Medicine sustainability interventions
Clinical care
Sharing the indication and intended treatment duration of multiple anticoagulant therapies with primary care
The prescription of multiple anticoagulant therapy (e.g. double or triple therapy with anticoagulants and antiplatelet agents) is complex and associated with an increased risk of bleeding. Patients often use these combinations temporarily, for example after acute coronary syndrome, percutaneous coronary intervention, or concomitant atrial fibrillation and stent implantation (1). European and Dutch guidelines therefore emphasize that double or triple therapy is never indicated for life, but always has a limited treatment period, depending on the clinical situation and the individual balance between the risk of bleeding or an ischemic event (1).
In practice, however, it appears that these drugs are regularly used for too long or are continued without a current indication, which significantly increases the risk of serious, preventable bleeding. For example, research in Dutch pharmacies showed that 14— 23% of patients who used dual anticoagulation no longer had a valid indication (2). During hospitalization, it was found that more than 40% of patients with multiple anticoagulant therapies used these combinations incorrectly (3). This risks bleeding complications, and thus unnecessary hospital admissions (4), but also contributes to unnecessary costs and environmental impact.
To prevent this, clear communication during dismissal and transfer is crucial. Explicitly sharing the indication and the intended treatment duration with primary care (general practitioner and pharmacist) enables follow-up care providers to continue treatment responsibly or to stop it in time. This contributes to medication safety, reduces the risk of complications and prevents unnecessary drug use.
Intervention
Preventing unnecessarily long use of multiple anticoagulant therapies by sharing the indication and intended treatment duration with primary care providers.
Environmental impact
This intervention primarily focuses on improving communication about the indication and intended treatment duration of multiple anticoagulation. A possible link to environmental impact will follow.
Working method
1. Determine population and formulate goals
- Determine the department (s) and/or patient group (s) that this intervention will focus on.
- Focus on departments and/or indications where multiple anticoagulant therapies are indicated, such as neurology, cardiology and vascular surgery.
- Evaluate how often indication and treatment duration are currently recorded and shared in letters of discharge and medication transfer using prescription data and letters of discharge in the EPD, see “How to evaluate a drug intervention”.
- Formulate SMART goals together with (the green team of) the relevant department (s). For example: Within six months, ≥ 90% of discharge prescriptions for multiple anticoagulation include both an indication and an intended treatment duration.
2. Implementation
- Establish a standard method for prescribing multiple anticoagulation, which always explicitly states the indication and intended treatment duration, see “How to ensure the transfer of information between hospital and primary care”.
- Make this mandatory in the EPD, for example via mandatory fields in order sets or prescribing modules.
- Make sure that letters of resignation and medication transfers to the front line automatically include the indication and treatment duration.
- Make process agreements about exceptions, for example patients whose treatment time depends on later evaluation.
- Inform the prescribers and pharmacists of the department concerned and, if necessary, the Medicines Committee about the change, for example by briefly explaining the change during transfers and/or team meetings.
3. Monitoring and Evaluation
- Monitor implementation using (outpatient) clinical prescriptions and discharge prescriptions, see “Method of evaluating a drug intervention”. Discuss (interim) results regularly, for example (twice) monthly, during transfers, team meetings and/or teaching.
- Reflect on results in relation to the set goal, obstructing and promoting factors. Adjust interventions if necessary.
- At the end of the follow-up period, evaluate whether the goal (s) is/have been achieved and how the change is secured.
- Provide (interim) results back to the implementation supervisor.
How is this measured?
This intervention focuses on improving communication about the indication and intended treatment duration of multiple anticoagulation, which can be measured by the proportion of discharge prescriptions and letters stating the indication and intended treatment duration.
When successfully implemented?
Based on the increase in the proportion of prescriptions with indications and intended treatment duration, as described in the previous section, determine when the implementation is considered successful, and reflect on the set goal.
Resources
- van Uden RCAE, Houtenbos I, Griffioen-Keijzer A, Odekerken DAM, van den Bemt PMLA, Becker ML. Guidelines for mono, double and triple antithrombotic therapy. Postgrad Med. 2021 Nov; 97 (1153) :730-737.
- Warlé-Van Herwaarden MF, Roukens M, Pop GAM, et al. Adherence to guidelines for the prescribing of double and triple combinations of antithrombotic agents. Eur J Prev Cardiol 2014; 21:231 —43.
- van Uden RCAE, van den Broek MPH, Houtenbos I, Jaspers TCC, Harmsze AM, Kingma HJ, Odekerken DAM, Meijer K, van den Bemt PMLA, Becker ML. Unintentional guideline deviations in hospitalized patients with two or more antithrombotic agents: an intervention study. Eur J Clin Pharmacol. 2021 Dec; 77 (12) :1919-1926.
- Leendertse AJ, Egberts ACG, Stoker LJ, et al. Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands. Arch Intern Med 2008; 168:1890 —6.
Attachments
View our other interventions
Clinical care and outpatient care
Targeted prescribing of proton pump inhibitors (as stomach protection)
Proton pump inhibitors (PPIs) are antacids that are frequently used. Pantoprazole (1.3 million users) and (es) omeprazole (1.2 million users) were among the top 3 most used medicines in 2023 (1). However, it appears that a large number of these drug users have no indication for PPI use (anymore) (2). With short-term use, more than half of the patients appeared to have no indication (3). Part of this is caused by starting PPIs as stomach protection without indication.
The NHG guideline “Prevention of stomach complications due to drug use (NL)” and the knowledge document proton pump inhibitors (NL) indicate that a PPI is indicated as stomach protection based on risk factors, such as age, ulcer or history of stomach complications, NSAID dosing, co-medication with an increased risk of stomach complications and comorbidities, such as rheumatoid arthritis, heart failure or diabetes (4 - 6). By prescribing PPIs based on risk factors for stomach protection, unnecessary PPI use can be reduced, thereby preventing environmental impact.
Clinical care and outpatient care
Discontinuation of proton pump inhibitors without a current indication
Proton pump inhibitors (PPIs) are antacids that are frequently used. Pantoprazole (1.3 million users) and (es) omeprazole (1.2 million users) were among the top 3 most used medicines in 2023 (1). However, it appears that a large number of these drug users have no indication for PPI use (2). In short-term use, more than half of the patients appeared to have no indication (3); in chronic use, this figure is even 87% (4). Overtreatment with PPIs risks side effects, such as an increased risk of bone fractures and vitamin B12 deficiency, but also leads to unnecessary costs and environmental impact (2).
The NHG 'Stomach Disease (NL)' guideline and the NVMDL guideline 'Gastroesophageal Reflux Disease (NL)' provide recommendations to prevent overtreatment with PPIs (5.6). These guidelines recommend that patients with stomach problems or disorders with a temporary indication for PPIs should reduce a PPI within three months. Only patients with grade C and D4 reflux esophagitis, Barrett's oesophagus and Zollinger-Ellison syndrome should use a PPI for life (5 - 7). A PPI for stomach protection should be stopped when a patient stops taking the medication for which it was prescribed (8).
The Proton Pump Inhibitors Knowledge Paper (NL) explains the consideration for reducing or discontinuing proton pump inhibitors when using PPIs chronically (7). Reducing appears to be successful in approximately 40 - 70% of the patients, depending on the intervention that is chosen (9). In this way, any long-term side effects of PPIs can be prevented and costs and environmental impact can be saved (5 - 7).
Clinical care
Paracetamol should be administered orally instead of intravenously
To treat postoperative pain, intravenous (IV) acetaminophen is usually administered. However, research shows that oral (PO) administration is equally effective and more sustainable in most patients. A systematic review of 14 studies shows that there is no convincing difference in the analgesic effect between IV and oral acetaminophen at different times after surgery (1). However, the environmental impact varies considerably: CO2 emissions from IV administration are up to 16x higher (2). Where an oral administration of 1 gram of acetaminophen from a blister results in the emission of approximately 38 grams of CO₂ eq., this can be up to 628 grams when administered IV, depending on the packaging and administration material (2).
In most patients, acetaminophen can be administered orally, as described in the NVZA Monograph 'Paracetamol' (3). The paracetamol challenge demonstrated that IV acetaminophen administration can be reduced by at least 25%, saving staff time, costs and environmental impact (4). These results underline deployment at a larger scale.
Clinical care
Treatment with oral antibiotics when bioavailability is good
Timely conversion from intravenous (IV) to oral antibiotics is an important intervention within appropriate and sustainable care. Within the national antimicrobial stewardship program, as developed by SWAB, it is recommended to re-evaluate the route of antibiotic administration daily and switch to oral therapy as soon as possible once the patient is clinically stable and oral intake is possible (1). Switching to oral therapy contributes to shortening hospital stays, reduces complications from IV administration such as line infections and phlebitis, decreases the time spent preparing and administering infusions, and reduces material usage (2).
The Dutch Healthcare Institute explicitly states in its improvement report on Lower Respiratory Tract Infections that, where possible, a switch to oral antibiotics should be made for community-acquired pneumonia (CAP) (3). This recommendation has been translated into a target of 80% IV-to-oral switch, as included in the implementation agenda for Healthcare Evaluation and Appropriate Use (4). The Antimicrobial Stewardship Monitor (AMSM), which provides feedback on prescribing behavior to local A-teams, shows that this target percentage is often not yet achieved in practice (5).
Besides CAP, there is increasing evidence for IV-to-oral switch in other indications. A systematic review shows that in clinically stable patients with osteomyelitis, bacteremia, and endocarditis, an early switch to oral antibiotics leads to a clinically equivalent, but safer treatment, including a shorter hospital stay (6). For bone and joint infections, it has been shown that oral therapy during the first six weeks of treatment is non-inferior to intravenous therapy (7). It also appears that in patients with cellulitis, a switch to oral treatment, once the spread of the infection has stopped, leads to a non-inferior treatment (8).
Timely switching to oral treatment offers not only clinical benefits but also sustainability gains. For example, for penicillin use in pneumonia, based on the baseline situation in Denmark, it has been shown that timely completion of oral treatment leads to a reduction in climate impact of approximately 56%, increasing to 94% with fully oral treatment (9). For ciprofloxacin, a recent study has shown that one oral dose has a climate impact of 12.6 grams of CO2-equivalent, while an IV dose corresponds to a climate impact of almost 900 grams of CO2-equivalent (10).
