmacological interventions, although these were recommended as first-line treatment. Pharmacological specific practice recommendations were proposed as second-line treatment, with agreement for the use of a selection of antipsychotics based on strong supporting evidence, but with guidance for timely discontinuation. LIMITATIONS The appraisal of the level of agreement between guidelines for each specific practice recommendation was complicated by variation in grading systems, and was performed with criteria developed a posteriori. CONCLUSION Despite the limited number of recommendations for which agreement was found, guidelines did agree on careful antipsychotic use for BPSD. Adverse events might outweigh the supporting evidence of efficacy, weakening the recommendation. More pivotal trials on the effectiveness of non-pharmacological interventions, as well as guidelines specifically focusing on BPSD, are needed.

Pharmacists' Interventions for Optimization of Medication Use in Nursing Homes : A Systematic Review

The elderly use more medications than younger adults. In addition, the prevalence of inappropriate prescribing is high in nursing homes. The aim of this review was to collect and interpret the results of clinical studies of interventions involving pharmacists aimed at improving the quality of prescribing in nursing homes, and to identify the key elements for a successful intervention. To this end, we searched MEDLINE, International Pharmaceutical Abstracts and EMBASE from January 1987 to May 2008. Studies were selected that (i) involved a pharmacist; (ii) took place in the nursing home setting; (iii) involved residents aged ≥65 years; (iv) included residents with a range of diseases (not targeted at a specific pathology); (v) were controlled trials (randomized or not). The search strategy retrieved eight controlled studies that fitted the inclusion criteria. A meta-analysis was not possible because of the difference in outcomes chosen in the publications. We found mixed evidence for the effectiveness of various interventions by pharmacists on pharmacotherapy in the nursing home setting. Pharmacists can have different roles in the nursing home such as performing regular medication reviews, being an active member of a multidisciplinary team and/or educating physicians, nurses and other nursing home staff about medication use. Our review shows that the available evidence is mixed concerning the effectiveness of interventions by pharmacists on pharmacotherapy in the nursing home setting. At the same time, greater pharmacist involvement has been shown in published studies to increase physicians’ and nurses’ knowledge and awareness about medication. Evidence is scarce, however, and there is a need for large, well conducted randomized controlled trials in the nursing home setting. Attention should be paid to the choice of outcome measures and to multidisciplinary collaboration when assessing the effects of pharmacists’ interventions on medication use in nursing homes.

Nursing Home Residents Dying With Dementia in Flanders, Belgium: A Nationwide Postmortem Study on Clinical Characteristics and Quality of Dying

OBJECTIVES There is a lack of large-scale, nationwide data describing clinical characteristics and quality of dying of nursing home residents dying with dementia. We set out to investigate quality of end-of-life care and quality of dying of nursing home residents with dementia in Flanders, Belgium. DESIGN/SETTING/PARTICIPANTS To obtain representativity, we conducted a postmortem study (2010) using random cluster sampling. In selected nursing homes, all deceased residents with dementia in a period of 3 months were reported. For each case, a structured questionnaire was filled in by the nurse most involved in care, the family physician, and the nursing home administrator. We used the Cognitive Performance Scale and Global Deterioration Scale to assess dementia. Main outcome measures were health status, clinical complications, symptoms at the end of life, and quality of dying. MEASUREMENTS Health status, clinical complications, symptoms at the end of life, and quality of dying. RESULTS We identified 198 deceased residents with dementia in 69 nursing homes (58% response rate). Age distribution was the same as all deceased residents with dementia in Flanders, 2010. Fifty-four percent had advanced dementia. In the last month of life, 95.5% had 1 or more sentinel events (eg, eating/drinking problems, febrile episodes, or pneumonia); most frequently reported symptoms were pain, fear, anxiety, agitation, and resistance to care. In the last week, difficulty swallowing and pain were reported most frequently. Pressure sores were present in 26.9%, incontinence in 89.2%, and cachexia in 45.8%. Physical restraints were used in 21.4% of cases, and 10.0% died outside the home. Comparing stages of dementia revealed few differences between groups regarding clinical complications, symptoms, or quality of dying. CONCLUSION Regardless of the dementia stage, many nursing home residents develop serious clinical complications and symptoms in the last phase of life, posing major challenges to the provision of optimum end-of-life care.

Wet combing versus traditional scalp inspection to detect head lice in schoolchildren: observational study

Lice infestation is a problem in local communities, probably because reservoirs remain undetected. Wet combing (combing systematically through wet, well conditioned hair with a fine toothed comb) has been presented as a cheap, ecological, self sufficient, and feasible technique for diagnosis and treatment of head lice.1-3 Compared with traditional scalp inspection it uses five elements to make living lice more visible, to better distinguish them from dandruff, and to assess the maturity of the infestation: water, conditioner, a fine toothed comb, a systematic sweep of the scalp, and a magnifying glass (10×). However, its efficacy as a diagnostic tool and as a therapeutic intervention has not been proved; hence it is not evidence based. We did an observational study comparing detection of head lice using traditional scalp inspection and wet combing. After ethical approval had been obtained, all 260 pupils, aged 2-12 years, of a primary school in a socially deprived urban area …

Barriers and facilitators for general practitioners to engage in advance care planning: A systematic review

Abstract Objective. The aim of this systematic review is to identify the perceived factors hindering or facilitating GPs in engaging in advance care planning (ACP) with their patients about care at the end of life. Design. Studies from 1990 to 2011 were found in four electronic databases (PubMed, CINAHL, EMBASE, PsycINFO); by contacting first authors of included studies and key experts; and searching through relevant journals and reference lists. Studies were screened, graded for quality, and analysed independently by two authors; those reporting the perception by GPs of barriers and facilitators to engagement in ACP were included. Results. Eight qualitative studies and seven cross-sectional studies were included for data extraction. All barriers and facilitators identified were categorized as GP characteristics, perceived patient factors, or health care system characteristics. Stronger evidence was found for the following barriers: lack of skills to deal with patients’ vague requests, difficulties with defining the right moment, the attitude that it is the patient who should initiate ACP, and fear of depriving patients of hope. Stronger evidence was found for the following facilitators: accumulated skills, the ability to foresee health problems in the future, skills to respond to a patients initiation of ACP, personal convictions about who to involve in ACP, and a longstanding patient–GP relationship and the home setting. Conclusion. Initiation of ACP in general practice may be improved by targeting the GPs’ skills, attitudes, and beliefs but changes in health care organization and financing could also contribute.

Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme

BackgroundExcessive use of antibiotics is worldwide the most important reason for development of antimicrobial resistance. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries. Initiatives have been taken to improve the quality of antibiotic prescribing in primary care, but only few studies have been designed to determine the effectiveness of multifaceted strategies across countries with different practice setting. The aim of this study was to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different health organization and different prevalence of antibiotic resistance.MethodsGPs from two Nordic countries, two Baltic Countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) in 2008 and 2009. After first registration they received individual prescriber feedback and they were offered an intervention programme that included training courses, clinical guidelines, posters for waiting rooms, patient brochures and access to point of care tests (Strep A and C-Reactive Protein). Antibiotic prescribing rates were compared before and after the intervention.ResultsA total of 440 GPs registered 47011 consultations; 24436 before the intervention (2008) and 22575 after the intervention (2009). After the intervention, the GPs significantly reduced the percentage of consultations resulting in an antibiotic prescription. In patients with lower RTI the GPs in Lithuania reduced the prescribing rate by 42%, in Russia by 25%, in Spain by 25%, and in Argentina by 9%. In patients with upper RTIs, the corresponding reductions in the antibiotic prescribing rates were in Lithania 20%, in Russia 15%, in Spain 9%, and in Argentina 5%.ConclusionA multifaceted intervention programme targeting GPs and patients and focusing on improving diagnostic procedures in patients with RTIs may lead to a marked reduction in antibiotic prescribing. The pragmatic before-after design used may suffer from some limitations and the reduction in antibiotic prescribing could be influenced by factors not related to the intervention.