PRISMA-symposium, 25 mei 2023

A.T.M. Wasylewicz *, B.W.M. van de Burgt, T. Manten, M. Kerskes, W.N. Compagner, H.H.M. Korsten, A.C.G. Egberts and R.J.E. Grouls

* Correspondence: a.wasylewicz@gmail.com.

Background
Drug-drug interactions (DDIs) frequently trigger adverse drug events or reduced efficacy. Most DDI alerts, however, are overridden because of irrelevance for the specific patient. Basic DDI clinical decision support (CDS) systems offer limited possibilities for decreasing the number of irrelevant DDI alerts without missing relevant ones.

Objective
To design computerized decision tree rules to context dependently suppress irrelevant DDI alerts.

Methods
A crossover study was performed to compare the clinical utility of contextualized and basic DDI management in hospitalized patients. First, a basic DDI-CDS system was used in clinical practice while contextualized DDI alerts were collected in the background. Next, this process was reversed. All medication orders (MOs) from hospitalized patients with at least one DDI alert were included. The following outcome measures were used to assess clinical utility: positive predictive value (PPV), negative predictive value (NPV), number of pharmacy interventions (PIs)/1,000 MOs and the median time spent on DDI management/1,000 MOs.

Results
During the basic DDI management phase 1,919 MO/day were included, triggering 220 DDI alerts/1,000 MOs; showing 57 basic DDI alert/1,000 MOs to pharmacy staff; PPV was 2.8% with 1.6 PIs/1,000 MOs costing 37.2 min/1,000 MOs. No DDIs were missed by the contextualized CDS system (NPV 100%).
During the contextualized DDI management phase 1,853 MO/day were included, triggering 244 basic DDI alerts/1,000 MOs, showing 9.6 contextualized DDIs/1,000 MOs to pharmacy staff; PPV was 41.4% (P < 0.01) with 4.0 PIs/1,000 MOs (P < 0.01) and 13.7 min/1,000 MOs.

Conclusion
The clinical utility of contextualized DDI management exceeds that of basic DDI management.

Dit abstract is ook gepubliceerd in:
• Wasylewicz ATM, van de Burgt BWM, Manten T, Kerskes M, Compagner WN, Korsten EHM, Egberts TCG, Grouls RJE. Contextualized Drug-Drug Interaction Management Improves Clinical Utility Compared With Basic Drug-Drug Interaction Management in Hospitalized Patients. Clin Pharmacol Ther. 2022 Aug;112(2):382-390. doi: 10.1002/cpt.2624.

Frederique Claessens *, Milou Scholten, Samah Bouarfa, Pierre Bet, Wilma Göttgens and Jacqueline Hugtenburg

* Correspondence: frederique-claessens@hotmail.com.

Background
Discontinuation of antidepressants involves risks for patients such as experiencing withdrawal symptoms or relapse of depression. Therefore, patients should receive proper guidance and education from healthcare providers (HCPs) in this process.

Objective
To assess patients’ experiences with and perspectives on the discontinuation of antidepressants.

Methods
Fifteen semi-structured, in-depth interviews were conducted with patients who use or have used antidepressants for at least six months. These patients were selected from pharmacies in Amstelveen and Nijmegen. The interviews were audiotaped, transcribed verbatim, coded openly with MAXQDA, and thematically analysed.

Results
Patients perceive a lack of initiative, time, and knowledge from HCPs. Perceptions, expectations, and relations influenced the decision-making regarding the discontinuation process. The participants believed HCPs, both general practitioners, psychiatrists, and pharmacists should have a more proactive role in taking the initiative to start a conversation about discontinuing antidepressants. The possibility to reach out to their HCP during discontinuation was also indicated as highly important by many participants.

Conclusion
The needs of patients for support during the process of discontinuation of antidepressants are not fully met yet. Patient education and support should take experiences, expectations, and perceptions into account, and require patient involvement and good collaboration between HCPs. Practical guidance including tools to counsel and support patients during the discontinuation of antidepressants should be developed.

Eline Poulussen *, Lisse Commandeur and Sander Borgsteede

* Correspondence: eline.poulus@live.nl.

Background
About half of the population has problems with understanding instructions on prescription drug labels (PDLs), resulting in unintentional nonadherence and adverse events. So far, the opinions of patients about the amount and type of information they desire on PDLs is unknown. As patients need PDLs for proper use of their medication, their opinions should be taken into account when adjusting the PDLs and making them more suitable to the patients’ needs.

Objective
To explore the perspective of patients in pharmacies on the type and right amount of information on PDLs.

Methods
Qualitative, semi-structured patient interviews (n = 26) were conducted in four community pharmacies until data saturation was reached. The transcripts were coded and an inductive and deductive qualitative analysis was performed.

Results
No relation between patient characteristics and content-related aspects was found. The optimal PDL contained four lines of information about the medication. Information on PDLs should include the usage instructions and directions about combining medicines with food and drinks. Auxiliary warnings about the use of alcohol and driving should be included when they are applicable to the patient. Other, more detailed information may better be explained verbally and written in the package leaflet.

Conclusion
Patients prefer specific information on PDL concerning drug use and information about how to combine medication with food and drinks, and concise information concerning auxiliary instructions. Using the PDL as a supporting aid when verbally explaining the instructions can help patients to understand the information better.

Lisa E.M. Davies *, Elsemiek A.W. Jansen-Groot Koerkamp, Ellen S. Koster, Arnt F.A. Schellekens, Mette Heringa en Marcel L. Bouvy

* Correspondentie: l.e.m.davies@uu.nl.

Achtergrond
In Nederland is het aantal gebruikers van opioïden op recept tussen 2008 en 2022 verdubbeld. Het gebruik van opioïden voor niet-maligne pijn in de eerste lijn komt veelvuldig voor, ondanks de bekende risico’s.

Doel
Om onnodig langdurig gebruik van opioïden te voorkomen, is het belangrijk om te begrijpen waarom patiënten langdurig
opioïden gebruiken en wat de rol van de zorgverlener hierin is. Zo kunnen we de zorg voor opioïdengebruikers in de toekomst
verbeteren.

Methode
Via 7 openbare apotheken werden 25 chronische pijnpatiënten geworven die langdurig opioïden gebruikten. Met deze patiënten werden diepgaande, semigestructureerde interviews per telefoon- of videogesprek gehouden. Transcripten werden geanalyseerd middels NVivo (versie 12), aan de hand van een directed content analysis.

Resultaten
Drie thema’s werden geïdentificeerd: (1) de rol van de zorgverlener bij de start van de opioïdenbehandeling, (2) de rol van de zorgverlener tijdens langdurige behandeling en (3) de rol van de zorgverlener bij het afbouwen van opioïden. Belangrijke aandachtspunten die patiënten aangaven waren: een gebrek aan risico-educatie tijdens de eerste voorschrijfgesprekken, gemakkelijke toegang tot opioïden, gebrek aan medicatie-evaluatie en het belang van afbouwgesprekken.

Conclusie
De resultaten bieden mogelijke verbeteringen voor de richtlijnen voor veilig en effectief gebruik van opioïden. Daarnaast benadrukt het de noodzaak om zorgverleners op te leiden in het bieden van passende begeleiding en informatie over opioïden aan patiënten, zoals het voeren van gesprekken over de risico’s van gebruik, de duur van gebruik, het doen van regelmatige medicatie-evaluaties, en het bespreken en opstellen van een afbouwplan.

Renate van Uden *, Barzo Sulaiman, Patricia Pols, Karina Meijer, Patricia van den Bemt en Matthijs Becker

* Correspondentie: ruden@sahz.nl.

Achtergrond
Meervoudige antistolling wordt in principe niet oneindig lang gebruikt. Verschillende studies hebben aangetoond dat patiënten meervoudige antistolling te lang gebruiken en hierdoor hebben patiënten een onnodig hoog bloedingsrisico. Openbare apotheken ontvangen in het algemeen onvoldoende informatie over de indicatie en beoogde gebruiksduur van meervoudige antistolling.

Doel
Bepalen of met een antitrombotische patiëntenvragenlijst patiënten kunnen worden geïdentificeerd met mogelijk incorrecte meervoudige antistolling.

Methode
In 8 openbare apotheken zijn gestandaardiseerde vragenlijsten afgenomen bij patiënten die meervoudige antistolling gebruiken. De vragenlijst omvatte vragen over de indicatie en startdatum van de antistolling. De apotheker beoordeelde of de meervoudige antistolling correct was, op basis van de ingevulde vragenlijst en op basis van het medisch dossier. De primaire uitkomstmaat was de sensitiviteit en de specificiteit van de vragenlijst om patiënten met mogelijk incorrecte meervoudige antistolling te identificeren.

Resultaten
Van de 108 geïncludeerde patiënten beantwoordden 95 patiënten de vragen over indicatie en startdatum. Indien ze de vragen konden beantwoordden, was dit in 98% van de gevallen correct. De apotheker beoordeelde op basis van de vragenlijst dat bij 14 van de 95 patiënten (15%) de meervoudige antistolling mogelijk niet correct was. Op basis van het medisch dossier was bij 9 van deze 14 patiënten de meervoudige antistolling niet correct. Bij de overige patiënten was deze wel correct en werd bewust langdurig de meervoudige antistolling gecontinueerd. De sensitiviteit van de vragenlijst was 100% en de specificiteit 94%.

Conclusie
De vragenlijst is een goed instrument om patiënten met potentieel niet correcte meervoudige antistolling te identificeren.

M. van Geel, T. Leenders, A. Keyany, D. Arnoldussen, T. van Asseldonk, S. Saini and B. Maat *

* Correspondence: b.maat@etz.nl.

Background
Patients’ anticholinergic burden is the cumulative effect of anticholinergic medication and is associated with increased morbidity. Hospitalisation may increase anticholinergic burden. Pharmacotherapeutic interventions supported by electronic clinical decision support (eCDS) may have the potential to prevent this.

Objective
To investigate whether eCDS-based pharmacotherapeutic interventions could reduce anticholinergic burden, expressed as score on the Anticholinergic Burden Scale (ACB score), in older hospitalised patients.

Methods
Prospective intervention study in April/May 2022. eCDS was used to detect patients aged ≥ 65 years with an ACB score ≥ 8. Patients were included if anticholinergic medication was reviewed for potential interventions. An intervention consisted of a pharmacist-led advice to the patient’s attending physician. Primary outcome: proportion of patients whose anticholinergic burden was reduced. Secondary outcomes: (1) physicians’ acceptance rate and (2) nature and frequency of anticholinergic side effects.

Results
43 patients were included (44.2% female; mean age 78.2 [± 7.0] years). Their anticholinergic medication was reviewed which led to 43 interventions for 23 patients (53.5%): 7 suggestions for dose reduction (16.3%), 4 for alternative medication (9.3%) and 32 for discontinuation (74.4%). 28 of the 43 interventions were directly accepted by the attending physician (acceptance rate 65.1%) leading to an average ACB score reduction of 1.46 points (± 0.79) per intervention. 33 of the 43 reviewed patients (76.7%) experienced ≥ 1 anticholinergic side effects. Constipation occurred most often (44.2%).

Conclusion
Anticholinergic burden was reduced through eCDS-based pharmacotherapeutic interventions in almost half of reviewed patients and acceptance by physicians was high, indicating a promising potential for this initiative in clinical practice.

Laura Schackmann *, Ellen S. Koster, Liset van Dijk, Marcia Vervloet and Mette Heringa

* Correspondence: L.Schackmann@nivel.nl.

Background
Non-medical medication switches can lead to difficult conversations. To support pharmacy staff, a communication training
has been developed based on two strategies: (1) ‘positive message framing’ to emphasize positive elements of the message
and (2) ‘breaking bad news model’ to break the news immediately and address emotions.

Objective
To assess how patients and trained pharmacy staff experience the application of communication strategies for non-medical
medication switch conversations and which are barriers and facilitators for the application.

Methods
The Kirkpatrick training evaluation model (level 3 [‘behaviour’, including barriers and facilitators] and 4 [‘results’]) was used.
Trained pharmacy staff registered conversation characteristics and asked patients to fill in a questionnaire. Semi-structured
interviews with trained participants were conducted. Quantitative data were analysed using descriptive statistics and interview
data was analysed thematically.

Results
Of the 39 trained participants, 21 registered characteristics of 71 conversations, 31 patients filled in questionnaires, and
13 trained participants were interviewed. Level 3: participants self-reported they applied (aspects of) the strategies, though
indicated this was not (yet) a standard process. Interviewees indicated signs of increased patient contact and job satisfaction.
Time, face-to-face conversations, colleague support, and patient cooperation were facilitators. Level 4: participants
were satisfied with most conversations (89%) post-training, particularly with addressing emotions (74%). Patients were
(very) positive (77%) about the communication, particularly about clear explanations about the switch.

Conclusion
Pharmacy staff’s learned behaviour includes being able to apply aspects of the strategies. The training results show first
signs of better patient-pharmacy staff relationships and increased job satisfaction.