Falls are the leading cause of injury-related mortality and hospitalization among adults aged greater than or equal to 65 years. An important modifiable fall-risk factor is use of fall-risk ...increasing drugs (FRIDs). However, deprescribing is not always attempted or performed successfully. The ADFICE_IT trial evaluates the combined use of a clinical decision support system (CDSS) and a patient portal for optimizing the deprescribing of FRIDs in older fallers. The intervention aims to optimize and enhance shared decision making (SDM) and consequently prevent injurious falls and reduce healthcare-related costs. A multicenter, cluster-randomized controlled trial with process evaluation will be conducted among hospitals in the Netherlands. We aim to include 856 individuals aged greater than or equal to 65 years that visit the falls clinic due to a fall. The intervention comprises the combined use of a CDSS and a patient portal. The CDSS provides guideline-based advice with regard to deprescribing and an individual fall-risk estimation, as calculated by an embedded prediction model. The patient portal provides educational information and a summary of the patient's consultation. Hospitals in the control arm will provide care-as-usual. Fall-calendars will be used for measuring the time to first injurious fall (primary outcome) and secondary fall outcomes during one year. Other measurements will be conducted at baseline, 3, 6, and 12 months and include quality of life, cost-effectiveness, feasibility, and shared decision-making measures. Data will be analyzed according to the intention-to-treat principle. Difference in time to injurious fall between the intervention and control group will be analyzed using multilevel Cox regression. The findings of this study will add valuable insights about how digital health informatics tools that target physicians and older adults can optimize deprescribing and support SDM. We expect the CDSS and patient portal to aid in deprescribing of FRIDs, resulting in a reduction in falls and related injuries.
The electronic health record (EHR) is central to medical informatics. Its use is also recognized as an important skill for future clinicians. Typically, medical students' first exposure to an EHR is ...when they start their clinical internships, and medical informatics students may or may not get experience with an EHR before graduation. We describe the process of implementing an open-source EHR in two curricula: Medicine and Medical informatics. For medical students, the primary goals were to allow students to practice analyzing information from the EHR, creating therapeutic plans, and communicating with their colleagues via the EHR before they start their first clinical rotations. For medical informatics students, the primary goal was to give students hands-on experience with creating decision support in an EHR.
We used the OpenMRS electronic health record with a custom decision support module based on Arden Syntax. Medical students needed a secure, stable environment to practice medical reasoning. Medical informatics students needed a more isolated system to experiment with the EHR's internal configuration. Both student groups needed synthetic patient cases that were realistic, but in different aspects. For medical students, it is essential that these cases are clinically consistent, and events unfold in a logical order. By contrast, synthetic data for medical informatics students should mimic the data quality problems found in real patient data.
Medical informatics students show more mature reasoning about data quality issues and workflow integration than prior to using the EHR. Comments on both course evaluations have been positive, including comments on how working with a real-world EHR provides a realistic experience.
The open-source EHR OpenMRS has proven to be a valuable addition to both the medicine and medical informatics curriculum. Both sets of students experience use of the EHR as giving them valuable, realistic learning experiences.
In the initial B-proof, we found inconsistent results of B vitamin supplementation. However, the debate regarding the effects of B vitamins on age-related diseases continues. Therefore, our aim was ...to investigate the long-term effects (5–7 years follow-up) of an intervention with folic acid and vitamin-B12 supplementation on fracture and cardiovascular disease risk.
Extended follow-up of the B-PROOF trial, a multi-center, double-blind randomized placebo-controlled trial designed to assess the effect of 2–3 years daily supplementation with folic acid (400 μg) and vitamin-B12 (500 μg) versus placebo (n = 2,919). Primary outcome was verified self-reported fracture incidence and secondary outcomes were self-reported cardiovascular endpoints, which were collected through a follow-up questionnaires Proportional hazard analyses was used for the effect of the intervention on risk of fracture(s) and logistic regression for the effect of the intervention on risk of cardiovascular disease.
A total of 1,298 individuals (44.5%) participated in the second follow-up round with median of 54 months 51–58, (n = 662 and n = 636, treatment versus placebo group). Median age at baseline was 71.0 years 68.0–76.0 for both groups. No effect was observed of the intervention on osteoporotic fracture or any fracture risk after a follow-up (HR: 0.99, 95% CI: 0.62–1.59 and HR: 0.77; 95% CI: 0.50–1.19, respectively), nor on cardiovascular or cerebrovascular disease risk (OR: 1.05; 95%CI: 0.80–1.44 and OR: 0.85; 95%CI: 0.50–1.45, respectively). Potential interaction by baseline homocysteine concentration was observed for osteoporotic- and any fracture (p = 0.10 and 0.06 respectively), which indicated a significantly lower risk of any fracture in the treatment group with higher total homocysteine concentrations (>15.1 μmol/l). No age-dependent effects were present.
This study supports and extends previous null-findings of the B-PROOF trial and shows that supplementation of folic acid and vitamin-B12 has no effect on fracture risk, nor on cardiovascular disease in older individuals over a longer follow-up period. However, B-vitamin supplementation may be beneficial in reducing fractures in individuals with high total homocysteine concentrations, a finding which needs to be replicated.
Fall-Risk Increasing Drugs (FRIDs) are an important and modifiable fall-risk factor. A Clinical Decision Support System (CDSS) could support doctors in optimal FRIDs deprescribing. Understanding ...barriers and facilitators is important for a successful implementation of any CDSS. We conducted a European survey to assess barriers and facilitators to CDSS use and explored differences in their perceptions.
We examined and compared the relative importance and the occurrence of regional differences of a literature-based list of barriers and facilitators for CDSS usage among physicians treating older fallers from 11 European countries.
We surveyed 581 physicians (mean age 44.9 years, 64.5% female, 71.3% geriatricians). The main barriers were technical issues (66%) and indicating a reason before overriding an alert (58%). The main facilitators were a CDSS that is beneficial for patient care (68%) and easy-to-use (64%). We identified regional differences, e.g., expense and legal issues were barriers for significantly more Eastern-European physicians compared to other regions, while training was selected less often as a facilitator by West-European physicians. Some physicians believed that due to the medical complexity of their patients, their own clinical judgement is better than advice from the CDSS.
When designing a CDSS for Geriatric Medicine, the patient's medical complexity must be addressed whilst maintaining the doctor's decision-making autonomy. For a successful CDSS implementation in Europe, regional differences in barrier perception should be overcome. Equipping a CDSS with prediction models has the potential to provide individualized recommendations for deprescribing FRIDs in older falls patients.
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