Effects of an interprofessional deprescribing intervention in Swiss nursing homes: the Individual Deprescribing Intervention (IDeI) randomised controlled trial

Background Deprescribing polypharmacy and potentially inappropriate medications (PIMs) has been shown to be beneficial to nursing home (NH) residents' health. Medication reviews are the most widely studied deprescribing intervention; in a previous trial, we showed that another intervention, a deprescribing-focused interprofessional quality circle, can reduce the use of inappropriate medications at the NH level. However, this intervention cannot account for the variety of the residents’ clinical situations. Therefore, we trialled a subsequent intervention in NH that enacted the quality circle intervention in the previous year. Methods In 7 NHs, the most heavily medicated residents were recruited and randomised to receive usual care or the intervention. The intervention was a pharmacist-led, deprescribing-focused medication review, followed by the creation of an individualised treatment modification plan in collaboration with nurses and physicians. Intervention’s effects were assessed after four months on the number and dose of PIMs used, quality of life, and safety outcomes (mortality, hospitalisations, falls, and use of physical restraints). Data were analysed using Poisson multivariate regression models. Results Sixty-two NH residents participated, falling short of the expected 100 participants; 4 died before initial data collection. Participants used a very high number of drugs (median 15, inter-quartile range [12-19]) and PIMs (median 5, IQR [3-7]) at baseline. The intervention did not reduce the number of PIMs prescribed to the participants; however, it significantly decreased their dose (incidence rate ratio 0.763, CI95 [0.594; 0.979]), in particular for chronic drugs (IRR 0.716, CI95 [0.546; 0.938]). No adverse effects were seen on mortality, hospitalisations, falls, and restraints use, but, in the intervention group, three participants experienced adverse events that required the reintroduction of withdrawn treatments, and a decrease in quality of life is possible. Conclusions As it did not reach its recruitment target, this trial should be seen as exploratory. Results indicate that, following a NH-level deprescribing intervention, a resident-level intervention can further reduce some aspects of PIMs use. Great attention must be paid to residents’ well-being when further developing such deprescribing interventions, as a possible reduction in quality of life was found in the intervention group, and some participants suffered adverse events following deprescribing. Trial registration ClinicalTrials.gov (NCT03688542, https://clinicaltrials.gov/ct2/show/NCT03688542), registered on 31.08.2018.

Re-Engineering Collaborative Practice in Primary Care: Integrating Community Pharmacy to the Clinic; Creating a Pharmacy Referral and Quality Circle

Pharmacy practice is part of a value chain made up of suppliers(S), inputs(I), processes(P), outputs(O), and customers(C). The interface between community pharmacies and clinic-based prescribers is complicated by challenges related to gaps in the design of the chain. The supplier-input-process-outcome-customer (SIPOC) model can be used to re-engineer the chain: integrating an intervening clinical pharmacist in the interface creates a structure for interprofessional collaboration and communication across the interface. This innovation has important implications for patient referral between clinic and pharmacy, and the future role and scope of all patient-facing pharmacists.

Effects of an interprofessional Quality Circle-Deprescribing Module (QC-DeMo) in Swiss nursing homes: a randomised controlled trial

Background Potentially inappropriate medications (PIMs) are common among nursing homes (NH) residents, as is polypharmacy. Deprescribing has emerged in the past decade as a safe and effective way to reduce the use of PIMs and improve patient outcomes. However, effective deprescribing interventions are expensive, as they require specialised staff and a great amount of time for each resident. The Quality Circle Deprescribing Module (QC-DeMo) intervention was designed to be less resource-intensive than medication reviews, the current deprescribing gold standard. It consists of a QC session in which physicians, nurses, and pharmacists define a local deprescribing consensus for specific PIMs classes, which is then implemented in the NH. The intervention was trialled in a RCT, with the NH as unit of analysis. Methods After randomisation, intervention NHs enacted the QC-DeMo at the start of the follow-up year. The primary outcomes were the proportion of PIM galenic units and number of PIM defined daily dose per average resident and per day (DDD/res). PIM status was assessed by a combination of the 2015 Beers list and the Norwegian General Practice-Nursing Home criteria. Secondary outcomes were the number of DDD/res to avoid and to reevaluate; safety outcomes were mortality, hospitalisations, falls, and use of physical restraints. Outcomes were evaluated at follow-up using linear regression models, adjusting for the outcome baseline values. Results Fifty-eight NHs took part in the trial; no individual residents were recruited. The intervention did not reduce the primary outcomes, but a strong trend towards reduction was seen for the number of PIM DDD/res, which accounts for the doses used. PIM DDD/res to reevaluate were significantly reduced, mostly through a reduction in the use of proton-pump inhibitors. Falls and use of physical restraints were not affected, but a statistical interaction between the mission of the NH (geriatric unit or specialised dementia unit) and the intervention group was seen for mortality and hospitalisations. Conclusions The QC-DeMo intervention can reduce the use of some PIM classes, and could usefully complement other deprescribing interventions. Trial registration ClinicalTrials.gov (NCT03688542), registered on 26.09.2018, retrospectively registered.

EFFECTS OF CHANGE MANAGEMENT PRACTICES ON ORGANIZATIONAL PERFORMANCE: THE CASE OF ETHIO TELECOM SOUTH REGION ETHIOPIA

The main objective of this study was to investigate the effect of change management practices on organization performance in the case of ethio telecom south region. To attain this objective, 50 males and 19 females totally (69) respondents were selected using simple random sampling. The population of the study was employees, supervisors and managers of ethio telecom south region. Simple Random sampling was used to select the appropriate sample of the respondent and the shops were selected by purposive sampling with respect to balanced scorecard management practices, kaizen philosophy management practice and standard quality circle management practice. Descriptive research designs as well qualitative and quantitative research approach were employed in conducting the study. Data was collected using questionnaires and interviews and analyzed using SPSS Version 24. Descriptive analysis namely percentage, mean, standard deviation and inferential analysis namely multiple linear regression were employed. The study indicated that balanced scored cared, kaizen and standard quality circle management practiced in ethio telecom south region occasionally. Moreover, this study revealed that balanced scored cared, kaizen and standard quality circle management practice contributed to ethio telecom south region organizational performance to a great extent. The study also showed that there was significant relationship between balanced scored cared, kaizen and standard quality circle management practices and organizational performance of ethio telecom south region. This study further revealed that balanced scored card, kaizen and standard quality circle management practices had a positive effect on organizational performance of ethio telecom south region. Likewise, this study showed that kaizen management practice is statistically significant in predicting organizational performance. More importantly, this study recommended ethio telecom south region to practice the balanced scorecard

Quality Circle: A Methodology to Enhance the Plant Capacity through Why-Why Analysis

In the manufacturing firms, hospitals, banks, schools and research institutes etc., total customer satisfaction with products and services have very much importance and also necessary for their survival. Quality services and reducing wastages of all types are the primary need of every organisation. Quality Circle is (QC) is one of the techniques that can be utilised to solve industrial problems and can reduce the rejection level. In present paper, QC concept is implemented to solve wastage problem by taking a real case study of an automobile industry. The observed data was analysed through various problem solving techniques such as 80/20 rule and fishbone diagram etc. Finally, Why-Why analysis was carried out to identify the root cause of the problem and suggested actions to solve the problem. The following results were obtained: Gradually reduction in materials wastage minimises the rejection and hence reduces the overhead expenses of the firm. Further, QC helps in motivating employees to do their best for the organisation, which not only improves the productivity of the organisation, but also helps in discovering hidden talent and creative skill of the workforce. Finally, QC helps in developing the sense of belongingness towards organisations.

Texture modified diet in German nursing homes: availability, best practices and association with nursing home characteristics

Background For nursing home (NH) residents with swallowing or chewing problems, appealing texture-modified-diets (TMD) need to be available in order to support adequate nutrition. The aim of this study was to describe the availability of TMD and best practices for TMD in German NHs and to identify related NH characteristics. Methods Information on NH characteristics, available texture-modified (TM)-levels (soft, “minced & moist”, pureed) and implemented best practices for TMD (derived from menu plan, separately visible components, re-shaped components, considering individual capabilities of the resident) was collected in a survey in German NHs. The number of TM-levels as well as the number of best practices for TMD were tested for their association with 4 structural, 16 operational and 3 resident-related NH characteristics. Results The response rate was 7.2% (n = 590) and 563 NHs were included. The vast majority of NHs (95.2%) reported offering “minced & moist” texture and 84.2% preparing separately visible meal components. Several operational characteristics were more frequently (p < 0.05) reported from NHs offering three TM-levels (27.7%) or four best practices for TMD (13.0%) compared to NHs offering one TM-level (28.4%) or one best practice for TMD (20.1%): special diets and delivery forms (e.g. fingerfood 71.2% vs 38.8%; 80.8% vs. 44.3%), written recipes (69.9% vs. 53.1%; 68.5% vs. 53.9%), a dietetic counseling service (85.9% vs. 66.3%; 89.0% vs. 65.2%), a quality circle for nutritional care (66.7% vs. 43.8%; 71.2% vs. 50.4%), regular staff training (89.7% vs. 73.1%; 95.9% vs. 74.8%) and process instructions (73.7% vs. 53.1%; 75.3% vs. 47.8%). No associations were found regarding structural and resident-related NH characteristics, except a higher percentage of residents receiving TMD in NHs with three compared to one TM-level (median 16.3% vs. 13.2%, p = 0.037). Conclusion All participating NHs offer some form of TMD, but only a small number offers a selection of TMD and pays adequate attention to its preparation. Operational NH characteristics – which might reflect a general nutritional awareness of the NH – seem to be pivotal for provision of TMD, whereas neither structural nor resident-related characteristics seem to play a role in this regard.