@article {452, title = {Interventions to reduce inappropriate polypharmacy: Implications for research and practice.}, journal = {Maturitas}, volume = {97}, year = {2017}, month = {2017 Mar}, pages = {66-68}, issn = {1873-4111}, doi = {10.1016/j.maturitas.2016.12.007}, author = {Johansson, Tim and Flamm, Maria and S{\"o}nnichsen, Andreas and Schuler, Jochen} } @article {453, title = {Impact of strategies to reduce polypharmacy on clinically relevant endpoints: a systematic review and meta-analysis.}, journal = {Br J Clin Pharmacol}, volume = {82}, year = {2016}, month = {2016 Aug}, pages = {532-48}, abstract = {

AIM: The aim of the present study was to explore the impact of strategies to reduce polypharmacy on mortality, hospitalization and change in number of drugs.

METHODS: Systematic review and meta-analysis: a systematic literature search targeting patients >=65 years with polypharmacy (>=4 drugs), focusing on patient-relevant outcome measures, was conducted. We included controlled studies aiming to reduce polypharmacy. Two reviewers independently assessed studies for eligibility, extracted data and evaluated study quality.

RESULTS: Twenty-five studies, including 10 980 participants, were included, comprising 21 randomized controlled trials and four nonrandomized controlled trials. The majority of the included studies aimed at improving quality or the appropriateness of prescribing by eliminating inappropriate and non-evidence-based drugs. These strategies to reduce polypharmacy had no effect on all-cause mortality (odds ratio 1.02; 95\% confidence interval 0.84, 1.23). Only single studies found improvements, in terms of reducing the number of hospital admissions, in favour of the intervention group. At baseline, patients were taking, on average, 7.4 drugs in both the intervention and the control groups. At follow-up, the weighted mean number of drugs was reduced (-0.2) in the intervention group but increased (+0.2) in controls.

CONCLUSIONS: There is no convincing evidence that the strategies assessed in the present review are effective in reducing polypharmacy or have an impact on clinically relevant endpoints. Interventions are complex; it is still unclear how best to organize and implement them to achieve a reduction in inappropriate polypharmacy. There is therefore a need to develop more effective strategies to reduce inappropriate polypharmacy and to test them in large, pragmatic randomized controlled trials on effectiveness and feasibility.

}, keywords = {Aged, Drug-Related Side Effects and Adverse Reactions, Hospitalization, Humans, Inappropriate Prescribing, Outcome Assessment, Health Care, Polypharmacy, Practice Patterns, Physicians{\textquoteright}, Randomized Controlled Trials as Topic}, issn = {1365-2125}, doi = {10.1111/bcp.12959}, author = {Johansson, Tim and Abuzahra, Muna E and Keller, Sophie and Mann, Eva and Faller, Barbara and Sommerauer, Christina and H{\"o}ck, Jennifer and L{\"o}ffler, Christin and K{\"o}chling, Anna and Schuler, Jochen and Flamm, Maria and S{\"o}nnichsen, Andreas} } @article {12, title = {The impact of preoperative testing for blood glucose concentration and haemoglobin A1c on mortality, changes in management and complications in noncardiac elective surgery: a systematic review.}, journal = {Eur J Anaesthesiol}, volume = {32}, year = {2015}, month = {2015 Mar}, pages = {152-9}, abstract = {

BACKGROUND: The risks associated with surgery are elevated in patients with diabetes mellitus. For this reason, preoperative diagnostics frequently include the measurement of blood glucose and haemoglobin A1c (HbA1c), but it is unclear whether these tests contribute to improved perioperative or postoperative outcomes.

OBJECTIVES: This systematic review aimed to evaluate the evidence that preoperative testing for blood glucose and HbA1c might influence the following outcome parameters: changes in clinical management; mortality; and the incidence of perioperative and postoperative complications in patients undergoing elective, noncardiac surgery.

DESIGN: We performed a systematic search of the literature from January 2001 to March 2013, thus updating a review carried out by the National Institute for Health and Clinical Excellence (NICE) up to the year 2001.

ELIGIBILITY CRITERIA: Controlled studies including cohort and case-control studies with a population of at least 60 patients were eligible.

RESULTS: The search retrieved 1346 records (including hand-search). Twenty-two studies met all inclusion criteria and were included in the review. Fifteen cohort and two case-control studies evaluated the effectiveness of preoperative blood glucose testing and nine studies the effectiveness of testing HbA1c. Four of the included studies evaluated both tests. There were no data derived from high-quality studies supporting routine preoperative testing for blood glucose or HbA1c in otherwise healthy adult patients undergoing elective noncardiac surgery. Only in vascular and orthopaedic surgery may screening identify patients at an increased risk.

CONCLUSION: Preoperative blood glucose testing and testing for HbA1c is not required in nondiabetic patients unless there are clinical sings arousing suspicion. Patients scheduled for vascular and orthopaedic surgery carry an elevated risk justifying preoperative testing for blood glucose or HbA1c as a screening tool.

}, keywords = {Biomarkers, Blood Glucose, Diabetes Mellitus, Elective Surgical Procedures, Glycated Hemoglobin, Humans, Orthopedic Procedures, Predictive Value of Tests, Preoperative Care, Risk Assessment, Risk Factors, Time Factors, Treatment Outcome, Vascular Surgical Procedures}, issn = {1365-2346}, doi = {10.1097/EJA.0000000000000117}, author = {Bock, Matthias and Johansson, Tim and Fritsch, Gerhard and Flamm, Maria and Hansbauer, Bernhard and Mann, Eva and S{\"o}nnichsen, Andreas} } @article {454, title = {Quality improvement in preoperative assessment by implementation of an electronic decision support tool.}, journal = {J Am Med Inform Assoc}, volume = {20}, year = {2013}, month = {2013 Jun}, pages = {e91-6}, abstract = {

OBJECTIVES: To evaluate the impact of the electronic decision support (eDS) tool {\textquoteright}PReOPerative evaluation{\textquoteright} (PROP) on guideline adherence in preoperative assessment in statutory health care in Salzburg, Austria.

MATERIALS AND METHODS: The evaluation was designed as a non-randomized controlled trial with a historical control group (CG). In 2007, we consecutively recruited 1363 patients admitted for elective surgery, and evaluated the preoperative assessment. In 2008, PROP was implemented and available online. In 2009 we recruited 1148 patients preoperatively assessed using PROP (294 outpatients, 854 hospital sector). Our analysis includes full blood count, liver function tests, coagulation parameters, electrolytes, ECG, and chest x-ray.

RESULTS: The number of tests/patient without indication was 3.39 in the CG vs 0.60 in the intervention group (IG) (p<0.001). 97.8\% (CG) vs 31.5\% (IG) received at least one unnecessary test. However, we also observed an increase in recommended tests not performed/patient (0.05{\textpm}0.27 (CG) vs 0.55{\textpm}1.00 (IG), p<0.001). 4.2\% (CG) vs 30.1\% (IG) missed at least one necessary test. The guideline adherence (correctly tested/not tested) improved distinctively for all tests (1.6\% (CG) vs 49.3\% (IG), p<0.001).

DISCUSSION: PROP reduced the number of unnecessary tests/patient by 2.79 which implied a reduction of patients{\textquoteright} burden, and a relevant cut in unnecessary costs. However, the advantage in specificity caused an increase in the number of patients incorrectly not tested. Further research is required regarding the impact of PROP on perioperative outcomes.

}, keywords = {Adult, Aged, Austria, Decision Support Systems, Clinical, Diagnostic Tests, Routine, Elective Surgical Procedures, Female, Guideline Adherence, Humans, Male, Middle Aged, Practice Guidelines as Topic, Preoperative Care, Quality Improvement}, issn = {1527-974X}, doi = {10.1136/amiajnl-2012-001178}, author = {Flamm, Maria and Fritsch, Gerhard and Hysek, Martin and Klausner, Sabine and Entacher, Karl and Panisch, Sigrid and Soennichsen, Andreas C} }