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BackgroundInappropriate prescribing is frequent in older adults and associated with adverse outcomes. Prescribing indications aim to optimize prescribing, but little is known about the focus and features of prescribing indications for the most common chronic conditions in older adults. Understanding the conditions, medications, and issues addressed (e.g., patient perspective, drug-disease interaction, adverse drug event) in current prescribing indications may help to identify missing indications and develop standardized measures to improve prescribing quality.MethodsWe searched Ovid/MEDLINE and EMBASE for articles published between 2015 and 2020 reporting prescribing indications for older adults. Prescribing indication included 1) prescribing "criteria," or statements that guide prescribing action, and 2) prescribing "measures," or prescribing actions observed in a population. We categorized their focus by conditions, medications and issues addressed, as well as level of evidence provided.ResultsAmong 16 sets of prescribing indications, we identified 748 criteria and 47 measures. The most common addressed medications were antihypertensives, analgesics/antirheumatics, and antiplatelets/anticoagulants. The most frequently addressed issues were drug-disease interaction, adverse drug event, administration, better therapeutic alternative, and (co-)prescription omission (20.8-36.1%). Age/functioning, drug-drug interaction, monitoring, and efficacy/safety ratio were found in only 9.9-16.5% of indications. Indications rarely focused on the patient perspective or issues with multiple providers.ConclusionMost prescribing indications for chronic conditions in older patients are criteria rather than measures. Indications accounting for patient perspective and multiple providers are limited. The gaps identified in this review may help improve the development of prescribing measures for older adults and ultimately improve quality of care.

Background Inappropriate diagnosis of infections results in antibiotic overuse and may delay diagnosis of underlying conditions. Here we describe the development and characteristics of 2 safety measures of inappropriate diagnosis of urinary tract infection (UTI) and community-acquired pneumonia (CAP), the most common inpatient infections on general medicine services. Methods Measures were developed from guidelines and literature and adapted based on data from patients hospitalized with UTI and CAP in 49 Michigan hospitals and feedback from end-users, a technical expert panel (TEP), and a patient focus group. Each measure was assessed for reliability, validity, feasibility, and usability. Results Two measures, now endorsed by the National Quality Forum (NQF), were developed. Measure reliability (derived from 24 483 patients) was excellent (0.90 for UTI; 0.91 for CAP). Both measures had strong validity demonstrated through (a) face validity by hospital users, the TEPs, and patient focus group, (b) implicit case review (ĸ 0.72 for UTI; ĸ 0.72 for CAP), and (c) rare case misclassification (4% for UTI; 0% for CAP) due to data errors (<2% for UTI; 6.3% for CAP). Measure implementation through hospital peer comparison in Michigan hospitals (2017 to 2020) demonstrated significant decreases in inappropriate diagnosis of UTI and CAP (37% and 32%, respectively, P <.001), supporting usability. Conclusions We developed highly reliable, valid, and usable measures of inappropriate diagnosis of UTI and CAP for hospitalized patients. Hospitals seeking to improve diagnostic safety, antibiotic use, and patient care should consider using these measures to reduce inappropriate diagnosis of CAP and UTI. [ABSTRACT FROM AUTHOR]

BackgroundOvertreatment and overtesting expose patients to unnecessary, wasteful, and potentially harmful care. Reducing overtreatment or overtesting that has become ingrained in current clinical practices and is being delivered on a routine basis will require solutions that incorporate a deep understanding of multiple perspectives, particularly those on the front lines of clinical care: patients and their clinicians. Design approaches are a promising and innovative way to incorporate stakeholder needs, desires, and challenges to develop solutions to complex problems. ObjectiveThis study aimed (1) to engage patients in a design process to develop high-level deintensification strategies for primary care (ie, strategies for scaling back or stopping routine medical services that more recent evidence reveals are not beneficial) and (2) to engage both patients and primary care providers in further co-design to develop and refine the broad deintensification strategies identified in phase 1. MethodsWe engaged stakeholders in design charrettes—intensive workshops in which key stakeholders are brought together to develop creative solutions to a specific problem—focused on deintensification of routine overuse in primary care. We conducted the study in 2 phases: a 6.5-hour design charrette with 2 different groups of patients (phase 1) and a subsequent 4-hour charrette with clinicians and a subgroup of phase 1 patients (phase 2). Both phases included surveys and educational presentations related to deintensification. Phase 1 involved several design activities (mind mapping, business origami, and empathy mapping) to help patients gain a deeper understanding of the individuals involved in deintensification. Following that, we asked participants to review hypothetical scenarios where patients, clinicians, or the broader health system context posed a barrier to deintensification and then to brainstorm solutions. The deintensification themes identified in phase 1 were used to guide phase 2. This second phase primarily involved 1 design activity (WhoDo). In this activity, patients and clinicians worked together to develop concrete actions that specific stakeholders could take to support deintensification efforts. This activity included identifying barriers to the actions and approaches to overcoming those barriers. ResultsA total of 35 patients participated in phase 1, and 9 patients and 7 clinicians participated in phase 2. The analysis of the deintensification strategies and survey data is currently underway. The results are expected to be submitted for publication in early 2020. ConclusionsHealth care interventions are frequently developed without input from the people who are most affected. The exclusion of these stakeholders in the design process often influences and limits the impact of the intervention. This study employed design charrettes, guided by a flexible user-centered design model, to bring clinicians and patients with differing backgrounds and with different expectations together to cocreate real-world solutions to the complex issue of deintensifying medical services. International Registered Report Identifier (IRRID)RR1-10.2196/15618