key: cord-0845378-0ktb8u1u
authors: Catrini, Elisabetta; Ferrario, Lucrezia; Mazzone, Antonino; Varalli, Luca; Gatti, Federico; Cannavacciuolo, Lorella; Ponsiglione, Cristina; Foglia, Emanuela
title: Tools supporting polypharmacy management in Italy: Factors determining digital technologies' intention to use in clinical practice
date: 2022-05-19
journal: Health Sci Rep
DOI: 10.1002/hsr2.647
sha: a58a2e0a4e37b0304974be77815fbeae12837504
doc_id: 845378
cord_uid: 0ktb8u1u

BACKGROUND AND AIMS: INTERCheckWEB is one of the most outstanding digital technologies, that could be implemented at the hospital level, supporting the clinicians in the evaluation of the therapy appropriateness, reducing the potentially inappropriate prescriptions, for the improvement of the clinical decision‐making process. The paper aims at investigating the relationship between clinicians' behaviors towards digital decision support system in therapy appropriateness for elderly patients in polytherapy in medical departments, defining the factors that could influence clinicians to use INTERCheckWEB, for supporting drugs' prescription. METHODS: A questionnaire was administered to 70 clinicians referring to Internal Medicine wards, of four Italian hospitals. The authors assessed how perceived usefulness, perceived ease of use, image, and output quality, would affect INTERCheckWeb intention to use. Inferential statistics, by means of a regression analysis, were conducted to define the main aspects useful to understand the factors impacting on such digital technology adoption in clinical practice. RESULTS: The regression analysis reported that image, perceived ease of use and perceived usefulness, as well as the moderator effect of the voluntary use between the perceived usefulness and the intention to use, are the factors that most influence the use of INTERCheckWEB (adjusted R (2) = 0.870). CONCLUSIONS: Results demonstrated that clinicians would use INTERCheckWEB, when available, to identify all the information on situations that could be dangerous for the patients, thus limiting the drug–drug interactions, optimizing the overall patient's clinical pathway. Furthermore, the implementation of INTERCheckWEB could also contribute to the proper management of COVID‐19 patients, since both hospitalized and symptomatic COVID‐19 patients are frequently older, with comorbidities.

Digital technologies (DTs) are frequently used to improve the decision-making process in hospitals, reducing the complexity of the process management in healthcare sector and limiting clinical errors. [1] [2] [3] [4] [5] As such, DTs would offer new opportunities for identifying needs and delivering healthcare services, potentially transforming healthcare organizations in ways that may contribute to achieve healthcare systems goals (high-quality services, efficiency, equity, affordability, and accessibility to care). [1] [2] [3] [4] [5] [6] Despite DTs positive impact on the process efficiency improvement, their adoption is usually related to a professional resistance to change, because of DTs being usually perceived as disruptive innovations.

Therefore, considering the importance of correctly assessing the impact of innovative healthcare technologies adoption on the existing clinical pathways, it is important to directly involve all the healthcare professionals in the DTs use. 4, 7, 8 Nowadays, INTERCheckWEB is one of the most outstanding DT innovative technologies that could be implemented, at hospital level, supporting the clinicians in the evaluation of the therapy appropriateness for a patient, specially reducing the potentially inappropriate prescriptions and drug-drug interactions (DDI) for elderly patients in polytherapy. 9, 10 INTERCheckWEB is a Computerized Prescription Support System, developed by the "Istituto di Ricerche Farmacologiche Mario Negri IRCCS." 11 This is an open-access DT, that aims at storing information about DDI, potentially inappropriate medications, anticholinergic burden, and dose adjustment, in case of renal disease and modality for drug withdrawals. It has a user-friendly interface and could guide clinicians in the evaluation of any possible therapy switches or changes, according to the most recent versions of "Beers" and "START and STOPP" criteria. 12, 13 The standardized implementation of INTERCheckWEB is acquiring a strong relevance, since polypharmacy in the elderly is estimated to be around 40% of outpatient population, and even higher in hospitalized patients. [14] [15] [16] [17] [18] In addition, with an increasing number of medications, low adherence is a growing concern, seriously undermining the benefits of medical care. 19 The above situation may be aggravated in patients with COVID-19 as the polypharmacy burden is increased by the addition of specific treatments for the virus infection, thus presenting a higher risk to develop DDIs, that would potentially worsen their clinical conditions, independently from the COVID-19 severity. 20 Despite the relevance of this tool, no consensus exists, regarding its continuous and routine use, during the phase of drug therapies prescription, thus requiring an in-depth analysis of the clinicians' acceptance to use such DT. 21, 22 Given the foregoing premises, the study aims at investigating the acceptance and the intentions to use the innovative INTERCheck-WEB, for preventive DDIs, by addressing the following research question: "Which are the key factors determining the intention to use INTERCheckWEB, as a DT supporting clinicians in the clinical practice decisions, in medical departments?"

The present research activity focused the attention on the definition of the main factors influencing INTERCheckWEB acceptance and intention to use, analyzed with a narrative literature review approach, thus seeking study areas not yet addressed. [23] [24] [25] In the extant literature, INTERCheckWEB has been analyzed to highlight its strategic relevance to support the clinicians in choosing the proper medication for specific categories of patients, such as chronic and frail patients in hospitals' medical departments or staying in nursing homes. 9, 10, [14] [15] [16] [17] [18] Once demonstrated its clinical feasibility and practical effectiveness, no evidence exists with regard to the organizational and/or professional factors that could suggest or facilitate the clinicians' approach towards DT in general (and INTERCheckWEB in particular) within the clinical practice, thus generating an important research gap to be further explored.

Based on these considerations, although technical expertize may present one of the barriers to technology acceptance in healthcare, a large body of research has indicated that social and psychological barriers to technology acceptance are also important. 26, 27 According to the above, literature suggested several operative models implemented for defining the end-users' acceptance level, to use innovative technologies. Among all the referenced models proposed in the literature for investigating the users' acceptance in approaching DTs, the Technology Acceptance Model (TAM) and its revisions, TAM 2, as well as the unified theory of acceptance and use of technology (UTAUT) were applied. 28, 29 No literature evidence exists concerning the implementation of these models for INTERCheckWEB acceptance assessment. It should be noted here that UTAUT frameworks have seen little use in the healthcare setting in investigating the technology acceptance for healthcare professionals working in high-intensive knowledge setting, such as hospitals. UTAUT has thus been extensively used in the definition of mobile APP acceptance, [30] [31] [32] [33] thus being little replicable within the healthcare setting. Despite UTAUT is the most popular model to define technology acceptance focusing on the information system, in the healthcare setting TAM and its revisions are more applicable and implementable, given not only the nature of the technology being assessed but also for their parsimony and strong explanatory power. [34] [35] [36] Thus, TAM and TAM 2 are proposed for identifying factors determining whether healthcare professionals will use health information technology, 37 thus appearing to be particularly applicable in this field because they focus their attention on specific variables influencing the use of information technologies. The TAM distinguishes ease of use, perceived usefulness, and attitudes towards using, as the factors which most influence the adoption of new technologies. 38 Moving on from these premises, the study is intended to define the main factors predicting the individuals' acceptance of INTERCheckWEB, as innovative DT, in medical departments, based on the following variables derived from the TAM 2 core constructs: perceived usefulness, perceived ease of use, image, and output quality.

For the achievement of the study objective already defined, the following hypotheses were, accordingly, set.

Perceived usefulness could be defined as "the degree to which a person believes that using a particular system would enhance his or her job performance." 28 The perceived usefulness of INTERCheckWEB is related to the clinician's effort to improve daily activities, and to the proper use of the tool itself, intended to simplify all the activities, aiming at the best quality and safety, for the patient factors. 26, 28, 29, 35 According to the above, the greater the instrument's perceived usefulness, the greater the clinician's willingness to accept the introduction of INTERCheck-WEB in the daily activities. 

Perceived ease of use could be defined as "the level a person believes that using a specific innovative DT would be free of effort." 28 The perceived ease of use influences the innovation adoption. The ease of use is also influenced by the complexity and compatibility of the innovative system, compared with the current situation. [27] [28] In particular, the greater the simplicity of INTERCheckWEB, the greater the perceived ease of use, the greater the willingness of the clinician to accept this instrument.

HP2: Perceived ease of use has a positive impact on INTERCheck-WEB intention to use.

Image could be defined as "the degree to which the use of an innovation is perceived to enhance a person's status in a social system." 39 If an innovative technology is strongly recommended by the healthcare organization and the clinician does not embrace this innovation, its image would be negatively compromised. On the other hand, the acceptance of technology and the perceived ease of use of the system would modify the behavior of the clinician, having a positive impact on his image. 26, 33 In this view, the image of the clinician will be improved as much as the use of INTERCheckWEB is welcome by third parties.

HP3: Image has a positive impact on INTERCheckWEB intention to use.

Quality output focuses on the fact that, the information, could be clearer and more detailed, encouraging the clinicians to accept its introduction.

The strength of the tool is to provide the clinicians with high-quality information, identifying the best way to manage the individuals and organizational aspects of the process. Flexibility is the aspect that best summarizes the tool characteristics, and it is expected to strongly encourage the clinicians to adopt this DT. 33 The greater the flexibility of INTERCheckWEB, meant as the ability of the system to provide information for each investigated element, the greater the quality of the requested output, therefore, the propensity of the clinician to use this instrument.

HP4: Quality output has a positive impact on INTERCheckWEB intention to use.

Despite the direct relationships between the above-mentioned independent variables and INTERCheckWEB intention to use, the proposed framework also includes two moderator variables (voluntary use and experience).

Voluntary use is related to people perceptions. In workplace environment, the employees' resort to tools because they are influenced by the circumstances. 33 The matter, hereby investigated, is the clinicians' willingness to break down the traditional barriers that may impede the innovation acceptance. 40 Thus, the clinician is more likely to use INTERCheckWEB if the willingness to overcome traditional barriers is higher. 

Perceived usefulness and intention to use innovative DTs could be higher with increasing experience over time. The experience level of healthcare professionals could act as an important predictor in a CATRINI ET AL. | 3 of 11 higher level of perceived usefulness and use for various healthcare technologies. Furthermore, as individuals gained direct experience with a system, they relied less on social information in defining perceived usefulness. However, they continued to judge a system's usefulness, based on potential status benefits, resulting from its use. 33 Based on the above, the following hypotheses were developed. A synthesis of the research framework is proposed in Figure 1 . 

A study design composed of the following three phases was conducted.

1. Adaptation of the existing scales for a specific healthcare sector questionnaire A specific questionnaire was developed to gather clinicians' perceptions, concerning their intention to use INTERCheckWEB.

The questionnaire, based on validated English scales, was translated into the Italian language, to avoid comprehension concerns (please see File S1).

Before administering the questionnaire, a draft was reviewed by five experts, thus creating consensus regarding the contents, to verify the coherence and the comprehensibility of the document, especially in the adaptation of some sentences, from other sectors, to the healthcare one.

Before analyzing data, the problem of common method variance was addressed and solved, with an ex-ante (by maintaining the anonymity of respondent) and an ex-post approach (by conducting the Harman's single-factor test, useful to verify an acceptable level of bias). Thus, an exploratory factor analysis was carried out, to establish if changes introduced in the adaptation process for healthcare sector had affected the structure of the scales.

All the items presenting a factor loading higher than 0.3 were included in the creation of variables, because of the maximization of each construct variance, along one dimension. Furthermore, to assure the reliability of the constructs, the assessment of Cronbach's α was implemented. A cut-off threshold of 0.7 was used to test the items and create the new variables, useful to verify the study hypotheses. 41 

The sample of the study was composed of head physicians, clinicians, It should be noted that the sample was based on a convenience approach, according to a snowball sampling technique, that is a commonly

employed sampling method in qualitative research, used in medical science. [42] [43] [44] [45] [46] All the clinicians involved in the study were representative of the experts working in the Internal Medicine Wards, and taking rotations in the Emergency Departments, thus being clinicians usually devoted to the management of elderly patients with multiple chronic diseases and taking several medications. The clinicians involved, voluntarily participated in the study, filling in the questionnaire declaring their perceptions. The questionnaires were collected and then processed in an anonymous and aggregated manner.

In June 2019, they completed the questionnaire previously defined, through an interview conducted by a trained interviewer, with specific competences both in managerial arguments and in social qualitative study.

Besides the personal information related to each respondent (professional role, age, seniority, and working experience), the questionnaire was composed of a qualitative section in which a 7item Likert scale was implemented (1: completely disagree; 7:

completely agree). In particular, the interview process aimed at getting the clinicians' insight concerning their intention to use INTERCheck-WEB and the independent/moderator/control variables previously described that are perceived usefulness, perceived ease of use, image, quality output, voluntary use, as well as IT skills and attitude.

Data derived from the questionnaire were first analyzed considering descriptive statistics. Preliminary analyses were performed to ensure no violation of the assumptions of normality, linearity, and homoscedasticity.

In addition, differences among sample subgroups were defined by means of independent sample t-tests and contingency tables. Quantitative variables were presented as average value ± standard error, and qualitative variables were presented as counts or percentages.

Furthermore, inferential analyses were conducted.

1. Relationships between the variables were investigated, to test the existence of correlations among them. In particular, the "Pearson product-moment" correlation coefficient was assessed, to test the existence of small (from 0.10 to 0.29), medium (from 0.3 to 0.49), or large (from 0.5 to 1) correlations among variables. 47 2. A final investigation of the relationship among the variables, using a hierarchical sequential linear regression model (with enter methodology), was implemented to test the hypotheses; this is useful to establish the impacts of independent variables and moderators. In particular, the adjusted R 2 was examined, to gauge the explanatory power of each model. 48 This approach allows testing the hypotheses, through incremental models to establish the specific impact of each single input variable, on the dependent variable. The option "exclude case pairwise" was implemented, as it is the preferable methodology, for a small sample and precludes any kind of data exclusion. Three different models were developed, thus defining the influence of the different set of variables (control, independent, and moderator variables), on the dependent variable (INTERCheckWEB intention to use). 

The sample was composed of 70 clinicians ( be prone to adopt any DT able to facilitate their daily activities, and the therapy prescription.

The reliability of the scales, and the related constructs were assessed, proving the freedom of the scale from the random error, and establishing their internal consistency.

Detailed information is shown in Table 2 . Focusing on the relationships between the control and the independent variables, the following considerations emerged. A regression analysis was conducted to test the hypotheses. Thus, the analyses demonstrated that, at least in the investigated setting, INTERCheckWEB intention to use is strictly dependent on the usefulness and the ease of use perceived by the clinicians (Figure 2 ).

The presence of comorbidities/multiple chronic diseases and the related prescription of complex medications are becoming typical problems, particularly in medical wards and departments, and present many professional challenges. 49, 50 The issue of "polypharmacy" and high dosage frequency are both associated with high rates of adverse drug reactions, poor adherence, and recurrent hospitalization, requiring a simplification of drug regimens. 51, 52 Thus, any strategy able to prevent potentially severe DDIs, and able to support the clinicians in prescribing the right therapy could Another topic for further research could be an evaluation of the economic gain related to a reduction in drugs prescribed, that could consequently reduce the economic burden of the management of a chronic and elder patient. 68 Ferrario had full access to the study data and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

The authors of the present paper would like to sincerely thank all the healthcare professionals involved in the administration of the questionnaire, useful to retrieve important data for the achievement of the study objective. Furthermore, the authors would like also to thank Prof. Luca Pasina (Istituto di Ricerche Farmacologiche Mario Negri), who critically revised the contents.

The authors declare no conflicts of interest.

Lucrezia Ferrario affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Lucrezia Ferrario http://orcid.org/0000-0002-8561-898X

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