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Lee TC, Bortolussi-Courval É, McCarthy LM, McDonald EG. Deprescribing is associated with reduced readmission to hospital: An updated meta-analysis of randomized controlled trials. J Am Geriatr Soc 2024. [PMID: 39238319 DOI: 10.1111/jgs.19166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 06/21/2024] [Indexed: 09/07/2024]
Abstract
See the related reply by Fontana et al.
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Affiliation(s)
- Todd C Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Émilie Bortolussi-Courval
- Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Lisa M McCarthy
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Emily G McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Fontana A, Carollo M, Crisafulli S, Trifirò G. Reply to: Deprescribing is associated with reduced readmission to hospital: An updated meta-analysis of randomized controlled trials. J Am Geriatr Soc 2024. [PMID: 39238318 DOI: 10.1111/jgs.19169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Accepted: 08/02/2024] [Indexed: 09/07/2024]
Abstract
See the related letter by Lee et al.
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Affiliation(s)
- Andrea Fontana
- Unit of Biostatistics, IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | - Massimo Carollo
- Department of Diagnostics and Public Health, Clinical Pharmacology Unit, University of Verona, Verona, Italy
| | | | - Gianluca Trifirò
- Department of Diagnostics and Public Health, Clinical Pharmacology Unit, University of Verona, Verona, Italy
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Robinson M, Vangaveti V, Edelman A, Mallett AJ. Active deprescribing attitudes and practices in a large regional tertiary health service: a mixed methods study. Intern Med J 2024. [PMID: 39221918 DOI: 10.1111/imj.16512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 08/04/2024] [Indexed: 09/04/2024]
Abstract
In this pilot study, we explored current attitudes and deprescribing practices of clinicians in a large regional health service through a mixed methods approach. Respondents included doctors, pharmacists and nurse practitioners, who outlined three themes including professional and organisational contexts, disconnect between goals and practices and factors influencing deprescribing.
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Affiliation(s)
- Michael Robinson
- Townsville Institute of Health Research and Innovation, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Venkat Vangaveti
- Townsville Institute of Health Research and Innovation, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Alexandra Edelman
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Menzies School of Health Research, Alice Springs, Northern Territory, Australia
| | - Andrew J Mallett
- Townsville Institute of Health Research and Innovation, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
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Wahler RG, Olbrich CL, McCarthy LM. Preventing Prescribing Cascades: Ensuring Medication Safety for Older Adults. J Gerontol Nurs 2024; 50:7-11. [PMID: 39194326 DOI: 10.3928/00989134-20240809-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
PURPOSE To define prescribing cascades (PCs) and provide tools to identify PCs, including the most common PCs described in the literature. PCs lead to the accumulation of medications prescribed to older adults, disproportionately affecting those who often have additional health care complexities, such as multiple chronic conditions and multiple transitions of care. METHOD Review of recent research efforts to identify and describe evolving clinical practice interventions to detect and reverse PCs. RESULTS Clinicians can contribute to mitigating PCs through better understanding of how PCs occur in practice. Armed with this knowledge, clinical team members can implement proposed strategies and techniques to engage in primary and secondary prevention of PCs. CONCLUSION Ultimately, PCs are a culprit of preventable medication harm. Several tools are presented, which are initiated through maintaining a high index of suspicion for PCs in the evaluation of a new symptom presentation by older patients. [Journal of Gerontological Nursing, 50(9), 7-11.].
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Pierson T, Arcand V, Farrell B, Gagnon CL, Leung L, McCarthy LM, Murphy AL, Persaud N, Raman-Wilms L, Silvius JL, Steinman MA, Tannenbaum C, Thompson W, Trimble J, Sadowski CA, McDonald EG. Proceedings of the Canadian Medication Appropriateness and Deprescribing Network's 2023 National Meeting. Drug Saf 2024; 47:829-839. [PMID: 38884849 PMCID: PMC11324714 DOI: 10.1007/s40264-024-01444-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Tiphaine Pierson
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Verna Arcand
- Kipohtakaw Education Centre, Alexander First Nations, Sturgeon County, AB, Canada
| | - Barbara Farrell
- Bruyėre Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- University of Waterloo School of Pharmacy, Waterloo, ON, Canada
| | - Camille L Gagnon
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, QC, Canada
| | - Larry Leung
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Lisa M McCarthy
- Bruyėre Research Institute, Ottawa, ON, Canada
- University of Waterloo School of Pharmacy, Waterloo, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute for Better Health and Family Department, Trillium Health Partners, Mississauga, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrea L Murphy
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Nav Persaud
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Lalitha Raman-Wilms
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Centre on Aging, University of Manitoba, Winnipeg, MB, Canada
| | - James L Silvius
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, QC, Canada
- Provincial Seniors Health and Continuing Care, Alberta Health Services, Calgary, AB, Canada
- Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael A Steinman
- University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Cara Tannenbaum
- Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Cheryl A Sadowski
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Emily G McDonald
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, QC, Canada.
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Office 3E.03, 5252 De Maisonneuve Blvd, Montreal, QC, H4A3S9, Canada.
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada.
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Pavon JM, Zhang AD, Fish LJ, Falkovic M, Colón-Emeric CS, Gallagher DM, Schmader KE, Hastings SN. Factors influencing central nervous system medication deprescribing and behavior change in hospitalized older adults. J Am Geriatr Soc 2024; 72:2359-2371. [PMID: 38826146 PMCID: PMC11323177 DOI: 10.1111/jgs.19011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/29/2024] [Accepted: 05/03/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Central nervous system (CNS) medications are linked to higher morbidity and mortality in older adults. Hospitalization allows for deprescribing opportunities. This qualitative study investigates clinician and patient perspectives on CNS medication deprescribing during hospitalization using a behavioral change framework, aiming to inform interventions and identify recommendations to enhance hospital deprescribing processes. METHODS This qualitative study focused on hospitalists, primary care providers, pharmacists, and patients aged ≥60 years hospitalized on a general medicine service and prescribed ≥1 CNS medications. Using semi-structured interviews and focus groups, we aimed to evaluate patient medication knowledge, prior deprescribing experiences, and decision-making preferences, as well as provider processes and tools for medication evaluation and deprescribing. Rapid qualitative analysis applying the Capability, Opportunity, Motivation, and Behavior (COM-B) framework revealed themes influencing deprescribing behavior in patients and providers. RESULTS A total of 52 participants (20 patients and 32 providers) identified facilitators and barriers across deprescribing steps and generated recommended strategies to address them. Clinicians and patients highlighted the opportunity for CNS medication deprescribing during hospitalizations, facilitated by multidisciplinary teams enhancing clinicians' capability to make medication changes. Both groups also stressed the importance of intensive patient engagement, education, and monitoring during hospitalizations, acknowledging challenges in timing and extent of deprescribing, with some patients preferring decisions deferred to outpatient clinicians. Hospitalist and pharmacist recommendations centered on early pharmacist involvement for medication reconciliation, expanding pharmacy consultation and clinician education on deprescribing, whereas patients recommended enhancing shared decision-making through patient education on medication adverse effects, tapering plans, and alternatives. Hospitalists and PCPs also emphasized standardized discharge instructions and transitional care calls to improve medication review and feedback during care transitions. CONCLUSIONS Clinicians and patients highlighted the potential advantages of hospital interventions for CNS medication deprescribing, emphasizing the necessity of addressing communication, education, and coordination challenges between inpatient and outpatient settings.
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Affiliation(s)
- Juliessa M. Pavon
- Division of Geriatrics, Duke University, Durham, NC
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Department of Medicine, Duke University, Durham, NC
| | | | - Laura J. Fish
- Department of Family Medicine and Community Health, Duke University, Durham, NC
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC
| | - Margaret Falkovic
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC
| | - Cathleen S. Colón-Emeric
- Division of Geriatrics, Duke University, Durham, NC
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Department of Medicine, Duke University, Durham, NC
| | | | - Kenneth E. Schmader
- Division of Geriatrics, Duke University, Durham, NC
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Department of Medicine, Duke University, Durham, NC
| | - Susan N. Hastings
- Division of Geriatrics, Duke University, Durham, NC
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Department of Medicine, Duke University, Durham, NC
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC
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Ie K, Hirose M, Sakai T, Motohashi I, Aihara M, Otsuki T, Tsuboya A, Matsumoto H, Hashi H, Inoue E, Takahashi M, Komiya E, Itoh Y, Machino R, Tsuchida T, Albert SM, Ohira Y, Okuse C. Medication Optimization Protocol Efficacy for Geriatric Inpatients: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2423544. [PMID: 39078632 PMCID: PMC11289701 DOI: 10.1001/jamanetworkopen.2024.23544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/14/2024] [Indexed: 07/31/2024] Open
Abstract
Importance There is currently no consensus on clinically effective interventions for polypharmacy among older inpatients. Objective To evaluate the effect of multidisciplinary team-based medication optimization on survival, unscheduled hospital visits, and rehospitalization in older inpatients with polypharmacy. Design, Setting, and Participants This open-label randomized clinical trial was conducted at 8 internal medicine inpatient wards within a community hospital in Japan. Participants included medical inpatients 65 years or older who were receiving 5 or more regular medications. Enrollment took place between May 21, 2019, and March 14, 2022. Statistical analysis was performed from September 2023 to May 2024. Intervention The participants were randomly assigned to receive either an intervention for medication optimization or usual care including medication reconciliation. The intervention consisted of a medication review using the STOPP (Screening Tool of Older Persons' Prescriptions)/START (Screening Tool to Alert to Right Treatment) criteria, followed by a medication optimization proposal for participants and their attending physicians developed by a multidisciplinary team. On discharge, the medication optimization summary was sent to patients' primary care physicians and community pharmacists. Main Outcomes and Measures The primary outcome was a composite of death, unscheduled hospital visits, and rehospitalization within 12 months. Secondary outcomes included the number of prescribed medications, falls, and adverse events. Results Between May 21, 2019, and March 14, 2022, 442 participants (mean [SD] age, 81.8 [7.1] years; 223 [50.5%] women) were randomly assigned to the intervention (n = 215) and usual care (n = 227). The intervention group had a significantly lower percentage of patients with 1 or more potentially inappropriate medications than the usual care group at discharge (26.2% vs 33.0%; adjusted odds ratio [OR], 0.56 [95% CI, 0.33-0.94]; P = .03), at 6 months (27.7% vs 37.5%; adjusted OR, 0.50 [95% CI, 0.29-0.86]; P = .01), and at 12 months (26.7% vs 37.4%; adjusted OR, 0.45 [95% CI, 0.25-0.80]; P = .007). The primary composite outcome occurred in 106 participants (49.3%) in the intervention group and 117 (51.5%) in the usual care group (stratified hazard ratio, 0.98 [95% CI, 0.75-1.27]). Adverse events were similar between each group (123 [57.2%] in the intervention group and 135 [59.5%] in the usual care group). Conclusions and Relevance In this randomized clinical trial of older inpatients with polypharmacy, the multidisciplinary deprescribing intervention did not reduce death, unscheduled hospital visits, or rehospitalization within 12 months. The intervention was effective in reducing the number of medications with no significant adverse effects on clinical outcomes, even among older inpatients with polypharmacy. Trial Registration UMIN Clinical Trials Registry: UMIN000035265.
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Affiliation(s)
- Kenya Ie
- Department of General Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | - Masanori Hirose
- Department of General Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Tsubasa Sakai
- Department of General Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | - Iori Motohashi
- Department of General Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | - Mari Aihara
- Department of General Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | - Takuya Otsuki
- Department of General Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | - Ayako Tsuboya
- Department of Pharmacy, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | - Hiroshi Matsumoto
- Department of Pharmacy, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | - Hikari Hashi
- Department of Pharmacy, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | - Eisuke Inoue
- Showa University Research Administration Center, Showa University, Tokyo, Japan
| | - Masaki Takahashi
- Division of Medical Informatics, St Marianna University School of Medicine, Kanagawa, Japan
| | - Eiko Komiya
- Department of Pharmacy, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | - Yuka Itoh
- Department of Pharmacy, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | - Reiko Machino
- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | - Tomoya Tsuchida
- Department of General Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Steven M. Albert
- Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Yoshiyuki Ohira
- Department of General Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Chiaki Okuse
- Department of General Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
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Lee JW, Hollingsworth EK, Shah AS, Szanton SL, Perrin N, Mixon AS, Vasilevskis EE, Boyd CM, Han HR, Green AR, Taylor JL, Simmons SF. Emergency department visits and hospital readmissions after a deprescribing intervention among hospitalized older adults. J Am Geriatr Soc 2024; 72:2038-2047. [PMID: 38725307 PMCID: PMC11226369 DOI: 10.1111/jgs.18945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 04/01/2024] [Accepted: 04/14/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Deprescribing is the planned/supervised method of dose reduction or cessation of medications that might be harmful, or no longer be beneficial. Though benefits of deprescribing are debatable in improving clinical outcomes, it has been associated with decreased number of potentially inappropriate medications, which may potentially reduce the risk of adverse events among hospitalized older adults. With unclear evidence for deprescribing in this population, this study aimed to examine time-to-first unplanned healthcare utilization, which included 90-day emergency department (ED) visits or hospital readmission and associated predictors, during a deprescribing intervention. METHODS A secondary data analysis of a clinical trial (Shed-MEDS NCT02979353) was performed. Cox regression was used to compare the time-to-first 90-day ED visit/readmission/death from hospital discharge for the intervention and control groups. Additionally, we performed exploratory analysis of predictors (comorbidities, functional health status, drug burden index (DBI), hospital length of stay, health literacy, food insecurity, and financial burden) associated with the time-to-first 90-day ED visit/readmission/death. RESULTS The hazard of first 90-day ED visits/readmissions/death was 15% lower in the intervention versus the control group (95% CI: 0.61-1.19, p = 0.352, respectively); however, this difference was not statistically significant. For every additional number of comorbidities (Hazard ratio (HR): 1.12, 95% CI: 1.04-1.21) and each additional day of hospital length of stay (HR: 1.04, 95% CI: 1.01-1.07) were significantly associated with a higher hazard of 90-day ED visit/readmission/death in the intervention group; whereas for each unit of increase in pre-hospital DBI score (HR: 1.08 and HR 1.16, respectively) was significantly associated with a higher hazard of 90-day ED visit/readmission/death in the control group. CONCLUSIONS The intervention and control groups had comparable time-to-first 90-day ED visit/readmission/death during a deprescribing intervention. This finding suggests that deprescribing did not result in a higher risk of ED visit/readmission/death during the 90-day period following hospital discharge.
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Affiliation(s)
- Ji Won Lee
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205
| | - Emily Kay Hollingsworth
- Vanderbilt Center for Quality Aging, Vanderbilt University Medical Center, Division of Geriatrics, Nashville, TN, USA
| | - Avantika Saraf Shah
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Sarah L. Szanton
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205
| | - Nancy Perrin
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205
| | - Amanda S. Mixon
- Vanderbilt Center for Quality Aging, Vanderbilt University Medical Center, Division of Geriatrics, Nashville, TN, USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN, USA
| | - Eduard Eric Vasilevskis
- Vanderbilt Center for Quality Aging, Vanderbilt University Medical Center, Division of Geriatrics, Nashville, TN, USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN, USA
- University of Wisconsin – Madison, School of Medicine and Public Health, Division of Hospital Medicine, Madison, WI, USA
| | - Cynthia M. Boyd
- Johns Hopkins School of Medicine, Center for Transformative Geriatric Research, 5200 Eastern Avenue, MFL Building, 3 Floor, Baltimore, MD 21224
| | - Hae-Ra Han
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205
| | - Ariel R. Green
- Johns Hopkins School of Medicine, Center for Transformative Geriatric Research, 5200 Eastern Avenue, MFL Building, 3 Floor, Baltimore, MD 21224
| | - Janiece L. Taylor
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205
| | - Sandra Faye Simmons
- Vanderbilt Center for Quality Aging, Vanderbilt University Medical Center, Division of Geriatrics, Nashville, TN, USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN, USA
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9
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Pavon JM, Sloane RJ, Colón-Emeric CS, Pieper CF, Schmader K, Gallagher D, Hastings SN. Central nervous system medication use around hospitalization. J Am Geriatr Soc 2024; 72:1707-1716. [PMID: 38600620 PMCID: PMC11187667 DOI: 10.1111/jgs.18915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/07/2024] [Accepted: 03/15/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Central nervous system (CNS) medication use is common among older adults, yet the impact of hospitalizations on use remains unclear. This study details CNS medication use, discontinuations, and user profiles during hospitalization periods. METHODS Retrospective cohort study using electronic health records on patients ≥65 years, from three hospitals (2018-2020), and prescribed a CNS medication around hospitalization (90 days prior to 90 days after). Latent class transitions analysis (LCTA) examined profiles of CNS medication class users across four time points (90 days prior, admission, discharge, 90 days after hospitalization). RESULTS Among 4666 patients (mean age 74.3 ± 9.3 years; 63% female; 70% White; mean length of stay 4.6 ± 5.6 days (median 3.0 [2.0, 6.0]), the most commonly prescribed CNS medications were antidepressants (56%) and opioids (49%). Overall, 74% (n = 3446) of patients were persistent users of a CNS medication across all four time points; 7% (n = 388) had discontinuations during hospitalization, but of these, 64% (216/388) had new starts or restarts within 90 days after hospitalization. LCTA identified three profile groups: (1) low CNS medication users, 54%-60% of patients; (2) mental health medication users, 30%-36%; and (3) acute/chronic pain medication users, 9%-10%. Probability of staying in same group across the four time points was high (0.88-1.00). Transitioning to the low CNS medication use group was highest from admission to discharge (probability of 9% for pain medication users, 5% for mental health medication users). Female gender increased (OR 2.4, 95% CI 1.3-4.3), while chronic kidney disease lowered (OR 0.5, 0.2-0.9) the odds of transitioning to the low CNS medication use profile between admission and discharge. CONCLUSIONS CNS medication use stays consistent around hospitalization, with discontinuation more likely between admission and discharge, especially among pain medication users. Further research on patient outcomes is needed to understand the benefits and harms of hospital deprescribing, particularly for medications requiring gradual tapering.
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Affiliation(s)
- Juliessa M. Pavon
- Department of Medicine/Division of Geriatrics, Duke University, Durham, NC
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, NC
| | - Richard J. Sloane
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, NC
| | - Cathleen S. Colón-Emeric
- Department of Medicine/Division of Geriatrics, Duke University, Durham, NC
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, NC
| | - Carl F. Pieper
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, NC
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Kenneth Schmader
- Department of Medicine/Division of Geriatrics, Duke University, Durham, NC
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, NC
| | - David Gallagher
- Department of Medicine/Division of General Internal Medicine/Hospital Medicine, Duke University, Durham, NC
| | - Susan N. Hastings
- Department of Medicine/Division of Geriatrics, Duke University, Durham, NC
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, NC
- Health Services Research & Development, Durham Veterans Affairs Health Care System
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10
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Daunt R, Curtin D, O'Mahony D. Optimizing drug therapy for older adults: shifting away from problematic polypharmacy. Expert Opin Pharmacother 2024; 25:1199-1208. [PMID: 38940370 DOI: 10.1080/14656566.2024.2374048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/25/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION The accelerated discovery and production of pharmaceutical products has resulted in many positive outcomes. However, this progress has also contributed to problematic polypharmacy, one of the rapidly growing threats to public health in this century. Problematic polypharmacy results in adverse patient outcomes and imposes increased strain and financial burden on healthcare systems. AREAS COVERED A review was conducted on the current body of evidence concerning factors contributing to and consequences of problematic polypharmacy. Recent trials investigating interventions that target polypharmacy and emerging solutions, including incorporation of artificial intelligence, are also examined in this article. EXPERT OPINION To shift away from problematic polypharmacy, a multifaceted interdisciplinary approach is necessary. Any potentially successful strategy must be adapted to suit various healthcare settings and must utilize all available resources, including artificial intelligence.
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Affiliation(s)
- Ruth Daunt
- Department of Medicine (Geriatrics), School of Medicine, University College Cork, Cork, Ireland
- Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland
| | - Denis Curtin
- Department of Medicine (Geriatrics), School of Medicine, University College Cork, Cork, Ireland
- Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland
| | - Denis O'Mahony
- Department of Medicine (Geriatrics), School of Medicine, University College Cork, Cork, Ireland
- Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland
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11
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Hung A, Kim YH, Pavon JM. Deprescribing in older adults with polypharmacy. BMJ 2024; 385:e074892. [PMID: 38719530 DOI: 10.1136/bmj-2023-074892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/15/2024]
Abstract
Polypharmacy is common in older adults and is associated with adverse drug events, cognitive and functional impairment, increased healthcare costs, and increased risk of frailty, falls, hospitalizations, and mortality. Many barriers exist to deprescribing, but increased efforts have been made to develop and implement deprescribing interventions that overcome them. This narrative review describes intervention components and summarizes findings from published randomized controlled trials that have tested deprescribing interventions in older adults with polypharmacy, as well as reports on ongoing trials, guidelines, and resources that can be used to facilitate deprescribing. Most interventions were medication reviews in primary care settings, and many contained components such as shared decision making and/or a focus on patient care priorities, training for healthcare professionals, patient facing education materials, and involvement of family members, representing great heterogeneity in interventions addressing polypharmacy in older adults. Just over half of study interventions were found to perform better than usual care in at least one of their primary outcomes, and most study interventions were assessed over 12 months or less.
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Affiliation(s)
- Anna Hung
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Co-first authors
| | - Yoon Hie Kim
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Co-first authors
| | - Juliessa M Pavon
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Geriatrics Research, Education, and Clinical Center (GRECC) Durham VA Health Care System, Durham, NC, USA
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12
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Umegaki H. Hospital-associated complications in frail older adults. NAGOYA JOURNAL OF MEDICAL SCIENCE 2024; 86:181-188. [PMID: 38962414 PMCID: PMC11219237 DOI: 10.18999/nagjms.86.2.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/05/2023] [Indexed: 07/05/2024]
Abstract
As the Japanese population continues to age steadily, the number of older adults requiring healthcare has increased. Evidence demonstrates that hospitalization for acute care has a negative impact on the health outcomes of older adults. Frail older adults tend to have multifactorial conditions collectively known as "geriatric syndromes." When those with these premorbid conditions are hospitalized for acute care, they tend to develop new problems such as delirium and new functional impairments. Adverse consequences of hospitalization include the risk of loss of functional independence and chronic disability. In 2019, the new concept of "hospital-associated complications" (HACs) was proposed to describe these new problems. HACs comprise five conditions: hospital-associated falls, delirium, functional decline, incontinence, and pressure injuries. This review discusses the important issues of HACs in relation to their classification, prevalence, risk factors, prevention, and management in older adults hospitalized for acute care. Robust prevention and management are imperative to address the serious consequences and escalating medical costs associated with HACs, and a multidimensional and multidisciplinary approach is key to achieving this goal. Comprehensive geriatric assessment (CGA) is the cornerstone of geriatric medicine and offers a holistic approach involving multidisciplinary and multidimensional assessments. Considerable evidence is accumulating regarding how CGA and coordinated care can improve the prognosis of hospitalized older adults. Further research is needed to understand the occurrence of HACs in this population and to develop effective preventive measures.
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Affiliation(s)
- Hiroyuki Umegaki
- Department of Community Healthcare and Geriatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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13
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Vijayan M, Mohottige D. Deprescribing in Dialysis: Operationalizing "Less is More" Through a Multimodal Deprescribing Intervention. Kidney Med 2024; 6:100819. [PMID: 38689837 PMCID: PMC11059387 DOI: 10.1016/j.xkme.2024.100819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Affiliation(s)
- Madhusudan Vijayan
- Barbara T. Murphy Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Dinushika Mohottige
- Barbara T. Murphy Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Institute for Health Equity Research, Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, NY
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14
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McDonald EG, Lundby C, Thompson W, Boyd C, Farrell B, Gagnon C, Herbin J, Khuong N, Moriarty F, Pierson T, Scott S, Scott IA, Silvius J, Spinewine A, Steinman MA, Tannenbaum C, Trimble J, Turner JP, Reeve E. Reducing potentially inappropriate polypharmacy at a national and international level: the impact of deprescribing networks. Expert Rev Clin Pharmacol 2024; 17:433-440. [PMID: 38739460 DOI: 10.1080/17512433.2024.2355270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/10/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Over the past decade, polypharmacy has increased dramatically. Measurable harms include falls, fractures, cognitive impairment, and death. The associated costs are massive and contribute substantially to low-value health care. Deprescribing is a promising solution, but there are barriers. Establishing a network to address polypharmacy can help overcome barriers by connecting individuals with an interest and expertise in deprescribing and can act as an important source of motivation and resources. AREAS COVERED Over the past decade, several deprescribing networks were launched to help tackle polypharmacy, with evidence of individual and collective impact. A network approach has several advantages; it can spark interest, ideas and enthusiasm through information sharing, meetings and conversations with the public, providers, and other key stakeholders. In this special report, the details of how four deprescribing networks were established across the globe are detailed. EXPERT OPINION Networks create links between people who lead existing and/or budding deprescribing practices and policy initiatives, can influence people with a shared passion for deprescribing, and facilitate sharing of intellectual capital and tools to take initiatives further and strengthen impact.This report should inspire others to establish their own deprescribing networks, a critical step in accelerating a global deprescribing movement.
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Affiliation(s)
- Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Carina Lundby
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
| | - Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology in the School of Medicine, the Center on Aging and Health, and the departments of Epidemiology and Health Policy and Management at Johns Hopkins University in Baltimore, Baltimore, MD, USA
| | - Barbara Farrell
- Bruyère Research Institute, Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Camille Gagnon
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Jennie Herbin
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ninh Khuong
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Tiphaine Pierson
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Sion Scott
- School of Healthcare, University of Leicester, Leicester, UK
| | - Ian A Scott
- Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jim Silvius
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Provincial Seniors Health & Continuing Care, Alberta Health Services, Alberta, Canada
| | - Anne Spinewine
- Louvain Drug Research Institute, Clinical Pharmacy Research Group UCLouvain, Brussels, Belgium
| | - Michael A Steinman
- Department of Medicine, University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Cara Tannenbaum
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Johanna Trimble
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Justin P Turner
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Emily Reeve
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Melbourne, SA, Australia
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Gray SL, Brandt N, Schmader KE, Hanlon JT. Medication use quality and safety in older adults: 2022 update. J Am Geriatr Soc 2024; 72:1329-1337. [PMID: 38038490 PMCID: PMC11090755 DOI: 10.1111/jgs.18684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/20/2023] [Accepted: 10/25/2023] [Indexed: 12/02/2023]
Abstract
Improving the quality of medication use and medication safety are important priorities for healthcare providers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2022. We selected high-quality studies from an OVID search and hand searching of major high impact journals that advanced the field of research forward. The chosen articles cover domains related to deprescribing, medication safety, and optimizing medication use. The MedSafer Study, a cluster randomized clinical trial in Canada, evaluated whether patient specific deprescribing reports generated by electronic decision support software resulted in reduced adverse drug events in the 30 days post hospital discharge in older adults (domain: deprescribing). The second study, a retrospective cohort study using data from Premier Healthcare Database, examined in-hospital adverse clinical events associated with perioperative gabapentin use among older adults undergoing major surgery (domain: medication safety). The third study used an open-label parallel controlled trial in 39 Australian aged-care facilities to examine the effectiveness of a pharmacist-led intervention to reduce medication-induced deterioration and adverse reactions (domain: optimizing medication use). Lastly, the fourth study engaged experts in a Delphi method process to develop a consensus list of clinically important prescribing cascades that adversely affect older persons' health to aid clinicians to identify, prevent, and manage prescribing cascades (domain: optimizing medication use). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.
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Affiliation(s)
- Shelly L Gray
- Plein Center for Geriatric Pharmacy Research, Education and Outreach, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Nicole Brandt
- Peter Lamy Center on Drug Therapy and Aging, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Kenneth E Schmader
- Department of Medicine (Geriatrics), School of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Joseph T Hanlon
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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Bortolussi-Courval É, Podymow T, Battistella M, Trinh E, Mavrakanas TA, McCarthy L, Moryousef J, Hanula R, Huon JF, Suri R, Lee TC, McDonald EG. Medication Deprescribing in Patients Receiving Hemodialysis: A Prospective Controlled Quality Improvement Study. Kidney Med 2024; 6:100810. [PMID: 38628463 PMCID: PMC11019279 DOI: 10.1016/j.xkme.2024.100810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Rationale & Objective Patients treated with dialysis are commonly prescribed multiple medications (polypharmacy), including some potentially inappropriate medications (PIMs). PIMs are associated with an increased risk of medication harm (eg, falls, fractures, hospitalization). Deprescribing is a solution that proposes to stop, reduce, or switch medications to a safer alternative. Although deprescribing pairs well with routine medication reviews, it can be complex and time-consuming. Whether clinical decision support improves the process and increases deprescribing for patients treated with dialysis is unknown. This study aimed to test the efficacy of the clinical decision support software MedSafer at increasing deprescribing for patients treated with dialysis. Study Design Prospective controlled quality improvement study with a contemporaneous control. Setting & Participants Patients prescribed ≥5 medications in 2 outpatient dialysis units in Montréal, Canada. Exposures Patient health data from the electronic medical record were input into the MedSafer web-based portal to generate reports listing candidate PIMs for deprescribing. At the time of a planned biannual medication review (usual care), treating nephrologists in the intervention unit additionally received deprescribing reports, and patients received EMPOWER brochures containing safety information on PIMs they were prescribed. In the control unit, patients received usual care alone. Analytical Approach The proportion of patients with ≥1 PIMs deprescribed was compared between the intervention and control units following a planned medication review to determine the effect of using MedSafer. The absolute risk difference with 95% CI and number needed to treat were calculated. Outcomes The primary outcome was the proportion of patients with one or more PIMs deprescribed. Secondary outcomes include the reduction in the mean number of prescribed drugs and PIMs from baseline. Results In total, 195 patients were included (127, control unit; 68, intervention unit); the mean age was 64.8 ± 15.9 (SD), and 36.9% were women. The proportion of patients with ≥1 PIMs deprescribed in the control unit was 3.1% (4/127) vs 39.7% (27/68) in the intervention unit (absolute risk difference, 36.6%; 95% CI, 24.5%-48.6%; P < 0.0001; number needed to treat = 3). Limitations This was a single-center nonrandomized study with a type 1 error risk. Deprescribing durability was not assessed, and the study was not powered to reduce adverse drug events. Conclusions Deprescribing clinical decision support and patient EMPOWER brochures provided during medication reviews could be an effective and scalable intervention to address PIMs in the dialysis population. A confirmatory randomized controlled trial is needed.
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Affiliation(s)
- Émilie Bortolussi-Courval
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Tiina Podymow
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marisa Battistella
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Emilie Trinh
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Thomas A. Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Lisa McCarthy
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Moryousef
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Ryan Hanula
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Jean-François Huon
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Pharmacy, Nantes University Health Centre, Nantes University, Nantes, France
| | - Rita Suri
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Todd C. Lee
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Disease, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Emily G. McDonald
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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17
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Thompson W, Lundby C, Bleik A, Waring H, Hong JA, Xi C, Hughes C, Salzwedel DM, McDonald EG, Pruskowski J, Scott S, Spinewine A, Kutner JS, Graabæk T, Elmi S, Moriarty F. Measuring Quality of Life in Deprescribing Trials: A Scoping Review. Drugs Aging 2024; 41:379-397. [PMID: 38709466 DOI: 10.1007/s40266-024-01113-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Quality of life (QoL) is an important outcome to capture in clinical trials evaluating deprescribing interventions. OBJECTIVE We aimed to conduct a scoping review to examine how QoL has been measured in deprescribing trials among older people and identify potentially relevant QoL scales, to better inform QoL measurement in future deprescribing trials. METHODS We searched MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials, Google Scholar, Epistemonikos, ClinicalTrials.gov, and reference lists of eligible studies (from inception to October 2023). We included randomized and non-randomized comparative studies with a control group that evaluated deprescribing and polypharmacy reduction interventions in people ≥ 65 years of age and measured QoL as an outcome. We also included studies describing the development and validation of QoL scales related to deprescribing, polypharmacy, or medication burden in adults ≥ 18 years of age. Two independent reviewers screened titles and abstracts, then full texts. Two independent reviewers extracted data from 25% of eligible studies in order to verify agreement, then a single reviewer extracted data from the remaining studies, which a second reviewer cross-checked. We critically appraised scales based on the COSMIN checklist. RESULTS We retrieved 7290 articles, of which 52 were eligible for inclusion, including 44 deprescribing trials and eight scale development studies. From these studies, we found 21 scales that have been used in the context of deprescribing/polypharmacy (12 generic scales used in clinical trials and nine medication-specific scales). Variations of the generic EQ-5D were the most used scales. The measurement properties of scales for capturing changes in QoL from deprescribing were uncertain. Medication-specific QoL scales have not been employed in deprescribing clinical trials and thus, their performance in this context is also not clear. CONCLUSIONS Several existing QoL scales have been applied to the context of deprescribing/polypharmacy clinical trials, and new scales specific to the problem have been proposed. If deprescribing does impact QoL, our findings suggest it is uncertain whether existing QoL scales can practically and reliably capture such a change or whether any scale is best. However, this review compares various aspects of the scales that researchers and clinicians can consider in decisions about measuring QoL in deprescribing trials, and in planning future research. PROTOCOL REGISTRATION Open Science Framework: osf.io/aez6w.
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Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, 317-2176 Health Sciences Mall, Vancouver, BC, V6T 2A1, Canada.
| | - Carina Lundby
- Clinical Pharmacology, Pharmacy, and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
| | - Adam Bleik
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Harman Waring
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Jung Ah Hong
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Chris Xi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland
| | - Douglas M Salzwedel
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, 317-2176 Health Sciences Mall, Vancouver, BC, V6T 2A1, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Jennifer Pruskowski
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatric Research Education and Clinical Center, Pittsburgh Veteran Affairs Healthcare System, Pittsburgh, PA, USA
| | - Sion Scott
- School of Healthcare, University of Leicester, Leicester, UK
| | - Anne Spinewine
- Louvain Drug Research Institute, Clinical Pharmacy Research Group, UCLouvain, Brussels, Belgium
| | - Jean S Kutner
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Trine Graabæk
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
| | - Shahrzad Elmi
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, 317-2176 Health Sciences Mall, Vancouver, BC, V6T 2A1, Canada
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Holbrook A, Perri D, Levine M, Mbuagbaw L, Jarmain S, Thabane L, Tarride JE, Dolovich L, Hyland S, Telford V, Silva J, Nieuwstraten C. Improving medication prescribing-related outcomes for vulnerable elderly in transitions on high-risk medications (IMPROVE-IT HRM): a pilot randomized trial protocol. Pilot Feasibility Stud 2024; 10:60. [PMID: 38600599 PMCID: PMC11005201 DOI: 10.1186/s40814-024-01484-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 03/25/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Seniors with recurrent hospitalizations who are taking multiple medications including high-risk medications are at particular risk for serious adverse medication events. We will assess whether an expert Clinical Pharmacology and Toxicology (CPT) medication management intervention during hospitalization with follow-up post-discharge and communication with circle of care is feasible and can decrease drug therapy problems amongst this group. METHODS The design is a pragmatic pilot randomized trial with 1:1 patient-level concealed randomization with blinded outcome assessment and data analysis. Participants will be adults 65 years and older admitted to internal medicine services for more than 2 days, who have had at least one other hospitalization in the prior year, taking five or more chronic medications including at least one high-risk medication. The CPT intervention identifies medication targets; completes consult, including priorities for improving prescribing negotiated with the patient; starts the care plan; ensures a detailed discharge medication reconciliation and circle-of-care communication; and sees the patient at least twice after hospital discharge via virtual visits to consolidate the care plan in the community. Control group receives usual care. Primary outcomes are feasibility - recruitment, retention, costs, and clinical - number of drug therapy problems improved, with secondary outcomes examining coordination of transitions in care, quality of life, and healthcare utilization and costs. Follow-up is to 3-month posthospital discharge. DISCUSSION If results support feasibility of ramp-up and promising clinical outcomes, a follow-up definitive trial will be organized using a developing national platform and medication appropriateness network. Since the intervention allows a very scarce medical specialty expertise to be offered via virtual care, there is potential to improve the safety, outcomes, and cost of care widely. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier: NCT04077281.
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Affiliation(s)
- Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada.
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada.
| | - Dan Perri
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Digital Solutions, St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Mitch Levine
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Biotatistics Unit, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
- Centre for Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Sarah Jarmain
- Medical and Academic Affairs, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Biotatistics Unit, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Center for Health Economic and Policy Analysis, McMaster University, Hamilton, ON, Canada
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
| | - Lisa Dolovich
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Sylvia Hyland
- Institute for Safe Medication Practices Canada, North York, ON, Canada
| | - Victoria Telford
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
| | - Jessyca Silva
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
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Massé O, Flamand Villeneuve J, Lahaie A, Marcoux C, Hill J, Papillon-Ferland L, Desforges K. STOPP/START version 3: clinical pharmacists are raising concerns. Eur Geriatr Med 2024; 15:589-591. [PMID: 38416401 DOI: 10.1007/s41999-024-00961-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/06/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Olivier Massé
- Department of Pharmacy and Research Center, Hôpital du Sacré-Coeur-de-Montréal, CIUSSS du Nord-de-l'Île-de-Montréal, Montréal, QC, Canada.
| | - Joëlle Flamand Villeneuve
- Department of Pharmacy, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec, QC, Canada
| | - Alexandre Lahaie
- Department of Pharmacy, Institut Universitaire de Gériatrie de Montréal, CIUSSS Centre-Sud-de-l'Île-de-Montréal, Montréal, QC, Canada
| | - Claudia Marcoux
- Department of Pharmacy, CIUSSS de la Capitale-Nationale, Québec, QC, Canada
| | - James Hill
- Department of Pharmacy, Hôpital régional de Rimouski, CISSS du Bas-St-Laurent, Rimouski, QC, Canada
| | - Louise Papillon-Ferland
- Department of Pharmacy, Institut Universitaire de Gériatrie de Montréal, CIUSSS Centre-Sud-de-l'Île-de-Montréal, Montréal, QC, Canada
- Faculty of Pharmacy, Montreal University, Montréal, QC, Canada
| | - Katherine Desforges
- Department of Pharmacy, McGill University Health Centre, Montréal, QC, Canada
- Faculty of Pharmacy, Montreal University, Montréal, QC, Canada
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20
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. Implementation considerations of deprescribing interventions: A scoping review. J Intern Med 2024; 295:436-507. [PMID: 36524602 DOI: 10.1111/joim.13599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.
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Affiliation(s)
- Jinjiao Wang
- Elaine, Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Harriet J. Kitzman Center for Research Support, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- UR Medicine Home Care, University of Rochester Medical Center, Rochester, New York, USA
- University of Rochester Medical Center, Finger Lakes Geriatric Education Center, Rochester, New York, USA
| | - Kobi Nathan
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Donna M Fick
- Ross and Carol Nese College of Nursing, Penn State University, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Department of Medicine, Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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21
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Zwietering NA, Linkens A, Kurstjens D, van der Kuy P, van Nie-Visser N, van de Loo B, Hurkens K, Spaetgens B. Clinical decision support system supported interventions in hospitalized older patients: a matter of natural course and adequate timing. BMC Geriatr 2024; 24:256. [PMID: 38486200 PMCID: PMC10941377 DOI: 10.1186/s12877-024-04823-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 02/18/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Drug-related problems (DRPs) and potentially inappropriate prescribing (PIP) are associated with adverse patient and health care outcomes. In the setting of hospitalized older patients, Clinical Decision Support Systems (CDSSs) could reduce PIP and therefore improve clinical outcomes. However, prior research showed a low proportion of adherence to CDSS recommendations by clinicians with possible explanatory factors such as little clinical relevance and alert fatigue. OBJECTIVE To investigate the use of a CDSS in a real-life setting of hospitalized older patients. We aim to (I) report the natural course and interventions based on the top 20 rule alerts (the 20 most frequently generated alerts per clinical rule) of generated red CDSS alerts (those requiring action) over time from day 1 to 7 of hospitalization; and (II) to explore whether an optimal timing can be defined (in terms of day per rule). METHODS All hospitalized patients aged ≥ 60 years, admitted to Zuyderland Medical Centre (the Netherlands) were included. The evaluation of the CDSS was investigated using a database used for standard care. Our CDSS was run daily and was evaluated on day 1 to 7 of hospitalization. We collected demographic and clinical data, and moreover the total number of CDSS alerts; the total number of top 20 rule alerts; those that resulted in an action by the pharmacist and the course of outcome of the alerts on days 1 to 7 of hospitalization. RESULTS In total 3574 unique hospitalized patients, mean age 76.7 (SD 8.3) years and 53% female, were included. From these patients, in total 8073 alerts were generated; with the top 20 of rule alerts we covered roughly 90% of the total. For most rules in the top 20 the highest percentage of resolved alerts lies somewhere between day 4 and 5 of hospitalization, after which there is equalization or a decrease. Although for some rules, there is a gradual increase in resolved alerts until day 7. The level of resolved rule alerts varied between the different clinical rules; varying from > 50-70% (potassium levels, anticoagulation, renal function) to less than 25%. CONCLUSION This study reports the course of the 20 most frequently generated alerts of a CDSS in a setting of hospitalized older patients. We have shown that for most rules, irrespective of an intervention by the pharmacist, the highest percentage of resolved rules is between day 4 and 5 of hospitalization. The difference in level of resolved alerts between the different rules, could point to more or less clinical relevance and advocates further research to explore ways of optimizing CDSSs by adjustment in timing and number of alerts to prevent alert fatigue.
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Affiliation(s)
- N A Zwietering
- Department of Geriatric Medicine, Laurentius Hospital, 6040 AX, Roermond, PO box 920, The Netherlands.
- Department of Hospital Pharmacy, Erasmus Medical Centre, Rotterdam, The Netherlands.
| | - Aemjh Linkens
- Department of Hospital Pharmacy, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - D Kurstjens
- Department of Internal Medicine, Geriatric Medicine, Zuyderland Medical Centre, Heerlen/Sittard-Geleen, The Netherlands
| | - Phm van der Kuy
- Department of Hospital Pharmacy, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - N van Nie-Visser
- Senior Project Manager, Innovation and Funding (Scientific Research), Zuyderland Medical Centre, Heerlen, The Netherlands
| | | | - Kpgm Hurkens
- Department of Internal Medicine, Geriatric Medicine, Zuyderland Medical Centre, Heerlen/Sittard-Geleen, The Netherlands
| | - B Spaetgens
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
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22
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Thompson W, McDonald EG. Polypharmacy and Deprescribing in Older Adults. Annu Rev Med 2024; 75:113-127. [PMID: 37729029 DOI: 10.1146/annurev-med-070822-101947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.
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Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada;
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada;
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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23
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Robinson M, Mokrzecki S, Mallett AJ. Attitudes and barriers towards deprescribing in older patients experiencing polypharmacy: a narrative review. NPJ AGING 2024; 10:6. [PMID: 38263176 PMCID: PMC10806180 DOI: 10.1038/s41514-023-00132-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 11/28/2023] [Indexed: 01/25/2024]
Abstract
Polypharmacy, commonly defined as ≥5 medications, is a rising public health concern due to its many risks of harm. One commonly recommended strategy to address polypharmacy is medication reviews, with subsequent deprescription of inappropriate medications. In this review, we explore the intersection of older age, polypharmacy, and deprescribing in a contemporary context by appraising the published literature (2012-2022) to identify articles that included new primary data on deprescribing medications in patients aged ≥65 years currently taking ≥5 medications. We found 31 articles were found which describe the current perceptions of clinicians towards deprescribing, the identified barriers, key enabling factors, and future directions in approaching deprescribing. Currently, clinicians believe that deprescribing is a complex process, and despite the majority of clinicians reporting feeling comfortable in deprescribing, fewer engage with this process regularly. Common barriers cited include a lack of knowledge and training around the deprescribing process, a lack of time, a breakdown in communication, perceived 'abandonment of care', fear of adverse consequences, and resistance from patients and/or their carers. Common enabling factors of deprescribing include recognition of key opportunities to instigate this process, regular medication reviews, improving lines of communication, education of both patients and clinicians and a multidisciplinary approach towards patient care. Addressing polypharmacy requires a nuanced approach in a generally complex group of patients. Key strategies to reducing the risks of polypharmacy include education of patients and clinicians, in addition to improving communication between healthcare providers in a multidisciplinary approach.
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Affiliation(s)
- Michael Robinson
- Townsville Institute of Health Research and Innovation, Townsville University Hospital, Douglas, QLD, Australia
- College of Medicine and Dentistry, James Cook University, Douglas, QLD, Australia
| | - Sophie Mokrzecki
- Townsville Institute of Health Research and Innovation, Townsville University Hospital, Douglas, QLD, Australia
- College of Medicine and Dentistry, James Cook University, Douglas, QLD, Australia
- Department of Pharmacy, Townsville University Hospital, Douglas, QLD, Australia
| | - Andrew J Mallett
- Townsville Institute of Health Research and Innovation, Townsville University Hospital, Douglas, QLD, Australia.
- College of Medicine and Dentistry, James Cook University, Douglas, QLD, Australia.
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia.
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24
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Sirois C, Gosselin M, Laforce C, Gagnon ME, Talbot D. How does deprescribing (not) reduce mortality? A review of a meta-analysis in community-dwelling older adults casts uncertainty over claimed benefits. Basic Clin Pharmacol Toxicol 2024; 134:51-62. [PMID: 37376746 DOI: 10.1111/bcpt.13921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 05/22/2023] [Accepted: 06/22/2023] [Indexed: 06/29/2023]
Abstract
Some meta-analyses suggest that deprescribing may reduce mortality. Our aim was to determine the underlying factors contributing to this observed reduction. We analysed data from 12 randomized controlled trials included in the latest meta-analysis on deprescribing in community-dwelling older adults. Our analysis focused on deprescribed medications and potential methodological concerns. Only a third (4/12) of the trials aimed to study mortality, and that too as a secondary outcome. Five trials reported a reduction in total medications, potentially inappropriate medications or drug-related problems. Information on specific classes of deprescribed medications was limited, although a wide array was concerned (e.g., antihypertensive, sedative, gastro-intestinal medications and vitamins). Follow-up periods were ≤1 year in 11 trials, and five trials included ≤150 participants. Small sample sizes often resulted in imbalanced groups (e.g., comorbidities, number of potentially inappropriate medications), yet no trials presented multivariable analyses. In the two trials with the most weight in the meta-analysis, several deaths occurred before the intervention, making it difficult to draw conclusions about the impact of the deprescribing intervention on mortality. These methodological issues cast significant uncertainty on the benefits of deprescribing on mortality outcomes. Large-scale, well-designed trials are needed to address this issue effectively.
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Affiliation(s)
- Caroline Sirois
- Faculté de pharmacie, Université Laval, Québec, Canada
- Centre d'excellence sur le vieillissement de Québec and VITAM- Centre de recherche en santé durable, Québec, Canada
- Centre de recherche du CHU de Québec- Université Laval, Québec, Canada
| | - Maude Gosselin
- Centre d'excellence sur le vieillissement de Québec and VITAM- Centre de recherche en santé durable, Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | | | - Marie-Eve Gagnon
- Faculté de pharmacie, Université Laval, Québec, Canada
- Centre d'excellence sur le vieillissement de Québec and VITAM- Centre de recherche en santé durable, Québec, Canada
- Département des sciences de la santé, Université du Québec à Rimouski, Rimouski, Canada
| | - Denis Talbot
- Centre de recherche du CHU de Québec- Université Laval, Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
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25
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Boyd CM, Shetterly SM, Powers JD, Weffald LA, Green AR, Sheehan OC, Reeve E, Drace ML, Norton JD, Maiyani M, Gleason KS, Sawyer JK, Maciejewski ML, Wolff JL, Kraus C, Bayliss EA. Evaluating the Safety of an Educational Deprescribing Intervention: Lessons from the Optimize Trial. Drugs Aging 2024; 41:45-54. [PMID: 37982982 PMCID: PMC11101016 DOI: 10.1007/s40266-023-01080-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Patients, family members, and clinicians express concerns about potential adverse drug withdrawal events (ADWEs) following medication discontinuation or fears of upsetting a stable medical equilibrium as key barriers to deprescribing. Currently, there are limited methods to pragmatically assess the safety of deprescribing and ascertain ADWEs. We report the methods and results of safety monitoring for the OPTIMIZE trial of deprescribing education for patients, family members, and clinicians. METHODS This was a pragmatic cluster randomized trial with multivariable Poisson regression comparing outcome rates between study arms. We conducted clinical record review and adjudication of sampled records to assess potential causal relationships between medication discontinuation and outcomes. This study included adults aged 65+ with dementia or mild cognitive impairment, one or more additional chronic conditions, and prescribed 5+ chronic medications. The intervention included an educational brochure on deprescribing that was mailed to patients prior to primary care visits, a clinician notification about individual brochure mailings, and an educational tip sheets was provided monthly to primary care clinicians. The outcomes of the safety monitoring were rates of hospitalizations and mortality during the 4 months following brochure mailings and results of record review and adjudication. The adjudication process was conducted throughout the trial and included classifications: likely, possibly, and unlikely. RESULTS There was a total of 3012 (1433 intervention and 1579 control) participants. There were 420 total hospitalizations involving 269 (18.8%) people in the intervention versus 517 total hospitalizations involving 317 (20.1%) people in the control groups. Adjusted risk ratios comparing intervention to control groups were 0.92 [95% confidence interval (CI) 0.72, 1.16] for hospitalization and 1.19 (95% CI 0.67, 2.11) for mortality. Both groups had zero deaths "likely" attributed to a medication change prior to the event. A total of 3 out of 30 (10%) intervention group hospitalizations and 7 out of 35 (20%) control group hospitalizations were considered "likely" due to a medication change. CONCLUSIONS Population-based deprescribing education is safe in the older adult population with cognitive impairment in our study. Pragmatic methods for safety monitoring are needed to further inform deprescribing interventions. TRIAL REGISTRATION NCT03984396. Registered on 13 June 2019.
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Affiliation(s)
- Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Veterans Affairs Medical Center, Durham, NC, USA.
| | - Susan M Shetterly
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - John D Powers
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Linda A Weffald
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Emily Reeve
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Science, University of South Australia, Adelaide, SA, Australia
| | - Melanie L Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jonathan D Norton
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mahesh Maiyani
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Kathy S Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jennifer K Sawyer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Jennifer L Wolff
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Courtney Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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26
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Bongiovanni T, Pletcher MJ, Robinson A, Lancaster E, Zhang L, Behrends M, Wick E, Auerbach A. Electronic health record intervention to increase use of NSAIDs as analgesia for hospitalised patients: a cluster randomised controlled study. BMJ Health Care Inform 2023; 30:e100842. [PMID: 38159932 PMCID: PMC10759061 DOI: 10.1136/bmjhci-2023-100842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 12/13/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Prescribing non-opioid pain medications, such as non-steroidal anti-inflammatory (NSAIDs) medications, has been shown to reduce pain and decrease opioid use, but it is unclear how to effectively encourage multimodal pain medication prescribing for hospitalised patients. Therefore, the aim of this study is to evaluate the effect of prechecking non-opioid pain medication orders on clinician prescribing of NSAIDs among hospitalised adults. METHODS This was a cluster randomised controlled trial of adult (≥18 years) hospitalised patients admitted to three hospital sites under one quaternary hospital system in the USA from 2 March 2022 to 3 March 2023. A multimodal pain order panel was embedded in the admission order set, with NSAIDs prechecked in the intervention group. The intervention group could uncheck the NSAID order. The control group had access to the same NSAID order. The primary outcome was an increase in NSAID ordering. Secondary outcomes include NSAID administration, inpatient pain scores and opioid use and prescribing and relevant clinical harms including acute kidney injury, new gastrointestinal bleed and in-hospital death. RESULTS Overall, 1049 clinicians were randomised. The study included 6239 patients for a total of 9595 encounters. Both NSAID ordering (36 vs 43%, p<0.001) and administering (30 vs 34%, p=0.001) by the end of the first full hospital day were higher in the intervention (prechecked) group. There was no statistically significant difference in opioid outcomes during the hospitalisation and at discharge. There was a statistically but perhaps not clinically significant difference in pain scores during both the first and last full hospital day. CONCLUSIONS This cluster randomised controlled trial showed that prechecking an order for NSAIDs to promote multimodal pain management in the admission order set increased NSAID ordering and administration, although there were no changes to pain scores or opioid use. While prechecking orders is an important way to increase adoption, safety checks should be in place.
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Affiliation(s)
- Tasce Bongiovanni
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Andrew Robinson
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Elizabeth Lancaster
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Li Zhang
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Matthias Behrends
- Department of Anesthesia, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
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27
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Thompson W, Reeve E, McDonald EG, Farrell B, Scott S, Steinman MA, Morin L, Lundby C. Ten deprescribing articles you should know about: A guide for newcomers to the field. Basic Clin Pharmacol Toxicol 2023; 133:661-664. [PMID: 37142559 PMCID: PMC10831497 DOI: 10.1111/bcpt.13877] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 05/06/2023]
Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, SA, Australia
| | - Emily G. McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Barbara Farrell
- Bruyere Research Institute, Ottawa, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
- University of Waterloo School of Pharmacy, Waterloo, Canada
| | - Sion Scott
- School of Healthcare, University of Leicester, United Kingdom
| | - Michael A. Steinman
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, California, USA
| | - Lucas Morin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Inserm CIC 1431, CHU Besançon, Besançon, France
- Inserm U1018, High-Dimensional Biostatistics for Drug Safety and Genomics, CESP, Villejuif, France
| | - Carina Lundby
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
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28
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van Poelgeest E, Seppala L, Bahat G, Ilhan B, Mair A, van Marum R, Onder G, Ryg J, Fernandes MA, Cherubini A, Denkinger M, Eidam A, Egberts A, Gudmundsson A, Koçak FÖK, Soulis G, Tournoy J, Masud T, Wehling M, van der Velde N. Optimizing pharmacotherapy and deprescribing strategies in older adults living with multimorbidity and polypharmacy: EuGMS SIG on pharmacology position paper. Eur Geriatr Med 2023; 14:1195-1209. [PMID: 37812379 PMCID: PMC10754739 DOI: 10.1007/s41999-023-00872-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/19/2023] [Indexed: 10/10/2023]
Abstract
Inappropriate polypharmacy is highly prevalent among older adults and presents a significant healthcare concern. Conducting medication reviews and implementing deprescribing strategies in multimorbid older adults with polypharmacy are an inherently complex and challenging task. Recognizing this, the Special Interest Group on Pharmacology of the European Geriatric Medicine Society has compiled evidence on medication review and deprescribing in older adults and has formulated recommendations to enhance appropriate prescribing practices. The current evidence supports the need for a comprehensive and widespread transformation in education, guidelines, research, advocacy, and policy to improve the management of polypharmacy in older individuals. Furthermore, incorporating deprescribing as a routine aspect of care for the ageing population is crucial. We emphasize the importance of involving geriatricians and experts in geriatric pharmacology in driving, and actively participating in this transformative process. By doing so, we can work towards achieving optimal medication use and enhancing the well-being of older adults in the generations to come.
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Affiliation(s)
- Eveline van Poelgeest
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Lotta Seppala
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Gülistan Bahat
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, Istanbul, Turkey
| | - Birkan Ilhan
- Division of Geriatrics, Department of Internal Medicine, Liv Hospital Vadistanbul, Istanbul, Turkey
| | - Alpana Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh, Scotland, UK
- Edinburgh Napier University, Edinburgh, UK
| | - Rob van Marum
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Department of Elderly Care Medicine, Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Graziano Onder
- Fondazione Policlinico Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Marília Andreia Fernandes
- Department of Internal Medicine, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Antonio Cherubini
- Geriatria Accettazione geriatrica e Centro di Ricerca per l'invecchiamento IRCCS INRCA, Ancona, Italy
| | - Michael Denkinger
- Agaplesion Bethesda Clinic Ulm, Institute for Geriatric Research, Ulm University, Geriatric Center Ulm, Ulm, Germany
| | - Annette Eidam
- Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Angelique Egberts
- Department of Hospital Pharmacy, Franciscus Gasthuis & Vlietland, Rotterdam, Schiedam, The Netherlands
| | - Aðalsteinn Gudmundsson
- Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Fatma Özge Kayhan Koçak
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Ege University, Izmir, Turkey
| | - George Soulis
- Outpatient Geriatric Assessment Unit, Henry Dunant Hospital Center, Athens, Greece
- Hellenic Open University, Patras, Greece
| | - Jos Tournoy
- Department of Geriatric Medicine, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven Biomedical Sciences Group, Leuven, Belgium
| | - Tahir Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Martin Wehling
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nathalie van der Velde
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Gray SL, Perera S, Soverns T, Hanlon JT. Systematic Review and Meta-analysis of Interventions to Reduce Adverse Drug Reactions in Older Adults: An Update. Drugs Aging 2023; 40:965-979. [PMID: 37702981 PMCID: PMC10600043 DOI: 10.1007/s40266-023-01064-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND We previously reported that interventions to optimize medication use reduced adverse drug reactions (ADRs) by 21% and serious ADRs by 36% in older adults. With new evidence, we sought to update the systematic review and meta-analysis. METHOD We searched OVID, Cochrane Library, ClinicalTrials.gov and Google Scholar from 30 April 2017-30 April 2023. Included studies had to be randomized controlled trials of older adults (mean age ≥65 years) taking medications that examined the outcome of ADRs. Two authors independently reviewed all citations, extracted relevant data, and assessed studies for potential bias. The outcomes were any and serious ADRs. We performed subgroup analyses by intervention type and setting. Random-effects models were used to combine the results from multiple studies and create summary estimates. RESULTS Six studies are new to the update, resulting in 19 total studies (15,675 participants). Interventions were pharmacist-led (10 studies), other healthcare professional-led (5 studies), technology based (3 studies), and educational (1 study). The interventions were implemented in various clinical settings, including hospitals, outpatient clinics, long-term care facilities/rehabilitation wards, and community pharmacies. In the pooled analysis, the intervention group participants were 19% less likely to experience an ADR (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.68-0.96) and 32% less likely to experience a serious ADR (OR 0.68, 95% CI 0.48-0.96). We also found that pharmacist-led interventions reduced the risk of any ADR by 35%, compared with 8% for other types of interventions. CONCLUSION Interventions significantly and substantially reduced the risk of ADRs and serious ADRs in older adults. Future research should examine whether effectiveness of interventions vary across health care settings to identify those most likely to benefit. Implementation of successful interventions in health care systems may improve medication safety in older patients.
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Affiliation(s)
- Shelly L Gray
- Department of Pharmacy, School of Pharmacy, University of Washington, Health Sciences Building, H-361D, Box 357630, Seattle, WA, 98195-7630, USA.
| | - Subashan Perera
- Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tim Soverns
- Department of Pharmacy, School of Pharmacy, University of Washington, Health Sciences Building, H-361D, Box 357630, Seattle, WA, 98195-7630, USA
| | - Joseph T Hanlon
- Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Cole JA, Gonçalves-Bradley DC, Alqahtani M, Barry HE, Cadogan C, Rankin A, Patterson SM, Kerse N, Cardwell CR, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2023; 10:CD008165. [PMID: 37818791 PMCID: PMC10565901 DOI: 10.1002/14651858.cd008165.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, so that many medicines may be used to achieve better clinical outcomes for patients. This is the third update of this Cochrane Review. OBJECTIVES To assess the effects of interventions, alone or in combination, in improving the appropriate use of polypharmacy and reducing medication-related problems in older people. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 13 January 2021, together with handsearching of reference lists to identify additional studies. We ran updated searches in February 2023 and have added potentially eligible studies to 'Characteristics of studies awaiting classification'. SELECTION CRITERIA For this update, we included randomised trials only. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy (four or more medicines) in people aged 65 years and older, which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people). DATA COLLECTION AND ANALYSIS Four review authors independently reviewed abstracts of eligible studies, and two authors extracted data and assessed the risk of bias of the included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS We identified 38 studies, which includes an additional 10 in this update. The included studies consisted of 24 randomised trials and 14 cluster-randomised trials. Thirty-six studies examined complex, multi-faceted interventions of pharmaceutical care (i.e. the responsible provision of medicines to improve patients' outcomes), in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists, nurses and geriatricians, and most were conducted in high-income countries. Assessments using the Cochrane risk of bias tool found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low. It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool) (mean difference (MD) -5.66, 95% confidence interval (CI) -9.26 to -2.06; I2 = 97%; 8 studies, 947 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs) (standardised mean difference (SMD) -0.19, 95% CI -0.34 to -0.05; I2 = 67%; 9 studies, 2404 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIM (risk ratio (RR) 0.81, 95% CI 0.68 to 0.98; I2 = 84%; 13 studies, 4534 participants; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.48, 95% CI -1.05 to 0.09; I2 = 92%; 3 studies, 691 participants; low-certainty evidence), however it must be noted that this effect estimate is based on only three studies, which had serious limitations in terms of risk of bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPO (RR 0.50, 95% CI 0.27 to 0.91; I2 = 95%; 7 studies, 2765 participants; very low-certainty evidence). Pharmaceutical care may make little or no difference to hospital admissions (data not pooled; 14 studies, 4797 participants; low-certainty evidence). Pharmaceutical care may make little or no difference to quality of life (data not pooled; 16 studies, 7458 participants; low-certainty evidence). Medication-related problems were reported in 10 studies (6740 participants) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies. This also applied to studies examining adherence to medication (nine studies, 3848 participants). AUTHORS' CONCLUSIONS It is unclear whether interventions to improve appropriate polypharmacy resulted in clinically significant improvement. Since the last update of this review in 2018, there appears to have been an increase in the number of studies seeking to address potential prescribing omissions and more interventions being delivered by multidisciplinary teams.
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Affiliation(s)
- Judith A Cole
- Clinical Trial Service Unit, University of Oxford, Oxford, UK
| | | | | | | | - Cathal Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Audrey Rankin
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | | | - Ngaire Kerse
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Chris R Cardwell
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Cristin Ryan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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Mena S, Moullin JC, Schneider M, Niquille A. Implementation of interprofessional quality circles on deprescribing in Swiss nursing homes: an observational study. BMC Geriatr 2023; 23:620. [PMID: 37789286 PMCID: PMC10548671 DOI: 10.1186/s12877-023-04335-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 09/20/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Polypharmacy and potentially inappropriate medications (PIMs) are still frequent among older adults in nursing homes. Deprescribing is an intervention that has been shown to be effective in reducing their use. However, the implementation of deprescribing in clinical practice has not yet been widely evaluated. The Quality Circle Deprescribing Module (QC-DeMo) intervention has been trialled through an effectiveness-implementation hybrid type 2 design. The intervention consists of a quality circle workshop session between healthcare professionals HCPs (physicians, nurses, and pharmacists) within a nursing home, in which they define a consensus to deprescribe specific PIMs classes. The aim of this study was to evaluate the implementation of the QC-DeMo intervention in nursing homes. METHODS This observational study focuses on the implementation part of the QC-DeMo trial. Implementation was based on the Framework for Implementation of Pharmacy Services (FISpH). Questionnaires at baseline and follow-up were used to evaluate reach, adoption, implementation effectiveness, fidelity, implementation, maintenance and the implementation strategies. Other data were collected from the QC-DeMo trial and routine data collected as part of the integrated pharmacy service where the QC-Demo trial was embedded. Implementation strategies included training of pharmacists, integration of the intervention into an existing quality circle dynamic and definition of tailored strategies to operationalise the consensus by each nursing home. RESULTS The QC-DeMo intervention was successfully implemented in 26 nursing homes in terms of reach, fidelity, adoption, implementation and implementation effectiveness. However, the intervention was found to be implemented with low maintenance as none of the nursing homes repeated the intervention after the trial. Implementation strategies were well received by HCPs: training was adequate according to pharmacists. Pre-existing quality circle dynamic facilitated interprofessional collaboration as involvement and support of each HCP was rated as high. HCPs recognized a specific and important role for each HCP in the deprescribing process. The most relevant tailored strategies to implement the consensus defined by each nursing home were identification of the patients by the pharmacist and a systematic review of medication's patients. CONCLUSIONS The implementation of a Quality Circle on Deprescribing is feasible but its maintenance in practice remains challenging. This study explores multiple implementation outcomes to better inform future implementation efforts of these types of interventions. TRIAL REGISTRATION ClinicalTrials.gov ( NCT03688542 ), registered on 26.09.2018.
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Affiliation(s)
- Stephanie Mena
- Community Pharmacy, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Rue du Bugnon 44, CH-1011, Lausanne, Switzerland.
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland.
| | - Joanna C Moullin
- Faculty of Health Sciences, Curtin University, Curtin School of Population Health, Perth, Australia
| | - Marie Schneider
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Anne Niquille
- Community Pharmacy, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Rue du Bugnon 44, CH-1011, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland
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Anderson PA, McLachlan AJ, Abdel Shaheed C, Gnjidic D, Ivers R, Mathieson S. Deprescribing interventions for gabapentinoids in adults: A scoping review. Br J Clin Pharmacol 2023; 89:2677-2690. [PMID: 37221314 DOI: 10.1111/bcp.15798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/08/2023] [Accepted: 05/03/2023] [Indexed: 05/25/2023] Open
Abstract
The emerging issue of rising gabapentinoid misuse is being recognized alongside the lack of current evidence supporting the safe and effective deprescribing of gabapentinoids. This scoping review aimed to assess the extent and nature of gabapentinoid deprescribing interventions in adults, either in reducing dosages, or prescribing of, gabapentinoids. Electronic databases were searched on 23 February 2022 without restrictions. Eligible studies included randomized, non-randomized and observational studies that assessed an intervention aimed at reducing/ceasing the prescription/use of a gabapentinoid in adults for any indication in a clinical setting. The research outcomes investigated the type of intervention, prescribing rates, cessations, patient outcomes and adverse events. Extracted outcome data were categorized as either short (≤3 months), intermediate (>3 but <12 months) or long (≥12 months) term. A narrative synthesis was conducted. The four included studies were conducted in primary and acute care settings. Interventions were of dose-reducing protocols, education and/or pharmacological-based approaches. In the randomized trials, gabapentinoid use could be ceased in at least one third of participants. In the two observational trials, gabapentinoid prescribing rates decreased by 9%. Serious adverse events and adverse events specifically related to gabapentinoids were reported in one trial. No study included patient-focused psychological interventions in the deprescribing process, nor provided any long-term follow-up. This review highlights the lack of existing evidence in this area. Due to limited available data, our review was unable to make any firm judgements on the most effective gabapentinoid deprescribing interventions in adults, highlighting the need for more research in this area.
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Affiliation(s)
- Prue A Anderson
- Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
- Pharmacy Department, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Andrew J McLachlan
- Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Christina Abdel Shaheed
- Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
- Sydney Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Danijela Gnjidic
- Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Rowena Ivers
- Faculty of Science, Medicine and Health, University of Wollongong, Sydney, Australia
| | - Stephanie Mathieson
- Sydney Musculoskeletal Health, Kolling Institute, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
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Bongiovanni T, Pletcher MJ, Lau C, Robinson A, Lancaster E, Zhang L, Behrends M, Wick E, Auerbach A. A behavioral intervention to promote use of multimodal pain medication for hospitalized patients: A randomized controlled trial. J Hosp Med 2023; 18:685-692. [PMID: 37357367 PMCID: PMC10578203 DOI: 10.1002/jhm.13153] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/01/2023] [Accepted: 06/04/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND The use of nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce pain and has become a core strategy to decrease opioid use, but there is a lack of data to describe encouraging use when admitting patients using electronic health record systems. OBJECTIVE Assess an electronic health record system to increase ordering of NSAIDs for hospitalized adults. DESIGNS, SETTINGS AND PARTICIPANTS We performed a cluster randomized controlled trial of clinicians admitting adult patients to a health system over a 9-month period. Clinicians were randomized to use a standard admission order set. INTERVENTION Clinicians in the intervention arm were required to actively order or decline NSAIDs; the control arm was shown the same order but without a required response. MAIN OUTCOME AND MEASURES The primary outcome was NSAIDs ordered and administered by the first full hospital day. Secondary outcomes included pain scores and opioid prescribing. RESULTS A total of 20,085 hospitalizations were included. Among these hospitalizations, patients had a mean age of 58 years, and a Charlson comorbidity score of 2.97, while 50% and 56% were female and White, respectively. Overall, 52% were admitted by a clinician randomized to the intervention arm. NSAIDs were ordered in 2267 (22%) interventions and 2093 (22%) control admissions (p = .10). Similarly, there were no statistical differences in NSAID administration, pain scores, or opioid prescribing. Average pain scores (0-5 scale) were 3.36 in the control group and 3.39 in the intervention group (p = .46). There were no differences in clinical harms. CONCLUSIONS AND RELEVANCE Requiring an active decision to order an NSAID at admission had no demonstrable impact on NSAID ordering. Multicomponent interventions, perhaps with stronger decision support, may be necessary to encourage NSAID ordering.
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Affiliation(s)
- Tasce Bongiovanni
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Catherine Lau
- Division of Hospital Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Andrew Robinson
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Elizabeth Lancaster
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Li Zhang
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Matthias Behrends
- Department of Anesthesia, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
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Bortolussi-Courval É, Podymow T, Trinh E, Moryousef J, Hanula R, Huon JF, Mavrakanas T, Suri R, Lee TC, McDonald EG. Electronic Decision Support for Deprescribing in Patients on Hemodialysis: Clinical Research Protocol for a Prospective, Controlled, Quality Improvement Study. Can J Kidney Health Dis 2023; 10:20543581231165712. [PMID: 37435299 PMCID: PMC10331104 DOI: 10.1177/20543581231165712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/13/2023] [Indexed: 07/13/2023] Open
Abstract
Background Patients on dialysis are commonly prescribed multiple medications (polypharmacy), many of which are potentially inappropriate medications (PIMs). Potentially inappropriate medications are associated with an increased risk of falls, fractures, and hospitalization. MedSafer is an electronic tool that generates individualized, prioritized reports with deprescribing opportunities by cross-referencing patient health data and medications with guidelines for deprescribing. Objectives Our primary aim was to increase deprescribing, as compared with usual care (medication reconciliation or MedRec), for outpatients receiving maintenance hemodialysis, through the provision of MedSafer deprescribing opportunity reports to the treating team and patient empowerment deprescribing brochures provided directly to the patients themselves. Design This controlled, prospective, quality improvement study with a contemporary control builds on existing policy at the outpatient hemodialysis centers where biannual MedRecs are performed by the treating nephrologist and nursing team. Setting The study takes place on 2 of the 3 outpatient hemodialysis units of the McGill University Health Centre in Montreal, Quebec, Canada. The intervention unit is the Lachine Hospital, and the control unit is the Montreal General Hospital. Patients A closed cohort of outpatient hemodialysis patients visit one of the hemodialysis centers multiple times per week for their hemodialysis treatment. The initial cohort of the intervention unit includes 85 patients, whereas the control unit has 153 patients. Patients who are transplanted, hospitalized during their scheduled MedRec, or die before or during the MedRec will be excluded from the study. Measurements We will compare rates of deprescribing between the control and intervention units following a single MedRec. On the intervention unit, MedRecs will be paired with MedSafer reports (the intervention), and on the control unit, MedRecs will take place without MedSafer reports (usual care). On the intervention unit, patients will also receive deprescribing patient empowerment brochures for select medication classes (gabapentinoids, proton-pump inhibitors, sedative hypnotics and opioids for chronic non-cancer pain). Physicians on the intervention unit will be interviewed post-MedRec to determine implementation barriers and facilitators. Methods The primary outcome will be the proportion of patients with 1 or more PIMs deprescribed on the intervention unit, as compared with the control unit, following a biannual MedRec. This study will build on existing policies aimed at optimizing medication therapy in patients undergoing maintenance hemodialysis. The electronic deprescribing decision support tool, MedSafer, will be tested in a dialysis setting, where nephrologists are regularly in contact with patients. MedRecs are an interdisciplinary clinical activity performed biannually on the hemodialysis units (in the Spring and Fall), and within 1 week following discharge from any hospitalization. This study will take place in the Fall of 2022. Semi-structured interviews will be conducted among physicians on the intervention unit to determine barriers and facilitators to implementation of the MedSafer-supplemented MedRec process and analyzed according to grounded theory in qualitative research. Limitations Deprescribing can be limited due to nephrologists' time constraints, cognitive impairment of the hemodialyzed patient stemming from their illness and complex medication regimens, and lack of sufficient patient resources to learn about the medications they are taking and their potential harms. Conclusions Electronic decision support can facilitate deprescribing for the clinical team by providing a nudge reminder, decreasing the time it takes to review and effectuate guideline recommendations, and by lowering the barrier of when and how to taper. Guidelines for deprescribing in the dialysis population have recently been published and incorporated into the MedSafer software. To our knowledge, this will be the first study to examine the efficacy of pairing these guidelines with MedRecs by leveraging electronic decision support in the outpatient dialysis population. Trial registration This study was registered on Clinicaltrials.gov (NCT05585268) on October 2, 2022, prior to the enrolment of the first participant on October 3, 2022. The registration number is pending at the time of protocol submission.
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Affiliation(s)
- Émilie Bortolussi-Courval
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Tiina Podymow
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Emilie Trinh
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Joseph Moryousef
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - R. Hanula
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Jean-François Huon
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Thomas Mavrakanas
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Rita Suri
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Todd C. Lee
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Emily Gibson McDonald
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation, Montreal, QC, Canada
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Darvall J. A Wake-Up Call: Ongoing Sedatives in ICU Survivors. Chest 2023; 163:1346-1347. [PMID: 37295872 DOI: 10.1016/j.chest.2023.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/19/2023] [Indexed: 06/12/2023] Open
Affiliation(s)
- Jai Darvall
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia.
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Jungo KT, Ansorg AK, Floriani C, Rozsnyai Z, Schwab N, Meier R, Valeri F, Stalder O, Limacher A, Schneider C, Bagattini M, Trelle S, Spruit M, Schwenkglenks M, Rodondi N, Streit S. Optimising prescribing in older adults with multimorbidity and polypharmacy in primary care (OPTICA): cluster randomised clinical trial. BMJ 2023; 381:e074054. [PMID: 37225248 PMCID: PMC10206530 DOI: 10.1136/bmj-2022-074054] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To study the effects of a primary care medication review intervention centred around an electronic clinical decision support system (eCDSS) on appropriateness of medication and the number of prescribing omissions in older adults with multimorbidity and polypharmacy compared with a discussion about medication in line with usual care. DESIGN Cluster randomised clinical trial. SETTING Swiss primary care, between December 2018 and February 2021. PARTICIPANTS Eligible patients were ≥65 years of age with three or more chronic conditions and five or more long term medications. INTERVENTION The intervention to optimise pharmacotherapy centred around an eCDSS was conducted by general practitioners, followed by shared decision making between general practitioners and patients, and was compared with a discussion about medication in line with usual care between patients and general practitioners. MAIN OUTCOME MEASURES Primary outcomes were improvement in the Medication Appropriateness Index (MAI) and the Assessment of Underutilisation (AOU) at 12 months. Secondary outcomes included number of medications, falls, fractures, and quality of life. RESULTS In 43 general practitioner clusters, 323 patients were recruited (median age 77 (interquartile range 73-83) years; 45% (n=146) women). Twenty one general practitioners with 160 patients were assigned to the intervention group and 22 general practitioners with 163 patients to the control group. On average, one recommendation to stop or start a medication was reported to be implemented per patient. At 12 months, the results of the intention-to-treat analysis of the improvement in appropriateness of medication (odds ratio 1.05, 95% confidence interval 0.59 to 1.87) and the number of prescribing omissions (0.90, 0.41 to 1.96) were inconclusive. The same was the case for the per protocol analysis. No clear evidence was found for a difference in safety outcomes at the 12 month follow-up, but fewer safety events were reported in the intervention group than in the control group at six and 12 months. CONCLUSIONS In this randomised trial of general practitioners and older adults, the results were inconclusive as to whether the medication review intervention centred around the use of an eCDSS led to an improvement in appropriateness of medication or a reduction in prescribing omissions at 12 months compared with a discussion about medication in line with usual care. Nevertheless, the intervention could be safely delivered without causing any harm to patients. TRIAL REGISTRATION NCT03724539Clinicaltrials.gov NCT03724539.
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Affiliation(s)
| | | | - Carmen Floriani
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Zsofia Rozsnyai
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Nathalie Schwab
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Rahel Meier
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Fabio Valeri
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | | | | | - Claudio Schneider
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Sven Trelle
- CTU Bern, University of Bern, Bern, Switzerland
| | - Marco Spruit
- Department of Information and Computing Sciences, Utrecht University, Utrecht, Netherlands
- Public Health and Primary Care (PHEG), Leiden University Medical Center, Leiden University, Leiden, Netherlands
- Leiden Institute of Advanced Computer Science (LIACS), Faculty of Science, Leiden University, Leiden, Netherlands
| | - Matthias Schwenkglenks
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
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Sibille FX, de Saint-Hubert M, Henrard S, Aubert CE, Goto NA, Jennings E, Dalleur O, Rodondi N, Knol W, O'Mahony D, Schwenkglenks M, Spinewine A. Benzodiazepine Receptor Agonists Use and Cessation Among Multimorbid Older Adults with Polypharmacy: Secondary Analysis from the OPERAM Trial. Drugs Aging 2023; 40:551-561. [PMID: 37221407 DOI: 10.1007/s40266-023-01029-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Benzodiazepine receptor agonists (BZRAs) are commonly prescribed in older adults despite an unfavorable risk-benefit ratio. Hospitalizations may provide a unique opportunity to initiate BZRA cessation, yet little is known about cessation during and after hospitalization. We aimed to measure the prevalence of BZRA use before hospitalization and the rate of cessation 6 months later, and to identify factors associated with these outcomes. METHODS We conducted a secondary analysis of a cluster randomized controlled trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly [OPERAM]), comparing usual care and in-hospital pharmacotherapy optimization in adults aged 70 years or over with multimorbidity and polypharmacy in four European countries. BZRA cessation was defined as taking one or more BZRA before hospitalization and not taking any BZRA at the 6-month follow-up. Multivariable logistic regression was performed to identify factors associated with BZRA use before hospitalization and with cessation at 6 months. RESULTS Among 1601 participants with complete 6-month follow-up data, 378 (23.6%) were BZRA users before hospitalization. Female sex (odds ratio [OR] 1.52 [95% confidence interval 1.18-1.96]), a higher reported level of depression/anxiety (OR up to 2.45 [1.54-3.89]), a higher number of daily drugs (OR 1.08 [1.05-1.12]), use of an antidepressant (OR 1.74 [1.31-2.31]) or an antiepileptic (OR 1.46 [1.02-2.07]), and trial site were associated with BZRA use. Diabetes mellitus (OR 0.60 [0.44-0.80]) was associated with a lower probability of BZRA use. BZRA cessation occurred in 86 BZRA users (22.8%). Antidepressant use (OR 1.74 [1.06-2.86]) and a history of falling in the previous 12 months (OR 1.75 [1.10-2.78]) were associated with higher BZRA cessation, and chronic obstructive pulmonary disease (COPD) (OR 0.45 [0.20-0.91]) with lower BZRA cessation. CONCLUSION BZRA prevalence was high among included multimorbid older adults, and BZRA cessation occurred in almost a quarter of them within 6 months after hospitalization. Targeted BZRA deprescribing programs could further enhance cessation. Specific attention is needed for females, central nervous system-acting co-medication, and COPD co-morbidity. REGISTRATION ClinicalTrials.gov identifier: NCT02986425. December 8, 2016.
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Affiliation(s)
- François-Xavier Sibille
- Department of Geriatric Medicine, CHU UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium.
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium.
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium.
| | - Marie de Saint-Hubert
- Department of Geriatric Medicine, CHU UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
| | - Séverine Henrard
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Carole Elodie Aubert
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Namiko Anna Goto
- Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Emma Jennings
- Department of Medicine, School of Medicine, University College Cork, Cork, Republic of Ireland
| | - Olivia Dalleur
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
- Department of Pharmacy, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Wilma Knol
- Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Denis O'Mahony
- Department of Medicine, School of Medicine, University College Cork, Cork, Republic of Ireland
| | | | - Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
- Department of Pharmacy, CHU UCL Namur, Yvoir, Belgium
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Fujita K, Hooper P, Masnoon N, Lo S, Gnjidic D, Etherton-Beer C, Reeve E, Magin P, Bell JS, Rockwood K, O'Donnell LK, Sawan M, Baysari M, Hilmer SN. Impact of a Comprehensive Intervention Bundle Including the Drug Burden Index on Deprescribing Anticholinergic and Sedative Drugs in Older Acute Inpatients: A Non-randomised Controlled Before-and-After Pilot Study. Drugs Aging 2023:10.1007/s40266-023-01032-6. [PMID: 37160561 DOI: 10.1007/s40266-023-01032-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION Implementation of the Drug Burden Index (DBI) as a risk assessment tool in clinical practice may facilitate deprescribing. OBJECTIVE The purpose of this study is to evaluate how a comprehensive intervention bundle using the DBI impacts (i) the proportion of older inpatients with at least one DBI-contributing medication stopped or dose reduced on discharge, compared with admission; and (ii) the changes in deprescribing of different DBI-contributing medication classes during hospitalisation. METHODS This before-and-after study was conducted in an Australian metropolitan tertiary referral hospital. Patients aged ≥ 75 years admitted to the acute aged care service for ≥ 48 h from December 2020 to October 2021 and prescribed DBI-contributing medication were included. During the control period, usual care was provided. During the intervention, access to the intervention bundle was added, including a clinician interface displaying DBI score in the electronic medical record. In a subsequent 'stewardship' period, a stewardship pharmacist used the bundle to provide clinicians with patient-specific recommendations on deprescribing of DBI-contributing medications. RESULTS Overall, 457 hospitalisations were included. The proportion of patients with at least one DBI-contributing medication stopped/reduced on discharge increased from 29.9% (control period) to 37.5% [intervention; adjusted risk difference (aRD) 6.5%, 95% confidence intervals (CI) -3.2 to 17.5%] and 43.1% (stewardship; aRD 12.1%, 95% CI 1.0-24.0%). The proportion of opioid prescriptions stopped/reduced rose from 17.9% during control to 45.7% during stewardship (p = 0.04). CONCLUSION Integrating a comprehensive intervention bundle and accompanying stewardship program is a promising strategy to facilitate deprescribing of sedative and anticholinergic medications in older inpatients.
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Affiliation(s)
- Kenji Fujita
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Patrick Hooper
- eMR Connect Program, eHealth NSW, Sydney, NSW, Australia
| | - Nashwa Masnoon
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Sarita Lo
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Parker Magin
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Kenneth Rockwood
- Department of Medicine (Geriatric Medicine & Neurology), Dalhousie University; Frailty and Elder Care Network, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Lisa Kouladjian O'Donnell
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Mouna Sawan
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Melissa Baysari
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Sarah N Hilmer
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia.
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Daunt R, Curtin D, O'Mahony D. Polypharmacy stewardship: a novel approach to tackle a major public health crisis. THE LANCET. HEALTHY LONGEVITY 2023; 4:e228-e235. [PMID: 37030320 DOI: 10.1016/s2666-7568(23)00036-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 04/10/2023] Open
Abstract
With growing global concern regarding medication-related harm, WHO launched a global patient safety challenge, Medication Without Harm, in March, 2017. Multimorbidity, polypharmacy, and fragmented health care (ie, patients attending appointments with multiple physicians in various health-care settings) are key drivers of medication-related harm, which can result in negative functional outcomes, high rates of hospitalisation, and excess morbidity and mortality, particularly in patients with frailty older than 75 years. Some studies have examined the effect of medication stewardship interventions in older patient cohorts, but focused on a narrow spectrum of potentially adverse medication practices, with mixed results. In response to the WHO challenge, we propose the novel concept of broad-spectrum polypharmacy stewardship, a coordinated intervention designed to improve the management of multimorbidities, taking into account potentially inappropriate medications, potential prescribing omissions, drug-drug and drug-disease interactions, and prescribing cascades, aligning treatment regimens with the condition, prognosis, and preferences of the individual patient. Although the safety and efficacy of polypharmacy stewardship need to be tested with well designed clinical trials, we propose that this approach could minimise medication-related harm in older people with multimorbidities exposed to polypharmacy.
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Affiliation(s)
- Ruth Daunt
- Department of Medicine, School of Medicine, University College Cork, and Department of Geriatric Medicine, Cork University Hospital, Wilton, Cork, Ireland
| | - Denis Curtin
- Department of Medicine, School of Medicine, University College Cork, and Department of Geriatric Medicine, Cork University Hospital, Wilton, Cork, Ireland
| | - Denis O'Mahony
- Department of Medicine, School of Medicine, University College Cork, and Department of Geriatric Medicine, Cork University Hospital, Wilton, Cork, Ireland.
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Fujita K, Masnoon N, Mach J, O’Donnell LK, Hilmer SN. Polypharmacy and precision medicine. CAMBRIDGE PRISMS. PRECISION MEDICINE 2023; 1:e22. [PMID: 38550925 PMCID: PMC10953761 DOI: 10.1017/pcm.2023.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/26/2023] [Accepted: 03/01/2023] [Indexed: 07/05/2024]
Abstract
Precision medicine is an approach to maximise the effectiveness of disease treatment and prevention and minimise harm from medications by considering relevant demographic, clinical, genomic and environmental factors in making treatment decisions. Precision medicine is complex, even for decisions about single drugs for single diseases, as it requires expert consideration of multiple measurable factors that affect pharmacokinetics and pharmacodynamics, and many patient-specific variables. Given the increasing number of patients with multiple conditions and medications, there is a need to apply lessons learned from precision medicine in monotherapy and single disease management to optimise polypharmacy. However, precision medicine for optimisation of polypharmacy is particularly challenging because of the vast number of interacting factors that influence drug use and response. In this narrative review, we aim to provide and apply the latest research findings to achieve precision medicine in the context of polypharmacy. Specifically, this review aims to (1) summarise challenges in achieving precision medicine specific to polypharmacy; (2) synthesise the current approaches to precision medicine in polypharmacy; (3) provide a summary of the literature in the field of prediction of unknown drug-drug interactions (DDI) and (4) propose a novel approach to provide precision medicine for patients with polypharmacy. For our proposed model to be implemented in routine clinical practice, a comprehensive intervention bundle needs to be integrated into the electronic medical record using bioinformatic approaches on a wide range of data to predict the effects of polypharmacy regimens on an individual. In addition, clinicians need to be trained to interpret the results of data from sources including pharmacogenomic testing, DDI prediction and physiological-pharmacokinetic-pharmacodynamic modelling to inform their medication reviews. Future studies are needed to evaluate the efficacy of this model and to test generalisability so that it can be implemented at scale, aiming to improve outcomes in people with polypharmacy.
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Affiliation(s)
- Kenji Fujita
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Nashwa Masnoon
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
| | - John Mach
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Lisa Kouladjian O’Donnell
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Sarah N. Hilmer
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
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Mortsiefer A, Löscher S, Pashutina Y, Santos S, Altiner A, Drewelow E, Ritzke M, Wollny A, Thürmann P, Bencheva V, Gogolin M, Meyer G, Abraham J, Fleischer S, Icks A, Montalbo J, Wiese B, Wilm S, Feldmeier G. Family Conferences to Facilitate Deprescribing in Older Outpatients With Frailty and With Polypharmacy: The COFRAIL Cluster Randomized Trial. JAMA Netw Open 2023; 6:e234723. [PMID: 36972052 PMCID: PMC10043750 DOI: 10.1001/jamanetworkopen.2023.4723] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/08/2023] [Indexed: 03/29/2023] Open
Abstract
Importance For older adults with frailty syndrome, reducing polypharmacy may have utility as a safety-promoting treatment option. Objective To investigate the effects of family conferences on medication and clinical outcomes in community-dwelling older adults with frailty receiving polypharmacy. Design, Setting, and Participants This cluster randomized clinical trial was conducted from April 30, 2019, to June 30, 221, at 110 primary care practices in Germany. The study included community-dwelling adults aged 70 years or older with frailty syndrome, daily use of at least 5 different medications, a life expectancy of at least 6 months, and no moderate or severe dementia. Interventions General practitioners (GPs) in the intervention group received 3 training sessions on family conferences, a deprescribing guideline, and a toolkit with relevant nonpharmacologic interventions. Three GP-led family conferences for shared decision-making involving the participants and family caregivers and/or nursing services were subsequently held per patient at home over a period of 9 months. Patients in the control group received care as usual. Main Outcomes and Measures The primary outcome was the number of hospitalizations within 12 months, as assessed by nurses during home visits or telephone interviews. Secondary outcomes included the number of medications, the number of European Union list of the number of potentially inappropriate medication (EU[7]-PIM) for older people, and geriatric assessment parameters. Both per-protocol and intention-to-treat analyses were conducted. Results The baseline assessment included 521 individuals (356 women [68.3%]; mean [SD] age, 83.5 [6.17] years). The intention-to-treat analysis with 510 patients showed no significant difference in the adjusted mean (SD) number of hospitalizations between the intervention group (0.98 [1.72]) and the control group (0.99 [1.53]). In the per-protocol analysis including 385 individuals, the mean (SD) number of medications decreased from 8.98 (3.56) to 8.11 (3.21) at 6 months and to 8.49 (3.63) at 12 months in the intervention group and from 9.24 (3.44) to 9.32 (3.59) at 6 months and to 9.16 (3.42) at 12 months in the control group, with a statistically significant difference at 6 months in the mixed-effect Poisson regression model (P = .001). After 6 months, the mean (SD) number of EU(7)-PIMs was significantly lower in the intervention group (1.30 [1.05]) than in the control group (1.71 [1.25]; P = .04). There was no significant difference in the mean number of EU(7)-PIMs after 12 months. Conclusions and Relevance In this cluster randomized clinical trial with older adults taking 5 or more medications, the intervention consisting of GP-led family conferences did not achieve sustainable effects in reducing the number of hospitalizations or the number of medications and EU(7)-PIMs after 12 months. Trial Registration German Clinical Trials Register: DRKS00015055.
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Affiliation(s)
- Achim Mortsiefer
- Institute of General Practice and Primary Care, Chair of General Practice II and Patient-Centredness in Primary Care, Faculty of Health, Witten/Herdecke University, Witten, Germany
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Susanne Löscher
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Yekaterina Pashutina
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sara Santos
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Attila Altiner
- Institute of General Practice, University Medical Center Rostock, Rostock, Germany
| | - Eva Drewelow
- Institute of General Practice, University Medical Center Rostock, Rostock, Germany
| | - Manuela Ritzke
- Institute of General Practice, University Medical Center Rostock, Rostock, Germany
| | - Anja Wollny
- Institute of General Practice, University Medical Center Rostock, Rostock, Germany
| | - Petra Thürmann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Veronika Bencheva
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Matthias Gogolin
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Gabriele Meyer
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Jens Abraham
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Steffen Fleischer
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Andrea Icks
- Institute for Health Services and Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Joseph Montalbo
- Institute for Health Services and Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Birgitt Wiese
- WG Medical Statistics and IT-Infrastructure, Institute of General Practice, Hannover Medical School, Hannover, Germany
| | - Stefan Wilm
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Gregor Feldmeier
- Institute of General Practice, University Medical Center Rostock, Rostock, Germany
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Cucinotta D. 2022 - Pros and Cons in General Internal Medicine and Geriatrics. ACTA BIO-MEDICA : ATENEI PARMENSIS 2023; 94:e2023063. [PMID: 36786245 PMCID: PMC9987499 DOI: 10.23750/abm.v94i1.14226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 01/26/2023] [Indexed: 02/15/2023]
Affiliation(s)
- Domenico Cucinotta
- Former Chairman Department of Internal Medicine and Aging, University Hospital Bologna, Italy; Advisor and Professor Master of Geriatric Medicine, San Marino and Ferrara Universities. Italy..
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. How "age-friendly" are deprescribing interventions? A scoping review of deprescribing trials. Health Serv Res 2023; 58 Suppl 1:123-138. [PMID: 36221154 DOI: 10.1111/1475-6773.14083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To assess how age-friendly deprescribing trials are regarding intervention design and outcome assessment. Reduced use of potentially inappropriate medications (PIMs) can be addressed by deprescribing-a systematic process of discontinuing and/or reducing the use of PIMs. The 4Ms-"Medication", "Mentation", "Mobility", and "What Matters Most" to the person-can be used to guide assessment of age-friendliness of deprescribing trials. DATA SOURCE Published literature. STUDY DESIGN Scoping review. DATA EXTRACTION METHODS The literature was identified using keywords related to deprescribing and polypharmacy in PubMed, EMBASE, Web of Science, ProQuest, CINAHL, and Cochrane and snowballing. Study characteristics were extracted and evaluated for consideration of 4Ms. PRINCIPAL FINDINGS Thirty-seven of the 564 trials identified met the review eligibility criteria. Intervention design: "Medication" was considered in the intervention design of all trials; "Mentation" was considered in eight trials; "Mobility" (n = 2) and "What Matters Most" (n = 6) were less often considered in the design of intervention. Most trials targeted providers without specifying how matters important to older adults and their families were aligned with deprescribing decisions. OUTCOME ASSESSMENT "Medication" was the most commonly assessed outcome (n = 33), followed by "Mobility" (n = 13) and "Mentation" (n = 10) outcomes, with no study examining "What Matters Most" outcomes. CONCLUSIONS "Mentation" and "Mobility", and "What Matters Most" have been considered to varying degrees in deprescribing trials, limiting the potential of deprescribing evidence to contribute to improved clinical practice in building an age-friendly health care system.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Kobi Nathan
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Arizona State University, Edson College of Nursing and Health Innovation, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- University of Rochester Medical Center, Department of Medicine, Division of Hematology/Oncology, Rochester, New York, USA
| | - Donna M Fick
- Penn State University, Ross and Carol Nese College of Nursing, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Division of Geriatrics & Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Masnoon N, Lo S, Hilmer S. A stewardship program to facilitate anticholinergic and sedative medication deprescribing using the drug burden index in electronic medical records. Br J Clin Pharmacol 2023; 89:687-698. [PMID: 36038522 PMCID: PMC10953400 DOI: 10.1111/bcp.15517] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/22/2022] [Accepted: 08/12/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS The drug burden index (DBI) measures a person's total exposure to anticholinergic and sedative medications, which are commonly associated with harm. Through incorporating the DBI in electronic medical records (eMR) and implementing a DBI stewardship program, we aimed to determine (i) uptake of the steward's recommendations to deprescribe anticholinergic and/or sedative drugs by the medical team and (ii) whether accepted recommendations were actioned in hospital or recommended for follow-up by the General Practitioner post-discharge. METHODS A single-arm, non-randomised feasibility study was performed at an Australian tertiary referral metropolitan hospital. The stewardship pharmacist reviewed eMRs of patients aged ≥75 years with DBI scores > 0, during admission. The steward identified and discussed potential opportunities to deprescribe anticholinergic and/or sedative medications with the medical registrars. RESULTS Amongst 256 patients reviewed, the steward made 170 recommendations for 117 patients. Registrars agreed with 141 recommendations (82.9%) for 95 patients (81.2%), and actioned 115 deprescribing recommendations for 80 patients, most commonly for antidepressants and opioids. The 115 actioned recommendations resulted in 125 changes, with 44 changes to the inpatient drug chart and 81 additional changes recommended post-discharge in the discharge summary. CONCLUSION Opportunities exist for deprescribing anticholinergic and sedative medications in older inpatients and a DBI stewardship program may help implement these. It is important to capture different outcomes of deprescribing interventions, including in-hospital medication changes, recommendations in the Discharge Summary, sustainability of deprescribing and clinical outcomes.
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Affiliation(s)
- Nashwa Masnoon
- Kolling Institute, Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
| | - Sarita Lo
- Kolling Institute, Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
| | - Sarah Hilmer
- Kolling Institute, Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
- Departments of Clinical Pharmacology and Aged CareRoyal North Shore HospitalSydneyNSWAustralia
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Alqenae FA, Steinke D, Carson-Stevens A, Keers RN. Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study. Ther Adv Drug Saf 2023; 14:20420986231154365. [PMID: 36949766 PMCID: PMC10026140 DOI: 10.1177/20420986231154365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 01/16/2023] [Indexed: 03/18/2023] Open
Abstract
Introduction Improving medication safety during transition of care is an international healthcare priority. While existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy. Aim To characterise the nature and contributory factors of medication-related incidents during transition of care from secondary to primary care. Method A retrospective analysis of medication incidents reported to the National Reporting and Learning System (NRLS) in England and Wales between 2015 and 2019. Descriptive analysis identified the frequency and nature of incidents and content analysis of free text data, coded using the Patient Safety Research Group (PISA) classification, examined the contributory factors and outcome of incidents. Results A total of 1121 medication-related incident reports underwent analysis. Most incidents involved patients over 65 years old (55%, n = 626/1121). More than one in 10 (12.6%, n = 142/1121) incidents were associated with patient harm. The drug monitoring (17%) and administration stages (15%) were associated with a higher proportion of harmful incidents than any other drug use stages. Common medication classes associated with incidents were the cardiovascular (n = 734) and central nervous (n = 273) systems. Among 408 incidents reporting 467 contributory factors, the most common contributory factors were organisation factors (82%, n = 383/467) (mostly related to continuity of care which is the delivery of a seamless service through integration, co-ordination, and the sharing of information between different providers), followed by staff factors (16%, n = 75/467). Conclusion Medication incidents after hospital discharge are associated with patient harm. Several targets were identified for future research that could support the development of remedial interventions, including commonly observed medication classes, older adults, increase patient engagement, and improve shared care agreement for medication monitoring post hospital discharge. Plain language summary Study using reports about unsafe or substandard care mainly written by healthcare professionals to better understand the type and causes of medication safety problems following hospital discharge Why was the study done? The safe use of medicines after hospital discharge has been highlighted by the World Health Organization as an important target for improvement in patient care. Yet, the type of medication problems which occur, and their causes are poorly understood across England and Wales, which may hamper our efforts to create ways to improve care as they may not be based on what we know causes the problem in the first place.What did the researchers do? The research team studied medication safety incident reports collected across England and Wales over a 5-year period to better understand what kind of medication safety problems occur after hospital discharge and why they happen, so we can find ways to prevent them from happening in future.What did the researchers find? The total number of incident reports studied was 1121, and the majority (n = 626) involved older people. More than one in ten of these incidents caused harm to patients. The most common medications involved in the medication safety incidents were for cardiovascular diseases such as high blood pressure, conditions such as mental illness, pain and neurological conditions (e.g., epilepsy) and other illnesses such as diabetes. The most common causes of these incidents were because of the organisation rules, such as information sharing, followed by staff issues, such as not following protocols, individual mistakes and not having the right skills for the task.What do the findings mean? This study has identified some important targets that can be a focus of future efforts to improve the safe use of medicines after hospital discharge. These include concentrating attention on medication for the cardiovascular and central nervous systems (e.g., via incorporating them in prescribing safety indicators and pharmaceutical prioritisation tools), staff skill mix (e.g., embedding clinical pharmacist roles at key parts of the care pathway where greatest risk is suspected), and implementation of electronic interventions to improve timely communication of medication and other information between healthcare providers.
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Affiliation(s)
| | - Douglas Steinke
- Centre for Pharmacoepidemiology and Drug
Safety, Division of Pharmacy and Optometry, School of Health Sciences,
University of Manchester, Manchester, UK
- Pharmacy Department, Manchester University NHS
Foundation Trust, Manchester, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of
Medicine, Cardiff University, Cardiff, UK
| | - Richard N. Keers
- Centre for Pharmacoepidemiology and Drug
Safety, Division of Pharmacy and Optometry, School of Health Sciences,
University of Manchester, Manchester, UK
- Suicide, Risk and Safety Research Unit, Greater
Manchester Mental Health NHS Foundation Trust, Manchester, UK
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Nohner M, De Lima B, Drago K. Validating ICD-10 codes for adverse drug events in hospitalised older adults: protocol for a cross-sectional study. BMJ Open 2022; 12:e062853. [PMID: 36323472 PMCID: PMC9639084 DOI: 10.1136/bmjopen-2022-062853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Adverse drug events (ADEs) among hospitalised older adults are common yet often preventable. Efforts to recognise ADEs using pharmacist review and electronic health record adaptations have had mixed results. Our health system developed and implemented a geriatric prescribing context designed to offer age-friendly dose and frequency defaults for hospitalised patients 75 years and older. The impact of this context on ADEs remains unknown. To measure its impact, our team created a list of ADE-related International Classification of Diseases (ICD) codes specific to 10 commonly used medications at our institution. This protocol paper presents the process of designing a screening tool for ADEs, validating the tool with manual chart reviews and measuring the impact of the context on ADEs. METHODS AND ANALYSIS This retrospective cross-sectional study will assess our list of ICD-10 codes against manual chart review to determine its accuracy. An electronic health record report for patients aged 75 years and older admitted to the hospital for a minimum of two nights was generated to identify 100 test positives and 100 test negatives. Test positives need at least one code from each level of our ICD-10 code list. The first level of codes identifies any possible ADEs while the second level is more symptom based. Test negatives must not have any code from the list. Two physicians blinded to test status will complete a structured chart review to determine if a patient had an ADE during their hospitalisation. Acceptable inter-rater reliability will need to be met before proceeding with independent chart review. Positive predictive value and negative predictive value will be calculated once all the chart reviews are completed. ETHICS AND DISSEMINATION The Oregon Health & Science University Institutional Review Board approved this study (#21385). The results of the study will be disseminated in peer-reviewed journals and conference presentations.
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Affiliation(s)
- Mitchell Nohner
- General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - Bryanna De Lima
- General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - Katie Drago
- General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon, USA
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Martin-Kerry J, Taylor J, Scott S, Patel M, Wright D, Clark A, Turner D, Alldred DP, Murphy K, Keevil V, Witham MD, Kellar I, Bhattacharya D. Developing a core outcome set for hospital deprescribing trials for older people under the care of a geriatrician. Age Ageing 2022; 51:6782998. [PMID: 36317291 PMCID: PMC9724769 DOI: 10.1093/ageing/afac241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 07/06/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Half of older people are prescribed unnecessary/inappropriate medications that are not routinely deprescribed in hospital hence there is a need for deprescribing trials. We aimed to develop a Core Outcome Set (COS) for deprescribing trials for older people under the care of a geriatrician during hospital admission. METHODS We developed a list of potentially relevant outcomes from the literature. Using a two-round Delphi survey of stakeholder groups representing older people and carers, hospital clinicians, hospital managers, and ageing/deprescribing researchers, each outcome was scored according to Grading of Recommendations Assessment, Development and Evaluation, followed by two consensus workshops to finalise the COS. RESULTS Two hundred people completed Round 1 and 114 completed Round 2. Representing all stakeholder groups, 10 people participated in workshop 1 and 10 in workshop 2. Six outcomes were identified as most important, feasible and acceptable to collect in a trial: number of prescribed medicines stopped; number of prescribed medicines with dosage reduced; quality of life; mortality; adverse drug events and number of hospital stays. Three other outcomes were identified as important, but currently too burdensome to collect: number of potentially inappropriate medicines prescribed; burden from medication routine; and medication-related admissions to hospital. CONCLUSIONS A COS represents the minimum outcomes that should be collected and reported. Whilst uncommon practice for COS development, the value of considering outcome collection feasibility is demonstrated by the removal of three potential outcomes that, if included, may have compromised COS uptake due to challenges with collecting the data.
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Affiliation(s)
| | - Jo Taylor
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Sion Scott
- School of Healthcare, University of Leicester, Leicester LE1 7RH, UK
| | - Martyn Patel
- Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK,Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - David Wright
- School of Healthcare, University of Leicester, Leicester LE1 7RH, UK,School of Pharmacy, University of Bergen, Bergen 5008, Norway
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - David Turner
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | | | - Katherine Murphy
- Patient and Public Involvement Lead, School of Healthcare, University of Leicester, Leicester, LE1 7RH, UK
| | - Victoria Keevil
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Miles D Witham
- Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne NE4 5PL, UK,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK
| | - Ian Kellar
- School of Psychology, University of Leeds, Leeds LS2 9JU, UK
| | - Debi Bhattacharya
- School of Healthcare, University of Leicester, Leicester LE1 7RH, UK
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Scott IA, Reeve E, Hilmer SN. Establishing the worth of deprescribing inappropriate medications: are we there yet? Med J Aust 2022; 217:283-286. [PMID: 36030510 DOI: 10.5694/mja2.51686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/14/2022] [Accepted: 06/21/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Ian A Scott
- Princess Alexandra Hospital, Brisbane, QLD
- University of Queensland, Brisbane, QLD
| | | | - Sarah N Hilmer
- Royal North Shore Hospital, Sydney, NSW
- University of Sydney, Sydney, NSW
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Seppala LJ, Kamkar N, van Poelgeest EP, Thomsen K, Daams JG, Ryg J, Masud T, Montero-Odasso M, Hartikainen S, Petrovic M, van der Velde N. Medication reviews and deprescribing as a single intervention in falls prevention: a systematic review and meta-analysis. Age Ageing 2022; 51:afac191. [PMID: 36153749 PMCID: PMC9509688 DOI: 10.1093/ageing/afac191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND our aim was to assess the effectiveness of medication review and deprescribing interventions as a single intervention in falls prevention. METHODS DESIGN systematic review and meta-analysis. DATA SOURCES Medline, Embase, Cochrane CENTRAL, PsycINFO until 28 March 2022. ELIGIBILITY CRITERIA randomised controlled trials of older participants comparing any medication review or deprescribing intervention with usual care and reporting falls as an outcome. STUDY RECORDS title/abstract and full-text screening by two reviewers. RISK OF BIAS Cochrane Collaboration revised tool. DATA SYNTHESIS results reported separately for different settings and sufficiently comparable studies meta-analysed. RESULTS forty-nine heterogeneous studies were included. COMMUNITY meta-analyses of medication reviews resulted in a risk ratio (RR) of 1.05 (95% confidence interval, 0.85-1.29, I2 = 0%, 3 studies(s)) for number of fallers, in an RR = 0.95 (0.70-1.27, I2 = 37%, 3 s) for number of injurious fallers and in a rate ratio (RaR) of 0.89 (0.69-1.14, I2 = 0%, 2 s) for injurious falls. HOSPITAL meta-analyses assessing medication reviews resulted in an RR = 0.97 (0.74-1.28, I2 = 15%, 2 s) and in an RR = 0.50 (0.07-3.50, I2 = 72% %, 2 s) for number of fallers after and during admission, respectively. LONG-TERM CARE meta-analyses investigating medication reviews or deprescribing plans resulted in an RR = 0.86 (0.72-1.02, I2 = 0%, 5 s) for number of fallers and in an RaR = 0.93 (0.64-1.35, I2 = 92%, 7 s) for number of falls. CONCLUSIONS the heterogeneity of the interventions precluded us to estimate the exact effect of medication review and deprescribing as a single intervention. For future studies, more comparability is warranted. These interventions should not be implemented as a stand-alone strategy in falls prevention but included in multimodal strategies due to the multifactorial nature of falls.PROSPERO registration number: CRD42020218231.
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Affiliation(s)
- Lotta J Seppala
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Nellie Kamkar
- Gait and Brain Laboratory, Lawson Research Health Institute, Parkwood Hospital, London Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London Ontario, Canada
| | - Eveline P van Poelgeest
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Katja Thomsen
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Joost G Daams
- Research Support, Medical Library, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- ODIN (Odense Deprescribing INitiative), Denmark
| | - Tahir Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Manuel Montero-Odasso
- Gait and Brain Laboratory, Lawson Research Health Institute, Parkwood Hospital, London Ontario, Canada
- Schulich School of Medicine and Dentistry, London Ontario, Canada
- Departments of Medicine (Geriatrics) and of Epidemiology and Biostatistics, University of Western Ontario, London Ontario, Canada
| | | | - Mirko Petrovic
- Department of Internal Medicine and Paediatrics (Section of Geriatrics), Ghent University, Ghent, Belgium
| | - Nathalie van der Velde
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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50
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Hanlon JT, Gray SL. Deprescribing trials: A focus on adverse drug withdrawal events. J Am Geriatr Soc 2022; 70:2738-2741. [PMID: 35596673 PMCID: PMC9489612 DOI: 10.1111/jgs.17883] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/26/2022] [Accepted: 04/30/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Joseph T Hanlon
- Geriatric Research, Education, and Clinical Center Veterans Affairs, Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Veterans Affairs, Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Shelly L Gray
- Plein Center for Geriatric Pharmacy Research, Education, and Outreach, Department of Pharmacy, University of Washington, Seattle, Washington, USA
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