1
|
Hetherington MM, Thomas JM, McLeod CJ. "I see it very much as an end-of-life food" - Barriers to oral nutritional supplement adherence, views from healthy older adults. Appetite 2024; 197:107327. [PMID: 38555018 DOI: 10.1016/j.appet.2024.107327] [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: 01/15/2024] [Revised: 03/15/2024] [Accepted: 03/26/2024] [Indexed: 04/02/2024]
Abstract
Malnutrition affects approximately one quarter of UK adults aged 65 years and over. As the global demographic shift continues, malnutrition is expected to increase. Oral nutritional supplements (ONS) are used both to prevent and to treat malnutrition. However, their effectiveness is compromised by poor adherence, and it is not well understood what contributes to this. Therefore, the current research was designed to explore ONS adherence from the parallel perspectives of ONS as a prescribed "medication" and as a food supplement/substitute. Eighteen older adults (13F, 5M; mean age = 73.4 yr; range: 70-80 yr) participated in focus groups (three in-person and one online), to investigate experiences of taking prescribed medications, including dietary supplements, and what should be factors to consider in supporting regular intake of ONS for trial development, as well as any potential improvements to products. Focus group sessions were recorded and then transcribed. Thematic Analysis was applied to the transcripts by the first author, and themes were discussed in depth, using exemplar quotes from participants. Five dominant themes were identified from the data: Disgust, Palatability and Acceptance; End-of-Life Care; Resistance to Medicines; Rituals and Reminders; and Real Food Displacement. Nutritional supplements were characterised as "disgusting", "manufactured", and associated with serious, chronic illness, as well as end-of-life care, in contrast to probiotics which were linked with health and wellness. The sweet taste of ONS was identified as a barrier to intake, given that it is generally associated with a signal to stop eating, and low hunger. As a group, participants tried to "avoid taking medicines", and viewed the need to have them negatively, yet most regularly took prescribed medication and/or vitamin supplements. Participants identified several, rituals and reminders to take medicines, including meal-based, or time-of-day-based prompts (e.g., before, with or after meals). To improve adherence, savoury products were suggested, as well as a more person-centred approach to individual nutritional needs and preferences. Overall, the group discussion mainly identified barriers to intake, but that improving taste, adding to "real food" (not replacing meals), and offering variety of flavour and form (e.g., savoury soups as well as sweet drinks) could be included in future trials to improve appeal and therefore intake. Future work should continue to explore how best to formulate, market and/or prescribe ONS, and how this might vary for malnutrition prevention vs treatment strategies.
Collapse
Affiliation(s)
| | - Jason M Thomas
- School of Psychology, College of Health and Life Sciences, Aston University, Birmingham, B4 7ET, UK
| | - Chris J McLeod
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, LE11 3TU, UK
| |
Collapse
|
2
|
Schwartz JB, Liu RY, Boscardin J, Liu Q, Lau SWJ, Khatri S, Tarn D. Attitudes on participation in clinical drug trials: A nationally representative survey of older adults with multimorbidity. J Am Geriatr Soc 2024; 72:1717-1727. [PMID: 38485469 PMCID: PMC11187642 DOI: 10.1111/jgs.18857] [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: 01/10/2024] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Older adults with multimorbidity are under-represented in clinical drug trials. Their inclusion will not increase unless they are willing and able to participate. Data on motivators and barriers to participation in trials of new medications of older adults with multimorbidity are needed. METHODS Cross-sectional internet and telephone survey of a nationally representative sample of adults ≥65 years with ≥3 chronic conditions (NORC University of Chicago Amerispeak Panel) conducted from March-April, 2023 to determine motivators and barriers to drug trial participation, described graphically and using statistics. RESULTS Surveyed 1318 (1142 Internet, 176 phone) with mean age 72.3 ± 6.3 (SD), 52% women; race: 83% White, 10% Black or African American, 5% Hispanic or Latino, 1.1% Asian; 4.4 ± 1.9 chronic conditions (of 16 queried), taking 7.5 ± 3.3 medications. Barriers included fear of side effects (48%), taking too many medications (44%), placebo (44%), mobility (33%), bathroom needs (25%), hearing (19%), eyesight (15%), video visits (33%; higher in women, Black or African-American respondents, and those ≥80 years). Sixty-five percent would join all in-person trials, 49% would join all-video trials. Travel >1 h was difficult for 66%, most difficult for women. Trust was a concern in 25% of Black respondents. Caregiving responsibilities or lack of time were not obstacles. Participants were most likely to consider a drug trial for a problem they have (63%) versus prevention (44%) and if invited by a physician (80%) or University healthcare system (58%). Getting better care was ranked very important (79%) followed by helping others (57%). CONCLUSIONS Major concerns of older patients with multimorbidity about participation in drug trials are potential side effects, taking too many medicines, and video visits. Physicians have the greatest influence on decisions and in-person visits are preferred. Proposed changes in trial design to increase enrollment of under-represented older adults may not align with patient-reported preferences.
Collapse
Affiliation(s)
- Janice B. Schwartz
- Department of Medicine, Division of Geriatrics and Division of Clinical Pharmacology, University of California, San Francisco, California, USA
| | - Ruey-ying Liu
- Department of Sociology, National Chengchi University, Taipei, Taiwan
| | - John Boscardin
- Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Qi Liu
- Center for Drug Evaluation and Research, Office of Translational Sciences and Office of Clinical Pharmacology, U.S. Food and Drug Administration, Silver Springs, Maryland, USA
| | - S. W. Johnny Lau
- Center for Drug Evaluation and Research, Office of Translational Sciences and Office of Clinical Pharmacology, U.S. Food and Drug Administration, Silver Springs, Maryland, USA
| | - Sadhna Khatri
- Center for Biologics Evaluation and Research, Office of Compliance Biologics Quality, U.S. Food and Drug Administration, Silver Springs, Maryland, USA
| | - Derjung Tarn
- Department of Family Medicine, University of California, Los Angeles, California, USA
| |
Collapse
|
3
|
Dix C, Dolan G, Hunt BJ. Reducing the risk of atherosclerotic cardiovascular disease in people with hemophilia: the importance of primary prevention. J Thromb Haemost 2024; 22:1304-1312. [PMID: 38309435 DOI: 10.1016/j.jtha.2024.01.017] [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: 11/27/2023] [Revised: 01/12/2024] [Accepted: 01/23/2024] [Indexed: 02/05/2024]
Abstract
Revolutionary advances in the treatment of hemophilia has led to a significant improvement in life expectancy. Associated with this has been an increase in age-related diseases especially atherosclerotic cardiovascular disease (CVD). While people with hemophilia (PWH) develop atherosclerosis at rates similar to those of the general population, rates of atherothrombosis and mortality related to CVD have been much lower, due to their hypocoagulable state. Changing treatment paradigms, aimed at reducing the risk of bleeding by improving hemostasis to levels approaching normality, has meant that the protection they are thought to have had may be lost. CVD risk factors are just as common in PWH as in the general population, but appear to be undertreated. In particular, primary prevention of CVD is vital in all individuals, but particularly in PWH as treatment of established CVD can be difficult. Active identification and management of CVD risk factors, such as obesity, physical inactivity, hypertension, and hypercholesterolemia, is required. In particular, statins have been shown to significantly reduce cardiovascular and all-cause mortality with few adverse events and no increased risk of bleeding in the general population, and their use needs urgent assessment in PWH. Further longitudinal research into preventing CVD in PWH, including accurate CVD risk assessment, is required to optimize prevention and management.
Collapse
Affiliation(s)
- Caroline Dix
- Haemophilia & Thrombosis Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Gerry Dolan
- Haemophilia & Thrombosis Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Beverley J Hunt
- Haemophilia & Thrombosis Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.
| |
Collapse
|
4
|
Tinetti ME, Hashmi A, Ng H, Doyle M, Goto T, Esterson J, Naik AD, Dindo L, Li F. Patient Priorities-Aligned Care for Older Adults With Multiple Conditions: A Nonrandomized Controlled Trial. JAMA Netw Open 2024; 7:e2352666. [PMID: 38261319 PMCID: PMC10807252 DOI: 10.1001/jamanetworkopen.2023.52666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/01/2023] [Indexed: 01/24/2024] Open
Abstract
Importance Older adults with multiple conditions receive health care that may be burdensome, of uncertain benefit, and not focused on what matters to them. Identifying and aligning care with patients' health priorities may improve outcomes. Objective To assess the association of receiving patient priorities care (PPC) vs usual care (UC) with relevant clinical outcomes. Design, Setting, and Participants In this nonrandomized controlled trial with propensity adjustment, enrollment occurred between August 21, 2020, and May 14, 2021, with follow-up continuing through February 26, 2022. Patients who were aged 65 years or older and with 3 or more chronic conditions were enrolled at 1 PPC and 1 UC site within the Cleveland Clinic primary care multisite practice. Data analysis was performed from March 2022 to August 2023. Intervention Health professionals at the PPC site guided patients through identification of values, health outcome goals, health care preferences, and top priority (ie, health problem they most wanted to focus on because it impeded their health outcome goal). Primary clinicians followed PPC decisional strategies (eg, use patients' health priorities as focus of communication and decision-making) to decide with patients what care to stop, start, or continue. Main Outcomes and Measures Main outcomes included perceived treatment burden, Patient-Reported Outcomes Measurement Information System (PROMIS) social roles and activities, CollaboRATE survey scores, the number of nonhealthy days (based on healthy days at home), and shared prescribing decision quality measures. Follow-up was at 9 months for patient-reported outcomes and 365 days for nonhealthy days. Results A total of 264 individuals participated, 129 in the PPC group (mean [SD] age, 75.3 [6.1] years; 66 women [48.9%]) and 135 in the UC group (mean [SD] age, 75.6 [6.5] years; 55 women [42.6%]). Characteristics between sites were balanced after propensity score weighting. At follow-up, there was no statistically significant difference in perceived treatment burden score between groups in multivariate models (difference, -5.2 points; 95% CI, -10.9 to -0.50 points; P = .07). PPC participants were almost 2.5 times more likely than UC participants to endorse shared prescribing decision-making (adjusted odds ratio, 2.40; 95% CI, 0.90 to 6.40; P = .07), and participants in the PPC group experienced 4.6 fewer nonhealthy days (95% CI, -12.9 to -3.6 days; P = .27) compared with the UC participants. These differences were not statistically significant. CollaboRATE and PROMIS Social Roles and Activities scores were similar in the 2 groups at follow-up. Conclusions and Relevance This nonrandomized trial of priorities-aligned care showed no benefit for social roles or CollaboRATE. While the findings for perceived treatment burden and shared prescribing decision-making were not statistically significant, point estimates for the findings suggested that PPC may hold promise for improving these outcomes. Randomized trials with larger samples are needed to determine the effectiveness of priorities-aligned care. Trial Registration ClinicalTrials.gov Identifier: NCT04510948.
Collapse
Affiliation(s)
- Mary E. Tinetti
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Ardeshir Hashmi
- Center for Geriatric Medicine, Cleveland Clinic, Cleveland, Ohio
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Henry Ng
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Margaret Doyle
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Toyomi Goto
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
| | - Jessica Esterson
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Aanand D. Naik
- Institute on Aging, University of Texas Health Science Center, Houston
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Lilian Dindo
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas
- Department of Medicine, Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut
| |
Collapse
|
5
|
Ng XR, Tey YXS, Lew KJ, Lee PSS, Lee ES, Sim SZ. Cross-sectional study assessing health outcome priorities of older adults with multimorbidity at a primary care setting in Singapore. BMJ Open 2023; 13:e079990. [PMID: 38081675 PMCID: PMC10729092 DOI: 10.1136/bmjopen-2023-079990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/27/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES Managing older adults with multimorbidity may be challenging due to the conflicting benefits and harms of multiple treatments. Thus, it is important to identify patients' health outcome priorities to align treatment goals with their health preferences. This study aimed to use the Outcome Prioritisation Tool (OPT) to describe the health outcome priorities of older adults with multimorbidity and determine the factors associated with these priorities. Additionally, it aimed to assess the ease of completing the OPT in Singapore's primary care population. DESIGN Cross-sectional study conducted from January to March 2022. SETTING A public primary care centre in Singapore. PARTICIPANTS 65 years and older with multimorbidity. OUTCOME MEASURES Primary outcome measure was the most important health outcome priorities on the OPT. Secondary outcome measures were factors affecting these priorities and ease of completing the OPT. RESULTS We enrolled 180 participants (mean age: 73.2±6.1 years). Slightly more than half (54.4%) prioritised 'staying alive', while the remainder (45.6%) prioritised 'maintaining independence' (25.6%), 'relieving pain' (10.6%) and 'relieving other symptoms' (9.4%). Participants with six or more chronic conditions were three times (OR 3.03 (95% CI1.09 to 8.42)) more likely to prioritise 'staying alive' compared with participants with three conditions. Most participants (69.4%) agreed that the OPT was easy to complete, and the mean time taken to complete the OPT was 3.8±1.6 minutes. CONCLUSION 'Staying alive' was the most important health outcome priority, especially for older adults with six or more chronic conditions. The OPT was easily completed among older adults with multimorbidity in primary care. Further qualitative studies can be conducted to understand the factors influencing patients' priorities and explore the relevance of the OPT in guiding treatment decisions.
Collapse
Affiliation(s)
- Xin Rong Ng
- National Healthcare Group Polyclinics, Singapore
| | | | - Kaiwei Jeremy Lew
- Clinical Research Unit, National Healthcare Group Polyclinics, Singapore
| | | | - Eng Sing Lee
- Clinical Research Unit, National Healthcare Group Polyclinics, Singapore
| | - Sai Zhen Sim
- National Healthcare Group Polyclinics, Singapore
| |
Collapse
|
6
|
Weir KR, Shang J, Choi J, Rana R, Vordenberg SE. Factors Important to Older Adults Who Disagree With a Deprescribing Recommendation. JAMA Netw Open 2023; 6:e2337281. [PMID: 37819657 PMCID: PMC10568363 DOI: 10.1001/jamanetworkopen.2023.37281] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/29/2023] [Indexed: 10/13/2023] Open
Abstract
Importance Little is known about why older adults decline deprescribing recommendations, primarily because interventional studies rarely capture the reasons. Objective To examine factors important to older adults who disagree with a deprescribing recommendation given by a primary care physician to a hypothetical patient experiencing polypharmacy. Design, Setting, and Participants This online, vignette-based survey study was conducted from December 1, 2020, to March 31, 2021, with participants 65 years or older in the United Kingdom, the US, Australia, and the Netherlands. The primary outcome of the main study was disagreement with a deprescribing recommendation. A content analysis was subsequently conducted of the free-text reasons provided by participants who strongly disagreed or disagreed with deprescribing. Data were analyzed from August 22, 2022, to February 12, 2023. Main Outcomes and Measures Attitudes, beliefs, fears, and recommended actions of older adults in response to deprescribing recommendations. Results Of the 899 participants included in the analysis, the mean (SD) age was 71.5 (4.9) years; 456 participants (50.7%) were men. Attitudes, beliefs, and fears reported by participants included doubts about deprescribing (361 [40.2%]), valuing medications (139 [15.5%]), and a preference to avoid change (132 [14.7%]). Valuing medications was reported more commonly among participants who strongly disagreed compared with those who disagreed with deprescribing (48 of 205 [23.4%] vs 91 of 694 [13.1%], respectively; P < .001) or had personal experience with the same medication class as the vignette compared with no experience (93 of 517 [18.0%] vs 46 of 318 [12.1%], respectively; P = .02). Participants shared that improved communication (225 [25.0%]), alternative strategies (138 [15.4%]), and consideration of medication preferences (137 [15.2%]) may increase their agreement with deprescribing. Participants who disagreed compared with those who strongly disagreed were more interested in additional communication (196 [28.2%] vs 29 [14.2%], respectively; P < .001), alternative strategies (117 [16.9%] vs 21 [10.2%], respectively; P = .02), or consideration of medication preferences (122 [17.6%] vs 15 [7.3%], respectively; P < .001). Conclusions and Relevance In this survey study, older adults who disagreed with a deprescribing recommendation were more interested in additional communication, alternative strategies, or consideration of medication preferences compared with those who strongly disagreed. These findings suggest that identifying the degree of disagreement with deprescribing could be used to tailor patient-centered communication about deprescribing in older adults.
Collapse
Affiliation(s)
- Kristie Rebecca Weir
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Jenny Shang
- currently a graduate student at University of Michigan College of Pharmacy, Ann Arbor
| | - Jae Choi
- currently a graduate student at University of Michigan College of Pharmacy, Ann Arbor
| | - Ruchi Rana
- currently a graduate student at University of Michigan College of Pharmacy, Ann Arbor
| | - Sarah E. Vordenberg
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor
| |
Collapse
|
7
|
Cao J, Zhang L, Zhou X. Constructing a prognostic tool for predicting the risk of non-adherence to antiplatelet therapy in discharged patients with coronary heart disease: a retrospective cohort study. PeerJ 2023; 11:e15876. [PMID: 37576506 PMCID: PMC10422952 DOI: 10.7717/peerj.15876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/18/2023] [Indexed: 08/15/2023] Open
Abstract
Objective To investigate the incidence and influencing factors affecting the non-adherence behavior of patients with coronary heart disease (CHD) to antiplatelet therapy after discharge and to construct a personalized predictive tool. Methods In this retrospective cohort study, 289 patients with CHD who were admitted to the Department of Cardiology of The First Affiliated Hospital of the University of Science and Technology of China between June 2021 and September 2021 were enrolled. The clinical data of all patients were retrospectively collected from the hospital information system, and patients were followed up for 1 year after discharge to evaluate their adherence level to antiplatelet therapy, analyze their present situation and influencing factors for post-discharge adherence to antiplatelet therapy, and construct a nomogram model to predict the risk of non-adherence. Results Based on the adherence level to antiplatelet therapy within 1 year after discharge, the patients were divided into the adherence (n = 216) and non-adherence (n = 73) groups. Univariate analysis revealed statistically significant differences between the two groups in terms of variable distribution, including age, education level, medical payment method, number of combined risk factors, percutaneous coronary intervention, duration of antiplatelet medication, types of drugs taken at discharge, and CHD type (P < 0.05). Furthermore, multivariate logistic regression analysis revealed that, except for the medical payment method, all the seven abovementioned variables were independent risk factors for non-adherence to antiplatelet therapy (P < 0.05). The areas under the receiver operating characteristic curve before and after the internal validation of the predictive tool based on the seven independent risk factors and the nomogram were 0.899 (95% confidence interval [CI]: 0.858-0.941) and 0.89 (95% CI: 0.847-0.933), respectively; this indicates that the tool has good discrimination ability. The calibration curve and Hosmer-Lemeshow goodness of fit test revealed that the tool exhibited good calibration and prediction consistency (χ2 = 5.17, P = 0.739). Conclusion In this retrospective cohort study, we investigated the incidence and influencing factors affecting the non-adherence behavior of patients with CHD after discharge to antiplatelet therapy. For this, we constructed a personalized predictive tool based on seven independent risk factors affecting non-adherence behavior. The predictive tool exhibited good discrimination ability, calibration, and clinical applicability. Overall, our constructed tool is useful for predicting the risk of non-adherence behavior to antiplatelet therapy in discharged patients with CHD and can be used in personalized intervention strategies to improve patient outcomes.
Collapse
Affiliation(s)
- Jiaoyu Cao
- Department of Cardiology, The First Affiliated Hospital of the University of Science and Technology of China, Hefei, China
| | - Lixiang Zhang
- Department of Cardiology, The First Affiliated Hospital of the University of Science and Technology of China, Hefei, China
| | - Xiaojuan Zhou
- Department of Cardiology, The First Affiliated Hospital of the University of Science and Technology of China, Hefei, China
| |
Collapse
|
8
|
Wallis KA, Taylor DA, Fanueli EF, Saravanakumar P, Wells S. Older peoples' views on cardiovascular disease medication: a qualitative study. Fam Pract 2022; 39:897-902. [PMID: 35078221 DOI: 10.1093/fampra/cmab186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is increasing evidence for the potential benefits and harms of cardiovascular disease (CVD) medications in older people (>75 years) prompting updating of clinical guidelines. We explored the views of older people about CVD medication to inform guideline development. METHODS Qualitative study using semistructured interviews and focus groups. An ethnically diverse group of community dwelling older people were purposefully recruited from northern New Zealand using flyers in primary care clinics, local libraries, social groups, and places of worship, and by word of mouth. Interviews and focus groups were digitally recorded, transcribed verbatim, and analysed using an iterative and inductive approach to thematic analysis. RESULTS Thirty-nine participants from 4 ethnic groups were recruited (mean 74 years; range 61-91 years; Māori (7), South Asian (8), European (9), and Pasifika (15)). Most participants were taking CVD medication/s. Four main themes emerged: (i) emphasizing the benefits of CVD medication and downplaying the harms; (ii) feeling compelled to take medication; (iii) trusting "my" doctor; and (iv) expecting medication to be continued. CONCLUSION Findings raise questions about older people's agency in decision-making regarding CVD medication. CVD risk management guidelines for older people could include strategies to support effective communication of the potential benefits and harms of CVD medication in older people, balancing life expectancy, and the expected duration of therapy.
Collapse
Affiliation(s)
- Katharine A Wallis
- School of Population Health, The University of Auckland, Auckland, New Zealand
- General Practice Clinical Unit, The University of Queensland, Level 8, Health Sciences Building, Brisbane, Qld, Australia
| | | | - Elizabeth F Fanueli
- School of Population Health, The University of Auckland, Auckland, New Zealand
| | | | - Susan Wells
- School of Population Health, The University of Auckland, Auckland, New Zealand
| |
Collapse
|
9
|
Shi S, Olivieri-Mui B, Oh G, McCarthy E, Kim DH. Analysis of Functional Recovery in Older Adults Discharged to Skilled Nursing Facilities and Then Home. JAMA Netw Open 2022; 5:e2225452. [PMID: 36006647 PMCID: PMC9412223 DOI: 10.1001/jamanetworkopen.2022.25452] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Although many older adults are discharged to skilled nursing facilities (SNFs) after hospitalization, rates of patients recovery afterward are unknown. OBJECTIVE To examine postacute functional recovery among older adults. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted among older adults treated in SNFs, then at home with home health care (HHC). Participants were a 5% random sample of Medicare fee-for-service beneficiaries discharged to community HHC after SNF stay from 2014 to 2016 with continuous part A and B enrollment in the prior 6 months. Medicare claims data from 2014 to 2016 were used, including inpatient, SNF, hospice, HHC, outpatient, carrier, and durable medical equipment data and Minimum Data Set (MDS) and Outcome Assessment Information Set (OASIS) for SNF and HHC assessments, respectively. Data were analyzed from July 20, 2020, to June 5, 2022. EXPOSURES Frailty was measured with a validated claims-based frailty index (CFI) (range, 0-1; higher scores indicate worse frailty) and categorized into not frail (<0.20), mildly frail (0.20-0.29), and moderately to severely frail (≥0.30). MAIN OUTCOMES AND MEASURES The primary outcome was functional recovery, defined by discharge from HHC with stable or improved ability to perform activities of daily living (ADL). Recovery status was examined at 15, 30, 45, 60, 75, and 90 days after discharge to HHC using OASIS. Covariates were obtained from the MDS admission file at SNF admission, including age, race and ethnicity, cognitive status, functional status, and geographic region. RESULTS Among 105 232 beneficiaries (mean [SD] age, 79.1 [10.6] years; 68 637 [65.2%] women; 8951 Black [8.5%], 3109 Hispanic [3.0%], and 88 583 White [84.2%] individuals), 65 796 individuals (62.5%) were discharged from HHC services with improved function over 90 days of follow-up. Among 39 436 beneficiaries not recovered, 19 612 individuals (49.7%) had mild frailty and 15 818 individuals (40.1%) had moderate to severe frailty. While 10 492 of 17 576 beneficiaries who were not frail recovered by 45 days (59.7%), 10 755 of 32 212 individuals with moderate to severe frailty had recovered (33.4%). Overall, frailty was negatively associated with functional recovery after adjustment for demographic characteristics, geographic census regions, and health-related variables, with a hazard ratio for moderate to severe frailty of 0.62 (95% CI, 0.60-0.63) compared with nonfrailty. CONCLUSIONS AND RELEVANCE This study found that recovery after posthospitalization SNF stay was particularly prolonged for individuals with frailty. Functional dependence in activities of daily living remained common among individuals with frailty long after discharge home.
Collapse
Affiliation(s)
- Sandra Shi
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Brianne Olivieri-Mui
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Northeastern University, Boston, Massachusetts
| | - Gahee Oh
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Ellen McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
10
|
Barnett NL, Oboh L. Medication review in hospitalised older people: what have we learnt? BMJ Qual Saf 2022; 31:853-856. [PMID: 35794010 DOI: 10.1136/bmjqs-2022-014882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Nina Lee Barnett
- Pharmacy, London North West Healthcare NHS Trust, Middlesex, UK .,Medicines Use and Safety, NHS Specialist Pharmacy Service, London, UK
| | - Lelly Oboh
- Pharmacy, Guy's and St Thomas' Hospitals NHS Trust, London, UK.,Medicines Use and Safety, NHS Specialist Pharmacy Services, London, UK
| |
Collapse
|
11
|
Schuttner L, Hockett Sherlock S, Simons C, Ralston JD, Rosland AM, Nelson K, Lee JR, Sayre G. Factors affecting primary care physician decision-making for patients with complex multimorbidity: a qualitative interview study. BMC PRIMARY CARE 2022; 23:25. [PMID: 35123398 PMCID: PMC8817776 DOI: 10.1186/s12875-022-01633-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 01/24/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Patients with multiple chronic conditions (multimorbidity) and additional psychosocial complexity are at higher risk of adverse outcomes. Establishing treatment or care plans for these patients must account for their disease interactions, finite self-management abilities, and even conflicting treatment recommendations from clinical practice guidelines. Despite existing insight into how primary care physicians (PCPs) approach care decisions for their patients in general, less is known about how PCPs make care planning decisions for more complex populations particularly within a medical home setting. We therefore sought to describe factors affecting physician decision-making when care planning for complex patients with multimorbidity within the team-based, patient-centered medical home setting in the integrated healthcare system of the U.S. Department of Veterans Affairs, the Veterans Health Administration (VHA). METHODS This was a qualitative study involving semi-structured telephone interviews with PCPs working > 40% time in VHA clinics. Interviews were conducted from April to July, 2020. Content was analyzed with deductive and inductive thematic analysis. RESULTS 23 physicians participated in interviews; most were MDs (n = 21) and worked in hospital-affiliated clinics (n = 14) across all regions of the VHA's national clinic network. We found internal, external, and relationship-based factors, with developed subthemes describing factors affecting decision-making for complex patients with multimorbidity. Physicians described tailoring decisions to individual patients; making decisions in keeping with an underlying internal style or habit; working towards an overarching goal for care; considering impacts from patient access and resources on care plans; deciding within boundaries provided by organizational structures; collaborating on care plans with their care team; and impacts on decisions from their own emotions and relationship with patient. CONCLUSIONS PCPs described internal, external, and relationship-based factors that affected their care planning for high-risk and complex patients with multimorbidity in the VHA. Findings offer useful strategies employed by physicians to effectively conduct care planning for complex patients in a medical home setting, such as delegation of follow-up within multidisciplinary care teams, optimizing visit time vs frequency, and deliberate investment in patient-centered relationship building to gain buy-in to care plans.
Collapse
Affiliation(s)
- Linnaea Schuttner
- Health Services Research & Development, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, Washington, 98108, USA. .,Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Stacey Hockett Sherlock
- Comprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System, Iowa City, IA, USA.,Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Carol Simons
- Health Services Research & Development, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, Washington, 98108, USA
| | - James D Ralston
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.,Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Karin Nelson
- Health Services Research & Development, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, Washington, 98108, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Jennifer R Lee
- Health Services Research & Development, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, Washington, 98108, USA.,Department of Urology, University of Washington, Seattle, WA, USA
| | - George Sayre
- Health Services Research & Development, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, Washington, 98108, USA.,Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| |
Collapse
|
12
|
Wells S, Choi Y, Jackson R, Parwaiz M, Mehta S, Selak V, Harwood M, Grey C, Kerse N, Poppe K. Cardiovascular disease preventive medication dispensing for almost every New Zealander 65 years and over: a preventive treatment paradox? Age Ageing 2022; 51:6514237. [PMID: 35077560 DOI: 10.1093/ageing/afab265] [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: 07/09/2021] [Revised: 09/15/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To describe the dispensing of cardiovascular disease (CVD) preventive medications among older New Zealanders with and without prior CVD or diabetes. METHODS New Zealanders aged ≥65 years in 2013 were identified using anonymised linkage of national administrative health databases. Dispensing of blood pressure lowering (BPL), lipid lowering (LL) or antithrombotic (AT) medications, was documented, stratified by age and by history of CVD, diabetes, or neither. RESULTS Of the 593,549 people identified, 32% had prior CVD, 14% had diabetes (of whom half also had prior CVD) and 61% had neither diagnosis. For those with prior CVD, between 79-87% were dispensed BPL and 73-79% were dispensed AT medications, across all age groups. In contrast, LL dispensing was lower than either BPL or AT in every age group, falling from 75% at age 65-69 years to 43% at 85+ years. For people with diabetes, BPL and LL dispensing was similar to those with prior CVD, but AT dispensing was approximately 20% lower. Among people without prior CVD or diabetes, both BPL and AT dispensing increased with age (from 39% and 17% at age 65-69 years to 56% and 35% at 85+ years respectively), whereas LL dispensing was 26-31% across the 65-84 year age groups, falling to 17% at 85+ years. CONCLUSION The much higher dispensing of BPL and AT compared to LL medications with increasing age suggests a preventive treatment paradox for older people, with the medications most likely to cause adverse effects being dispensed most often.
Collapse
|
13
|
Eidam A, Roth A, Frick E, Metzner M, Lampert A, Seidling HM, Haefeli WE, Bauer JM. Development of an Electronic Tool to Assess Patient Preferences in Geriatric Polypharmacy (PolyPref). Patient Prefer Adherence 2022; 16:1733-1747. [PMID: 35910298 PMCID: PMC9329442 DOI: 10.2147/ppa.s364681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/10/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Medical decision-making in older adults with multiple chronic conditions and polypharmacy should include the individual patient's treatment preferences. We developed and pilot-tested an electronic instrument (PolyPref) to elicit patient preferences in geriatric polypharmacy. PATIENTS AND METHODS PolyPref follows a two-stage direct approach to preference assessment. Stage 1 generates an individual preselection of relevant health outcomes and medication regimen characteristics, followed by stage 2, in which their importance is assessed using the Q-sort methodology. The feasibility of the instrument was tested in adults aged ≥70 years with ≥2 chronic conditions and regular intake of ≥5 medicines. After the assessment with PolyPref, the patients rated the tool with regard to its comprehensibility and usability and assessed the accuracy of the personal result. Evaluators rated the patients' understanding of the task. RESULTS Eighteen short-term health outcomes, 3 long-term health outcomes, and 8 medication regimen characteristics were included in the instrument. The final population for the pilot study comprised 15 inpatients at a clinic for geriatric rehabilitation with a mean age of 80.6 (± 6.0) years, a median score of 28 (range 25-30) points on the Mini-Mental State Examination, and a mean of 11.6 (± 3.6) regularly taken medicines. Feedback by the patients and the evaluators revealed ratings in favor of understanding and comprehensibility of 86.7% to 100%. The majority of the patients stated that their final result summarized the most important aspects of their pharmacotherapy (93.3%) and that its ranking order reflected their personal opinion (100%). Preference assessment took an average of 35 (± 8.5) min, with the instrument being handled by the evaluator in 14 of the 15 participants. CONCLUSION Preference assessment with PolyPref was feasible in older adults with multiple chronic conditions and polypharmacy, offering a new strategy for the standardized evaluation of patient priorities in geriatric pharmacotherapy.
Collapse
Affiliation(s)
- Annette Eidam
- Center for Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany
- Correspondence: Annette Eidam, Center for Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany, Tel +49 6221-319-1795, Fax +49 6221-319-1505, Email
| | - Anja Roth
- Center for Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Eduard Frick
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg, Germany
| | - Michael Metzner
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg, Germany
| | - Anette Lampert
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
| | - Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
| | - Jürgen M Bauer
- Center for Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany
- Network Aging Research (NAR), Heidelberg University, Heidelberg, Germany
| |
Collapse
|
14
|
Majd Z, Mohan A, Abughosh SM. Using group-based trajectory modeling to characterize the association of past ACEIs/ARBs adherence with subsequent statin adherence patterns among new statin users. J Am Pharm Assoc (2003) 2021; 61:829-837.e2. [PMID: 34344613 DOI: 10.1016/j.japh.2021.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/21/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Despite well-documented benefits, statin adherence remains suboptimal. Studies have suggested that previous adherence to other chronic medications is a strong predictor of future adherence to newly initiated statins. Group-based trajectory modeling (GBTM) has been applied as a method to longitudinally depict the dynamic nature of adherence. OBJECTIVES This study aimed to examine the association between patients' adherence patterns to newly initiated statins and previous adherence trajectories of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) using GBTM. METHODS This retrospective cohort study was conducted among continuously enrolled statin initiators using claims data. Patients were included if they had ACEI/ARB use within 1 year before statin initiation (preindex period). Monthly adherence to ACEIs/ARBs was calculated during the preindex period and monthly adherence to statins was assessed 1 year after statin initiation using proportion of days covered (PDC). The monthly PDCs were modeled as a longitudinal response in a logistic GBTM to provide distinct patterns of adherence for ACEIs/ARBs and statins, separately. A multinomial logistic regression was conducted to determine an association between ACEI/ARB adherence trajectories and future statin trajectories, controlling for patient characteristics. RESULTS A total of 1078 patients were categorized into 4 distinct statin adherence trajectories: adherent (40.8%), gradual decline (37.4%), gaps in adherence (13.9%), and rapid decline (7.9%). Patients were further categorized into 4 groups on the basis of their distinct past ACEIs/ARBs trajectories: adherent (43%), gaps in adherence (29%), delayed nonadherence (15.2%), and gradual decline (12.8%). In the multinomial logistic regression, patients in the gaps in adherence or gradual decline groups were more likely to follow similar trajectories for future statin use than the adherent trajectory. CONCLUSION Previous adherence trajectories of ACEIs/ARBs may predict future adherence patterns for newly initiated statins. Knowledge of past medication-taking behavior could provide valuable information for developing tailored interventions to improve adherence.
Collapse
|
15
|
Jaspers NEM, Visseren FLJ, van der Graaf Y, Smulders YM, Damman OC, Brouwers C, Rutten GEHM, Dorresteijn JAN. Communicating personalised statin therapy-effects as 10-year CVD-risk or CVD-free life-expectancy: does it improve decisional conflict? Three-armed, blinded, randomised controlled trial. BMJ Open 2021; 11:e041673. [PMID: 34272216 PMCID: PMC8287608 DOI: 10.1136/bmjopen-2020-041673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine whether communicating personalised statin therapy-effects obtained by prognostic algorithm leads to lower decisional conflict associated with statin use in patients with stable cardiovascular disease (CVD) compared with standard (non-personalised) therapy-effects. DESIGN Hypothesis-blinded, three-armed randomised controlled trial SETTING AND PARTICIPANTS: 303 statin users with stable CVD enrolled in a cohort INTERVENTION: Participants were randomised in a 1:1:1 ratio to standard practice (control-group) or one of two intervention arms. Intervention arms received standard practice plus (1) a personalised health profile, (2) educational videos and (3) a structured telephone consultation. Intervention arms received personalised estimates of prognostic changes associated with both discontinuation of current statin and intensification to the most potent statin type and dose (ie, atorvastatin 80 mg). Intervention arms differed in how these changes were expressed: either change in individual 10-year absolute CVD risk (iAR-group) or CVD-free life-expectancy (iLE-group) calculated with the SMART-REACH model (http://U-Prevent.com). OUTCOME Primary outcome was patient decisional conflict score (DCS) after 1 month. The score varies from 0 (no conflict) to 100 (high conflict). Secondary outcomes were collected at 1 or 6 months: DCS, quality of life, illness perception, patient activation, patient perception of statin efficacy and shared decision-making, self-reported statin adherence, understanding of statin-therapy, post-randomisation low-density lipoprotein cholesterol level and physician opinion of the intervention. Outcomes are reported as median (25th- 75th percentile). RESULTS Decisional conflict differed between the intervention arms: median control 27 (20-43), iAR-group 22 (11-30; p-value vs control 0.001) and iLE-group 25 (10-31; p-value vs control 0.021). No differences in secondary outcomes were observed. CONCLUSION In patients with clinically manifest CVD, providing personalised estimations of treatment-effects resulted in a small but significant decrease in decisional conflict after 1 month. The results support the use of personalised predictions for supporting decision-making. TRIAL REGISTRATION NTR6227/NL6080.
Collapse
Affiliation(s)
- Nicole E M Jaspers
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht University, Utrecht, Utrecht, The Netherlands
| | - Frank L J Visseren
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht University, Utrecht, Utrecht, The Netherlands
| | - Yolanda van der Graaf
- Julius Center for Health Sciences and Primary Care, Utrecht University, Utrecht, Utrecht, The Netherlands
| | - Yvo M Smulders
- University Medical Centre, Department of Internal Medicine, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - Olga C Damman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, North-Holland, The Netherlands
| | - Corline Brouwers
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, North-Holland, The Netherlands
| | - Guy E H M Rutten
- Julius Center for Health Sciences and Primary Care, Utrecht University, Utrecht, Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht University, Utrecht, Utrecht, The Netherlands
| |
Collapse
|
16
|
Moriarty F, Barry A, Kenny RA, Fahey T. Aspirin prescribing for cardiovascular disease in middle-aged and older adults in Ireland: Findings from The Irish Longitudinal Study on Ageing. Prev Med 2021; 147:106504. [PMID: 33667470 DOI: 10.1016/j.ypmed.2021.106504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/19/2021] [Accepted: 02/27/2021] [Indexed: 10/22/2022]
Abstract
Aspirin use for cardiovascular indications is widespread despite evidence not supporting use in patients without cardiovascular disease (CVD). This study characterises aspirin prescribing among people aged ≥50 years in Ireland for primary and secondary prevention, and factors associated with prescription. This cross-sectional study includes participants from wave 3 (2014-2015) of The Irish Longitudinal Study on Ageing. We identified participants reporting use of prescribed aspirin, other antiplatelets/anticoagulants, and doctor-diagnosed CVD (MI, angina, stroke, TIA) and other cardiovascular conditions. We examined factors associated with aspirin use for primary and secondary prevention in multivariate regression. For a subset, we also examined 10-year cardiovascular risk (using the Framingham general risk score) as a predictor of aspirin use. Among 6618 participants, the mean age was 66.9 years (SD 9.4) and 55.6% (3679) were female. Prescribed aspirin was reported by 1432 participants (21.6%), and 77.6% of aspirin users had no previous CVD. Among participants with previous CVD, 16.5% were not prescribed aspirin/another antithrombotic. This equates to 201,000 older adults nationally using aspirin for primary prevention, and 16,000 with previous CVD not prescribed an antithrombotic. Among those without CVD, older age, male sex, free health care, and more GP visits were associated with aspirin prescribing. Cardiovascular risk was significantly associated with aspirin use (adjusted relative risk 1.15, 95%CI 1.08-1.23, per 1% increase in cardiovascular risk). Almost four-fifths of people aged ≥50 years on aspirin have no previous CVD, equivalent to 201,000 adults nationally, however prescribing appears to target higher cardiovascular risk patients.
Collapse
Affiliation(s)
- Frank Moriarty
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Ireland; The Irish Longitudinal Study on Ageing, Trinity College Dublin, Ireland.
| | - Alan Barry
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Ireland
| |
Collapse
|
17
|
Green AR, Aschmann H, Boyd CM, Schoenborn N. Assessment of Patient-Preferred Language to Achieve Goal-Aligned Deprescribing in Older Adults. JAMA Netw Open 2021; 4:e212633. [PMID: 33818621 PMCID: PMC8022217 DOI: 10.1001/jamanetworkopen.2021.2633] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE How clinicians communicate about deprescribing, the structured process of reducing or stopping unnecessary, potentially harmful, or goal-discordant medicines, may be associated with the extent to which older adults are willing to do it. OBJECTIVE To examine older adults' preferences regarding different rationales a clinician may use to explain why a patient should stop an unnecessary or potentially harmful medication. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional survey study was conducted from March 25 to April 19, 2020, among a nationally representative, probability-based online survey panel (KnowledgePanel). KnowledgePanel members aged 65 years and older were recruited by random digit dialing and address-based sampling. Data were analyzed from May 4 to July 8, 2020. EXPOSURES The survey presented 2 vignettes involving hypothetical older adults. One described a statin being used for primary prevention by a person with functional impairment and polypharmacy. The second described a sedative-hypnotic, such as zolpidem, being used for insomnia by a person with good functional status. MAIN OUTCOMES AND MEASURES After each vignette, participants expressed preferences using a best-worst scaling method for 7 different phrases a clinician may use to explain why they should reduce or stop the medication. Conditional logistic regression was used to quantify respondents' relative preferences. RESULTS A total of 1193 KnowledgePanel members were invited, and 835 respondents (70.0%) completed the survey. The mean (SD) age was 73 (6) years, 414 (49.6%) were women, and 671 (80.4%) self-identified as White individuals. A total of 496 respondents (59.8%) had ever used a statin, and 124 respondents (14.9%) had ever used a sedative-hypnotic. For both medications, the most preferred phrase to explain deprescribing focused on the risk of side effects. For statins, this phrase was 5.8-fold (95% CI, 5.3-6.3) more preferred than the least preferred option, which focused on the effort (treatment burden) involved in taking the medicine. For sedative-hypnotics, the phrase about side effects was 8.6-fold (95% CI, 7.9-9.5) more preferred over the least preferred option, "This medicine is unlikely to help you function better." CONCLUSIONS AND RELEVANCE These findings suggest that among older adults, the most preferred rationale for deprescribing both preventive and symptom-relief medicines focused on the risk of side effects. These results could be used to inform clinical practice and improve effective communications around deprescribing in older adults.
Collapse
Affiliation(s)
- Ariel R. Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hélène Aschmann
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Cynthia M. Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Nancy Schoenborn
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
18
|
Tinetti ME, Costello DM, Naik AD, Davenport C, Hernandez-Bigos K, Van Liew JR, Esterson J, Kiwak E, Dindo L. Outcome Goals and Health Care Preferences of Older Adults With Multiple Chronic Conditions. JAMA Netw Open 2021; 4:e211271. [PMID: 33760091 PMCID: PMC7991967 DOI: 10.1001/jamanetworkopen.2021.1271] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Older adults with multiple chronic conditions (MCCs) vary in their health outcome goals and the health care that they prefer to receive to achieve these goals. OBJECTIVE To describe the outcome goals and health care preferences of this population with MCCs. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included participants in the Patient Priorities Care study who underwent health priorities identification from February 1, 2017, to August 31, 2018, in a primary care practice. Patients eligible to participate were 65 years or older, English speaking, and had at least 3 chronic conditions; in addition, they used at least 10 medications, saw at least 2 specialists, or had at least 2 emergency department visits or 1 hospitalization during the past year. Of 236 eligible patients, 163 (69%) agreed to participate in this study. Data were analyzed from August 1 to October 31, 2020. EXPOSURES Guided by facilitators, participants identified their core values, as many as 3 actionable and realistic outcome goals, health-related barriers to these goals, and as many as 3 helpful and 3 bothersome health care activities. MAIN OUTCOMES AND MEASURES Frequencies were ascertained for outcome goals and health care preferences. Preferences included health care activities (medications, health care visits, procedures, diagnostic tests, and self-management) reported as either helpful or bothersome. RESULTS Most of the 163 participants were White (158 [96.9%]) and women (109 [66.9%]), with a mean (SD) age of 77.6 (7.6) years. Of 459 goals, the most common encompassed meals and other activities with family and friends (111 [24.2%]), shopping (28 [6.1%]), and exercising (21 [4.6%]). Twenty individuals (12.3%) desired to live independently without specifying necessary activities. Of 312 barriers identified, the most common were pain (128 [41.0%]), fatigue (45 [14.4%]), unsteadiness (42 [13.5%]), and dyspnea (19 [6.1%]). Similar proportions of patients identified at least 1 medication that was helpful (130 [79.8%]) or bothersome (128 [78.5%]). Medications most commonly cited as helpful were pain medications, including nonopiods (36 of 55 users [65.5%]) and opioids (15 of 27 users [55.6%]); sleep medications (27 of 51 users [52.9%]); and respiratory inhalants (19 of 45 [42.2%]). Most often mentioned as bothersome were statins (25 of 97 users [25.8%]) and antidepressants (13 of 40 users [32.5%]). Thirty-two participants (19.6%) reported using too many medications. Health care visits were identified as helpful by 43 participants (26.4%); 15 (9.2%) reported too many visits. Procedures were named helpful by 38 participants (23.3%); 24 (14.7%) cited unwanted procedures. Among 48 participants with diabetes, monitoring of glucose levels was doable for 18 (37.5%) and too bothersome for 9 (18.8%). CONCLUSIONS AND RELEVANCE Participants identified realistic and actionable goals while varying in health care activities deemed helpful or bothersome. The goals and health care preferences of more diverse populations must be explored. Previous work suggests that clinicians can use this information in decision-making.
Collapse
Affiliation(s)
- Mary E. Tinetti
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Darcé M. Costello
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Baylor College of Medicine, Houston, Texas
| | - Claire Davenport
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Julia R. Van Liew
- Department of Behavioral Medicine, Medical Humanities, and Bioethics, Des Moines University, Des Moines, Iowa
| | - Jessica Esterson
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Eliza Kiwak
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lilian Dindo
- Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Baylor College of Medicine, Houston, Texas
| |
Collapse
|
19
|
Older participant perspectives on permanent study drug discontinuation in an ongoing primary prevention trial of statins. Eur J Clin Pharmacol 2021; 77:841-847. [PMID: 33410972 DOI: 10.1007/s00228-020-03073-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Study drug discontinuation is commonplace in clinical trials of older populations. Little is known about why older participants discontinue the study drug. This qualitative study aimed to understand factors contributing to permanent study drug discontinuation among participants aged ≥ 70 years within an ongoing primary prevention trial of statins by exploring their experiences and perceptions. METHODS Trial participants who had permanently discontinued the study drug within 2 years of randomisation were purposively sampled by age (< 75 and ≥ 75 years) and sex to participate in semi-structured phone interviews between March 2019 and February 2020. Interviews were audio-recorded, transcribed and analysed thematically. RESULTS Thirty participants were interviewed (21 females; mean age, 77 years), and three themes were identified from the data. Perceived adverse events (AEs) and their effect on daily living (mobility, functional capacity, quality of life) were identified as the major factors leading to the participants permanently discontinuing their study drug, despite an ambiguity about the cause of the AE. For some, concurrent challenging life circumstances further lowered their tolerance to perceived AEs thus making discontinuation more likely. A few discontinuations were attributed to other factors (e.g. GP advice, unrelated illness). CONCLUSION Among healthy older participants enrolled in a statin trial, perceived AEs and their related impact were key factors contributing to the permanent study drug discontinuation. Addressing anticipated participant-reported AEs and their concerns about drug-related side effects at trial entry, as well as offering timely medical assistance and support when AEs occur, may be useful to reduce drug discontinuation rates.
Collapse
|
20
|
van Weert JCM, Alblas MC, van Dijk L, Jansen J. Preference for and understanding of graphs presenting health risk information. The role of age, health literacy, numeracy and graph literacy. PATIENT EDUCATION AND COUNSELING 2021; 104:109-117. [PMID: 32727670 DOI: 10.1016/j.pec.2020.06.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 04/27/2020] [Accepted: 06/29/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To investigate 1) younger (< 65) and older (> 65) adults' preference for and understanding of graph formats presenting risk information, and 2) the contribution of age, health literacy, numeracy and graph literacy in understanding information. MATERIALS AND METHODS To assess preferences, participants (n = 219 < 65 and n = 227>65) were exposed to a storyboard presenting six types of graphs. Understanding (verbatim and gist knowledge) was assessed in an experiment using a 6 (graphs: clock, bar, sparkplug, table, pie vs pictograph) by 2 (age: younger [<65] vs older [>65]) between-subjects design. RESULTS Most participants preferred clock, pie or bar chart. Pie was not well understood by both younger and older people, and clock not by older people. Bar was fairly well understood in both groups. Table yielded high knowledge scores, particularly in the older group. Lower age, higher numeracy and higher graph literacy contributed to higher verbatim knowledge scores. Higher health literacy and graph literacy were associated with higher gist knowledge. DISCUSSION AND CONCLUSION Although not the preferred format, tables are best understood by older adults. PRACTICE IMPLICATIONS Graph literacy skills are essential for both verbatim and gist understanding, and are important to take into account when developing risk information.
Collapse
Affiliation(s)
- Julia C M van Weert
- Amsterdam School of Communication Research / ASCoR, Department of Communication Science, University of Amsterdam, Amsterdam, the Netherlands.
| | - Monique C Alblas
- Amsterdam School of Communication Research / ASCoR, Department of Communication Science, University of Amsterdam, Amsterdam, the Netherlands.
| | - Liset van Dijk
- Nivel, Netherlands Institute of Health Services Research, Utrecht, the Netherlands; Dept. of PharmacoTherapy, Epidemiology & -Economics (PTEE), Groningen Research Institute of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Groningen, Groningen, the Netherlands.
| | - Jesse Jansen
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, University of Sydney, 2006, Australia; Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands.
| |
Collapse
|
21
|
The Unintended Consequences of Adverse Event Information on Medicines' Risks and Label Content. Pharmaceut Med 2020; 34:369-380. [PMID: 33196966 DOI: 10.1007/s40290-020-00367-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2020] [Indexed: 10/23/2022]
Abstract
Patients and prescribers need to be aware of adverse drug events to minimize the risk of their occurrence and the severity with which they appear. However, numerous studies show that being informed about adverse events can increase the possibility of suffering from them. Patients tend to overestimate the likelihood of experiencing the adverse events included in the label, and this can contribute to worsening the negative expectations which are at the root of the nocebo effect. In fact, patients can become anxious after reading the undesirable effects section of the leaflet and, in addition to suffering from the nocebo effect, might not take a drug they could benefit from due to the fear of experiencing adverse events. In addition, patients' attention can focus towards non-specific symptoms of daily living that can be misattributed to the drug and included in the labelling. This article proposes a number of suggestions to reduce the abovementioned unintended effects associated with labelling, namely, an increased focus on the excess risk of experiencing adverse events rather than crude incidence, using attribute framing to help patients to better understand the risk of experiencing adverse events, dividing the undesirable effect section of the leaflet into subsections according to the level of evidence supporting causal relationships and, finally, restricting the addition of non-specific adverse events that are also symptoms of daily living to only those where there is enough evidence to show they have been caused by the drug. More studies on how to minimize the nocebo effect induced by adverse event information should be performed, and these should be done in collaboration with health authorities, to reach a shared consensus on how to better present adverse event information in the label.
Collapse
|
22
|
Fried TR, Street RL, Cohen AB. Reply to: Outcomes and Patient Goals: Comment on "Chronic Disease Decision Making and 'What Matters Most'". J Am Geriatr Soc 2020; 68:1615-1616. [PMID: 32391923 DOI: 10.1111/jgs.16505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Terri R Fried
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Richard L Street
- Department of Communication, Texas A&M University, College Station, Texas, USA.,The Houston Center for Quality of Care and Utilization Studies and Baylor College of Medicine, Houston, Texas, USA
| | - Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
23
|
Eidam A, Roth A, Lacroix A, Goisser S, Seidling HM, Haefeli WE, Bauer JM. Methods to Assess Patient Preferences in Old Age Pharmacotherapy - A Systematic Review. Patient Prefer Adherence 2020; 14:467-497. [PMID: 32184575 PMCID: PMC7061412 DOI: 10.2147/ppa.s236964] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 01/14/2020] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The aim of this systematic review was to identify methods used to assess medication preferences in older adults and evaluate their advantages and disadvantages with respect to their applicability to the context of multimorbidity and polypharmacy. MATERIAL AND METHODS Three electronic databases (PubMed, Web of Science, PsycINFO) were searched. Eligible studies elicited individual treatment or outcome preferences in a context that involved long-term pharmacological treatment options. We included studies with a study population aged ≥ 65 years and/or with a mean or median age of ≥ 75 years. Qualitative studies, studies assessing preferences for only two different treatments, and studies targeting preferences for life-sustaining treatments were excluded. The identified preference measurement methods were evaluated based on four criteria (time budget, cognitive demand, variety of pharmacological aspects, and link with treatment strategies) judged to be relevant for the elicitation of patient preferences in polypharmacy. RESULTS Sixty articles met the eligibility criteria and were included in the narrative synthesis. Fifty-five different instruments to assess patient preferences, based on 24 different elicitation methods, were identified. The most commonly applied preference measurement techniques were "medication willingness" (description of a specific medication with inquiry of the participant's willingness to take it), discrete choice experiments, Likert scale-based questionnaires, and rank prioritization. The majority of the instruments were created for disease-specific or context-specific settings. Only three instruments (Outcome Prioritization Tool, a complex intervention, "MediMol" questionnaire) dealt with the broader issue of geriatric multimorbidity. Only seven of the identified tools showed somewhat favorable characteristics for a potential use of the respective method in the context of polypharmacy. CONCLUSION Up to now, few instruments have been specifically designed for the assessment of medication preferences in older patients with multimorbidity. To facilitate valid preference elicitation in the context of geriatric polypharmacy, future research should focus on suitable characteristics of existing techniques to develop new measurement approaches for this increasingly relevant population.
Collapse
Affiliation(s)
- Annette Eidam
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
| | - Anja Roth
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
| | - André Lacroix
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
| | - Sabine Goisser
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
- Network Aging Research (NAR), Heidelberg University, Heidelberg69115, Germany
| | - Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg69120, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg69120, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg69120, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg69120, Germany
| | - Jürgen M Bauer
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
- Network Aging Research (NAR), Heidelberg University, Heidelberg69115, Germany
| |
Collapse
|
24
|
Ostroumova OD, Cherniaeva MS, Sychev DA. Deprescribing Antihypertensive Drugs in Patients of Older Age Groups. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-02-14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Arterial hypertension (AH) is one of the most common diseases in the elderly. It has been proven that lowering blood pressure (BP) is effective in preventing stroke and cardiovascular complications in patients even at the age of ≥80 years. On the other hand, there is evidence that a significant decrease in BP can be harmful to older people and may lead to a higher risk of overall mortality. Therefore, existing guidelines for the treatment of AH determine specific approaches for managing patients of older age groups, where the target BP levels are determined not only by age and concomitant diseases, but also by the presence of frailty. Moreover, there is a need to monitor the dynamics of frailty indicators (social, functional, cognitive and mental status of the patient), since their deterioration may require changes in the tactics of antihypertensive therapy (dose reduction, drug withdrawal or replacement) and changes in target BP levels. In this regard, in recent years, the possibility/necessity of a planned and controlled process of dose reduction, drug withdrawal or replacement, if this drug can be harmful and/or does not bring benefits (deprescribing), has attracted attention. This article is a review of current literature, which presents the design and main characteristics of randomized clinical trials (RCTs) and systematic reviews on the deprescribing of antihypertensive drugs in elderly patients with AH and frailty. An analysis of these studies showed the benefits of deprescribing of antihypertensive drugs for elderly patients with frailty, which avoids potential harm to their health, improves the quality of life and reduces the economic cost of treatment. Therefore, deprescribing of antihypertensive drugs can be used as an additional tool to achieve the necessary target BP values in patients of an older age group. However, for the development of deprescribing of antihypertensive drugs schemes and its introduction into clinical practice, the results of large specially planned RCTs are needed to study this issue.
Collapse
Affiliation(s)
- O. D. Ostroumova
- Russian Medical Academy of Continuing Professional Education;
I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - M. S. Cherniaeva
- Central State Medical Academy, Administrative Directorate of the President of the Russian Federation Marshala
| | - D. A. Sychev
- Russian Medical Academy of Continuing Professional Education
| |
Collapse
|
25
|
Age, knowledge, preferences, and risk tolerance for invasive cardiac care. Am Heart J 2020; 219:99-108. [PMID: 31733450 DOI: 10.1016/j.ahj.2019.09.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/13/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND/OBJECTIVES The extent to which individual knowledge, preferences, and priorities explain lower use of invasive cardiac care among older vs. younger adults presenting with acute coronary syndrome (ACS) is unknown. We directly surveyed a group of patients to ascertain their preferences and priorities for invasive cardiovascular care. DESIGN We performed a prospective cohort study of adults hospitalized with ACS. We surveyed participants regarding their knowledge, preferences, goals, and concerns for cardiac care, as well as their risk tolerance for coronary artery bypass grafting (CABG). SETTING Single academic medical center. PARTICIPANTS Six hundred twenty-eight participants (373 <75 years old; 255 ≥75 years old). MEASUREMENTS We compared baseline characteristics, knowledge, priorities, and risk tolerance for care across age strata. We also assessed pairwise differences with 95% confidence intervals (CI) between age groups for key variables of interest. RESULTS Compared with younger patients, older participants had less knowledge of invasive care; were less willing to consider cardiac catheterization (difference between 75-84 and< 65 years old: -7.8%, 95% CI: -14.4%,-1.3%; for ≥85 vs. <65: -15.7%, 95% CI: -29.8%,-1.6%), percutaneous coronary intervention (difference between 75-84 and< 65 years old: -12.8%, 95% CI: -20.8%,-4.8%; for ≥85 vs. <65: -24.8%, 95% CI: -41.2%,-8.5%), and CABG (difference between 75-84 and< 65 years old: -19.0%, 95% CI: -28.2%,-9.9%; for ≥85 vs. <65: -39.1%, 95% CI: -56.0%,-22.2%); and were more risk averse for CABG surgery (p < .001), albeit with substantial inter-individual variability and individual outliers. Many patients who stated they were not initially willing to undergo an invasive cardiovascular procedure actually ended up undergoing the procedure (49% for cardiac catheterization and 22% for PCI or CABG). CONCLUSION Age influences treatment goals and willingness to consider invasive cardiac care, as well as risk tolerance for CABG. Individuals' willingness to undergo invasive cardiovascular procedures loosely corresponds with whether that procedure is performed after discussion with the care team.
Collapse
|
26
|
Gonzalez AI, Schmucker C, Nothacker J, Motschall E, Nguyen TS, Brueckle MS, Blom J, van den Akker M, Röttger K, Wegwarth O, Hoffmann T, Straus SE, Gerlach FM, Meerpohl JJ, Muth C. Health-related preferences of older patients with multimorbidity: an evidence map. BMJ Open 2019; 9:e034485. [PMID: 31843855 PMCID: PMC6924802 DOI: 10.1136/bmjopen-2019-034485] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 10/23/2019] [Accepted: 11/01/2019] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES To systematically identify knowledge clusters and research gaps in the health-related preferences of older patients with multimorbidity by mapping current evidence. DESIGN Evidence map (systematic review variant). DATA SOURCES MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL and Science Citation Index/Social Science Citation Index/-Expanded from inception to April 2018. STUDY SELECTION Studies reporting primary research on health-related preferences of older patients (mean age ≥60 years) with multimorbidity (≥2 chronic/acute conditions). DATA EXTRACTION Two independent reviewers assessed studies for eligibility, extracted data and clustered the studies using MAXQDA-18 content analysis software. RESULTS The 152 included studies (62% from North America, 28% from Europe) comprised 57 093 patients overall (range 9-9105). All used an observational design except for one interventional study: 63 (41%) were qualitative (59 cross-sectional, 4 longitudinal), 85 (57%) quantitative (63 cross-sectional, 22 longitudinal) and 3 (2%) used mixed methods. The setting was specialised care in 85 (56%) and primary care in 54 (36%) studies. We identified seven clusters of studies on preferences: end-of-life care (n=51, 34%), self-management (n=34, 22%), treatment (n=32, 21%), involvement in shared decision making (n=25, 17%), health outcome prioritisation/goal setting (n=19, 13%), healthcare service (n=12, 8%) and screening/diagnostic testing (n=1, 1%). Terminology (eg, preferences, views and perspectives) and concepts (eg, trade-offs, decision regret, goal setting) used to describe health-related preferences varied substantially between studies. CONCLUSION Our study provides the first evidence map on the preferences of older patients with multimorbidity. Included studies were mostly conducted in developed countries and covered a broad range of issues. Evidence on patient preferences concerning decision-making on screening and diagnostic testing was scarce. Differences in employed terminology, decision-making components and concepts, as well as the sparsity of intervention studies, are challenges for future research into evidence-based decision support seeking to elicit the preferences of older patients with multimorbidity and help them construct preferences. TRIAL REGISTRATION NUMBER Open Science Framework (OSF): DOI 10.17605/OSF.IO/MCRWQ.
Collapse
Affiliation(s)
- Ana Isabel Gonzalez
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Madrid, Spain
| | - Christine Schmucker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Baden-Württemberg, Germany
| | - Julia Nothacker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Baden-Württemberg, Germany
| | - Edith Motschall
- Institute of Medical Biometry and Statistics, University of Freiburg Faculty of Medicine, Freiburg, Baden-Württemberg, Germany
| | - Truc Sophia Nguyen
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
| | - Maria-Sophie Brueckle
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
| | - Jeanet Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Marjan van den Akker
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Limburg, Netherlands
| | - Kristian Röttger
- Patient Representative, Federal Joint Committee, Gemeinsamer Bundesausschuss, Berlin, Germany
| | - Odette Wegwarth
- Center for Adaptative Rationality, Max-Planck-Institute for Human Development, Berlin, Germany
| | - Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Bond University Faculty of Health Sciences and Medicine, Gold Coast, Queensland, Australia
| | - Sharon E Straus
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ferdinand M Gerlach
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Baden-Württemberg, Germany
| | - Christiane Muth
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
| |
Collapse
|
27
|
Harsha N, Kőrösi L, Pálinkás A, Bíró K, Boruzs K, Ádány R, Sándor J, Czifra Á. Determinants of Primary Nonadherence to Medications Prescribed by General Practitioners Among Adults in Hungary: Cross-Sectional Evaluation of Health Insurance Data. Front Pharmacol 2019; 10:1280. [PMID: 31736757 PMCID: PMC6836763 DOI: 10.3389/fphar.2019.01280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 10/07/2019] [Indexed: 12/17/2022] Open
Abstract
Background: Primary nonadherence to prescribed medications occurs when patients do not fill or dispense prescriptions written by healthcare providers. Although it has become an important public health issue in recent years, little is known about its frequency, causes, and consequences. Moreover, the pattern of risk factors shows remarkable variability across countries according to the published results. Our study aimed to assess primary nonadherence to medications prescribed by general practitioners (GPs) and its associated factors among adults in Hungary for the period of 2012–2015. Methods: Data on all general medical practices (GMPs) of the country were obtained from the National Health Insurance Fund and the Central Statistical Office. The ratio of the number of dispensed medications to the number of prescriptions written by a GP for adults was used to determine the medication adherence, which was aggregated for GMPs. The effect of GMP characteristics (list size, GP vacancy, patients’ education provided by a GMP, settlement type [urban or rural], and geographical location [by county] of the center) on adherence, standardized for patients’ age, sex, and eligibility for an exemption certificate, were investigated through generalized linear regression modeling. Results: A total of 281,315,386 prescriptions were dispensed out of 438,614,000 written by a GP. Overall, 64.1% of prescriptions were filled. According to the generalized linear regression coefficients, there was a negative association between standardized adherence and urban settlement type (b = -0.099, 95%CI = -0.103 to -0.094), higher level of education (b = -0.440, 95%CI = -0.468 to -0.413), and vacancy of the general practices (b = -0.193, 95%CI = -0.204 to -0.182). The larger GMP size proved to be a risk factor, and there was a significant geographical inequality for counties as well. Conclusions: More than one-third of the written prescriptions of GPs for adults in Hungary were not dispensed. This high level of nonadherence had great variability across GMPs, and can be explained by structural characteristics of GMPs, the socioeconomic status of patients provided, and the quality of cooperation between patients and GPs. Moreover, our findings suggest that the use of the dispensed-to-prescribed medication ratio in routine monitoring of primary health care could effectively support the necessary interventions.
Collapse
Affiliation(s)
- Nouh Harsha
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - László Kőrösi
- Department of Financing, National Health Insurance Fund, Budapest, Hungary
| | - Anita Pálinkás
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Klára Bíró
- Department of Health Systems Management and Quality Management in Health Care, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Klára Boruzs
- Department of Health Systems Management and Quality Management in Health Care, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Róza Ádány
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - János Sándor
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Árpád Czifra
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| |
Collapse
|
28
|
Affiliation(s)
- Paula Byrne
- JE Cairnes School of Business and Economics, National University of Ireland Galway, Galway, Ireland
| | - John Cullinan
- JE Cairnes School of Business and Economics, National University of Ireland Galway, Galway, Ireland
| | - Susan M Smith
- Royal College of Surgeons in Ireland-General Practice, Dublin, Ireland
| |
Collapse
|
29
|
Irawati L, Alrasheedy AA, Hassali MA, Saleem F. Low-income community knowledge, attitudes and perceptions regarding antibiotics and antibiotic resistance in Jelutong District, Penang, Malaysia: a qualitative study. BMC Public Health 2019; 19:1292. [PMID: 31615486 PMCID: PMC6794866 DOI: 10.1186/s12889-019-7718-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 09/30/2019] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND Understanding community perspectives on antibiotics and antibiotic resistance (ABR) is a key component in designing educational interventions to combat ABR at the community level in Malaysia. Therefore, this study aimed to explore community residents' knowledge, attitudes and perceptions regarding antibiotics and ABR in Jelutong District, Penang, Malaysia. Moreover, it intended to identify areas of focus to be addressed when designing an educational intervention to increase residents' knowledge and change their attitudes and perceptions. METHODS A qualitative approach was adopted to gain a deeper understanding of community residents' knowledge, attitudes and perceptions regarding antibiotics and ABR. A purposive sampling was employed. Twenty-two residents (aged ≥18 years) were interviewed with the aid of a semi-structured interview guide. All interviews were audio recorded, transcribed verbatim and thematically analysed. RESULTS The majority of the participants asserted that antibiotics could be effective against viral infections. Moreover, many participants were unaware that antibiotics have adverse effects. Some acquired antibiotics from a community pharmacy without a prescription, took antibiotics given to them by their family or friends, or took leftover antibiotics prescribed for a previous illness. A few indicated that they would request antibiotics from their physician when they had viral infections. More than half of the participants discontinued taking antibiotics when their symptoms improved. The majority stated that ABR occurs when the body becomes used to antibiotics. Most participants were unaware of the causes, consequences and prevention of ABR. In fact, they were not concerned about it. As a result, only a few perceived themselves as having responsibility for preventing this problem. CONCLUSIONS The community residents had misconceptions about antibiotics and ABR, negative attitudes towards antibiotics and negative perceptions of ABR. The areas of focus that need to be addressed when designing an educational intervention to increase the general public knowledge and change their attitudes and perceptions are the appropriate use of antibiotics and their adverse effects; the importance of adhering to antibiotic therapy; and the definition, causes, consequences and prevention of ABR.
Collapse
Affiliation(s)
- Lyna Irawati
- Faculty of Pharmaceutical Sciences, UCSI University, Kuala Lumpur, Malaysia
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Alian A. Alrasheedy
- Unaizah College of Pharmacy, Qassim University, Buraydah, Qassim Saudi Arabia
| | | | - Fahad Saleem
- Faculty of Pharmacy and Health Sciences, University of Balochistan, Quetta, Pakistan
| |
Collapse
|
30
|
Abstract
PURPOSE OF REVIEW A patient's prognosis and risk of adverse drug effects are important considerations for individualizing care of older patients with diabetes. This review summarizes the evidence for risk assessment and proposes approaches for clinicians in the context of current clinical guidelines. RECENT FINDINGS Diabetes guidelines vary in their recommendations for how life expectancy should be estimated and used to inform the selection of glycemic targets. Readily available prognostic tools may improve estimation of life expectancy but require validation among patients with diabetes. Treatment decisions based on prognosis are difficult for clinicians to communicate and for patients to understand. Determining hypoglycemia risk involves assessing major risk factors; models to synthesize these factors have been developed. Applying risk assessment to individualize diabetes care is complex and currently relies heavily on clinician judgment. More research is need to validate structured approaches to risk assessment and determine how to incorporate them into patient-centered diabetes care.
Collapse
Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA.
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elbert S Huang
- Division of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
| |
Collapse
|
31
|
Falahee M, Finckh A, Raza K, Harrison M. Preferences of Patients and At-risk Individuals for Preventive Approaches to Rheumatoid Arthritis. Clin Ther 2019; 41:1346-1354. [PMID: 31196645 DOI: 10.1016/j.clinthera.2019.04.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/22/2019] [Accepted: 04/10/2019] [Indexed: 02/07/2023]
Abstract
Effective treatments for rheumatoid arthritis (RA) are available and can lead to remission for some patients, but most patients remain on potentially toxic and expensive medications in the long term. Interest is increasingly turning to the disease phases preceding the development of RA that represent opportunities for preventive interventions. At-risk target populations include individuals with genetic and environmental risk factors, those who have developed systemic autoimmunity, and those who have developed clinically suspect symptoms (eg, arthralgias without synovitis, or an early arthritis). Ongoing prospective studies will inform the development of increasingly accurate predictive tools to identify individuals at risk of developing RA. Furthermore, a range of preventive approaches has been suggested, including lifestyle modification (eg, smoking cessation) and pharmacologic interventions (eg, hydroxychloroquine, methotrexate, abatacept, rituximab) that are currently the subject of randomized controlled trials. As prediction and prevention of RA evolve, it is increasingly likely that individuals at risk (including asymptomatic individuals) may be faced with complex decisions about whether to accept assessment of their risk status or to take a preventive intervention associated with risk of serious adverse events and uncertain benefit. Acceptance of preventive medication in other contexts can be low. For example, <25% of women at high risk of breast cancer are willing to take preventive hormonal treatments. Actual uptake is lower still. Patients' beliefs and preferences predict treatment uptake and adherence. Before the dream of preventing RA can become reality, health care providers need to understand the perspectives of individuals in the target population and to identify barriers and facilitators for this approach. This commentary reviews what is currently known about the perspectives of patients and individuals at risk about predictive and preventive approaches for RA and identifies gaps to be addressed to inform the development of efficient preventive strategies.
Collapse
Affiliation(s)
- Marie Falahee
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.
| | - Axel Finckh
- Department of Rheumatology, Geneva University Hospital, Geneva, Switzerland
| | - Karim Raza
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Rheumatology, Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom; Arthritis Research UK Rheumatoid Arthritis Pathogenesis Centre of Excellence, MRC Arthritis Research UK Centre for Musculoskeletal Ageing Research, NIHR Biomedical Research Centre, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Mark Harrison
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada; Arthritis Research Centre of Canada, Richmond, British Columbia, Canada
| |
Collapse
|
32
|
Hajduk AM, Gurwitz JH, Tabada G, Masoudi FA, Magid DJ, Greenlee RT, Sung SH, Cassidy-Bushrow AE, Liu TI, Reynolds K, Smith DH, Fiocchi F, Goldberg R, Gill TM, Gupta N, Peterson PN, Schuger C, Vidaillet H, Hammill SC, Allore H, Go AS. Influence of Multimorbidity on Burden and Appropriateness of Implantable Cardioverter-Defibrillator Therapies. J Am Geriatr Soc 2019; 67:1370-1378. [PMID: 30892695 DOI: 10.1111/jgs.15839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 01/25/2019] [Accepted: 01/26/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To determine whether burden of multiple chronic conditions (MCCs) influences the risk of receiving inappropriate vs appropriate device therapies. DESIGN Retrospective cohort study. SETTING Seven US healthcare delivery systems. PARTICIPANTS Adults with left ventricular systolic dysfunction receiving an implantable cardioverter-defibrillator (ICD) for primary prevention. MEASUREMENTS Data on 24 comorbid conditions were captured from electronic health records and categorized into quartiles of comorbidity burden (0-3, 4-5, 6-7 and 8-16). Incidence of ICD therapies (shock and antitachycardia pacing [ATP] therapies), including appropriateness, was collected for 3 years after implantation. Outcomes included time to first ICD therapy, total ICD therapy burden, and risk of inappropriate vs appropriate ICD therapy. RESULTS Among 2235 patients (mean age = 69 ± 11 years, 75% men), the median number of comorbidities was 6 (interquartile range = 4-8), with 98% having at least two comorbidities. During a mean 2.2 years of follow-up, 18.3% of patients experienced at least one appropriate therapy and 9.9% experienced at least one inappropriate therapy. Higher comorbidity burden was associated with an increased risk of first inappropriate therapy (adjusted hazard ratio [HR] = 1.94 [95% confidence interval {CI} = 1.14-3.31] for 4-5 comorbidities; HR = 2.25 [95% CI = 1.25-4.05] for 6-7 comorbidities; and HR = 2.91 [95% CI = 1.54-5.50] for 8-16 comorbidities). Participants with 8-16 comorbidities had a higher total burden of ICD therapy (adjusted relative risk [RR] = 2.12 [95% CI = 1.43-3.16]), a higher burden of inappropriate therapy (RR = 3.39 [95% CI = 1.67-6.86]), and a higher risk of receiving inappropriate vs appropriate therapy (RR = 1.74 [95% CI = 1.07-2.82]). Comorbidity burden was not significantly associated with receipt of appropriate ICD therapies. Patterns were similar when separately examining shock or ATP therapies. CONCLUSIONS In primary prevention ICD recipients, MCC burden was independently associated with an increased risk of inappropriate but not appropriate device therapies. Comorbidity burden should be considered when engaging patients in shared decision making about ICD implantation.
Collapse
Affiliation(s)
- Alexandra M Hajduk
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jerry H Gurwitz
- Meyers Primary Care Institute, a Joint Endeavor of University of Massachusetts Medical School, Fallon Health, and Reliant Medical Group, Worcester, Massachusetts
| | - Grace Tabada
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Frederick A Masoudi
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David J Magid
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Robert T Greenlee
- Center for Clinical Epidemiology & Population Health, Marshfield Clinic Research Foundation, Marshfield, Wisconsin
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Taylor I Liu
- Department of Cardiac Electrophysiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - David H Smith
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Frances Fiocchi
- National Cardiovascular Data Registry, American College of Cardiology Foundation, Washington, DC
| | - Robert Goldberg
- Meyers Primary Care Institute, a Joint Endeavor of University of Massachusetts Medical School, Fallon Health, and Reliant Medical Group, Worcester, Massachusetts
| | - Thomas M Gill
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Nigel Gupta
- Department of Cardiac Electrophysiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Pamela N Peterson
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Claudio Schuger
- Heart and Vascular Institute, Henry Ford Health System, Detroit, Michigan
| | - Humberto Vidaillet
- Marshfield Clinical Research Foundation, Marshfield Clinic, Marshfield, Wisconsin
| | | | - Heather Allore
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California.,Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, California.,Departments of Medicine, Health Research and Policy, Stanford University School of Medicine, Palo Alto, California
| | | |
Collapse
|
33
|
Jansen J, McKinn S, Bonner C, Muscat DM, Doust J, McCaffery K. Shared decision-making about cardiovascular disease medication in older people: a qualitative study of patient experiences in general practice. BMJ Open 2019; 9:e026342. [PMID: 30898831 PMCID: PMC6475217 DOI: 10.1136/bmjopen-2018-026342] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To explore older people's perspectives and experiences with shared decision-making (SDM) about medication for cardiovascular disease (CVD) prevention. DESIGN, SETTING AND PARTICIPANTS Semi-structured interviews with 30 general practice patients aged 75 years and older in New South Wales, Australia, who had elevated CVD risk factors (blood pressure, cholesterol) or had received CVD-related lifestyle advice. Data were analysed by multiple researchers using Framework analysis. RESULTS Twenty eight participants out of 30 were on CVD prevention medication, half with established CVD. We outlined patient experiences using the four steps of the SDM process, identifying key barriers and challenges: Step 1. Choice awareness: taking medication for CVD prevention was generally not recognised as a decision requiring patient input; Step 2. Discuss benefits/harms options: CVD prevention poorly understood with emphasis on benefits; Step 3. Explore preferences: goals, values and preferences (eg, length of life vs quality of life, reducing disease burden vs risk reduction) varied widely but generally not discussed with the general practitioner; Step 4. Making the decision: overall preference for directive approach, but some patients wanted more active involvement. Themes were similar across primary and secondary CVD prevention, different levels of self-reported health and people on and off medication. CONCLUSIONS Results demonstrate how older participants vary widely in their health goals and preferences for treatment outcomes, suggesting that CVD prevention decisions are preference sensitive. Combined with the fact that the vast majority of participants were taking medications, and few understood the aims and potential benefits and harms of CVD prevention, it seems that older patients are not always making an informed decision. Our findings highlight potentially modifiable barriers to greater participation of older people in SDM about CVD prevention medication and prevention in general.
Collapse
Affiliation(s)
- Jesse Jansen
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
| | - Shannon McKinn
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
| | - Carissa Bonner
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
| | - Danielle Marie Muscat
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
| | - Jenny Doust
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Kirsten McCaffery
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
34
|
Boyd C, Smith CD, Masoudi FA, Blaum CS, Dodson JA, Green AR, Kelley A, Matlock D, Ouellet J, Rich MW, Schoenborn NL, Tinetti ME. Decision Making for Older Adults With Multiple Chronic Conditions: Executive Summary for the American Geriatrics Society Guiding Principles on the Care of Older Adults With Multimorbidity. J Am Geriatr Soc 2019; 67:665-673. [DOI: 10.1111/jgs.15809] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/16/2019] [Indexed: 01/21/2023]
Affiliation(s)
- Cynthia Boyd
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | | | - Frederick A. Masoudi
- Department of Medicine (Cardiology); University of Colorado Anschutz Medical Campus; Aurora Colorado
| | - Caroline S. Blaum
- Department of Medicine; New York University School of Medicine; New York New York
| | - John A. Dodson
- Department of Medicine; New York University School of Medicine; New York New York
| | - Ariel R. Green
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Amy Kelley
- Department of Geriatrics and Palliative Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | - Daniel Matlock
- Department of Medicine (General Internal Medicine); University of Colorado School of Medicine; Denver Colorado
| | - Jennifer Ouellet
- Department of Internal Medicine; Yale School of Medicine, Yale School of Public Health; New Haven Connecticut
| | - Michael W. Rich
- Department of Internal Medicine; Washington University School of Medicine; St Louis Missouri
| | - Nancy L. Schoenborn
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Mary E. Tinetti
- Department of Internal Medicine; Yale School of Medicine, Yale School of Public Health; New Haven Connecticut
| |
Collapse
|
35
|
Ouellet GM, Ouellet JA, Tinetti ME. Principle of rational prescribing and deprescribing in older adults with multiple chronic conditions. Ther Adv Drug Saf 2018; 9:639-652. [PMID: 30479739 PMCID: PMC6243421 DOI: 10.1177/2042098618791371] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/27/2018] [Indexed: 12/12/2022] Open
Abstract
Although the majority of older adults in the developed world live with multiple chronic conditions (MCCs), the task of selecting optimal treatment regimens is still fraught with difficulty. Older adults with MCCs may derive less benefit from prescribed medications than healthier patients as a result of the competing risk of several possible outcomes including, but not limited to, death before a benefit can be accrued. In addition, these patients may be at increased risk of medication-related harms in the form of adverse effects and significant burdens of treatment. At present, the balance of these benefits and harms is often uncertain, given that older adults with MCCs are often excluded from clinical trials. In this review, we propose a framework to consider patients' own priorities to achieve optimal treatment regimens. To begin, the practicing clinician needs information on the patient's goals, what the patient is willing and able to do to achieve these goals, an estimate of the patient's clinical trajectory, and what the patient is actually taking. We then describe how to integrate this information to understand what matters most to the patient in the context of an array of potential tradeoffs. Finally, we propose conducting serial therapeutic trials of prescribing and deprescribing, with success measured as progress towards the patient's own health outcome goals. The process described in this manuscript is truly an iterative process, which should be repeated regularly to account for changes in the patient's priorities and clinical status. With this process, we aim to achieve optimal prescribing, that is, treatment regimens that maximize benefits that matter to the patient and minimize burdens and potential harms.
Collapse
Affiliation(s)
- Gregory M. Ouellet
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, 367 Cedar Street, Harkness A, Room 308-A, New Haven, CT 06520-8093, USA
| | - Jennifer A. Ouellet
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mary E. Tinetti
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
36
|
Ho CLB, Chowdhury EK, Breslin M, Doust J, Reid CM, Wing LMH, Nelson MR. Short- and long-term association of lipid-lowering drug treatment and cardiovascular disease by estimated absolute risk in the Second Australian National Blood Pressure study. J Clin Lipidol 2018; 13:148-155. [PMID: 30293937 DOI: 10.1016/j.jacl.2018.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/30/2018] [Accepted: 08/31/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is currently insufficient evidence to support the use of lipid-lowering drug treatment (LLT) for primary prevention of cardiovascular disease (CVD) in the elderly. OBJECTIVES We examined the relationship of early initiation of LLT with short- and long-term all-cause and CVD mortality in persons older than 65 years in this post hoc study from the Second Australian National Blood Pressure study (ANBP2). METHODS This was an in- and post-trial observational study. About 4257 hypertensive participants aged 65 to 84 years within Australian family practices were randomized to an angiotensin-converting enzyme inhibitor or a diuretic treatment group. After excluding participants with a prior history of CVD, the cohort was stratified into "LLT" and "no LLT" subgroups based on LLT status at randomization. RESULTS At randomization, the participants had a mean age of 72 years, average blood pressure of 168/91 mm Hg and estimated 5-year CVD risk of 18.7 ± 8.3%. In the overall study population, the association of LLT with long-term (11-years) all-cause and non-CVD mortality was significant (hazard ratio [HR] 0.78 [95% confidence interval {CI} 0.66-0.92, P = .003] and HR 0.70 [95% CI 0.54-0.90, P = .006], respectively). Magnitudes of the association of LLT with long-term mortality and the association with short-term mortality were similar; however, no statistically significant association with short-term mortality was observed. In the subgroup analysis by baseline 5-year CVD risk, LLT participants in the highest risk tertile had a substantially lower relative risk for short-term all-cause mortality (HR 0.31, 95% CI 0.13-0.71, P for interaction .02) compared to those with lower estimated CVD risk. All analyses were adjusted for baseline and in-trial characteristics. CONCLUSION Our study showed a strong association between LLT and reduced long-term all-cause mortality. Thus, our findings support recommendations of the use of LLT in patients over 65 years, particularly those with high CVD risk who were more likely to obtain additional benefits in the short term. The findings also suggested that mortality benefits of LLT for the elderly may take longer to become evident.
Collapse
Affiliation(s)
- Chau L B Ho
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
| | - Enayet K Chowdhury
- CCRE Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; School of Public Health, Curtin University, Perth, Australia
| | - Monique Breslin
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Jenny Doust
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Christopher M Reid
- CCRE Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; School of Public Health, Curtin University, Perth, Australia
| | - Lindon M H Wing
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; CCRE Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| |
Collapse
|
37
|
Sheppard JP, Burt J, Lown M, Temple E, Benson J, Ford GA, Heneghan C, Hobbs FDR, Jowett S, Little P, Mant J, Mollison J, Nickless A, Ogburn E, Payne R, Williams M, Yu LM, McManus RJ. OPtimising Treatment for MIld Systolic hypertension in the Elderly (OPTiMISE): protocol for a randomised controlled non-inferiority trial. BMJ Open 2018; 8:e022930. [PMID: 30287610 PMCID: PMC6173263 DOI: 10.1136/bmjopen-2018-022930] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 08/10/2018] [Accepted: 08/18/2018] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Recent evidence suggests that larger blood pressure reductions and multiple antihypertensive drugs may be harmful in older people, particularly frail individuals with polypharmacy and multimorbidity. However, there is a lack of evidence to support deprescribing of antihypertensives, which limits the practice of medication reduction in routine clinical care. The aim of this trial is to examine whether antihypertensive medication reduction is possible in older patients without significant changes in blood pressure control at follow-up. METHODS AND ANALYSIS This trial will use a primary care-based, open-label, randomised controlled trial design. A total of 540 participants will be recruited, aged ≥80 years, with systolic blood pressure <150 mm Hg and receiving ≥2 antihypertensive medications. Participants will have no compelling indication for medication continuation and will be considered to potentially benefit from medication reduction due to existing polypharmacy, comorbidity and frailty. Following a baseline appointment, individuals will be randomised to a strategy of medication reduction (intervention) with optional self-monitoring or usual care (control). Those in the intervention group will have one antihypertensive medication stopped. The primary outcome will be to determine if a reduction in medication can achieve a proportion of participants with clinically safe blood pressure levels at 12-week follow-up (defined as a systolic blood pressure <150 mm Hg), which is non-inferior (within 10%) to that achieved by the usual care group. Qualitative interviews will be used to understand the barriers and facilitators to medication reduction. The study will use economic modelling to predict the long-term effects of any observed changes in blood pressure and quality of life. ETHICS AND DISSEMINATION The protocol, informed consent form, participant information sheet and all other participant facing material have been approved by the Research Ethics Committee (South Central-Oxford A; ref 16/SC/0628), Medicines and Healthcare products Regulatory Agency (ref 21584/0371/001-0001), host institution(s) and Health Research Authority. All research outputs will be published in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER EudraCT 2016-004236-38; ISRCTN97503221; Pre-results.
Collapse
Affiliation(s)
- James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jenni Burt
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Mark Lown
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Eleanor Temple
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - John Benson
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Gary A Ford
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sue Jowett
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jill Mollison
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alecia Nickless
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emma Ogburn
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rupert Payne
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | | | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
38
|
Robinson JG, Hernandez AF. The Call for Precision Health Trials in Older Adults: One Size Does Not Fit All. J Am Coll Cardiol 2018; 71:2537-2539. [PMID: 29852977 DOI: 10.1016/j.jacc.2018.03.503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 03/08/2018] [Accepted: 03/09/2018] [Indexed: 11/18/2022]
|
39
|
Hoffmann T, Jansen J, Glasziou P. The importance and challenges of shared decision making in older people with multimorbidity. PLoS Med 2018; 15:e1002530. [PMID: 29534067 PMCID: PMC5849298 DOI: 10.1371/journal.pmed.1002530] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
In a Perspective, Tammy Hoffmann and colleagues discuss medical decision making for elderly patients with multimorbidity.
Collapse
Affiliation(s)
- Tammy Hoffmann
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Jesse Jansen
- Wiser Healthcare Program, Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, Australia
| | - Paul Glasziou
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| |
Collapse
|
40
|
Linsky A, Simon SR, Stolzmann K, Meterko M. Patient attitudes and experiences that predict medication discontinuation in the Veterans Health Administration. J Am Pharm Assoc (2003) 2018; 58:13-20. [PMID: 29154017 PMCID: PMC6788281 DOI: 10.1016/j.japh.2017.10.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 10/16/2017] [Accepted: 10/20/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Polypharmacy is associated with adverse medication effects. One potential solution is deprescribing, which is the intentional, proactive, rational discontinuation of a medication that is no longer indicated or for which the potential harms outweigh the potential benefits. We identified patient characteristics, attitudes, and health care experiences associated with medication discontinuation. DESIGN, SETTING, AND PARTICIPANTS We conducted a national mail survey, with the use of the Patient Perceptions of Discontinuation (PPoD) instrument, of 1600 veterans receiving primary care at Veterans Affairs (VA) medical centers and prescribed 5 or more concurrent medications. MAIN OUTCOME MEASURES The primary outcome was the response to: "Have you ever stopped taking a medicine (with or without your doctor's knowledge)?" The primary predictors of interest were 8 validated attitudinal scales. Other predictors included demographics, health status, and health care experiences. RESULTS Respondents (n = 803; adjusted response rate 52%) were predominantly male (85%); non-Hispanic white (68%), 65 years of age or older (60%), and with poor (16%) or fair (45%) health. Participant attitudes toward medications and their providers were generally favorable. One in 3 patients (34%) reported having stopped a medicine in the past. In a multivariable logistic regression model (P < 0.001; pseudo-R2 = 0.31; c-statistic = 0.82), factors associated with discontinuation included being told or asking to stop a medicine, greater interest in deprescribing and shared decision making, and higher education. Factors associated with decreased discontinuation were more prescriptions, higher trust in provider, and seeing a VA clinical pharmacist. CONCLUSION More highly educated patients with interest in deprescribing and shared decision making may be more receptive to discontinuation discussions. Future research evaluating how to incorporate this survey and these findings into clinical workflow through the design of clinical interventions may help to promote safe and rational medication use.
Collapse
Affiliation(s)
- Amy Linsky
- General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA 02130
| | - Steven R. Simon
- General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA 02130
| | - Kelly Stolzmann
- General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA 02130
| | - Mark Meterko
- General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA 02130
| |
Collapse
|
41
|
Newton EH. Addressing overuse in emergency medicine: evidence of a role for greater patient engagement. Clin Exp Emerg Med 2017; 4:189-200. [PMID: 29306268 PMCID: PMC5758625 DOI: 10.15441/ceem.17.233] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/05/2017] [Accepted: 06/30/2017] [Indexed: 01/01/2023] Open
Abstract
Overuse of health care refers to tests, treatments, and even health care settings when used in circumstances where they are unlikely to help. Overuse is not only wasteful, it threatens patient safety by exposing patients to a greater chance of harm than benefit. It is a widespread problem and has proved resistant to change. Overuse of diagnostic testing is a particular problem in emergency medicine. Emergency physicians cite fear of missing a diagnosis, fear of law suits, and perceived patient expectations as key contributors. However, physicians' assumptions about what patients expect are often wrong, and overlook two of patients' most consistently voiced priorities: communication and empathy. Evidence indicates that patients who are more fully informed and engaged in their care often opt for less aggressive approaches. Shared decision making refers to (1) providing balanced information so that patients understand their options and the trade-offs involved, (2) encouraging them to voice their preferences and values, and (3) engaging them-to the extent appropriate or desired-in decision making. By adopting this approach to discretionary decision making, physicians are better positioned to address patients' concerns without the use of tests and treatments patients neither need nor value.
Collapse
Affiliation(s)
- Erika H. Newton
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
| |
Collapse
|
42
|
Abstract
The detection of biomarkers in the preclinical phase of rheumatoid arthritis (RA) and recent therapeutic advances suggest that it may be possible to identify and treat persons at high risk and to prevent the development of RA. Several trials are ongoing to test the efficacy of a therapeutic intervention in primary prevention. This paper reviews potential populations that might be considered for preventative medication. Further, we review the medications that are being explored to treat individuals considered at high risk of developing RA. Finally, in a group of asymptomatic individuals at high risk of developing RA, we assessed which factors mattered most when considering a preventive therapeutic intervention and what type of preventive treatment would be most acceptable to them. Understanding subjects' perceptions of risks and benefits and willingness to undergo preventive therapy will be important in designing and implementing screening and preventive strategies.
Collapse
|
43
|
Fried TR, Niehoff KM, Street RL, Charpentier PA, Rajeevan N, Miller PL, Goldstein MK, O’Leary JR, Fenton BT. Effect of the Tool to Reduce Inappropriate Medications on Medication Communication and Deprescribing. J Am Geriatr Soc 2017; 65:2265-2271. [PMID: 28804870 PMCID: PMC5641237 DOI: 10.1111/jgs.15042] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To examine the effect of the Tool to Reduce Inappropriate Medications (TRIM), a web tool linking an electronic health record (EHR) to a clinical decision support system, on medication communication and prescribing. DESIGN Randomized clinical trial. SETTING Primary care clinics at a Veterans Affairs Medical Center. PARTICIPANTS Veterans aged 65 and older prescribed seven or more medications randomized to receipt of TRIM or usual care (N = 128). INTERVENTION TRIM extracts information on medications and chronic conditions from the EHR and contains data entry screens for information obtained from brief chart review and telephonic patient assessment. These data serve as input for automated algorithms identifying medication reconciliation discrepancies, potentially inappropriate medications (PIMs), and potentially inappropriate regimens. Clinician feedback reports summarize discrepancies and provide recommendations for deprescribing. Patient feedback reports summarize discrepancies and self-reported medication problems. MEASUREMENTS Primary: subscales of the Patient Assessment of Care for Chronic Conditions (PACIC) related to shared decision-making; clinician and patient communication. Secondary: changes in medications. RESULTS 29.7% of TRIM participants and 15.6% of control participants provided the highest PACIC ratings; this difference was not significant. Adjusting for covariates and clustering of patients within clinicians, TRIM was associated with significantly more-active patient communication and facilitative clinician communication and with more medication-related communication among patients and clinicians. TRIM was significantly associated with correction of medication discrepancies but had no effect on number of medications or reduction in PIMs. CONCLUSION TRIM improved communication about medications and accuracy of documentation. Although there was no association with prescribing, the small sample size provided limited power to examine medication-related outcomes.
Collapse
Affiliation(s)
- Terri R. Fried
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT
- Department of Medicine (Program on Aging), Yale School of Medicine, New Haven, CT
| | - Kristina M. Niehoff
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT
| | - Richard L. Street
- Department of Communication, Texas A&M University, College Station, TX
- Houston Center for Quality of Care and Utilization Studies, Baylor College of Medicine, Houston, TX
| | | | - Nallakkandi Rajeevan
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT
- Center for Medical Informatics, Yale University School of Medicine, New Haven, CT
| | - Perry L. Miller
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT
- Center for Medical Informatics, Yale University School of Medicine, New Haven, CT
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, CT
| | - Mary K. Goldstein
- Palo Alto Geriatrics Research Education and Clinical Center (GRECC) and Medical Service, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Medicine (Center for Primary Care and Outcomes Research), Stanford University, Stanford, CA
| | - John R. O’Leary
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT
- Program on Aging, Yale School of Medicine, New Haven, CT
| | - Brenda T. Fenton
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, CT
| |
Collapse
|
44
|
Fraenkel L, Stolar M, Bates JR, Street RL, Chowdhary H, Swift S, Peters E. Variability in Affect and Willingness to Take Medication. Med Decis Making 2017; 38:34-43. [PMID: 28853340 DOI: 10.1177/0272989x17727002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine if 1) patients have distinct affective reaction patterns to medication information, and 2) whether there is an association between affective reaction patterns and willingness to take medication. METHODS We measured affect in real time as subjects listened to a description of benefits and side effects for a hypothetical new medication. Subjects moved a dial on a handheld response system to indicate how they were feeling from "Very Good" to "Very Bad". Patterns of reactions were identified using a cluster-analytic statistical approach for multiple time series. Subjects subsequently rated their willingness to take the medication on a 7-point Likert scale. Associations between subjects' willingness ratings and affect patterns were analyzed. Additional analyses were performed to explore the role of race/ethnicity regarding these associations. RESULTS Clusters of affective reactions emerged that could be classified into 4 patterns: "Moderate" positive reactions to benefits and negative reactions to side effects ( n = 186), "Pronounced" positive reactions to benefits and negative reactions to side effects ( n = 110), feeling consistently "Good" ( n = 58), and feeling consistently close to "Neutral" ( n = 33). Mean (standard error) willingness to take the medication was greater among subjects feeling consistently Good 4.72 (0.20) compared with those in the Moderate 3.76 (0.11), Pronounced 3.68 (0.14), and Neutral 3.62 (0.26) groups. Black subjects with a Pronounced pattern were less willing to take the medication compared with both Hispanic ( P = 0.0270) and White subjects ( P = 0.0001) with a Pronounced pattern. CONCLUSION Patients' affective reactions to information were clustered into specific patterns. Reactions varied by race/ethnicity and were associated with treatment willingness. Ultimately, a better understanding of how patients react to information may help providers develop improved methods of communication.
Collapse
Affiliation(s)
- Liana Fraenkel
- Yale University School of Medicine, New Haven, CT, USA (LF, JRB, HC, SS).,VA Connecticut Healthcare System, West Haven, CT, USA (LF)
| | - Marilyn Stolar
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT, USA (MS)
| | - Jonathan R Bates
- Yale University School of Medicine, New Haven, CT, USA (LF, JRB, HC, SS)
| | - Richard L Street
- Department of Communication, Texas A&M University, College Station, TX, USA (RLS).,Houston Center for Innovations in Quality, Effectiveness, and Safety and Baylor College of Medicine; Houston, TX, USA (RLS)
| | | | - Sarah Swift
- Yale University School of Medicine, New Haven, CT, USA (LF, JRB, HC, SS)
| | - Ellen Peters
- Psychology Department, The Ohio State University, Columbus, OH, USA (EP)
| |
Collapse
|
45
|
Albarqouni L, Doust J, Glasziou P. Patient preferences for cardiovascular preventive medication: a systematic review. Heart 2017; 103:1578-1586. [PMID: 28501795 DOI: 10.1136/heartjnl-2017-311244] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 04/11/2017] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To systematically review current evidence regarding the minimum acceptable risk reduction of a cardiovascular event that patients feel would justify daily intake of a preventive medication. METHODS We used the Web of Science to track the forward and backward citations of a set of five key articles until 15 November 2016. Studies were eligible if they quantitatively assessed the minimum acceptable benefit-in absolute values-of a cardiovascular disease preventive medication among a sample of the general population and required participants to choose if they would consider taking the medication. RESULTS Of 341 studies screened, we included 22, involving a total of 17 751 participants: 6 studied prolongation of life (POL), 12 studied absolute risk reduction (ARR) and 14 studied number needed to treat (NNT) as measures of risk reduction communicated to the patients. In studies framed using POL, 39%-54% (average: 48%) of participants would consider taking a medication if it prolonged life by <8 months and 56%-73% (average: 64%) if it prolonged life by ≥8 months. In studies framed using ARR, 42%-72% (average: 54%) of participants would consider taking a medication that reduces their 5-year cardiovascular disease (CVD) risk by <3% and 50%-89% (average: 77%) would consider taking a medication that reduces their 5-year CVD risk by ≥3%. In studies framed using 5-year NNT, 31%-81% (average: 60%) of participants would consider taking a medication with an NNT of >30 and 46%-87% (average: 71%) with an NNT of ≤30. CONCLUSIONS Many patients require a substantial risk reduction before they consider taking a daily medication worthwhile, even when the medication is described as being side effect free and costless.
Collapse
Affiliation(s)
- Loai Albarqouni
- Centre for Research in Evidence-Based Practice (CREBP), Bond University, Gold Coast, Australia
| | - Jenny Doust
- Centre for Research in Evidence-Based Practice (CREBP), Bond University, Gold Coast, Australia
| | - Paul Glasziou
- Centre for Research in Evidence-Based Practice (CREBP), Bond University, Gold Coast, Australia
| |
Collapse
|
46
|
Di Paolo A, Sarkozy F, Ryll B, Siebert U. Personalized medicine in Europe: not yet personal enough? BMC Health Serv Res 2017; 17:289. [PMID: 28424057 PMCID: PMC5395930 DOI: 10.1186/s12913-017-2205-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 03/30/2017] [Indexed: 12/17/2022] Open
Abstract
Background Personalized medicine has the potential to allow patients to receive drugs specific to their individual disease, and to increase the efficiency of the healthcare system. There is currently no comprehensive overview of personalized medicine, and this research aims to provide an overview of the concept and definition of personalized medicine in nine European countries. Methods A targeted literature review of selected health databases and grey literature was conducted to collate information regarding the definition, process, use, funding, impact and challenges associated with personalized medicine. In-depth qualitative interviews were carried out with experts with health technology assessment, clinical provisioning, payer, academic, economic and industry experience, and with patient organizations. Results We identified a wide range of definitions of personalized medicine, with most studies referring to the use of diagnostics and individual biological information such as genetics and biomarkers. Few studies mentioned patients’ needs, beliefs, behaviour, values, wishes, utilities, environment and circumstances, and there was little evidence in the literature for formal incorporation of patient preferences into the evaluation of new medicines. Most interviewees described approaches to stratification and segmentation of patients based on genetic markers or diagnostics, and few mentioned health-related quality of life. Conclusions The published literature on personalized medicine is predominantly focused on patient stratification according to individual biological information. Although these approaches are important, incorporation of environmental factors and patients’ preferences in decision making is also needed. In future, personalized medicine should move from treating diseases to managing patients, taking into account all individual factors. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2205-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Antonello Di Paolo
- Department of Clinical and Experimental Medicine, Section of Pharmacology, University of Pisa, Via Roma 55, 56126, Pisa, Italy.
| | | | - Bettina Ryll
- Melanoma Patient Network Europe; Evolutionary Biology Centre, Uppsala University, Uppsala, Sweden
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol, Austria.,Area of Health Technology Assessment, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| |
Collapse
|
47
|
Ferdinand KC, Senatore FF, Clayton-Jeter H, Cryer DR, Lewin JC, Nasser SA, Fiuzat M, Califf RM. Improving Medication Adherence in Cardiometabolic Disease: Practical and Regulatory Implications. J Am Coll Cardiol 2017; 69:437-451. [PMID: 28126162 PMCID: PMC5604316 DOI: 10.1016/j.jacc.2016.11.034] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 10/27/2016] [Accepted: 11/07/2016] [Indexed: 01/13/2023]
Abstract
Medication nonadherence, a major problem in cardiovascular disease (CVD), contributes yearly to approximately 125,000 preventable deaths, which is partly attributable to only about one-half of CVD patients consistently taking prescribed life-saving medications. Current interest has focused on how labeling and education influence adherence. This paper summarizes the scope of CVD nonadherence, describes key U.S. Food and Drug Administration initiatives, and identifies potential targets for improvement. We describe key adherence factors, methods, and technological applications for simplifying regimens and enhancing adherence, and 4 areas where additional collaborative research and implementation involving the regulatory system and clinical community could substantially reduce nonadherence: 1) identifying monitoring methods; 2) improving the evidence base to better understand adherence; 3) developing patient/health provider team-based engagement strategies; and 4) alleviating health disparities. Alignment of U.S. Food and Drug Administration approaches to dissemination of information about appropriate use with clinical practice could improve adherence, and thereby reduce CVD death and disability.
Collapse
Affiliation(s)
- Keith C Ferdinand
- Department of Medicine, Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, Louisiana.
| | | | | | | | - John C Lewin
- Cardiovascular Research Foundation, New York, New York
| | - Samar A Nasser
- Department of Clinical Research and Leadership, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Mona Fiuzat
- U.S. Food and Drug Administration, Silver Spring, Maryland
| | | |
Collapse
|
48
|
Caughey GE, Tait K, Vitry AI, Shakib S. Influence of medication risks and benefits on treatment preferences in older patients with multimorbidity. Patient Prefer Adherence 2017; 11:131-140. [PMID: 28176925 PMCID: PMC5268332 DOI: 10.2147/ppa.s118836] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Multimorbidity is associated with use of multiple medicines, increased risk of adverse events and treatment conflicts. This study aimed to examine how older patients with multimorbidity and clinicians balance the benefits and harms associated with a medication and in the presence of competing health outcomes. Interviews were conducted with 15 participants aged ≥65 years with 2 or more chronic conditions. Three clinical scenarios were presented to understand patient preference to take a medicine according to i) degree of benefit, ii) type of adverse event and impact on daily living and iii) influence of comorbid conditions as competing health outcomes. Semi-structured interviews were also conducted with participants (n=15) and clinicians (n=5) to understand patient preferences and treatment decisions, in the setting of multimorbidity. The median age of participants was 79 years, 55% had 5 or more conditions and 47% took 8 or more medicines daily. When the level of benefit of the medicine ranged from 14% to 70%, 80% of participants chose to take the medicine, but when adverse effects were present, this was reduced to 0-33% depending upon impact on daily activities. In the presence of competing health outcomes, 13%-26% of patients chose to take the medicine. Two-thirds of patients reported that their doctor respects and considers their preferences and discussed medication benefits and harms. Interviews with clinicians showed that their overall approach to treatment decision-making for older individuals with multimorbidity was based upon 2 main factors, the patients' prognosis and their preferences. The degree of benefit gained was not the driver of patients' preference to take a medicine; rather, this decision was influenced by type and severity of adverse effects. Inclusion of patient preferences in the setting of risks and benefits of medicines with consideration and prioritization of competing health outcomes may result in improved health outcomes for people with multimorbidity.
Collapse
Affiliation(s)
- Gillian E Caughey
- Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia
- Department of Clinical Pharmacology, Royal Adelaide Hospital
- Correspondence: Gillian E Caughey, Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA 5001, Australia, Tel +61 8 8302 1749, Email
| | - Kirsty Tait
- School of Pharmacy and Medical Sciences, University of South Australia
| | - Agnes I Vitry
- School of Pharmacy and Medical Sciences, University of South Australia
| | - Sepehr Shakib
- Department of Clinical Pharmacology, Royal Adelaide Hospital
- Discipline of Pharmacology, School of Medicine, University of Adelaide, North Terrace, Adelaide, SA, Australia
| |
Collapse
|
49
|
Gurwitz JH. Warfarin in Complex Older Patients: Have we Reached a Tipping Point? J Am Geriatr Soc 2017; 65:236-237. [PMID: 28039912 DOI: 10.1111/jgs.14747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Jerry H Gurwitz
- Meyers Primary Care Institute, a joint endeavor of Reliant Medical Group, Fallon Health, and University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| |
Collapse
|
50
|
Dickinson R, Raynor DK, Knapp P, MacDonald J. Providing additional information about the benefits of statins in a leaflet for patients with coronary heart disease: a qualitative study of the impact on attitudes and beliefs. BMJ Open 2016; 6:e012000. [PMID: 27913558 PMCID: PMC5168685 DOI: 10.1136/bmjopen-2016-012000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 11/03/2016] [Accepted: 11/08/2016] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To explore the impact of providing additional information about the potential benefits of simvastatin in a patient leaflet on attitudes and beliefs. DESIGN Interview-based study using a generic qualitative approach and framework analysis. PARTICIPANTS 21 participants receiving a prescription for simvastatin were recruited from a general practitioner practice (from a total of 120). 8 participants were women; the age range was 55-92. INTERVENTION Participants were provided with leaflets showing one of 3 types of additional benefit information: (1) textual statement, (2) number needed to treat (NNT) or (3) natural frequency. Semistructured interviews explored patient's attitudes and beliefs. RESULTS A descriptive narrative of preferences for format suggested patients prefer textual as opposed to numerical benefit information. Significant barriers to the acceptance of numerical benefit information included difficulty in understanding the numbers. Patients overestimated the benefits of statins and expressed surprise at the numerical information. CONCLUSIONS Textual information was preferred but numerical information, in particular in the form of a natural frequency, may help patients make judgements about their medicines. NNTs were found to be very difficult to understand. This raises the prospect that some patients might reject medicines because of disappointment with the perceived low benefits of their medicines. The self-reported impact on behaviour appeared minimal with reports of intentions to 'do what the doctor tells me'. Further research is needed to explore the impact of such statements on people who are yet to be prescribed a statin.
Collapse
Affiliation(s)
| | | | - Peter Knapp
- Department of Health Sciences and The Hull York Medical School, University of York, York, UK
| | - Jan MacDonald
- Medicines and Healthcare Products Regulatory Agency, London, UK
| |
Collapse
|