Prescribing-Assessment Tools for Long-Term Care Pharmacy Practice: Reaching Consensus through a Modified RAND/UCLA Appropriateness Method
Abstract
Medicines are the most used health technology in Long-Term Care. The prevalence of potentially inappropriate medicines amongst Long-Term Care patients is high. Pharmacists, assisted by prescribing-assessment tools, can play an important role in optimizing medication use at this level of care. Through a modified RAND/UCLA Appropriateness Method, 13 long-term care and hospital pharmacists assessed as ‘appropriate’, ‘uncertain’, or ‘inappropriate’ a collection of commonly used prescribing-assessment tools as to its suitability in assisting pharmacy practice in institutional long-term care settings. A qualitative analysis of written or transcribed comments of participants was pursued to identify relevant characteristics of prescribing-assessment tools and potential hinders in their use. From 24 different tools, pharmacists classified 9 as ‘appropriate’ for pharmacy practice targeted to long-term care patients, while 3 were classified as ‘inappropriate’. The tools feature most appreciated by study participants was the indication of alternatives to potentially inappropriate medication. Lack of time and/or pharmacists and limited access to clinical information seems to be the most relevant hinders for prescribing-assessment tools used in daily practice.
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Pharmacy2021,9,194.https://doi.org/10.3390/pharmacy9040194www.mdpi.com/journal/pharmacy Article Prescribing‐AssessmentToolsforLong‐TermCare PharmacyPractice:ReachingConsensusthrough aModifiedRAND/UCLAAppropriatenessMethod JoãoR.Gonçalves 1, *,BetsyL.Sleath 2 ,ManuelJ.Lopes 3 andAfonsoM.Cavaco 1 1 iMed.ULisboa,SocialPharmacyDepartment,FacultyofPharmacy,UniversityofLisbon, 1649‐003Lisboa,Portugal;acav[email protected]boa.pt 2 EshelmanSchoolofPharmacy,UniversityofNorthCarolinaatChapelHill,ChapelHill,NC27599,USA; [email protected] 3 CollegeofNursingS.JoãodeDeus,UniversityofÉvora,7000‐811Évora,Portugal;[email protected] *Correspondence:[email protected] Abstract:MedicinesarethemostusedhealthtechnologyinLong‐TermCare.Theprevalenceof potentiallyinappropriatemedicinesamongstLong‐TermCarepatientsishigh.Pharmacists,as‐ sistedbyprescribing‐assessmenttools,canplayanimportantroleinoptimizingmedicationuseat thislevelofcare.ThroughamodifiedRAND/UCLAAppropriatenessMethod,13long‐termcare andhospitalpharmacistsassessedas‘appropriate’,‘uncertain’,or‘inappropriate’acollectionof commonlyusedprescribing‐assessmenttoolsastoitssuitabilityinassistingpharmacypracticein institutionallong‐termcaresettings.Aqualitativeanalysisofwrittenortranscribedcommentsof participantswaspursuedtoidentifyrelevantcharacteristicsofprescribing‐assessmenttoolsand potentialhindersintheiruse.From24differenttools,pharmacistsclassified9as‘appropriate’for pharmacypracticetargetedtolong‐termcarepatients,while3wereclassifiedas‘inappropriate’. Thetoolsfeaturemostappreciatedbystudyparticipantswastheindicationofalternativestopo‐ tentiallyinappropriatemedication.Lackoftimeand/orpharmacistsandlimitedaccesstoclinical informationseemstobethemostrelevanthindersforprescribing‐assessmenttoolsusedindaily practice. Keywords:long‐termcare;potentiallyinappropriateprescribing;pharmacist;pharmacypractice; consensus;RAND/UCLA;prescribing‐assessmenttools 1.Introduction Long‐TermCare(LTC)encompassesarangeofhealthcare,personalcare,andother supportiveservicestargetedtopatientswhosecapacityforself‐careislimitedoveran extendedperiod[1,2].InPortugal,theNationalNetworkforLong‐TermIntegratedCare representsthecountry’sresponsetothegrowingdemandforthislevelofcare.Structur‐ ally,theNationalNetworkforLong‐TermIntegratedCare(NLTIC)comprehendsHome andCommunity‐BasedServices(outpatientsettings)andSkilledNursingHomes(inpa‐ tientsettings).Pharmacists’interventioninNLTICoutpatientsettingsisabsent.National NetworkforLong‐TermIntegratedinpatientsettingsisdividedinto‘Convalescence units’,‘MediumTerm&Rehabilitationunits’,and‘Long‐Term&Maintenanceunits’[3]. Althoughnotexplicitlytargetedtocareforagedpeople,LTCpopulationsareoftenel‐ derlypatients.In2020,84%ofNLTIC’spatientswereaged65orover,alignedwiththe worldwidedemographicageingtrend[4].Asextensivelyreported,theageingprocessis highlyassociatedwithmultimorbidityand,consequently,withaugmenteduseofmedi‐ cations[5–7].OlderpopulationsaremoresusceptibletoAdverseDrugEvents(ADEs) giventheage‐relatedpharmacokineticsandpharmacodynamicschanges,addingto Citation:Goncalves,J.R.;Sleath, B.L.;Lopes,M.J.;Cavaco,A.M. Prescribing‐AssessmentToolsfor Long‐TermCarePharmacyPractice: ReachingConsensusThrougha ModifiedRAND/UCLA AppropriatenessMethod. Pharmacy2021,9,194. https://doi.org/10.3390/ pharmacy9040194 AcademicEditor:BjarkeAbrahamsen Received:15November2021 Accepted:2December2021 Published:3December2021 Publisher’sNote:MDPIstaysneu‐ tralwithregardtojurisdictional claimsinpublishedmapsandinstitu‐ tionalaffiliations. Copyright:©2021bytheauthors.Li‐ censeeMDPI,Basel,Switzerland. Thisarticleisanopenaccessarticle distributedunderthetermsandcon‐ ditionsoftheCreativeCommonsAt‐ tribution(CCBY)license(http://crea‐ tivecommons.org/licenses/by/4.0/).
Pharmacy2021,9,1942of15 elders’usualunder‐representationinclinicaltrials.Allpreviousreasonsmightexplain thehighprevalenceofPotentiallyInappropriateMedication(PIM)inolderpatients[8,9]. Arecentsystematicreviewidentifiedaprevalenceofinappropriatemedicationuse amongtheelderlyrangingfrom11.5%to62.5%[10].InLTCfacilities,theprevalenceof inappropriatemedicationisalsohigh[11–13].Consequently,thequalityofprescribingin LTCpopulationsisofutmostimportance,beingacomplexandchallengingprocess.Po‐ tentiallyInappropriatePrescribing(PIP)hasbeenassociatedwithnegativehealthout‐ comesandeconomiclosses[14,15].PotentiallyInappropriatePrescribingconceptencom‐ passesthefollowingpractices:i)misprescribing,i.e.,theprescriptionofamedicationthat couldpotentiallyleadtoasignificantriskofADEs,duetoerroneousposologyorrouteof administrationorduetoincreasedriskofdrug‐drugordrug‐diseaseinteraction;ii)un‐ derprescribingorPotentialPrescribingOmission(PPO),i.e.,theomissionofamedication thatisclinicallyindicatedfordiseasetreatmentorprevention;iii)overprescribing,i.e.,the prescriptionofmedicationsforwhichnoclearclinicalindicationexists[16,17].Different methodshavebeendevelopedandimplementedfocusedoninappropriateprescribing prevention,suchaseducation,medicationreconciliation,andprescribing‐assessment tools[18].Overthelastthreedecades,severalcriteriaandscreeningtoolshavebeende‐ velopedtoassistcliniciansinidentifyingandpreventingPIP.Thesetoolscanbeexplicit (i.e.,criteria‐based)orimplicit(i.e.,judgement‐based)[19,20].Amongstthehealthcare professionalscapableofusingsuchinstrumentsarepharmacists.Pharmacists’practice encompassesseveralmedicine‐relatedinterventions,frommedicinesmanagementtoes‐ tablishing,assessing,ormonitoringtreatmentplans.Throughasetofclinicalandpatient‐ orientedactivitiesandcollaborationwithotherhealthcareprofessionals,pharmacistscan reducePIPalsoinLTCsettings[21,22]. Long‐TermCareconceptualizationanddeliveryvaryfromcountrytocountry,ham‐ peringscientificreportingandstandardizedutilizationofPotentiallyInappropriatePre‐ scribing(PIP)assessmenttools[23,24].InPortugal,nocommonorgenerallyaccepted guidelinesregardingtherapyoptimizationareknowninLTC.Theexistingheterogeneity ofmedicationprescribingpractices,thewiderangeofsupportinginstrumentsavailable, andtheLTCpopulationheterogeneoushealthstatusturnschallengingtoidentifythe mostsuitablePrescribing‐AssessmentTools(PATs).Thisstudyaimedtoidentifythemost suitablePrescribing‐AssessmentToolsusefulforLTCpharmacypractice.Anadditional goalwastomapkeycharacteristicsofPrescribing‐AssessmentToolsfromthepharmacist‐ userperspectiveandpotentialhindersfortheiruse. 2.MaterialsandMethods Thisstudyfollowedaconsensus‐buildingmethodologytoselectthemostappropri‐ atetoolsforpharmacypracticeinLTCsettings,adjustedtopatients’characteristicsand pharmacists’activitiesinthislevelofcare. ThemethodologicalapproachissummarizedinFigure1.
Pharmacy2021,9,1943of15 Figure1.Studymethodologyflowchart. Consensusmethodscanbedefinedasasetoffacilitationtechniquesdesignedtoex‐ plorethelevelofconsensusamongagroupofexpertsbysynthesizingandclarifyingex‐ pertopinions.Inhealthcareresearch,fourconsensusmethodsarefrequentlyused:Delphi, NominalGrouptechnique,ConsensusDevelopmentConference,andRAND/UCLAAp‐ propriatenessMethod(RAM)[25,26].RAMisaccomplishedfromalistofpredetermined items[27].Forthisreason,RAMsuitsourobjectivesoncePrescribing‐AssessmentTools arealreadydevelopedandpublishedinthescientificliterature.Generically,RAMmeth‐ odologycanbedescribedinfourmainsteps:i)literaturereview;ii)panelratingroundto reviewtheevidencegatheredfromliterature(withoutanyinteractionsbetweenpanelists, thesilentround);iii)face‐to‐facemeetingaimedatdiscussinggroup’sratings,followed byindividualopportunitiesforre‐ratings;iv)finalclassificationofevidenceas“appropri‐ ate”,“uncertain”or“inappropriate”(accordingtopanelistsmedianscores)anddiscus‐ sion[27].Apilotphasewasundertakentoanticipatepotentialhindersinapplyingthis method,particularlyforthemeetingstep(e.g.,timeandotherconstraints).Atthispoint, aRAMmodificationwasassumedtostrengthenaqualitativeperspectiveonPATsuse, inspiredbyamixed‐methodsapproach.Insteadofasingleround,twosilentroundswith allpanelistswereconductedtoobtainPATsquantitativeappraisalbeforetheface‐to‐face meeting. 2.1.LiteratureReviewandPrescribing‐AssessmentToolsIdentification Prescribing‐AssessmentToolswereidentifiedinstudiesreportingpharmacist‐ledin‐ terventionsininstitutionalLTCsettingsfrompublishedprimarysourcessummarizedin arecentsystematicreview,publishedelsewhere(Figure1)[28].Additionally,amanual searchofrelevantreferencesfromtheretrievedpaperswasundertaken.
Pharmacy2021,9,1944of15 2.2.Prescribing‐AssessmentToolsIndependentRating Panelists’enrollmentwasmadefollowingapurposivesamplingtechnique(Table1). PanelistswereLTCpharmacistsexclusivelydedicatedtoatleastoneofthethreetypesof RNCCIinpatientsettings(‘Convalescenceunits’,‘MediumTerm&Rehabilitationunits’, and‘Long‐Term&Maintenanceunits’)orhospitalpharmacists.Referralofpatientstothe NationalNetworkforLong‐TermIntegratedCareismademainlythroughhospitalset‐ tings;therefore,theinterventionofhospitalpharmacistsinthetransitionofpatientsto LTCoccurs.Communitypharmacistsarenotinvolvedinthetransitionofcare;thus,they werenotrecruited.ThefinalPATscollectionwasmailedtoinstitutionaladdressesofeach pharmacistforjudgmentandprivaterating,asdescribednext. Table1.Panelists’demographiccharacteristics. Participant GenderSettingofProfessionalActivityYearsofPractice 1FemaleLong‐TermCareFacility10 2FemaleLong‐TermCareFacility15 3FemaleLong‐TermCareFacility5 4FemaleLong‐TermCareFacility15 5FemaleLong‐TermCareFacility11 6FemaleLong‐TermCareFacility1 7FemaleLong‐TermCareFacility3 8FemaleLong‐TermCareFacility1 9FemaleHospital3 10FemaleHospital4 11MaleHospital5 12MaleHospital4 13MaleHospital24 PanelistswereaskedtorateeachPATregardingitssuitabilityforLTCpharmacy practice(HowappropriatecouldthisPATbeinprovidingcaretoLTCpatients?),usinga 9‐pointsLikertscale(1—totallyinappropriate;9—totallyappropriate),andtocomment ontheirratings.Ratingsof1–3,4–6and7–9wereclassifiedasInappropriate(I),Uncertain (B),andAppropriate(A),respectively.Aftereachround,thegroupmedianrate,Disagree‐ mentIndex(DI)andcommentssupportingratingswereanonymouslysharedwithall panelists,whowereallowedtochangetheirratingsbeforethesecondroundandface‐to‐ facemeeting. DisagreementIndexisanindicatorofconsensusandforitscalculation,thefollowing equationwasused:DI=IPR/IPRAS(IPR,Inter‐PercentileRange;IPRAS,Inter‐Percentile RangeAdjustedforSymmetry),consideringthefollowing:i)IPR=70th–30thpercentile; ii)IPRCentralPoint(IPRCP=(70th+30thpercentile)/2;iii)AsymmetryIndex(AI)=(5– IPRCP);iv)IPRAS=2,5+(AI×1,5)[27].ADIvaluelessthanorequalto1signalsagree‐ mentbetweenpanelists[29]. 2.3.Face‐to‐FaceMeetings Liveremotemeetingswereheldwithpanelistsafterthetwosilentroundstoreacha consensus.Anearlierpilotpanel,meetingonlinewith3LTCpharmacists,took3hand15 mintoitsend.Thus,toassurethatallparticipantscouldexpresstheirevaluationofall PATs,includingqualitativeaccounts,withinanacceptabletimeframe,itwasnecessaryto convenethreegroupsof3–5panelists.Allpanelsaimedtoreachanagreementonas‐ sessingPATsasAppropriate,UncertainandInappropriate,regardingtheirusefulnessfor LTCpharmacypractice.Incasepanelistsdisagreed,thatpanel’sratingwasconsideredas Uncertain(B).ForfinalconsensusasInappropriate(If),Uncertain(Bf),andAppropriate (Af),athumbrulewasfollowed:forPATswithatleasttwopanels’ratingalignedwith
Pharmacy2021,9,1945of15 the2ndroundoverallratingandaDIequalorbelow1,finalconsensusasIf,BforAfwas consideredaccordinglytotheoverallgroup’srating.Ifthetwopanels’ratingswerenot alignedwiththeoverallgroup’srating,thePATwasclassifiedasUncertain(B)usefor LTCpharmacypractice. 2.4.AnalysisofPanellists’AccountsandFinalClassification ToinformreasonsforratingsandconsensusandexplorePATs’characteristicsiden‐ tifiedasmoresuitableforpharmacistLTCpractice,arecordofcomments(writtenduring theprivateratingandtranscribedfromface‐to‐facemeetings)wasperformed.Thepanel‐ ists’accountswereinterpreted,organized,andsynthesizedintotwomainthemes(posi‐ tivefeaturesandusagehinders)withoutpursuingadetailedqualitativeanalyticalap‐ proach. 3.Results 3.1.LiteratureReview Theliteraturereviewprocess(Figure2)retrieved24PATs(SupplementaryTableS1). Thesewereorganizedintodifferentpracticeareas,namely:i)anticholinergicandsedative medicinesusage:ARS[30]andDBI[31];ii)hemorrhagicrisk:ATRIA[32],CHA2DS2VASc [33],HAS‐BLED[34]andHEMORR2HAGES[35];iii)antibioticsusage:Loeb[36];iv)med‐ icationcomplexity:MRCI[37,38]andMrs.GRACE[39];v)comprehensiveimplicitassess‐ mentofprescribing:MAI[40]andPAI[41];vi)comprehensive,explicitassessmentofpre‐ scribing:Beers’criteria[42];NORGEP[43];STOPP/START[44];FORTA[45,46];Winit‐Wat‐ jana’scriteria[47];Rancourt’scriteria[48];Poudel’scriteria[49];McLeod’scriteria[50]; Laroche’scriteria[51];AustralianPrescribingIndicatorsTool[52]vii)medicinesusagein dementia:APID[53],Holmes’criteria[54]andKroger’scriteria[55]. Figure2.FlowchartofliteraturereviewandPrescribing‐AssessmentToolsidentification. 3.2.Panellists’Characteristics Participants’characteristicsaredescribedinTable1.Participantsenrolledincluded pharmacistsworkinginLong‐TermCareFacilities(LTCFs)orhospitalsfromfourRe‐ gionalHealthAuthorities(RHAs)catchmentareas(outof5RAHsinmainlandPortugal). Threemeetingswiththreepanelistseachwereorganized.Theface‐to‐facepanels wereformedbyparticipants1,2,3(panel1–LTCpharmacists),4,5,6(panel2–LTCphar‐ macists),10,11,13(panel3–Hospitalpharmacists),i.e.,adropoutrateof30%wasverified (participants7,8and9).
Pharmacy2021,9,1946of15 3.3.RAMRounds,Face‐to‐FaceMeetingsandFinalConsensus For14PATs,consensuswasreachedinallcomponents,i.e.,overallgrouprating (withDI≤1)wasalignedwiththethreepanelsratings.Forinstance,inthecaseofATRIA, thesecond‐roundratingwas7(A)–withaDIof0.164–andpanels’1,2,and3ratingswere A;thus,thefinalconsensuswassetasAf(Appropriate).For10PATs,onepanelrating wasnotalignedwiththerestoftheratings.Forinstance,inthecaseofDBI,theoverall group’sratingwasC(Inappropriate)withaDIof0.438;panels’1and2ratingswereC, whilepanel’s3ratingwasB;thus,thefinaldecisionwasCf(Inappropriate).ForallPATs, DIatthesecondroundwaslowerthan1.Ifthisrulecouldnotbefollowed,aPATwas ratedforUncertain(Bf)usefulnessinLTCpharmacypractice.Resultsaresummarizedin Table2. Table2.Prescribing‐AssessmentToolsratings,representativequotationsandfinalconsensus. Prescribing‐ Assessment Tool Round1 MedianRating (13 Participants); Disagreement Index Round2 Median Rating (13 Participants) ; Disagreeme ntIndex Face‐to‐FacePanels Appropriate(A), Uncertain(B)orIn‐ appropriate(C) RepresentativeQuotations Appropriate(Af), Uncertain(Bf)or Inappropriate (Cf)forLTC Pharmacy Practice Panel 1 Panel 2 Panel 3 ARS7;0.3747;0.164AAB “Itcontainsmanydrugswithanticholinergicpotential,butin practice,thereisnotmuchalternative.Wecaneventellthephysician thatthesedrugscancauseanAdverseDrugEvent(ADE),butwhat isthealternative?Intheory,itisimportant,butinpractice,notso much”P11 “Ifinditveryusefulbecausemostpatientstakethismedication”P7 “CanbeusefultominimizecommonADEs(e.g.,fallsintheelderly)” P13 Af DBI3;0.7482;0.438CCB “isinappropriategivenmycontext“P4 “Ifinditinteresting,butinpracticalterms,itdoesnotmaterialise intosomethingIcanuse”P10 “Ifinditinterestingbecauseittakesintoaccountthedailydoseand defineddailydoseandallowsforbetterchoicesofdosagesand promotionofnon‐pharmacologicalstrategies;focusesonmedicines widelyusedinouragedpopulation”P13 Cf ATRIA6;0.5197;0.164AAA “Atthelevelofdailyprofessionalpractice,thescaleissimpletouse, allclinicalcriteriaareeasilyaccessed,unlikeothersimilarscalesin whichpersonalhistoryorotherdiagnosesarenotalwaysspecifiedin thehospitaldischargenote”P5 “Verypracticalandstraightforward,theexistenceofa“score”,thatis, “aquantifiablevalue”,makesitmucheasiertoarguewiththe physicians,whenoneintendstomakemedicationreconciliation,for instance,”P12 Af CHA2DS2VA Sc6;0.5196;0.519BBA “Easy‐to‐applyalgorithminmydailypractice”P6 “Thisscalemaybemoredifficulttouse,oncewedonotalwayshave accesstothepersonalbackgroundofpatients”P5 Bf HAS‐BLED6;0.5197;0.217AAA“Comprehensive,useful,verysystematized”P4Af HEMORR2H AGES5;0.9685;0.519BBB “itmaybeimportantbecauseitincludestheCYP2C9polymorphisms, althoughthisinformationisrarelyavailable”P13 “Presentspertinentparameterssuchasgeneticpolymorphismsand alcoholabuse”P7 “Ifinditausefulalgorithm,butitrequiresdatathatisnotalways accessibleinmydailyprofessionalpractice”P6 Bf Loebcriteria6;1.046;0.652AAC “IconsideranalgorithmveryadaptedtotheLTCrealityinorderto assesstheprescriptionofantibioticsforthemostcommoninfections” P5 “Itaddressesthethreemaintypesofinfectionthatwefacedailyand allowsyoutoscreentheappropriatenessofantibioticprescriptionina veryquickandsimpleway”P1 Bf
Pharmacy2021,9,1947of15 Prescribing‐ Assessment Tool Round1 MedianRating (13 Participants); Disagreement Index Round2 Median Rating (13 Participants) ; Disagreeme ntIndex Face‐to‐FacePanels Appropriate(A), Uncertain(B)orIn‐ appropriate(C) RepresentativeQuotations Appropriate(Af), Uncertain(Bf)or Inappropriate (Cf)forLTC Pharmacy Practice Panel 1 Panel 2 Panel 3 “Notusefulinapracticalcontext,sinceclinicalconditionsaremuch morecomplexthanthealgorithmreflects”P12 MRCI5;1.705;0.702BBB “Althoughtimeconsuming,veryinteresting”P2 “Itisnotfeasibleforaregularuseduetoitslength”P9 “Canbeusefulinthepost‐dischargemoment;however,itisnot practical”P5 “Itwouldbeveryusefulinmyprofessionalpractice,sincereducing thecomplexityoftheregimenswillreducepotentialmedicationerrors, increaseadherenceandreducecosts”P6 Bf Mrs.Grace5;0.9975;0.997BBB “Completeandwithobjectiveinstructionsforaction”P10 “Veryinteresting;however,Ibelieveitsimplementationishindered duetothelimitedhumanresourcesavailableinLTC”P4 “Ifinditveryusefultouseitintheplanneddischargesasawayto adaptthetherapeuticregimensindividuallytothepatientand caregiversandasawaytopromoteadherencetothetherapeutic regimen”P3 “thealgorithmhaslittlepracticalapplicationsinceduringpatient stayingitisnotalwayspossibleto“simplify”therapyduetohavinga pre‐defineddrugformulary”P5 Bf MAI7;0.2198;0.219ABA “Veryadaptedtopharmacists.Ifinditparticularlyusefulforsome patientsandnotforeveryone.Itallowsourparticipationin multidisciplinarymeetingstobecomemoreuseful.Itcanbeimportant indeprescribingactivities”P1 “Ifindthisalgorithmveryusefulandeasytoquery.However,itis verytime‐consumingasitisnecessarytorevieweachdrugatten differentpointsforeachpatient”P6 “Interestingfortherapeuticreconciliation,althoughtheseaspectsare alreadytakenintoaccount.Itcanservemoreasaguidethanforusein practice”P4 Af PAI5;0.0005;0.000BCB “Therearemanyquestionsthatwealreadyaskindailypractice”P5 “Ifinditveryeasytouse,clear,simple;Ithinkitcouldbea complementtoMAI”P10 Bf Australian Prescribing Indicators Tool 3;0.5613;0.519CCB “Time‐consuming,anditsusemaynotalwaysbefeasible.Contains veryusefulinformationformytechnical‐scientificdevelopment”P13 “ItisatoolengthyPAT”P9 “IconsiderthisPATimpracticaltoconsultduetoitsorganizationby statementsandnotbymedications,physiologicalsystemsor therapeuticclasses”P6 Cf Beerscriteria7;0.2927;0.292AAA “QuiteadequatetotherealityofLTC.Althoughitisthebestknown amonghealthprofessionalsandthisimpliesthattheprescriptionsare verymuchinlinewiththiscriterion,Ibelieveitsuseisfundamental” P1 “Veryuseful,justmissingthesuggestionofalternative”P4 Af FORTA7;0.0007;0.09AAA “Goodinstrumentformedicationreviewintheelderlyandbasedona diagnosis.Facilitatorofdoctor‐pharmacistandnurse‐pharmacist interactions”P13 “Veryorganizedandquickandeasytoconsult”P2 Af Laroche criteria7;0.0007;0.000AAA “Veryusefulandeasytoapplyinmydailyprofessionalpractice.Its mainadvantageisthefactthatitpresentsthereasonsfornon‐ suitabilityandwhatarethesafestalternatives”P6 “Ithasagoodcompromisebetweenextension,reasonsand alternatives”P3 Af McLeod criteria6;0.2176;0.217ABB“IappreciatethisPATbecauseitoffersalternatives,theriskassociated toPIMsandthestatisticsabouttheconsensus”P9Bf
Pharmacy2021,9,1948of15 Prescribing‐ Assessment Tool Round1 MedianRating (13 Participants); Disagreement Index Round2 Median Rating (13 Participants) ; Disagreeme ntIndex Face‐to‐FacePanels Appropriate(A), Uncertain(B)orIn‐ appropriate(C) RepresentativeQuotations Appropriate(Af), Uncertain(Bf)or Inappropriate (Cf)forLTC Pharmacy Practice Panel 1 Panel 2 Panel 3 “Itisorganizedbyincorrectpracticeandnotbymedication;itisnot sodirect,itislesspractical”P10 “Itcanbedifficulttoconsult,butitisusefultosuggesttherapeutic alternativestoprescribers”P2 NORGEP3;0.6523;0.652CCC“Itdidn’tseemveryusefultomeduetoitssparsecoverage”P4 “Littleinformationcomparedtoothercriteria”P11Cf Poudel criteria8;0.2928;0.292AAA “ThisPATisveryinterestingbecauseithasindicationsfor withdrawalregimens,inadditiontotherapeuticalternatives”P2 “ItcomplementstheBeerscriteriabypresentingsuggestionsofdrug tapering.Moreover,itpresentstherapeuticalternatives,similarto Laroche’scriteria”P12 Af Rancourt criteria5;0.8515;0.851BBB “Ifinditinterestingintermsofposology–durationoftreatmentand dosage–asawaytosensitizethedoctor”P13 “Itisnotveryinteresting,asitdidnotsuggestalternativesorgive guidance,comparedtootherPATs”P4 “Itisnottotallyincompletebecauseitconsidersinteractionsand dosages”P6 Bf STOPP/STAR T7;0.1647;0.164AAA “Easytoconsultsinceitisorganizedbyphysiologicalsystems.Italso hastheadvantageofallowingtheidentificationofpotential prescribingomissions”P6 “Completeandwithclearindicationsofactions”P10 Af Winit‐ Watjana criteria 5;0.9684;0.519BBC “Itsummarizesthemostsignificantinteractionsandadverse reactions,beingusefulforaconsultation”P5 “Nowadayslistinginteractionsdoesn’tmakemuchsensebecausewe havesearchenginesforinteractions”P10 “Doesnotproposealternatives.JustmentionMPIsandsome interactions”P13 Bf APID5;0.9685;0.968BBB “Weoftendonothavedataonadmissionaboutthepatienttoanswer thesequestions”P6 “Itshouldincludesituationsofexacerbation(e.g.,delirium)”P12 Bf Holmes criteria5;0.8515;0.851BBB“Informativeanduser‐friendly”P10 “Verylittleinformation[...]dependsoneachcase”P4Bf Kroger criteria6;0.5196;0.376BBA “ItisanadequatePATbecauseitofferssomejustificationand rationalefortheuseofmedication”P9 “Moreinterestingfortechnicaldevelopmentthanforpractical application”P4 Bf 3.4.RelevantCharacteristicsofPATs Severalcharacteristicsofinterestemergedfromcommentsandface‐to‐facemeetings qualitativeanalysis(Table3). Table3.Prescribing‐AssessmentTools’usefulcharacteristicsandrepresentativequotations. Prescribing‐AssessmentTools’ UsefulCharacteristicRepresentativeQuotations Levelsofevidence [FORTA]becauseitisorganizedbylevelofevidence(P7) [...]havingtheadvantageofpresentingthelevelofevidence(P8,onBeers’) Doseanddurationoftreatment Iconsideritaverycompleteandvaluablecriterionasitconsidersfactorssuchasdoseand durationoftreatment(P8onRancourt’s) Ifinditveryinterestingbecauseitconsidersdailydoseandallowstochoosebetterposology (P13,onDBI’s)
Pharmacy2021,9,1949of15 Prescribing‐AssessmentTools’ UsefulCharacteristicRepresentativeQuotations Usefulbecauseitgivesamaximumofdays,andmanytimesphysicianswanttouse antibioticsmoredaysthanthosepreconized(P3,onLoeb’s) Scoringsystem […]a“score”,i.e.,aquantifiablevalue,greatlyfacilitatesdiscussionwithphysicianswhen deliveringtherapeuticreconciliation,forexample(P12,onATRIA’s) ReasonsforPIMclassification ContainsveryusefulinformationsuchasreasonsforPIMclassification(P13,on Laroche’s) Presentsthereasonswhythemedicineispotentiallyinappropriate(P8,onBeers’) InclusionofalternativestoPIMs Veryuseful,onlythesuggestionofalternativesismissing(P4,onBeers’) suggeststherapeuticalternatives(P1,onLaroche’s) ItisahelpfulPATbecauseitsuggeststherapeuticalalternatives(P9,onLaroche’s) [...]suggeststherapeuticalalternative[...](P5,onMcLeod’s) [...]itofferstherapeuticalalternatives[...](P9,onMcLeod’s) [...]presentstherapeuticalalternatives,similarlytoLaroche’s(P12,onPoudel’s) Itdoesnotsuggestalternatives;justmentionPIMsandinteractions(P13,onWinit‐ Watjana’s) [...]ahelpfulPATshouldincludetherapeuticalalternatives(P3,McLeod) Containsvaluableinformationsuchasalternativemedicines(P13,onLaroche’s) Itsuggeststherapeuticalalternatives(P13,onPoudel’s) Itdoesnothavealternatives;Iconsiderita“lowerversion”(P12,onWinit‐Watjana’s) Organisedbymedicinesgroups Iconsiderthiscriterionmorecomplextoconsultbecauseitisorganizedbyinappropriate practiceandnotbymedicine,therapeuticindication,orphysiologicalsystem(P8,on McLeod’s) Ipreferatoolthatevaluatesbypharmacotherapeuticgroupandnotsomuchbypathology becausewhenI’mevaluatingaprescription,Ievaluatemedicinebymedicineand,ifa questionarises,itwillhelpmetohaveaPATbythepharmacotherapeuticgrouptoconsult andpreferably,withalternativesincaseyoufindsomethingwrong(P10) APATorganizedbypharmacotherapeuticgroupshelpsmore;itmakesitsimpler(P13) Itseemedtobethemostorganizedasitisdividedintotherapeuticgroups(P3,on McLeod’s) Easytoconsultasitisorganizedbytherapeuticgroups(P2,onPoudel’s) Inclusionofriskassociatedwith PIM IfindthisPATinterestingbecauseitmentionstherisktothepatient(P5,onMcLeod’s) Itincludestherisktothepatient[…](P9,onMcLeod’s) Ithastheriskassociatedwiththepatient(P3,McLeod’s) Organisedbydisease/syndromeIpreferadisease‐orientedPAT(P11) ItincludesthemostprevalentdiseasesontheLTCnationalnetwork(P1,onFORTA’s) ConsensusonPIM/alternative ItincludesthepanelagreementonthePIMalternative(P5,onMcLeod’s) Itincludesstatisticsabouttheconsensusontheuseofaparticularmedicine(P9,on McLeod’s) Withdrawalregimens IthasindicationsonhowtowithdrawthePIM,beingadifferentiatingfactorfromtheother PATs(P5,onPoudel’s) Inaway,itcomplementstheBeers’criteria,asitsuggestswithdrawalregimens(P12,on Poudel’s) Itsuggestswithdrawalregimens(P13,onPoudel’s) FourmaingroupsofpotentialdeterminantshinderingtheuseofPATshavealsobeen identifiedthroughqualitativeanalysis(Table4). Table4.PotentialdeterminantshinderingPrescribing‐AssessmentTooluse. PotentialPATsUseHindersRepresentativeQuotations