Search

Background: Knowing the barriers/enablers to deprescribing in people with a life-limiting disease is crucial for the development of successful deprescribing interventions. These barriers/enablers have been studied, but the available evidence has not been summarized in a systematic review. Aim: To identify the barriers/enablers to deprescribing of medications in people with a life-limiting disease. Design: Systematic review, registered in PROSPERO (CRD42017073693). Data sources: A systematic search of MEDLINE, Embase, Web of Science and CENTRAL was conducted and extended with a hand search. Peer-reviewed, primary studies reporting on barriers/enablers to deprescribing in the context of explicit life-limiting disease were included in this review. Results: A total of 1026 references were checked. Five studies met the criteria and were included in this review. Three types of barriers/enablers were found: organizational, professional and patient (family)-related barriers/enablers. The most prominent enablers were organizational support (e.g. for standardized medication review), involvement of multidisciplinary teams in medication review and the perception of the importance of coming to a joint decision regarding deprescribing, which highlighted the need for interdisciplinary collaboration and involving the patient and his family in the decision-making process. The most important barriers were shortages in staff and the perceived difficulty or resistance of the nursing home resident's family – or the resident himself. Conclusion and implications of key findings: The scarcity of findings in the literature highlights the importance of filling this gap. Further research should focus on deepening the knowledge on these barriers/enablers in order to develop sustainable multifaceted deprescribing interventions in palliative care. [ABSTRACT FROM AUTHOR]

Background: There is currently no system that aligns pharmaceutically equivalent medicinal products across nations, creating obstacles to transnational medication prescribing and medical research. EDQM has been internationally recognized as the leading system in systematic pharmaceutical product descriptions. RxNorm is a critical terminology based in the US and used widely in applications internationally that would benefit from alignment with EDQM-based dosage form descriptions.Goal: Demonstrate a method for alignment of RxNorm dosage forms with EDQM terminologies and with EDQM dosage forms. Describe obstacles and advantages of such an alignment for ultimate application in calculating universal Pharmaceutical Product Identifiers.Methods: A pharmaceutical sciences student and a clinical pharmacology expert in dosage forms used definitions supplied by RxNorm and EDQM technical documentation to align the 120 RxNorm dose forms to EDQM-based dosage form description terms. The alignment of RxNorm to EDQM was then used to fit the RxNorm dose forms into an ontology based on EDQM.Results and Conclusions: The alignment of RxNorm and EDQM requires further validation but provides a potential method of establishing interoperability between the two terminologies without cumbersome manual reclassification. There remain ambiguities within each dosage form nomenclature that create obstacles to integrating medication databases rooted in EDQM and RxNorm into a single worldwide database. [ABSTRACT FROM AUTHOR]

Objectives: Despite safety warnings on serious adverse effects and guidance advising discontinuation, antipsychotic use in nursing homes remains high. Studies documenting the barriers experienced to antipsychotic discontinuation are rare. This exploratory study investigates the willingness of nurses and general practitioners (GPs) as well as the barriers to undertake antipsychotic discontinuation. Design and setting: A mixed-method study involving an expert meeting, followed by a survey using structured questionnaires distributed to responsible nurses (primary caregivers) and treating GPs on selected nursing home residents in Belgian nursing homes to generate case-specific information. Results: Antipsychotic users (n = 113) had a mean age of 81 years (range 57–97); 62% were female and 81% had moderate to severe cognitive impairment. Nurses and GPs indicated a willingness for antipsychotic discontinuation in a small proportion of residents, 13.8% and 12.2%, respectively, with a shared willingness in only 4.2%. Residents for whom there was a higher willingness to try antipsychotic discontinuation were generally older (mean age 84.6 vs. 80.3, p = 0.07), had high physical dependency (ADL > 14, 93.3% vs. 60.9%, p = 0.01) and resided on a ward with controlled access (80.0% vs. 45.7%, p = 0.02). In contrast, residents for whom there was a significant lower willingness for discontinuation already had a previously failed discontinuation effort, and may present risk of harm to themselves or to others. Nurses working longer on the ward, with lower education, presented higher barriers to discontinuation of antipsychotics. Conclusion: Nurses and GPs share a very low willingness and high barriers to antipsychotic discontinuation. To implement discontinuation programs, complex multidisciplinary interventions should be offered taking existing barriers into account. [ABSTRACT FROM AUTHOR]

Objectives To develop a computerized assessment tool for monitoring the quality of prescribing in Belgian nursing homes. Design In a observational cross-sectional study of the medication charts of nursing home residents, potentially inappropriate medication (PIM) was investigated using three scoring systems for the elderly (Beers, ACOVE, BEDNURS) complemented with a list of drug–drug interactions. Setting A representative stratified sample of Belgian nursing homes (n = 76). Participants A random sample of nursing home residents with a complete data set (n = 1730) excluding palliative care patients. Main Outcome Measure A combination of PIM scores to assess inappropriate, under- and overprescribing. Results Included residents had a mean age of 85, 78% were female. They used a mean of 7.1 chronic medications. Most PIMs were detected by the application of the ACOVE criteria for underprescribing with 58% of patients having at least one PIM. Using the BEDNURS and the Beers criteria, at least one PIM was noticed in 56 and 27% of patients, respectively. Patients' characteristics showing a positive relationship with the PIM score were age, female gender, amount of clinical and nursing care problems, number of prescriptions and the use of psychotropic drugs (multiple regression analysis R2 = 0.332). Conclusions In Belgian nursing homes, the observed high level of drug utilization was associated with potentially inappropriate prescribing. The development of a combined assessment tool and the implementation of a computerized monitoring system of PIMs is highly recommended to improve the quality of prescribing. [ABSTRACT FROM AUTHOR]

Abstract: Changes in medical practices during transitions in regulating healthcare are rarely investigated. In this study, we investigated changes in medical end-of-life decisions with a possible or certain life-shortening effect (ELDs) that occurred during the legalization process of euthanasia in Belgium. We took representative random samples from deaths reported to registries in Flanders, Belgium in 1998 (n=3999) at the beginning of the process and in 2001 (N=5005), at the end of the process. The reporting physicians received an anonymous mail questionnaire about possible ELDs preceding the death involved. We found no significant shifts in the epidemiology of diseases between 1998 and 2001. The overall incidence of ELDs did not change. The incidence decreased for euthanasia, administering life-ending drugs without patient''s explicit request, and alleviation of pain and symptoms with life-shortening co-intention. Incidence increased for alleviation of pain and symptom without life-shortening intention, and remained stable for non-treatment decisions. All decisions in 2001 were more often discussed with patients, their relatives and nurses. In 2001, continuous deep sedation was reported in 8.3% of deaths. We can conclude that physicians’ end-of-life practices have substantially changed during the short but tumultuous legalization process of euthanasia in Belgium. Although follow-up research is needed to investigate the continuance of these changes, it is important for policy makers to keep in mind that social factors related to transitions in healthcare regulation may play an important role in the physicians’ actual behaviour. [Copyright &y& Elsevier]

Rationale In Belgium, several policies regulating reimbursement of acid suppressant drugs and evidence-based recommendations for clinical practice were issued in a short period of time, creating a unique opportunity to observe their effect on prescribing. Aims and objectives To describe the evolution of prescriptions for acid suppressants and explore the interaction of policies and practice recommendations with prescribing patterns. Method Monthly claims-based data for proton pump inhibitors (PPIs) and H2-antihistamines by general practitioners, internists and gastroenterologists were obtained from the Belgian national health insurance database (1997–2005). The evolution of reimbursed defined daily doses and expenses after introduction of reimbursement regulations and dissemination of practice recommendations was explored. Results Recommendations had no impact on prescribing. All changes can be related to concomitant policies. Lifting reimbursement restrictions for cheaper products did not control growth or save costs in the long term. Only restricting reimbursement of all PPIs managed to curb the growth. We observed an unintended increase of non-omeprazole PPIs by gastroenterologists. Conclusions Reimbursement policies influence prescribing, but their effect can be unintended. A dialogue between policymakers and guideline developers, and evidence-based policies that are linked to clinical guidelines, could be an effective way to pursue both cost-containment and quality of care. [ABSTRACT FROM AUTHOR]

Cultural differences are probably an important factor in the considerable variation in antibiotic use between countries. The objective of this study was to explore local cultural differences in the lay perspective on coping with URTD and using antibiotics. We interviewed 30 persons in a Dutch and a Belgian city. Twenty-one were interviewed a second time after 3 months. Between the first and second interview, they noted in a diary all URTD episodes experienced by themselves and their family members (N=69) and how they coped with them. The Dutch participants labelled most URTD episodes as “common cold” or “flu”. The Flemish participants labelled most of their URTD episodes as “bronchitis” and used more antibiotics. Four categories of antibiotic users could be distinguished. Participants with a Protestant background were more sceptical about medicines than those with a Catholic background. A thorough understanding of the cultural context is necessary to design effective campaigns to promote rational antibiotic use. [Copyright &y& Elsevier]

This study aims to assess the effect of the COVID-19 pandemic on the consumption of self-care products for pediculosis capitis management, in Portugal. A segmented regression analysis of interrupted time series (March 2020) was performed from January 2017 to August 2023 to analyze the short- and long-term impact of the COVID-19 pandemic on the consumption of pediculicides and related products. Monthly rates of absolute consumption were estimated by community pharmacies’ dispensing records. Portuguese municipalities were organized into quintiles according to their purchasing power index and percentage of youth, to study the association of these social and demographic variables on the sale of these products. COVID-19 pandemic significantly reduced the sales of products indicated for pediculosis. Since the start of the pandemic, an absolute decrease of 21.0 thousand packages was observed in the monthly average consumption (p < 0.0001) compared to the pre-pandemic period. After this reduction, the average monthly trend increased in the pandemic period in comparison with the previous period, although not significant (267.0 packages per month, p = 0.1102). Regions with higher disposable income and more young people were associated with higher sales of these products. The outbreak of the COVID-19 pandemic has had a notable impact on the sales of self-care products for pediculosis capitis in Portugal, in the short term. The lockdowns and other isolation measures implemented to control the spread of the virus may have led to a decrease in the number of head lice cases, consequently resulting in a reduction in sales of products. [ABSTRACT FROM AUTHOR]

The article offers information on the study on higher intake of medications for digestive disorders in children prenatally exposed to drugs with atropinic properties. Topics discussed include information on the anticholinergic drugs side effects; exploring a dose–response relationship in the association between exposure and outcome; and the adverse effects in the offspring of women exposed during pregnancy to anticholinergic drugs.

Objective and methods: An interrupted time series analysis was performed to measure the impact of two policy interventions on the accessibility to new targeted oncologic drugs in Ecuador. The first intervention decentralized the selection process allowing drug and therapeutic committees (DTCs) to directly select new drugs. The second brought back the final decision to a central body but kept the first decision level in hospitals. Five‐year (2010–2014) individual dispensing data from the six largest Ecuadorian cancer hospitals were analysed. Monthly incidence rate of targeted oncologic drug users (per 1000 cancer patients) was defined as the unit of analysis. Level and slope changes after policy interventions were studied; P value <0.05 was considered statistically significant. Key findings: In public hospitals, incidence rate immediately dropped (level) after the first policy intervention (P < 0.05). The slope increased not significantly until the second policy. After the second intervention, the incidence level dropped, and the slope was negative (both not significant). In private hospitals, the incidence level dropped significantly after the first policy, followed by a significant slope increase. After the second intervention, the incidence level dropped, and the slope was negative (both significant). Conclusions: Transferring to DTCs the responsibility to select new drugs produced an increase in prescription intensity of targeted oncologic drugs, mainly in the private sector. The second intervention changed this trend. Combination of different levels of decision, meaning a DTC analysis plus a reanalysis by a central body, seems to limit new prescriptions of targeted oncologic drugs. [ABSTRACT FROM AUTHOR]

Purpose: Balancing medications that are needed and beneficial and avoiding medications that may be harmful is important to prevent drug-related problems, and improve quality of life. The aim of this study is to describe medication use, the prevalence of deprescribing of medications suitable for deprescribing, and the prevalence of new initiation of potentially inappropriate medications (PIMs) in nursing home (NH) residents with life-limiting disease in Flanders. Methods: NH residents aged ≥ 65, suffering from end stage organ failure, advanced cancer, and/or dementia (n = 296), were included in this cross-sectional study with retrospective analyses of medication use at the time of data collection (t2) and 3 to 6 months before (t1). The appraisal of appropriateness of medications was done using a list of medications documented as suitable for deprescribing, and STOPPFrail criteria. Results: Residents' (mean age 86 years, 74% female) mean number of chronic medications increased from 7.4 (t1) to 7.9 (t2). In 31% of those using medications suitable for deprescribing, at least one medication was actually deprescribed. In 30% at least one PIM from the group of selected PIMs was newly initiated. In the subgroup (n = 76) for whom deprescribing was observed, deprescribing was associated with less new initiations of PIMs (r = − 0.234, p = 0.042). Conclusion: Medication use remained high at the end of life for NH residents with life-limiting disease, and deprescribing was limited. However, in the subgroup of 76 residents for whom deprescribing was observed, less new PIMs were initiated. [ABSTRACT FROM AUTHOR]

Highlights • 36% of nursing home residents were still alive after 4 years. • Polypharmacy and PIM use were high. • People with dementia and high care dependency died earlier. • No association between polypharmacy or PIM use and survival. Abstract Background Survival in older adults has a high variability. The possible association of length of survival with potentially inappropriate medication (PIM) use remains unclear. Aim To examine the four-year survival rate, the prevalence of polypharmacy and PIM use at admission, and the association between the two, in an inception cohort of newly admitted nursing home residents Methods Data were used from ageing@NH, a prospective observational cohort study in nursing homes. Residents (n = 613) were followed for four years after admission or until death. PIM use was measured at admission, using STOPPFrail. The Kaplan-Meier method was used to estimate survival, using log-rank tests for subgroup analyses. Cox regression analyses was used to explore associations with PIM use and polypharmacy, corrected for covariates Results Mean age was 84, 65% were females. After one, two, three and four years the survival rates were respectively 79%, 60.5%, 47% and 36%. At admission, 47% had polypharmacy and 40% excessive polypharmacy, 11% did not use any PIMs, and respectively 28%, 29%, and 32% used one, two and three or more PIMs. No difference in survival was found between polypharmacy and no polypharmacy, and PIM use and no PIM use at admission. Neither polypharmacy nor PIM use at admission were associated with mortality. Conclusion Residents survived a relatively short time after NH admission. Polypharmacy and PIM use at admission were relatively high in this cohort, although neither was associated with mortality. [ABSTRACT FROM AUTHOR]

Context: According to guideline recommendations, barbiturates and neuromuscular relaxants are the recommended drugs for euthanasia.Objectives: To describe changes over time in drugs used to perform euthanasia and differences in case characteristics according to the drugs used.Methods: Repeated population-based mortality follow-back study among physicians attending a large representative sample of deaths in 1998, 2007, and 2013 in Flanders, Belgium.Results: In 1998, we identified 25 euthanasia cases (1.2% of all deaths), 142 cases in 2007 (2.0% of all deaths), and 349 cases in 2013 (4.6% of all deaths). Use of recommended drugs to perform euthanasia increased from 11.9% of euthanasia cases in 1998 to 55.3% in 2007 and 66.8% in 2013 (P < 0.001). In 2013, cases with recommended drugs compared with nonrecommended drugs more often involved requests expressed both orally and in writing (86.8%/14.1%; P < 0.001), consultation with colleague physicians (93.8%/69.1%; P < 0.001), and administration in the presence of another physician (98.3%/54.3%; P < 0.001), and were more often self-labeled by physicians as euthanasia (95.5%/0.9%; P < 0.001) and reported to the euthanasia review committee (92.3%/3.8%; P < 0.001). Between 2007 and 2013, physicians consistently labeled cases in which nonrecommended drugs were used as palliative sedation (72.8%/78.4%; P = 0.791) or alleviation of pain and symptoms (13.2%/15.0%; P > 0.999).Conclusion: Physicians in Flanders are increasingly using the recommended drugs for euthanasia. This suggests that guidelines and training regarding the conduct and pharmacological aspects of euthanasia may have had important effects on the practice of euthanasia. However, the declining but persisting use of nonrecommended drugs requires further attention. [ABSTRACT FROM AUTHOR]

Abstract: Objective: In Ecuador, a new constitutional mandate (2008) allowed the government to implement free universal access to health care, including oncologic drugs. As most Latin American countries, Ecuadorian healthcare system is fragmented between public and private providers, posing a special challenge to collect valid drug utilization data. Data from the public and the private healthcare sectors were collected to examine the utilization of oncologic drugs in Ecuador over a 5‐year period (2010–2014). Methods: Oncologic drugs were extracted from individual dispensing data collected in the six largest Ecuadorian cancer hospitals. Drug utilization indicators include the yearly proportion of patients using selected therapeutic groups (targeted drugs, chemotherapy and hormonal drugs), and the mean and total expenditures, by healthcare sector. Key findings: Total number of patients ranged from 12 060 in 2010 to 12 769 in 2014. Median age was 56 years; 60.3% were women. Twenty‐three drugs were classified as targeted (monoclonal antibodies, protein kinase inhibitor, vismodegib, vorinostat and abiraterone), 43 as chemotherapy and 11 as hormonal. Patients using chemotherapy decreased from 56% to 52%. Proportion of patients using chemotherapy drugs was 30% lower in the public than in the private sector. Total expenditures on cancer drugs showed a constant increase from USD 17 912 865 in 2010 to USD 40 514 947 in 2014. Patients using targeted drugs doubled from 8% to 14% in 5 years. Targeted drugs accounted for 76% of total expenditures in 2014. Conclusion: Although only a small, but increasing proportion of patients used targeted drugs, it leads to a sharp rise in expenditures. In 2014, it represented three‐quarters of the total oncologic drugs expenditures. Differences in chemotherapy consumption between public and private sectors could reflect difficulties in public procurement, shortages and a faster, poorly controlled adoption of new drugs. If unmanaged, this is a possible threat to the health budget in the coming years. [ABSTRACT FROM AUTHOR]

Background: Information on medication use in the last months of life is limited. Aim: To describe which medications are prescribed and deprescribed in advanced cancer patients receiving palliative care in relation to time before death and to explore associations with demographic variables. Design: Prospective study, using case report forms for monthly data collection. Medication included cancer treatment and 19 therapeutic groups, grouped into four categories for: (1) cancer therapy, (2) specific cancer-related symptom relief, (3) other symptom relief and (4) long-term prevention. Data were analysed retrospectively using death as the index date. We compared medication use at 5, 4, 3, 2 and 1 month(s) before death by constructing five cross-sectional subsamples with medication use during that month. Paired analyses were done on a subsample of patients with at least two assessments before death. Setting/participants: We studied the medication use of 720 patients (mean age 67, 56% male) in 30 cancer centres representing 12 countries. Results: From 5 to 1 month(s) before death, cancer therapy decreased (55%-24%), most medications for symptom relief increased, for example, opioids (62%-81%) and sedatives (35%-46%), but medication for long-term prevention decreased (38%-27%). The prevalence of chemotherapy was 15.5% in the last month of life, with 9% of new courses started in the last 2 months. With higher age, chemotherapy and opioid use decreased. Conclusion: Medications for symptom relief increased in almost all medication groups. Deprescribing was found in heart medication/ anti-hypertensives and cancer therapy, although use of the latter remained relatively high. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: The aim of this study was to develop and test the effect of an instrument, Pharmanurse, to facilitate nurse-driven adverse drug reaction (ADR) screening as an input for interdisciplinary medication review in nursing homes. Design: Intervention study with a pre-posttest design Participants: All residents of a convenience sample of 8 nursing homes of more than 80 beds were eligible if they resided at least 1 month in the nursing home and took 4 or more different medications. Residents receiving palliative care were excluded. Intervention: The intervention consisted of interdisciplinary medication review, prepared by nurse observations of potential ADRs using personalized screening lists generated by the Pharmanurse software. Pharmanurse is specifically adapted to use by nurses and to use in nursing homes. Measurements: Outcome parameters were the number of ADRs detected by nurses, ADRs confirmed by general practitioners, and medication changes. After the intervention, health care professionals involved completed a questionnaire to evaluate the value and the feasibility of the intervention. Results: Nurses observed 1527 potential ADRs in 81% of the 418 residents (mean per resident 3.7). Physicians confirmed 821 ADRs in 60% of the residents (mean per resident 2.0). As a result, 214 medication changes were planned in 21% of the residents (mean per resident 0.5) because of ADRs. Health care professionals gave the Pharmanurse intervention a score of 7 of 10 for the potential to improve pharmacotherapy and 83% of the physicians were satisfied about nurses'' screening for ADRs. Conclusions: The Pharmanurse intervention supports nurses in ADR screening and may have the potential to improve pharmacotherapy. [Copyright &y& Elsevier]

Head louse infestations continue to be a concern of public health in most countries, including the most developed ones. The present recommendations are intended to inform and stress the role and impact of the different authorities, institutions, industry, and the public in the control of head lice in order to reduce the prevalence of this parasite. We encourage health authorities to pursue more effective methods to correctly identify such infestations, and evaluate existing and new pediculicides, medical devices, louse repellents, and louse- and nit-removal remedies. Pediculicides and medical devices must have verifiable claims in the instructions for use and should be tested periodically to document current levels of resistance by lice to the active ingredients and to the formulated products. Where the prevalence of lice is claimed to be epidemic, children should be periodically evaluated objectively to document the actual level of prevalence. Continuing education for health providers and the general population promises to correct misinformation regarding the biology, prevention, and management of lice. Parents should regularly inspect their children for head lice and treat as necessary. Health authorities are encouraged to eliminate policies and practices that rely upon school exclusion as a means to reduce incidence and prevalence, e.g., the 'no-nit' policy which lacks scientific justification, and are counterproductive to the health and welfare of children. [ABSTRACT FROM AUTHOR]

Purpose: There is an increasing demand for the use of quality indicators in palliative care. With previous research about implementation in this field lacking, we aimed to evaluate the barriers to and facilitators of implementation.Methods: Three focus group interviews were organized with 21 caregivers from 18 different specialized palliative care services in Belgium. Four had already worked with the indicators during a pilot study. The focus group discussions were transcribed verbatim and analyzed using the thematic framework approach.Results: The caregivers anticipated that a positive attitude by the team towards quality improvement, the presence of a good leader, and the possible link between quality indicators and reimbursement might facilitate the implementation of quality indicators in specialized palliative care services. Other facilitators concerned the presence of a need to demonstrate quality of care, to perform improvement actions, and to learn from other caregivers and services in the field. A negative attitude by caregivers towards quality measurement and a lack of skills, time, and staff were mentioned as barriers to successful implementation.Conclusion: Palliative caregivers anticipate a number of opportunities and problems when implementing quality indicators. These relate to the attitudes of the team regarding quality measurement; the attitudes, knowledge, and skills of the individual caregivers within the team; and the organizational context and the economic and political context. Training in the advantages of quality indicators and how to use them is indispensable, as are structural changes in the policy concerning palliative care, in order to progress towards systematic quality monitoring. [ABSTRACT FROM AUTHOR]

Background: Uptake of advance care planning in routine nursing home care is low. Through extensive literature review, theoretical development, and stakeholder involvement, we developed the ACP+ intervention. Aims: To evaluate the effects of ACP+ on the knowledge and self-efficacy (confidence in own skills) of nursing home care staff concerning advance care planning. Design: Cluster randomized controlled trial, conducted between February 2018 and January 2019 (NCT03521206, clinicaltrials.gov). ACP+ is a multicomponent intervention aimed at training and supporting nursing home staff and management in implementing advance care planning in nursing home practice through a train-the-trainer approach over 8 months. Fourteen nursing homes were randomized using a matched-pairing strategy, seven received ACP+, seven followed usual practice. Analyses (intention-to-treat) involved linear mixed models. Setting/participants: Nursing homes in Flanders (Belgium). Results: 694 of 1017 care staff (68% response rate) at baseline and 491 of 989 care staff (50%) post-intervention (8 months) returned questionnaires. Post-intervention, care staff's self-efficacy concerning advance care planning was significantly higher in the intervention than in the control group (baseline-adjusted mean difference 0.57; 95% CI 0.20–0.94; p = 0.003; Cohen's d = 0.30). Advance care planning knowledge (95% CI 0.95–1.15; p = 0.339; ratio: 1.04) did not differ significantly between groups. Conclusions: The ACP+ intervention for nursing homes improved care staff's self-efficacy but not their knowledge concerning advance care planning. Considering the comprehensive and multi-component approach used, these effects were smaller than expected. Reasons for this may be related to the chosen follow-up period, outcomes and measurements, or to the intervention itself and its implementation. [ABSTRACT FROM AUTHOR]

Head lice infestation is still a public health problem worldwide, with an intracountry and intercountry prevalence variation of 0.7 to 59 %. There is a large variety of over-the-counter anti-louse products, but their efficacy is not always well assessed. Our objective was to test the pediculicidal and ovicidal efficacy of 21 over-the-counter head louse products, available in France during the period of 2008 to 2012. We tested children living in Tours City in central France and visiting preschools, primary schools, kindergarten, camps, and child care facilities, as well as children in their family houses, and were examined for the presence of lice. The products were collected from randomly selected pharmacies by covert investigators and then tested in the laboratory on an ex vivo sample of head lice and their eggs, collected from the hair of infested children. Living lice and unharmed eggs were collected from the scalps of 3-12 years old. The laboratory conditions for ex vivo testing mimicked the manufacturers' instructions for exposure time and application method. In 21 runs, 3919 living lice and 4321 undamaged living eggs were collected from the scalp of over 400 children. The 21 products were classified in three groups: 6 products in a group of potentially 100 % pediculicidal activity and potentially 100 % ovicidal activity, 8 products in a group of potentially 100 % pediculicidal activity but insufficient ovicidal activity (including 2 products with claims of single application treatment), and 7 products in a group of insufficient pediculicidal activity and ovicidal activity. The pharmaceutical market for head lice products in France is swamped with poorly tested and ineffective products. Rigorous efficacy testing preregistration and periodic screening and testing of effectiveness in the post-registration period should be endorsed by the health authorities. [ABSTRACT FROM AUTHOR]

Background: Advance care planning is considered a central component of good quality palliative care and especially relevant for people who lose the capacity to make decisions at the end of life, which is the case for many nursing home residents with dementia. We set out to investigate to what extent (1) advance care planning in the form of written advance patient directives and verbal communication with patient and/or relatives about future care and (2) the existence of written advance general practitioner orders are related to the quality of dying of nursing home residents with dementia. Methods: Cross-sectional study of deaths (2010) using random cluster-sampling. Representative sample of nursing homes in Flanders, Belgium. Deaths of residents with dementia in a three-month period were reported; for each the nurse most involved in care, GP and closest relative completed structured questionnaires. Findings: We identified 101 deaths of residents with dementia in 69 nursing homes (58% response rate). A written advance patient directive was present for 17.5%, GP-orders for 56.7%. Controlling for socio-demographic/clinical characteristics in multivariate regression analyses, chances of having a higher mean rating of emotional well-being (less fear and anxiety) on the Comfort Assessment in Dying with Dementia scale were three times higher with a written advance patient directive and more specifically when having a do-not-resuscitate order (AOR 3.45; CI,1.1–11) than for those without either (AOR 2.99; CI,1.1–8.3). We found no association between verbal communication or having a GP order and quality of dying. Conclusion: For nursing home residents with dementia there is a strong association between having a written advance directive and quality of dying. Where wishes are written, relatives report lower levels of emotional distress at the end of life. These results underpin the importance of advance care planning for people with dementia and beginning this process as early as possible. [ABSTRACT FROM AUTHOR]

Background: A team-based approach has been advocated for advance care planning in nursing homes. While nurses are often put forward to take the lead, it is not clear to what extent other professions could be involved as well. Objectives: To examine to what extent engagement in advance care planning practices (e.g. conversations, advance directives), knowledge and self-efficacy differ between nurses, care assistants and allied care staff in nursing homes. Design: Survey study. Participants/setting: The study involved a purposive sample of 14 nursing homes in Flanders, Belgium. Nurses, care assistants and allied care staff (e.g. social workers, physical therapists) completed a survey. Ethical considerations: The study was approved by the University Hospital of Brussels (B.U.N. 143201834759), as part of a cluster randomized controlled trial (clinicaltrials.gov NCT03521206). Results: One hundred ninety-six nurses, 319 care assistants and 169 allied staff participated (67% response rate). After adjusting for confounders, nurses were significantly more likely than care assistants to have carried out advance care planning conversations (odds ratio 4; 95% confidence interval 1.73–9.82; p < 0.001) and documented advance care planning (odds ratio 2.67; 95% confidence interval 1.29–5.56; p < 0.001); differences not found between allied staff and care assistants. Advance care planning knowledge total scores differed significantly, with nurses (estimated mean difference 0.13 (score range 0–1); 95% confidence interval 0.08–0.17; p < 0.001) and allied staff (estimated mean difference 0.07; 95% confidence interval 0.03–0.12; p < 0.001) scoring higher than care assistants. We found no significant differences regarding self-efficacy. Discussion: While nursing home nurses conducted more advance care planning conversations and documentation than allied care staff and care assistants, these two professional groups may be a valuable support to nurses in conducting advance care planning, if provided with additional training. Conclusions: Allied care staff and care assistants, if trained appropriately, can be involved more strongly in advance care planning to enhance relational and individual autonomy of nursing home residents, alongside nurses. Future research to improve and implement advance care planning should consider this finding at the intervention development stage. [ABSTRACT FROM AUTHOR]

Background: Anticholinergic 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. Methods: We 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. Results: We 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. Conclusion: Considerable 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. [ABSTRACT FROM AUTHOR]

Abstract: Context: Death is often preceded by medical decisions that potentially shorten life (end-of-life decisions [ELDs]), for example, the decision to withhold or withdraw treatment. Respect for patient autonomy requires physicians to involve their patients in this decision making. Objectives: The objective of this study was to examine the involvement of advanced lung cancer patients and their families in ELD making and compare their actual involvement with their previously stated preferences for involvement. Methods: Patients with Stage IIIb/IV non-small cell lung cancer were recruited by physicians in 13 hospitals and regularly interviewed between diagnosis and death. When the patient died, the specialist and general practitioner were asked to fill in a questionnaire. Results: Eighty-five patients who died within 18 months of diagnosis were studied. An ELD was made in 52 cases (61%). According to the treating physician, half of the competent patients were not involved in the ELD making, one-quarter shared the decision with the physician, and one-quarter made the decision themselves. In the incompetent patients, family was involved in half of cases. Half of the competent patients were involved less than they had previously preferred, and 7% were more involved. Almost all of the incompetent patients had previously stated that they wanted their family involved in case of incompetence, but half did not achieve this. Conclusion: In half of the cases, advanced lung cancer patients—or their families in cases of incompetence—were not involved in ELD making, despite the wishes of most of them. Physicians should openly discuss ELDs and involvement preferences with their advanced lung cancer patients. [Copyright &y& Elsevier]

Background: The aim of this study is to discover how many nursing homes (NHs) in Flanders (Belgium) have policies on advance care planning (ACP) and their content regarding different medical end-of-life decisions. Methods: A structured mail questionnaire was sent to the NH administrators of all 594 NHs in Flanders (Belgium) at the end of 2006. The questionnaire asked about the existence, timing of implementation and content of ACP policy documents (guidelines and patient-specific planning forms), and on NH characteristics related to end-of-life care. Results: The response rate was 58.1%. The development of ACP policy documents began in 1989 with major increases in implementation taking place from 2000. In 2006, ACP policy documents were available in 95.1% of NHs. Most of these NHs had ACP guidelines as well as ACP patient-specific planning forms. Almost all patient-specific planning forms included anticipatory do-not-hospitalize (90.0%) and do-not-resuscitate decisions (83.2%). Anticipatory decisions about terminal sedation (29.2%) and euthanasia (19.7%) were mentioned less often and these decisions were not permitted to be made in all NHs. One out of three NHs had policies on the appointment of a patient's representative. Conclusion: By the end of 2006, almost all NHs in Flanders (Belgium) had an ACP policy. The implementation of ACP policies in Flemish NHs lagged behind other countries, but has developed rapidly since 2000. However, some NHs appear to ban some end-of-life options which are actually legal in Belgium. Further research is needed to investigate whether ACP policies have much impact on the quality of end-of-life care in NHs. [ABSTRACT FROM AUTHOR]

• The optimeds intervention is intended to structure and support a medication review with input of nurses, pharmacists and general practitioners GPs) in Belgian nursing Homes. It is an electronic assessment tool for the automated recognition of possible inappropriate medications and for the generation of patient-specific lists of medication side-effects for observations by nurses. • The medication reviews, supported the OptiMEDs tool, resulted in a decrease of at least one medication in 36% and least one possible inappropriate medication in 26% of residents after one month. All components in the intervention (nurse observations, pharmacist feedback, automated recognition of potentially inappropriate medications, anticholinergics or candidates for deprescribing) all contributed to changes in the medication list. • The OptiMEDs intervention was deemed feasible and user-friendly by the health care professionals and is of low-risk for the patient. Additionally, the time investment for this intervention was deemed acceptable. Exploring efficacy, feasibility and acceptability of a complex multifaced intervention (OptiMEDs) supporting multidisciplinary medication reviews in Belgian nursing homes (NHs). A pilot study in 2 intervention, 1 control NH was held, involving dementia and non-dementia NH residents (>65 years). OptiMEDs provided automated assessment of possible inappropriate medications (PIMs) and patient-specific nurse observation lists of potential side-effects. Medication changes were evaluated one month after the medication review. Feasibility and acceptability was collected via surveys among the health-care professionals. Trial registration NCT04142645, 31/10/2019. Participants (n = 148, n = 100 in the intervention NHs) had a mean age of 87.2 years, with 75.0% females and 49.3% non-dementia patients. Prevalence of PIM use was 84.7% and of potential medication side-effects 84.5%, (range 1–19 per resident). One month after the intervention, the medication use decreased in 35.8% and PIM use in 25.9% of surviving intervention NHresidents (n = 88). GPs changed more medications when side-effects were observed (42% when side-effects present versus 12% when no side-effects, p = 0.019). Median workload for nurses was 45 min, 20 for pharmacists, and 8 for GPs. User satisfaction for the OptiMEDs tool was high (n = 33, median score of 8, IQR 6 -8), with GPs (n = 19) showing the highest appreciation. Nurses (n = 9) reported a median score on the System Usability Scale of 70 (IQR 55 – 72), with lower scores for learnability aspects. The OptiMEDs intervention was feasible and user-friendly, showing decreases in the medication and PIM use; without affecting patient safety. A cluster-randomized trial is needed to explore impact on patient-related outcomes. [ABSTRACT FROM AUTHOR]

Background: Many new cancer drugs are being approved by reputed regulatory authorities without evidence of overall survival benefit, quality of life improvement, and often based on clinical trials at high risk of bias. In recent years, most Latin American (LA) countries have reformed their marketing authorization (MA) rules to directly accept or abbreviate the approval process in case of earlier authorization by the European Medicines Agency (EMA) and the US Food and Drug Administration, mainly. This study assessed the potential impact of decisions taken by EMA regarding the approval of new cancer drugs based on no evidence of overall survival or in potentially biased clinical trials in LA countries. Design: Descriptive analysis. Setting: Publicly accessible marketing authorization databases from LA regulators, European Public Assessment Report by EMA, and previous studies accessing EMA approvals of new cancer drugs 2009–2016. Main outcome and measures: Number of new cancer drugs approved by LA countries without evidence of overall survival (2009–2013), and without at least one clinical trial scored at low risk of bias, or with no trial supporting the marketing authorization at all (2014–2016). Results: Argentina, Brazil, Chile, Colombia, Ecuador, Panama and Peru have publicly accessible and trustful MA databases and were included. Of the 17 cancer drugs approved by EMA (2009–2013) without evidence of OS benefit after a postmarketing median time of 5.4 years, 6 LA regulators approved more than 70% of them. Of the 13 drugs approved by EMA (2014–2016), either without supporting trial or with no trial at low risk of bias, Brazil approved 11, Chile 10, Peru 10, Argentina 10, Colombia 9, Ecuador 9, and Panama 8. Conclusions: LA countries keep approving new cancer drugs often based on poorly performed clinical trials measuring surrogate endpoints. EMA and other reputed regulators must be aware that their regulatory decisions might directly influence decisions regarding MA, health budgets and patient's care elsewhere. [ABSTRACT FROM AUTHOR]

Head louse infestations continue to be a concern of public health in most countries, including the most developed ones. The present recommendations are intended to inform and stress the role and impact of the different authorities, institutions, industry, and the public in the control of head lice in order to reduce the prevalence of this parasite. We encourage health authorities to pursue more effective methods to correctly identify such infestations, and evaluate existing and new pediculicides, medical devices, louse repellents, and louse‐ and nit‐removal remedies. Pediculicides and medical devices must have verifiable claims in the instructions for use and should be tested periodically to document current levels of resistance by lice to the active ingredients and to the formulated products. Where the prevalence of lice is claimed to be epidemic, children should be periodically evaluated objectively to document the actual level of prevalence. Continuing education for health providers and the general population promises to correct misinformation regarding the biology, prevention, and management of lice. Parents should regularly inspect their children for head lice and treat as necessary. Health authorities are encouraged to eliminate policies and practices that rely upon school exclusion as a means to reduce incidence and prevalence, e.g., the 'no‐nit' policy which lacks scientific justification, and are counterproductive to the health and welfare of children. [ABSTRACT FROM AUTHOR]

Objective. To describe the current status of regulatory reliance in Latin America and the Caribbean (LAC) by assessing the countries' regulatory frameworks to approve new medicines, and to ascertain, for each country, which foreign regulators are considered as trusted regulatory authorities to rely on. Methods. Websites from LAC regulators were searched to identify the official regulations to approve new drugs. Data collection was carried out in December 2019 and completed in June 2020 for the Caribbean countries. Two independent teams collected information regarding direct recognition or abbreviated processes to approve new drugs and the reference (trusted) regulators defined as such by the corresponding national legislation. Results. Regulatory documents regarding marketing authorization were found in 20 LAC regulators' websites, covering 34 countries. Seven countries do not accept reliance on foreign regulators. Thirteen regulatory authorities (Argentina, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Mexico, Panama, Paraguay, Peru, Uruguay, and the unique Caribbean Regulatory System for 15 Caribbean States) explicitly accept relying on marketing authorizations issued by the European Medicines Agency, United States Food and Drug Administration, and Health Canada. Ten countries rely also on marketing authorizations from Australia, Japan, and Switzerland. Argentina, Brazil, Chile, and Mexico are reference authorities for eight LAC regulators. Conclusions. Regulatory reliance has become a common practice in the LAC region. Thirteen out of 20 regulators directly recognize or abbreviate the marketing authorization process in case of earlier approval by a regulator from another jurisdiction. The regulators most relied upon are the European Medicines Agency, United States Food and Drug Administration, and Health Canada. [ABSTRACT FROM AUTHOR]

Background: Considering social cognitive theory and current literature about successful advance care planning in nursing homes, sufficient knowledge and self-efficacy are important preconditions for staff to be able to carry out advance care planning in practice. Aim: Exploring to what extent nurses' knowledge about and self-efficacy is associated with their engagement in advance care planning in nursing homes. Design: Survey study as part of a baseline measurement of a randomised controlled cluster trial (NCT03521206). Setting/participants: Nurses in a purposive sample of 14 nursing homes in Belgium. Methods: A survey was distributed among nurses, evaluating knowledge (11 true/false items), self-efficacy (12 roles and tasks on 10-point Likert-type scale) and six advance care planning practices (yes/no), ranging from performing advance care planning conversations to completing advance directives. Results: A total of 196 nurses participated (66% response rate). While knowledge was not significantly associated with advance care planning practices, self-efficacy was. One unit's increase in self-efficacy was statistically associated with an estimated 32% increase in the number of practices having carried out. Conclusions: Nurses' engagement in advance care planning practices is mainly associated with their self-efficacy rather than their knowledge. Further research is necessary to improve the evidence regarding the causal relationship between constructs. However, these results suggest that educational programmes that focus solely on knowledge might not lead to increasing uptake of advance care planning in nurses. [ABSTRACT FROM AUTHOR]

Background: Research has highlighted the need for improving the implementation of advance care planning (ACP) in nursing homes. We developed a theory-based multicomponent ACP intervention (the ACP+ programme) aimed at supporting nursing home staff with the implementation of ACP into routine nursing home care. We describe here the protocol of a cluster randomised controlled trial (RCT) that aims to evaluate the effects of ACP+ on nursing home staff and volunteer level outcomes and its underlying processes of change. Methods: We will conduct a cluster RCT in Flanders, Belgium. Fourteen eligible nursing homes will be pair-matched and one from each pair will be randomised to either continue care and education as usual or to receive the ACP+ programme (a multicomponent programme which is delivered stepwise over an eight-month period with the help of an external trainer). Primary outcomes are: nursing home care staff's knowledge of, and self-efficacy regarding ACP. Secondary outcomes are: 1) nursing home care staff's attitudes towards ACP and ACP practices; 2) support staff's and volunteer's ACP practices and 3) support staff's and volunteers' self-efficacy. Measurements will be performed at baseline and eight months post-measurement, using structured self-reported questionnaires. A process evaluation will accompany the outcome evaluation in the intervention group, with measurements throughout and post-intervention to assess implementation, mechanisms of impact and context and will be carried out using a mixed-methods design. Discussion: There is little high-quality evidence regarding the effectiveness and underlying processes of change of ACP in nursing homes. This combined outcome and process evaluation of the ACP+ programme aims to contribute to building the necessary evidence to improve ACP and its uptake for nursing home residents and their family. Trial registration: The study is registered at ClinicalTrials.gov (no. NCT03521206). Registration date: May 10, 2018. Inclusion of nursing homes started March, 2018. Hence, the trial was retrospectively registered but before end of data collection and analyses. [ABSTRACT FROM AUTHOR]

While various initiatives have been taken to improve advance care planning in nursing homes, it is difficult to find enough details about interventions to allow comparison, replication and translation into practice. We report on the development and description of the ACP+ program, a multi-component theory-based program that aims to implement advance care planning into routine nursing home care. We aimed to 1) specify how intervention components can be delivered; 2) evaluate the feasibility and acceptability of the program; 3) describe the final program in a standardized manner. To develop and model the intervention, we applied multiple study methods including a literature review, expert discussions and individual and group interviews with nursing home staff and management. We recruited participants through convenience sampling. Management and staff (n = 17) from five nursing homes in Flanders (Belgium), a multidisciplinary expert group and a palliative care nurse-trainer. The work was carried out by means of 1) operationalization of key intervention components–identified as part of a previously developed theory on how advance care planning is expected to lead to its desired outcomes in nursing homes–into specific activities and materials, through expert discussions and review of existing advance care planning programs; 2) evaluation of feasibility and acceptability of the program through interviews with nursing home management and staff and expert revisions; and 3) standardized description of the final program according to the TIDieR checklist. During step 2, we used thematic analysis. The original program with nine key components was expanded to include ten intervention components, 22 activities and 17 materials to support delivery into routine nursing home care. The final ACP+ program includes ongoing training and coaching, management engagement, different roles and responsibilities in organizing advance care planning, conversations, documentation and information transfer, integration of advance care planning into multidisciplinary meetings, auditing, and tailoring to the specific setting. These components are to be implemented stepwise throughout an intervention period. The program involves the entire nursing home workforce. The support of an external trainer decreases as nursing home staff become more autonomous in organizing advance care planning. The multicomponent ACP+ program involves residents, family, and the different groups of people working in the nursing home. It is deemed feasible and acceptable by nursing home staff and management. The findings presented in this paper, alongside results of the subsequent randomized controlled cluster trial, can facilitate comparison, replicability and translation of the intervention into practice. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study was to examine the use of potentially inappropriate medication (PIM) in relation to time before death, to explore whether PIMs are discontinued at the end of life, and the factors associated with this discontinuation. Methods: We conducted a retrospective register‐based mortality cohort study of all deceased in 2012 in Belgium, aged at least 75 years at time of death (n = 74 368), using linked administrative databases. We used STOPPFrail to identify PIMs received during the period from 12 to 6 months before death (P1) and the last 4 months (P2) of life. Results: Median age was 86 (IQR 81–90) at time of death, 57% were female, 38% were living in a nursing home, and 16% were admitted to hospital between 2 years and 4 months before death. Overall, PIM use was high, and increased towards death for all PIMs. At least one PIM was discontinued during P2 for one in five (20%) of the population, and 49% had no discontinuation. Being hospitalized in the period before the last 4 months of life, living in a nursing home, female gender and a higher number of medications used during P1 were associated with discontinuation of PIMs (respective aOR [95% CI]: 2.89 [2.73–3.06], 1.29 [1.23–1.36], 1.26 [1.20–1.32], 1.17 [1.16–1.17]). Conclusion: Initial PIM use was high and increased towards death. Discontinuation was observed in only one in five PIM users. More guidance for discontinuation of PIMs is needed: practical, evidence‐based deprescribing guidelines and implementation plans, training for prescribers and a better consensus on what inappropriate medication is. [ABSTRACT FROM AUTHOR]

Aim: To explore the feasibility of the electronic assessment of potentially inappropriate medication (PIM) criteria in a large administrative database and to explore the validity of the cardiovascular subset of PIM criteria, by studying the association with relevant outcome. Method: A cohort study using administrative data from Stockholm County, Sweden (VAL database). Eligible for inclusion were community‐dwelling older people (≥65 years), alive in Stockholm County on 31 December 2015. We applied PIM criteria pertaining to the cardiovascular medication group (first‐level ATC C group), and we assessed the association between PIM use and mortality and hospitalisation. Results: Patients' (n = 315 120) mean age was 74.0 years (range 65‐114), and 54.7% were women. There were 111 cardiovascular PIM criteria in the repository, from which 44 were not registered or prescribed in our population. We excluded another 43 requiring information not available in the database, or duplicates, resulting in 24 applicable criteria. The prevalence of polypharmacy (≥ five medications) was 25.5% and the prevalence of at least one PIM use was 8.3%, including 2.8% underuse and 5.3% misuse. Patients with intake of ≥10 medications had 38% increased mortality risk compared to those with 0‐4 medications. Unplanned hospitalisation and emergency department visits were positively associated with underuse (12% and 25%, respectively) and misuse (13% and 12%, respectively). Conclusion: It was feasible to select a subset of cardiovascular PIM criteria originating from different PIM lists and to apply this subset in an administrative database. Additionally, by applying this subset, we showed significant associations with clinical outcome. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to: (a) determine adherence rates to oral anticoagulants in atrial fibrillation patients with a high risk for thromboembolic events postradiofrequency ablation; (b) evaluate patients' knowledge and perceptions towards oral anticoagulants; and (c) explore the impact of patients' knowledge and perceptions on treatment adherence. Background: Atrial fibrillation is a common arrhythmia associated with an increased risk of developing thromboembolic events such as stroke. Although adherence to oral anticoagulants is crucial to prevent such complications, the relationship between adherence, knowledge and patient perceptions is poorly understood in patients with atrial fibrillation at high risk for thromboembolic events after radiofrequency ablation. Design: A cross‐sectional observational survey study was performed in a single centre. Methods: The levels of adherence, knowledge, and perception towards oral anticoagulants were assessed using the 8‐item Morisky Medication Adherence Scale, Knowledge of Oral Anticoagulation Tool, Perception of Anticoagulant Treatment Questionnaire and Benefit‐Risk Perception Tool, respectively. Results from these self‐reported tools were analysed descriptively. A multivariable binary logistic regression model was used to identify factors associated with levels of adequate adherence. Results: Adequate treatment adherence was found in three‐quarters of patients. The total mean knowledge score was low. Participants expressed high ease of use and low burden of treatment. Higher total knowledge and satisfaction scores were significant factors associated with higher levels of adherence. Conclusion: There remains a huge unmet need to follow‐up and educate patients with atrial fibrillation, focusing on good knowledge and correct perception of the advantages and disadvantages of oral anticoagulants. Our results suggest that increased knowledge and satisfaction rates might have a positive impact on adherence to oral anticoagulants. [ABSTRACT FROM AUTHOR]

Problem/Goal: Sharing the results of research with General Practitioners (GPs) is crucial for the survival of the discipline of General Practice / Family Medicine (GP/FM). The production of abstracts in GP/FM probably exceeds 15,000 per year worldwide. Each abstract often represents two years of work for its authors and is expressed in local languages. Only 45% of them are published in indexed medical journals. Usual indexing systems like MeSH are not multilingual nor adapted to the particular field of GP/FM. Consequently, these abstracts are lacking bibliographic control and more than half of the research presented by GPs at congresses is lost. Considering the absence of appropriate domain-specific terminologies or classification systems, we propose a new multilingual indexing system. The existing International Classification of Primary Care (ICPC) is currently used for clinical purposes and has now been expanded with a taxonomy related to contextual aspects (called Q-Codes) such as education, research, practice organization, ethics or policy in GP/FM, currently not captured. The set is proposed under the name Core Content Classification in General Practice (3CGP). The aim is to facilitate indexing of GP/FM specific scientific work and to improve performance in information storage and retrieval for research purposes in this field. Research Method/Procedure: Using qualitative analysis, a corpus of 1,702 abstracts from six GP/FMrelated European congresses was analyzed to identify main themes discussed by GPs (e.g., continuity, accessibility or medical ethics), handled in a domain-specific taxonomy called Q-Codes and translated in 8 languages. In addition, a methodology for building a lightweight ontology (in OWL-2) was applied to QCodes, adding object and datatype properties to the hierarchical relations, including mapping to the MeSH thesaurus, Babelnet (www.babelnet.org) and Dbpedia. Finally, the Q-Codes in 8 languages have been integrated in a healthcare terminology service (www.hetop.eu/q) with a companion website (http://3cgp.docpatient.net). Results of the Research: The creation and the on-line publication of this multilingual terminological resource (see http://3cgp.docpatient.net), for indexing abstracts and for facilitating Medline searches, could reduce loss of knowledge in the domain. The database is available in 12 human languages and in Web Ontology Language (OWL) for computer use. In addition, through better indexing of the grey literature (online database, congress abstracts, master's and doctoral thesis) of which we show the first results, we hope to enhance the accessibility of research in GP/FM domain and promote the emergence of networks of researchers. Indication of costs related to the project: This project has not been funded. 3CGP is placed under Attribution-Non-Commercial-Share-Alike 4.0 International (CC BY-NC-SA 4.0). ICPC is copyrighted by WONCA. [ABSTRACT FROM AUTHOR]

Aim: Lack of electronic assessment of medication lists in electronic health records is a barrier for more generalized use of potentially inappropriate medications (PIM) lists, designed for older adults. The aim was to construct a European repository of explicit criteria on PIM, suitable for electronic assessment. Methods: PIM description, medication information, clinical information and level of evidence was entered. Criteria with unclear medication specifications were excluded. Too complex criteria were divided for more operable use. Results: We selected three lists: the European Union (7)-PIM (2015), STOPP/START (2014) and Beers criteria (2015). After exclusion and division, from 641 original criteria of the three PIM-lists, a total of 650 criteria were entered (n = 282 from European Union (7)-PIM, n = 201 from Beers and n = 167 from the STOPP/START list). Identification of the medication was possible with the Anatomical Therapeutic Chemical Classification System for practically all criteria, except for 23 (3.5%). From all criteria, 63.9% required only medication-related information. In 55.7% of the criteria, identification of the active substance(s) was the only medication data requirement and 8.2% required additional information (dose, duration, route of administration). From all criteria, 36.1% required clinical information, from which 17.8% requested disease information only, and 18.3% required additional information (indication, history of diseases, laboratory results or severity of diseases). Conclusions: It was feasible to enter most of the original criteria of the three PIM lists into a repository of electronically applicable criteria. In the future, developers of new PIM lists should take into account semantic interoperability and consider the suitability of the criteria for electronic use. [ABSTRACT FROM AUTHOR]

Anticholinergics are frequently prescribed for older adults and can lead to adverse drug events. The novel MARANTE (Muscarinic Acetylcholinergic Receptor ANTagonist Exposure) scale measures the anticholinergic exposure by incorporating potency and dosages of each medication into its calculations. The aims were to assess prevalence and intensity of the anticholinergic exposure in a longitudinal cohort study of community-dwelling patients aged 80 years and over (n = 503) and to study the impact on mortality and hospitalization. Chronic medication use at baseline (November 2008-September 2009) was entered and codified with the Anatomical Therapeutic Chemical classification. Time-to-event analysis until first hospitalization or death was performed at 18 months after inclusion, using Kaplan-Meier curves. Cox regression was performed to control for covariates. Mean age was 84 years (range 80-102), and mean number of medications was 5 (range 0-16). Prevalence of anticholinergic use was 31.8%, with 9% taking ≥2 anticholinergics (range 0-4). Main indications for anticholinergics were depression, pain and gastric dysfunction. Female gender, the level of multi-morbidity and the number of medications were associated with anticholinergic use. Mortality and hospitalization rate were 8.9% and 31.0%, respectively. After adjustment for the level of multi-morbidity and medication intake, multi-variable analysis showed increased risks of mortality ( HR 2.3, 95% CI: 1.07-4.78) and hospitalization ( HR 1.7; 95% CI: 1.13-2.59) in those with high anticholinergic exposure. The longitudinal study among Belgian community-dwelling oldest old demonstrated great anticholinergic exposure, which was associated with increased risk of mortality and hospitalization after 18 months. [ABSTRACT FROM AUTHOR]

Quantification of the anticholinergic exposure insufficiently or imprecisely incorporates dosage information, leading to inaccurate estimations. The aim was to construct a novel scale, including potency and dosage for the quantification of the anticholinergic exposure in older adults. Potency information was retrieved from a previous systematic review. The dosage range for each drug was delineated in minimal, maintenance and maximal dosage for adults and older adults. Dosage information was collected from authoritative sources and reviewed in an expert panel. The Muscarinic Acetylcholinergic Receptor ANTagonist Exposure ( MARANTE) scale was tested for clinimetric properties using cohorts of community-dwelling older adults and nursing home residents. After three data collection rounds, data for the dosage ranges remained incomplete for 32 active substances. Remaining gaps were filled in, and 11 dosage adjustments were proposed during the expert panel meeting. We chose the values {0; 1; 2) for the categories of potency and {0; 0.5; 1; 1.5; 2) for the levels of dosage ranges, showing good clinimetric properties. Forty-one anticholinergic drugs were prescribed in the two cohorts. Most (61%) were low potency anticholinergics and used for depression (19%, e.g. citalopram). There were 31.8% (median MARANTE 1.5, IQR 1.5-2.5) and 37.6% (median 2, IQR 1.5-2.5) anticholinergic users in the community-dwelling cohort and nursing home cohort, respectively. The MARANTE scale combines potency with the dosage spectrum, to quantify the anticholinergic exposure in older adults. An open feedback system on the list of anticholinergic and proposed anticholinergic potency and dosage values is advised. [ABSTRACT FROM AUTHOR]

Objectives There is growing evidence of the potential effectiveness of advance care planning. Yet important knowledge gaps remain regarding the preconditions for successful implementation of advance care planning in the nursing home setting. We aim to identify the preconditions related to successful advance care planning in the nursing home setting. By specifying those, we would be able to make well-founded choices for the future design and planning of advance care planning intervention programs. Design A systematic review. Data sources PubMed, PsycINFO, EMBASE and CINAHL. Review methods Two authors independently screened publications. One author assessed methodological quality and extracted textual data, which was double-checked for a random sample. We extracted textual data and used thematic synthesis to identify “preconditions”, defined as requirements, conditions and elements necessary to achieve the desired outcome of advance care planning, i.e. attaining concordance between residents' preferences and actual care or treatment received at the end of life. Main findings Based on 38 publications, we identified 17 preconditions at five different levels: resident, family, health-care professional, facility and community. Most preconditions were situated on multiple levels but the majority addressed professionals and the nursing home itself. We summarized preconditions in five domains: to have sufficient knowledge and skills, to be willing and able to participate in advance care planning, to have good relationships, to have an administrative system in place, and contextual factors supporting advance care planning within the nursing home. Conclusion There are multiple preconditions related to successfully implementing advance care planning in the complex nursing home setting that operate at micro, meso and macro level. Future interventions need to address these multiple domains and levels in a whole-system approach in order to be better implementable and more sustainable, while simultaneously target the important role of the health-care professional and the facility itself. [ABSTRACT FROM AUTHOR]

Aims Little is known about the impact of inappropriate prescribing (IP) in community-dwelling adults, aged 80 years and older. The prevalence at baseline (November 2008September 2009) and impact of IP (misuse and underuse) after 18 months on mortality and hospitalization in a cohort of community-dwelling adults, aged 80 years and older ( n = 503) was studied. Methods Screening Tool of Older People's Prescriptions (STOPP-2, misuse) and Screening Tool to Alert to Right Treatment (START-2, underuse) criteria were cross-referenced and linked to the medication use (in Anatomical Therapeutic Chemical coding) and clinical problems. Survival analysis until death or first hospitalization was performed at 18 months after inclusion using Kaplan-Meier, with Cox regression to control for covariates. Results Mean age was 84.4 (range 80-102) years. Mean number of medications prescribed was 5 (range 0-16). Polypharmacy (≥5 medications, 58%), underuse (67%) and misuse (56%) were high. Underuse and misuse coexisted in 40% and were absent in 17% of the population. A higher number of prescribed medications was correlated with more misused medications ( rs = .51, P < 0.001) and underused medications ( rs = .26, P < 0.001). Mortality and hospitalization rate were 8.9%, and 31.0%, respectively. After adjustment for number of medications and misused medications, there was an increased risk of mortality (HR 1.39, 95% CI 1.10, 1.76) and hospitalization (HR 1.26, 95% CI 1.10, 1.45) for every additional underused medication. Associations with misuse were less clear. Conclusion IP (polypharmacy, underuse and misuse) was highly prevalent in adults, aged 80 years and older. Surprisingly, underuse and not misuse had strong associations with mortality and hospitalization. [ABSTRACT FROM AUTHOR]

Context: Although the acute hospital setting is not considered to be an ideal place of death, many people are admitted to hospital at the end of life.Objectives: The present study aims to examine the reasons for hospital admissions that result in an expected death and the factors that play a role in the decision to admit to hospital.Methods: This was a survey among family physicians (FPs) about those of their patients who had died nonsuddenly in an acute university hospital setting in Belgium between January and August 2014. Questions were asked about the patient's health situation, care that the patient received before the admission, the circumstances of the hospital admission, the reasons necessitating the admission, and other factors that had played a role in the decision to admit the patient to hospital.Results: We received 245 completed questionnaires (response rate 70%), and 77% of those hospital deaths were considered to be nonsudden. FPs indicated that 55% of end-of-life hospitalizations were for palliative reasons and 26% curative or life-prolonging. Factors such as the patient feeling safer in hospital (35%) or family believing care to be better in hospital (54%) frequently played a role in the end-of-life hospitalization. When patients were admitted with a limited anticipated life expectancy, FPs were more likely to indicate that an inadequate caring capacity of the care setting had played a role in the admission.Conclusion: To reduce the number of hospital deaths, a combination of structural support for out-of-hospital end-of-life care and a more timely referral to out-of-hospital palliative care services may be needed. [ABSTRACT FROM AUTHOR]

Background High drug use and associated adverse outcomes are common in older adults. This study investigates association of medication use with mortality, hospitalisation, and institutionalisation in a cohort of community-dwelling oldest old (aged 80 and over). Methods Baseline data included socio-demographic, clinical, and functional characteristics, and prescribed medications. Medications were coded by the Anatomic Therapeutic Chemical classification. Survival analysis was performed at 18 months after inclusion using Kaplan–Meier, and multivariate analysis with Cox regression to control for covariates. Results Patients’ ( n = 503) mean age was 84.4 years (range 80–102), and 61.2% was female. The median medication use was 5 (0–16). The mortality, hospitalisation, and institutionalisation rate were 8.9%, 31.0%, and 6.4% respectively. The mortality and hospitalisation group had a higher level of multimorbidity and weaker functional profile. Adjusted multivariate models showed an 11% increased hospitalisation rate for every additional medication taken. No association was found between high medication use and mortality, nor with institutionalisation. A higher association for mortality was observed among verapamil/diltiazem users, hospitalisation was higher among users of verapamil/diltiazem, loop diuretics and respiratory agents. Institutionalisation was higher among benzodiazepines users. Conclusion In the community-dwelling oldest old (aged 80 and over), high medication was clearly associated with hospitalisation, independent of multimorbidity. The association with mortality was clear in univariate, but not in multivariate analysis. No association with institutionalisation was found. The appropriateness of the high medication use should be further studied in relation to mortality, hospitalisation, and institutionalisation for this specific age group. [ABSTRACT FROM AUTHOR]

Objectives: To explore how GPs conceptualise advance care planning (ACP), based on their experiences with ACP in their practice. Methods: Five focus groups were held with 36 GPs. Discussions were analysed using a constant comparative method. Results: Four overarching themes in the conceptualisations of ACP were discerned: (1) the organisation of professional care required to meet patients’ needs, (2) the process of preparing for death and discussing palliative care options, (3) the discussion of care goals and treatment decisions, (4) the completion of advance directives. Within these themes, ACP was both conceptualised in terms of content of ACP and/or in terms of tasks for the GP. A specific task that was mentioned throughout the discussion of the four different themes was (5) the task of actively initiating ACP by the GP versus passively waiting for patients’ initiation. Conclusions: This study illustrates that GPs have varying conceptualisations of ACP, of which some are more limited to specific aspects of ACP. A shared conceptualisation and agreement on the purpose and goals of ACP is needed to ensure successful implementation, as well as a systematic integration of ACP in routine practice that could lead to a better uptake of all the important elements of ACP. [ABSTRACT FROM AUTHOR]

Background: Most patients with life-limiting illnesses are treated and cared for over a long period of time in primary care and guidelines suggest that ACP discussions should be initiated in primary care. However, a practical model to implement ACP in general practice is lacking. Therefore, the objective of this study is to develop an intervention to support the initiation of ACP in general practice. Methods: We conducted a Phase 0-I study according to the Medical Research Council (MRC) Framework. Phase 0 consisted of a systematic literature review about the barriers and facilitators for GPs to engage in ACP, focus groups with GPs were held about their experiences, attitudes and concerns regarding initiating ACP in general practice and a review of ACP interventions to identify potential components for the development of our intervention. In Phase 1, we developed a complex intervention to support the initiation of ACP in general practice in patients at risk of deteriorating or dying, based on the results of Phase 0. The complex intervention and its components were reviewed and refined by two expert panels. Results: Phase 0 resulted in the identification of the factors inhibiting or enabling GPs' initiation of ACP and important components underpinning existing ACP interventions. Based on these findings, an intervention was developed in Phase 1 consisting of: (1) a training for GPs in initiating and conducting ACP discussions, (2) a register of patients eligible for ACP discussions, (3) an educational booklet on ACP for patients to prepare the ACP discussions that includes general information on ACP, a section on the role of GPs in the process of ACP and a prompt list, (4) a conversation guide to support GPs in the ACP discussions and (5) a structured documentation template to record the outcomes of discussions. Conclusion: Taking into account the barriers and facilitators for GPs to initiate ACP as well as the key factors underpinning successful ACP intervention in other health care settings, a complex intervention for general practice was developed, after gaining feedback from two expert panels. The feasibility and acceptability of the intervention will subsequently be tested in a Phase II study. [ABSTRACT FROM AUTHOR]

Background: To determine the extent to which members of the general population have talked to their physician about their wishes regarding medical treatment at the end of life, to describe the prevalence of advance directives on euthanasia, and to identify associated factors. Method: This study used data from the cross-sectional Health Interview Study (HIS) 2008 that collected data from a representative sample (N = 9651) of the Belgian population. Results: Of all respondents, 4.4 % had spoken to their physician about their wishes regarding medical treatment at the end of life, while 1.8 % had an advance directive on euthanasia. Factors positively associated with discussions regarding wishes for medical treatment at the end of life were being female, being older in age, having poorer health status and having more GP contacts. People older than 55 years and living in Flanders or Brussels were more likely than the youngest age categories to have an advance directive on euthanasia. Conclusion: Younger people, men, people living in the Walloon region of Belgium, people without a longstanding illness, chronic condition or disability and people with few GP contacts could represent a target group for education regarding advance care planning. Public information campaigns and education of physicians may help to enable the public and physicians to engage more in advance care planning. [ABSTRACT FROM AUTHOR]

International Non-proprietary Name ( INN) prescribing is the use of the name of the active ingredient(s) instead of the brand name for prescribing. In Belgium, INN prescribing began in 2005 and a major policy change occurred in 2012. The aim was to explore the opinions of Dutch-speaking general practitioners ( GPs) and pharmacists. An electronic questionnaire with 39 five-point Likert scale statements and one open question was administered in 2013. Multivariate analysis was performed with multiple linear regression on a sum score for benefit statements and for drawback statements. Answers to the open question were qualitatively analysed. We received 745 valid responses with a representable sample for both subgroups. Participants perceived the motives to introduce INN prescribing as purely economic (to reduce pharmaceutical expenditures for the government and the patient). Participants accepted the concept of INN prescribing, but 88% stressed the importance of guaranteed treatment continuity, especially in older, chronic patients, to prevent patient confusion, medication non-adherence and erroneous drug use. In conclusion, the current way in which INN prescribing is applied in Belgium leads to many concerns among primary health professionals about patient confusion and medication adherence. Slightly adapting the current concept of INN prescribing to these concerns can turn INN prescribing into one of the major policies in Belgium to reduce pharmaceutical expenditures and to stimulate rational drug prescribing. [ABSTRACT FROM AUTHOR]