Optimising prescribing of drugs to prevent CVD and drugs that cause dependency: an evidence-gap map. Final report

Abstract

What do we want to know? Evidence suggests the prescribing and taking of, or adherence to, certain types of medication is not at optimal levels. This review focuses on two areas of challenge. The first area of interest is under-prescribing and poor adherence to medications to prevent cardiovascular disease (CVD), specifically statins and antihypertensives. The second area of interest in this review concerns the over-prescribing of drugs that may cause dependency (DCD, which includes opioids, benzodiazepines, gabapentinoids and non-benzodiazepine hypnotics) and antidepressants. Scoping of the evidence base revealed an abundance of primary and secondary research across these two types of medication. This report presents the first stage of this programme of work, which aims to identify, categorise and map the existing systematic review evidence, identifying both abundant and scarce areas of research. What did we find? Overview One hundred and thirty systematic reviews met the eligibility criteria for inclusion in the evidence-gap map. All reviews were first critically appraised using four criteria from the Collaboration for Environmental Evidence Synthesis Assessment Tool (CEESAT). Only the thirty-six reviews which scored positively on all four of these items were prioritised for full quality appraisal using the AMSTAR-2 tool. Fifteen of these reviews were of ‘High’ overall quality, 12 of ‘Moderate’ overall quality, six of ‘Low’ overall quality and three of ‘Critically Low’ overall quality. Reviews with a negative score on one or more CEESAT item received a rating of ‘Critically Low’ overall quality. Summary of evidence and gaps The final evidence and gap map indicates areas where a significant body of systematic review research already exists. For example, with regard to the prescription of statins and antihypertensive medication, there are a number of reviews which synthesise qualitative evidence on patient and/or family/carer experience of adherence and/or taking this type of medication. There are also twelve reviews of predominantly ‘High’ and ‘Moderate’ overall quality which examine the effectiveness of interventions which aim to improve adherence to these two types of medication. These reviews were represented across the patient care-pathway for both types of medication, but particularly with regard to information and advice giving (n=8 statins, n=17 antihypertensives), choosing a medication (n=8 statins, n=14 antihypertensives) and progress review (n=14 statins, 27 antihypertensives) although the reviews were predominantly of ‘Critically Low’ quality. Twenty-two systematic reviews synthesised evaluations of interventions to promote the deprescribing of medication which included DCD and antidepressants, although only six of these were of ‘High’ or ‘Moderate’ overall quality. Similarly, all DCD and antidepressant medications (aside from gabapentinoids) were included in at least one review focusing on evaluating interventions to optimise prescribing which was appraised using the AMSTAR-2 tool, however the quality of this evidence was variable. Whilst there is a body of qualitative systematic review evidence which examines barriers and facilitators to the deprescribing of DCD and antidepressants, and of experiences of adhereing to/taking stain and antihypertensive medication, there were no systematic reviews which examined experiences or views of specific interventions to promote adherence or aid deprescribing. In addition, only two reviews of qualitative evidence scored positively on all four CEESAT criteria. The rest were deemed to be of ‘Critically Low’ overall quality. What are the implications? This evidence and gap map highlights the available quantitative and qualitative systematic review evidence to inform the optimal prescribing of DCD, antidepressants, statins and antihypertensive medication. The map summarises key characteristics of these systematic reviews and identifies areas where no, or low-quality systematic reviews have been conducted. These gaps highlight areas which may benefit from further searches to identify if any primary research exists, which could be combined within further evidence synthesis. Consultation with policy and commissioning stakeholders is required to confirm in which areas further evidence syntheses or primary research could best inform government policy. How did we get these results? Systematic reviews published since 2010 were sought from bibliographic databases, websites and author contact and included if they brought together quantitative and/or qualitive evidence on: - The effectiveness or experiences of interventions intended to improve prescribing practices or patient adherence; - The effectiveness or experiences of interventions intended to improve implementation of interventions intended to improve prescribing practices or patient adherence; - Practitioner views or perceptions of making prescribing decisions; - Guidelines intended to inform prescribing practise. Systematic reviews which met these criteria were organised within an evidence gap-map according to the medication of interest and the revelance to the patient care pathway. Key characteristics of each systematic review were extracted by two reviewers, with this information being used to filter the information displayed in the evidence and gap map.