398 CHAPTER 5 recommendations implemented at two months, with a mean of 1.16 (SD = 1.48) implemented recommendations per patient, mostly discontinuing inappropriate prescribing (Chapter 3.2). Reasons for intentional non-implementation of recommendations provided by the pharmacotherapy team were studied in the Dutch cohort of OPERAM intervention patients, revealing that approximately 40% of all recommendations were disagreed upon by either the attending physician, the patient or both (Chapter 4.2). Our results showed that, in addition to the aforementioned variability in the acceptance of CDSS-generated signals, the subsequent implementation of recommendations was also highly susceptible to variability, thereby impacting the effectiveness of the medication reviewon clinical outcomes. The level of agreement between the attending physician and the patient depended on the type of recommendation (Chapter 4.2, Box 2) which likely required different strategies to increase implementation [44]. In Box 2, Example 1 (discontinuation of benzodiazepines), strategies primarily focusing on patients’ barriers to deprescribe a benzodiazepine might increase successful implementation. We found that 90% of disagreed recommendations to discontinue a benzodiazepine were due to patient reluctance. A systematic review of primary care interventions to deprescribe benzodiazepines emphasised the importance of shared decision-making between health care professionals and patients [45], finding that patient education combined with tapering recommendations resulted in discontinuation rates varying from 27% to 36%, while pharmacological substitution or tapering recommendations combined with psychological support resulted in discontinuation rates between 65% and 80% [45]. These results highlighted how to overcome patient barriers and question the feasibility of successfully deprescribing of long-term benzodiazepine use in the acute hospital setting, given the importance of intensive patient follow-up and monitoring. In Box 2, Example 2 (discontinuation of unindicated acetylsalicylic acid), strategies primarily focused on prescriber’s barriers and the adequate transfer of medication changes across care settings might increase the implementation of this recommendation. A recent multicentre non-controlled intervention study in Dutch hospitals investigated unintentional guideline deviations in hospitalised patients with two or more antithrombotic agents. An algorithm prospectively selected patients based on antithrombotic prescriptions. In 42% of patients (median age 74; IQR 69–81]), an unintentional guideline deviation was observed and 70% were related to anticoagulation therapy combined with the use of unindicated antiplatelet therapy [46]. Admission to a non-cardiology ward was significantly associated with a higher risk of unintentional guideline deviations (OR 4.25 [95% confidence interval (CI); 3.07–5.88]). The overall proportion of patients with an unintentional deviation was reduced to 2.2% after a hospital pharmacist’s intervention, with
RkJQdWJsaXNoZXIy MTk4NDMw