1
|
Green AR, Quiles R, Daddato AE, Merrey J, Weffald L, Gleason K, Xue QL, Swarthout M, Feeser S, Boyd CM, Wolff JL, Blinka MD, Libby AM, Boxer RS. Pharmacist-led telehealth deprescribing for people living with dementia and polypharmacy in primary care: A pilot study. J Am Geriatr Soc 2024; 72:1973-1984. [PMID: 38488757 PMCID: PMC11226386 DOI: 10.1111/jgs.18867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 02/08/2024] [Accepted: 02/18/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND People living with dementia (PLWD) have complex medication regimens, exposing them to increased risk of harm. Pragmatic deprescribing strategies that align with patient-care partner goals are needed. METHODS A pilot study of a pharmacist-led intervention to optimize medications with patient-care partner priorities, ran May 2021-2022 at two health systems. PLWD with ≥7 medications in primary care and a care partner were enrolled. After an introductory mailing, dyads were randomized to a pharmacist telehealth intervention immediately (intervention) or delayed by 3 months (control). Feasibility outcomes were enrollment, intervention completion, pharmacist time, and primary care provider (PCP) acceptance of recommendations. To refine pragmatic data collection protocols, we assessed the Medication Regimen Complexity Index (MRCI; primary efficacy outcome) and the Family Caregiver Medication Administration Hassles Scale (FCMAHS). RESULTS 69 dyads enrolled; 27 of 34 (79%) randomized to intervention and 28 of 35 (80%) randomized to control completed the intervention. Most visits (93%) took more than 20 min and required multiple follow-up interactions (62%). PCPs responded to 82% of the pharmacists' first messages and agreed with 98% of recommendations. At 3 months, 22 (81%) patients in the intervention and 14 (50%) in the control had ≥1 medication discontinued; 21 (78%) and 12 (43%), respectively, had ≥1 new medication added. The mean number of medications decreased by 0.6 (3.4) in the intervention and 0.2 (1.7) in the control, reflecting a non-clinically meaningful 1.0 (±12.4) point reduction in the MRCI among intervention patients and a 1.2 (±12.9) point increase among control. FCMAHS scores decreased by 3.3 (±18.8) points in the intervention and 2.5 (±14.4) points in the control. CONCLUSION Though complex, pharmacist-led telehealth deprescribing is feasible and may reduce medication burden in PLWD. To align with patient-care partner goals, pharmacists recommended deprescribing and prescribing. If scalable, such interventions may optimize goal-concordant care for PLWD.
Collapse
Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rosalphie Quiles
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrea E Daddato
- Kaiser Permanente Colorado Institute for Health Research, Aurora, Colorado, USA
| | | | - Linda Weffald
- Kaiser Permanente Colorado Institute for Health Research, Aurora, Colorado, USA
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Kathy Gleason
- Kaiser Permanente Colorado Institute for Health Research, Aurora, Colorado, USA
| | - Qian-Li Xue
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Center on Aging and Health, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Scott Feeser
- Johns Hopkins Community Physicians, Baltimore, Maryland, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer L Wolff
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Marcela D Blinka
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Center on Aging and Health, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anne M Libby
- Department of Emergency Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rebecca S Boxer
- Davis Department of Medicine, University of California, Sacramento, California, USA
| |
Collapse
|
2
|
Growdon ME, Hunt LJ, Miller MJ, Halim M, Karliner LS, Gonzales R, Sudore RL, Steinman MA, Harrison KL. eConsultation for Deprescribing Among Older Adults: Clinician Perspectives on Implementation Barriers and Facilitators. J Gen Intern Med 2024:10.1007/s11606-024-08899-0. [PMID: 38941059 DOI: 10.1007/s11606-024-08899-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/12/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Electronic consultations (eConsults) enable asynchronous consultation between primary care providers (PCPs) and specialists. eConsults have been used successfully to manage a variety of conditions and have the potential to help PCPs manage polypharmacy and promote deprescribing. OBJECTIVE To elicit clinician perspectives on barriers/facilitators of using eConsults for deprescribing among older adults within a university health network. DESIGN Semi-structured interviews. PARTICIPANTS PCPs, geriatricians, and pharmacists. APPROACH We used the COM-B (Capability, Opportunity, Motivation, and Behavior) model to structure the interview guide and qualitative analysis methods to identify barriers/facilitators of (1) deprescribing and (2) use of eConsults for deprescribing. KEY RESULTS Of 28 participants, 19 were PCPs (13 physicians, 4 residents, 2 nurse practitioners), 7 were geriatricians, and 2 were pharmacists. Barriers and facilitators to deprescribing: PCPs considered deprescribing important but identified myriad barriers (e.g., time constraints, fragmented clinical care, lack of pharmacist integration, and patient/family resistance). Use of eConsults for deprescribing: Both PCPs and geriatricians highlighted the limits of contextual information available through electronic health record (vs. face-to-face) to render specific and actionable eConsults (e.g., knowledge of prior deprescribing attempts). Participants from all groups expressed interest in a targeted process whereby eConsults could be offered for select patients based on key factors (e.g., polypharmacy or certain comorbidities) and accepted or declined by PCPs, with pithy recommendations delivered in a timely manner relative to patient appointments. This was encapsulated by one PCP: "they need to be crisp and to the point to be helpful, with specific suggestions of something that could be discontinued or switched…not, 'hey, did you know your patient is on over 12 medicines?'". CONCLUSIONS Clinicians identified multifaceted factors influencing the utility of eConsults for deprescribing among older adults in primary care. Deprescribing eConsult interventions should be timely, actionable, and mindful of limitations of electronic chart review.
Collapse
Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California, San Francisco, CA, USA.
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Lauren J Hunt
- Department of Physiological Nursing, University of California, San Francisco, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Matthew J Miller
- Department of Physical Therapy and Rehabilitation Science, University of California, San Francisco, CA, USA
| | - Madina Halim
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Leah S Karliner
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Ralph Gonzales
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Rebecca L Sudore
- Division of Geriatrics, University of California, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Krista L Harrison
- Division of Geriatrics, University of California, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| |
Collapse
|
3
|
Pavon JM, Zhang AD, Fish LJ, Falkovic M, Colón-Emeric CS, Gallagher DM, Schmader KE, Hastings SN. Factors influencing central nervous system medication deprescribing and behavior change in hospitalized older adults. J Am Geriatr Soc 2024. [PMID: 38826146 DOI: 10.1111/jgs.19011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/29/2024] [Accepted: 05/03/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Central nervous system (CNS) medications are linked to higher morbidity and mortality in older adults. Hospitalization allows for deprescribing opportunities. This qualitative study investigates clinician and patient perspectives on CNS medication deprescribing during hospitalization using a behavioral change framework, aiming to inform interventions and identify recommendations to enhance hospital deprescribing processes. METHODS This qualitative study focused on hospitalists, primary care providers, pharmacists, and patients aged ≥60 years hospitalized on a general medicine service and prescribed ≥1 CNS medications. Using semi-structured interviews and focus groups, we aimed to evaluate patient medication knowledge, prior deprescribing experiences, and decision-making preferences, as well as provider processes and tools for medication evaluation and deprescribing. Rapid qualitative analysis applying the Capability, Opportunity, Motivation, and Behavior (COM-B) framework revealed themes influencing deprescribing behavior in patients and providers. RESULTS A total of 52 participants (20 patients and 32 providers) identified facilitators and barriers across deprescribing steps and generated recommended strategies to address them. Clinicians and patients highlighted the opportunity for CNS medication deprescribing during hospitalizations, facilitated by multidisciplinary teams enhancing clinicians' capability to make medication changes. Both groups also stressed the importance of intensive patient engagement, education, and monitoring during hospitalizations, acknowledging challenges in timing and extent of deprescribing, with some patients preferring decisions deferred to outpatient clinicians. Hospitalist and pharmacist recommendations centered on early pharmacist involvement for medication reconciliation, expanding pharmacy consultation and clinician education on deprescribing, whereas patients recommended enhancing shared decision-making through patient education on medication adverse effects, tapering plans, and alternatives. Hospitalists and PCPs also emphasized standardized discharge instructions and transitional care calls to improve medication review and feedback during care transitions. CONCLUSIONS Clinicians and patients highlighted the potential advantages of hospital interventions for CNS medication deprescribing, emphasizing the necessity of addressing communication, education, and coordination challenges between inpatient and outpatient settings.
Collapse
Affiliation(s)
- Juliessa M Pavon
- Division of Geriatrics, Duke University, Durham, North Carolina, USA
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Audrey D Zhang
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Laura J Fish
- Department of Family Medicine and Community Health, Duke University, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Margaret Falkovic
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cathleen S Colón-Emeric
- Division of Geriatrics, Duke University, Durham, North Carolina, USA
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - David M Gallagher
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University, Durham, North Carolina, USA
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - S Nicole Hastings
- Division of Geriatrics, Duke University, Durham, North Carolina, USA
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| |
Collapse
|
4
|
Farrell B. Engaging patients in conversations about deprescribing. Expert Rev Clin Pharmacol 2024; 17:419-422. [PMID: 38618915 DOI: 10.1080/17512433.2024.2343913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/12/2024] [Indexed: 04/16/2024]
Affiliation(s)
- Barbara Farrell
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| |
Collapse
|
5
|
Pilla SJ, Jalalzai R, Tang O, Schoenborn NL, Boyd CM, Bancks MP, Mathioudakis NN, Maruthur NM. A National Survey of Physicians' Views on the Importance and Implementation of Deintensifying Diabetes Medications. J Gen Intern Med 2024; 39:992-1001. [PMID: 37940754 DOI: 10.1007/s11606-023-08506-8] [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: 08/23/2023] [Accepted: 10/20/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Guidelines recommend deintensifying hypoglycemia-causing medications for older adults with diabetes whose hemoglobin A1c is below their individualized target, but this rarely occurs in practice. OBJECTIVE To understand physicians' decision-making around deintensifying diabetes treatment. DESIGN National physician survey. PARTICIPANTS US physicians in general medicine, geriatrics, or endocrinology providing outpatient diabetes care. MAIN MEASURES Physicians rated the importance of deintensifying diabetes medications for older adults with type 2 diabetes, and of switching medication classes, on 5-point Likert scales. They reported the frequency of these actions for their patients, and listed important barriers and facilitators. We evaluated the independent association between physicians' professional and practice characteristics and the importance of deintensifying and switching diabetes medications using multivariable ordered logistic regression models. KEY RESULTS There were 445 eligible respondents (response rate 37.5%). The majority of physicians viewed deintensifying (80%) and switching (92%) diabetes medications as important or very important to the care of older adults. Despite this, one-third of physicians reported deintensifying diabetes medications rarely or never. While most physicians recognized multiple reasons to deintensify, two-thirds of physicians reported barriers of short-term hyperglycemia and patient reluctance to change medications or allow higher glucose levels. In multivariable models, geriatricians rated deintensification as more important compared to other specialties (p=0.027), and endocrinologists rated switching as more important compared to other specialties (p<0.006). Physicians with fewer years in practice rated higher importance of deintensification (p<0.001) and switching (p=0.003). CONCLUSIONS While most US physicians viewed deintensifying and switching diabetes medications as important for the care of older adults, they deintensified infrequently. Physicians had ambivalence about the relative benefits and harms of deintensification and viewed it as a potential source of conflict with their patients. These factors likely contribute to clinical inertia, and studies focused on improving shared decision-making around deintensifying diabetes medications are needed.
Collapse
Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Rabia Jalalzai
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Olive Tang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cynthia M Boyd
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael P Bancks
- Department of Epidemiology & Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Nestoras N Mathioudakis
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
6
|
Turner JP, Newport K, McEvoy AM, Smith T, Tannenbaum C, Kelly DV. Strategies to guide the successful implementation of deprescribing in community practice: Lessons learned from the front line. Can Pharm J (Ott) 2024; 157:133-142. [PMID: 38737354 PMCID: PMC11086729 DOI: 10.1177/17151635241240737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 12/19/2023] [Accepted: 01/25/2024] [Indexed: 05/14/2024]
Abstract
Background Sustainable implementation of new professional services into clinical practice can be difficult. In 2019, a population-wide initiative called SaferMedsNL was implemented across the province of Newfoundland and Labrador (NL), to promote appropriate medication use. Two evidence-based interventions were adapted to the context of NL to promote deprescribing of proton pump inhibitors and sedatives. The objective of this study was to identify and prioritize which actions supported the implementation of deprescribing in community practice for pharmacists, physicians and nurse practitioners across the province. Methods Community pharmacists, physicians and nurse practitioners were invited to participate in virtual focus groups. Nominal Group Technique was used to elicit responses to the question: "What actions support the implementation of deprescribing into the daily workflow of your practice?" Participants prioritized actions within each group while thematic analysis permitted comparison across groups. Results Five focus groups were held in fall 2020 involving pharmacists (n = 11), physicians (n = 7) and nurse practitioners (n = 4). Participants worked in rural (n = 10) and urban (n = 12) settings. The different groups agreed on what the top 5 actions were, with the top 5 receiving 68% of the scores: (1) providing patient education, (2) allocating time and resources, (3) building interprofessional collaboration and communication, (4) fostering patient relationships and (5) aligning with public awareness strategies. Conclusion Pharmacists, physicians and nurse practitioners identified similar actions that supported implementing evidence-based deprescribing into routine clinical practice. Sharing these strategies may help others embed deprescribing into daily practice and assist the uptake of medication appropriateness initiatives by front-line providers. Can Pharm J (Ott) 2024;157:xx-xx.
Collapse
Affiliation(s)
- Justin P. Turner
- Centre for Medicines Use and Safety, Memorial University of Newfoundland, Newfoundland and Labrador
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia; the Faculty of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
- Université de Montréal, Québec; the Centre de recherche, Institut universitaire de gériatrie de Montréal, Memorial University of Newfoundland, Newfoundland and Labrador
- Québec; the Faculté de Pharmacie, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Kelda Newport
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Aisling M. McEvoy
- Centre for Medicines Use and Safety, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Tara Smith
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Cara Tannenbaum
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia; the Faculty of Pharmacy and Medicine, Memorial University of Newfoundland, Newfoundland and Labrador
- Université de Montréal, Québec; the Centre de recherche, Institut universitaire de gériatrie de Montréal, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Deborah V. Kelly
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| |
Collapse
|
7
|
Thompson W, McDonald EG. Polypharmacy and Deprescribing in Older Adults. Annu Rev Med 2024; 75:113-127. [PMID: 37729029 DOI: 10.1146/annurev-med-070822-101947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.
Collapse
Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada;
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada;
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
8
|
Vordenberg SE, Rana R, Shang J, Choi J, Scherer AM, Weir KR. Reasons why older adults in three countries agreed with a deprescribing recommendation in a hypothetical vignette. Basic Clin Pharmacol Toxicol 2023; 133:673-682. [PMID: 36894739 DOI: 10.1111/bcpt.13857] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/11/2023]
Abstract
The purpose of this study was to examine factors important to older adults who agreed with a deprescribing recommendation given by a general practitioner (GP) to a hypothetical patient experiencing polypharmacy. We conducted an online, vignette-based, experimental study in the United Kingdom, United States and Australia with participants ≥65 years. The primary outcome was an agreement with a deprescribing recommendation (6-point Likert scale; 1 = strongly disagree and 6 = strongly agree). We performed a content analysis of the free-text reasons provided by participants who agreed with deprescribing (score of 5 or 6). Among 2656 participants who agreed with deprescribing, approximately 53.7% shared a preference for following the GP's recommendation or considered the GP the expert. The medication was referred to as a reason for deprescribing by 35.6% of participants. Less common themes included personal experience with medicine (4.3%) and older age (4.0%). Older adults who agreed with deprescribing in a hypothetical vignette most frequently reported a desire to follow the recommendations given the GP's expertise. Future research should be conducted to help clinicians efficiently identify patients who have a strong desire to follow the doctor's recommendations related to deprescribing, as this may allow for a tailored, brief deprescribing conversation.
Collapse
Affiliation(s)
- Sarah E Vordenberg
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
- University of Michigan Center for Bioethics and Social Sciences in Medicine, 28000 Plymouth Rd, Ann Arbor, MI 48019, Michigan, USA
| | - Ruchi Rana
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Jenny Shang
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Jae Choi
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Aaron M Scherer
- University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, Iowa, USA
| | - Kristie Rebecca Weir
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland
| |
Collapse
|
9
|
van Poelgeest E, Seppala L, Bahat G, Ilhan B, Mair A, van Marum R, Onder G, Ryg J, Fernandes MA, Cherubini A, Denkinger M, Eidam A, Egberts A, Gudmundsson A, Koçak FÖK, Soulis G, Tournoy J, Masud T, Wehling M, van der Velde N. Optimizing pharmacotherapy and deprescribing strategies in older adults living with multimorbidity and polypharmacy: EuGMS SIG on pharmacology position paper. Eur Geriatr Med 2023; 14:1195-1209. [PMID: 37812379 PMCID: PMC10754739 DOI: 10.1007/s41999-023-00872-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/19/2023] [Indexed: 10/10/2023]
Abstract
Inappropriate polypharmacy is highly prevalent among older adults and presents a significant healthcare concern. Conducting medication reviews and implementing deprescribing strategies in multimorbid older adults with polypharmacy are an inherently complex and challenging task. Recognizing this, the Special Interest Group on Pharmacology of the European Geriatric Medicine Society has compiled evidence on medication review and deprescribing in older adults and has formulated recommendations to enhance appropriate prescribing practices. The current evidence supports the need for a comprehensive and widespread transformation in education, guidelines, research, advocacy, and policy to improve the management of polypharmacy in older individuals. Furthermore, incorporating deprescribing as a routine aspect of care for the ageing population is crucial. We emphasize the importance of involving geriatricians and experts in geriatric pharmacology in driving, and actively participating in this transformative process. By doing so, we can work towards achieving optimal medication use and enhancing the well-being of older adults in the generations to come.
Collapse
Affiliation(s)
- Eveline van Poelgeest
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Lotta Seppala
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Gülistan Bahat
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, Istanbul, Turkey
| | - Birkan Ilhan
- Division of Geriatrics, Department of Internal Medicine, Liv Hospital Vadistanbul, Istanbul, Turkey
| | - Alpana Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh, Scotland, UK
- Edinburgh Napier University, Edinburgh, UK
| | - Rob van Marum
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Department of Elderly Care Medicine, Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Graziano Onder
- Fondazione Policlinico Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Marília Andreia Fernandes
- Department of Internal Medicine, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Antonio Cherubini
- Geriatria Accettazione geriatrica e Centro di Ricerca per l'invecchiamento IRCCS INRCA, Ancona, Italy
| | - Michael Denkinger
- Agaplesion Bethesda Clinic Ulm, Institute for Geriatric Research, Ulm University, Geriatric Center Ulm, Ulm, Germany
| | - Annette Eidam
- Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Angelique Egberts
- Department of Hospital Pharmacy, Franciscus Gasthuis & Vlietland, Rotterdam, Schiedam, The Netherlands
| | - Aðalsteinn Gudmundsson
- Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Fatma Özge Kayhan Koçak
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Ege University, Izmir, Turkey
| | - George Soulis
- Outpatient Geriatric Assessment Unit, Henry Dunant Hospital Center, Athens, Greece
- Hellenic Open University, Patras, Greece
| | - Jos Tournoy
- Department of Geriatric Medicine, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven Biomedical Sciences Group, Leuven, Belgium
| | - Tahir Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Martin Wehling
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nathalie van der Velde
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| |
Collapse
|
10
|
Kelley CJ, Niznik JD, Ferreri SP, Schlusser C, Armistead LT, Hughes TD, Henage CB, Busby-Whitehead J, Roberts E. Patient Perceptions of Opioids and Benzodiazepines and Attitudes Toward Deprescribing. Drugs Aging 2023; 40:1113-1122. [PMID: 37792262 PMCID: PMC10768261 DOI: 10.1007/s40266-023-01071-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Opioids and benzodiazepines (BZDs) pose a public health problem. Older adults are especially susceptible to adverse events from opioids and BZDs owing to an increased usage of opioids and BZDs, multiple comorbidities, and polypharmacy. Deprescribing is a possible, yet challenging, solution to reducing opioid and BZD use. OBJECTIVE We aimed to explore older adult patients' knowledge of opioids and BZDs, perceived facilitators and barriers to deprescribing opioids and BZDs, and attitudes toward alternative treatments for opioids and BZDs. METHODS We conducted 11 semi-structured interviews with patients aged 65+ years with long-term opioid and/or BZD prescriptions. The interview guide was developed by an interprofessional team and focused on patients' knowledge of opioids and BZDs, perceived ability to reduce opioid or BZD use, and attitudes towards alternative treatments. RESULTS Three patients had taken opioids, either currently or in the past, three had taken BZDs, and five had taken both opioids and BZDs. Generally, knowledge of opioids and BZDs was variable among patients; yet facilitators and barriers to deprescribing both opioids and BZDs were consistent. Facilitators of deprescribing included patient-provider trust and slow tapering of medications, while barriers included concerns about re-emergence of symptoms and a lack of motivation, particularly if medications and symptoms were stable. Patients were generally unenthusiastic about pursuing alternative pharmacologic and non-pharmacologic alternatives to opioids and BZDs for symptom management. CONCLUSIONS Our findings indicate that patients are open to deprescribing opioids and BZDs under certain circumstances, but overall remain hesitant with a lack of enthusiasm for alternative treatments. Future studies should focus on supportive approaches to alleviate older adults' deprescribing concerns.
Collapse
Affiliation(s)
- Casey J Kelley
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Joshua D Niznik
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA.
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA.
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Stefanie P Ferreri
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Courtney Schlusser
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lori T Armistead
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Tamera D Hughes
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Cristine B Henage
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Jan Busby-Whitehead
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Ellen Roberts
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| |
Collapse
|
11
|
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
|
12
|
Norton JD, Zeng C, Bayliss EA, Shetterly SM, Williams N, Reeve E, Wynia MK, Green AR, Drace ML, Gleason KS, Sheehan OC, Boyd CM. Ethical Aspects of Physician Decision-Making for Deprescribing Among Older Adults With Dementia. JAMA Netw Open 2023; 6:e2336728. [PMID: 37787993 PMCID: PMC10548310 DOI: 10.1001/jamanetworkopen.2023.36728] [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: 02/16/2023] [Accepted: 08/27/2023] [Indexed: 10/04/2023] Open
Abstract
Importance Physicians endorse deprescribing of risky or unnecessary medications for older adults (aged ≥65 years) with dementia, but there is a lack of information on what influences decisions to deprescribe in this population. Objective To understand how physicians make decisions to deprescribe for older adults with moderate dementia and ethical and pragmatic concerns influencing those decisions. Design, Setting, and Participants A cross-sectional national mailed survey study of a random sample of 3000 primary care physicians from the American Medical Association Physician Masterfile who care for older adults was conducted from January 15 to December 31, 2021. Main Outcomes and Measures The study randomized participants to consider 2 clinical scenarios in which a physician may decide to deprescribe a medication for older adults with moderate dementia: 1 in which the medication could cause an adverse drug event if continued and the other in which there is no evidence of benefit. Participants ranked 9 factors related to possible ethical and pragmatic concerns through best-worst scaling methods (from greatest barrier to smallest barrier to deprescribing). Conditional logit regression quantified the relative importance for each factor as a barrier to deprescribing. Results A total of 890 physicians (35.0%) returned surveys; 511 (57.4%) were male, and the mean (SD) years since graduation was 26.0 (11.7). Most physicians had a primary specialty in family practice (50.4% [449 of 890]) and internal medicine (43.5% [387 of 890]). A total of 689 surveys were sufficiently complete to analyze. In both clinical scenarios, the 2 greatest barriers to deprescribing were (1) the patient or family reporting symptomatic benefit from the medication (beneficence and autonomy) and (2) the medication having been prescribed by another physician (autonomy and nonmaleficence). The least influential factor was ease of paying for the medication (justice). Conclusions and Relevance Findings from this national survey study of primary care physicians suggests that understanding ethical aspects of physician decision-making can inform clinician education about medication management and deprescribing decisions for older adults with moderate dementia.
Collapse
Affiliation(s)
| | - Chan Zeng
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
- Department of Family Medicine, University of Colorado School of Medicine, Aurora
| | | | - Nicole Williams
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia
| | - Matthew K. Wynia
- University of Colorado Center for Bioethics and Humanities, Anschutz Medical Campus, Aurora
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora
- Department of Health Policy and Management, Colorado School of Public Health, Aurora
| | - Ariel R. Green
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melanie L. Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Kathy S. Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | | | - Cynthia M. Boyd
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
13
|
Deardorff WJ, Covinsky K. Incorporating Prognosis into Clinical Decision-Making for Older Adults with Diabetes. J Gen Intern Med 2023; 38:2857-2859. [PMID: 37464148 PMCID: PMC10593647 DOI: 10.1007/s11606-023-08326-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Affiliation(s)
- W James Deardorff
- Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA.
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Kenneth Covinsky
- Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| |
Collapse
|
14
|
American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2023; 71:2052-2081. [PMID: 37139824 DOI: 10.1111/jgs.18372] [Citation(s) in RCA: 196] [Impact Index Per Article: 196.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 03/29/2023] [Indexed: 05/05/2023]
Abstract
The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults is widely used by clinicians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a regular cycle. The AGS Beers Criteria® is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. For the 2023 update, an interprofessional expert panel reviewed the evidence published since the last update (2019) and based on a structured assessment process approved a number of important changes including the addition of new criteria, modification of existing criteria, and formatting changes to enhance usability. The criteria are intended to be applied to adults 65 years old and older in all ambulatory, acute, and institutionalized settings of care, except hospice and end-of-life care settings. Although the AGS Beers Criteria® may be used internationally, it is specifically designed for use in the United States and there may be additional considerations for certain drugs in specific countries. Whenever and wherever used, the AGS Beers Criteria® should be applied thoughtfully and in a manner that supports, rather than replaces, shared clinical decision-making.
Collapse
|
15
|
Nevedal AL, Timko C, Lor MC, Hoggatt KJ. Patient and Provider Perspectives on Benefits and Harms of Continuing, Tapering, and Discontinuing Long-Term Opioid Therapy. J Gen Intern Med 2023; 38:1802-1811. [PMID: 36376623 PMCID: PMC9663196 DOI: 10.1007/s11606-022-07880-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Given efforts to taper patients off long-term opioid therapy (LTOT) because of known harms, it is important to understand if patients and providers align in LTOT treatment goals. OBJECTIVE To investigate patient and provider perceptions about the harms and benefits of continuing and discontinuing LTOT. DESIGN Qualitative study PARTICIPANTS: Patients and providers with experiences with LTOT for pain in two Veterans Health Affairs regions. APPROACH We conducted semi-structured interviews and analyzed data using rapid qualitative analysis to describe patient and provider preferences about LTOT continuation and discontinuation and non-opioid pain treatments. KEY RESULTS Participants (n=43) included 28/67 patients and 15/17 providers. When discussing continuing LTOT, patients emphasized the benefits outweighed the harms, whereas providers emphasized the harms. Participants agreed on the benefits of continuing LTOT for improved physical functioning. Provider-reported benefits of continuing LTOT included maintaining the status quo for patients without opioid alternatives or who were at risk for illicit drug use. Participants were aligned regarding the harms of negative side-effects (e.g., constipation) from continued LTOT. In contrast, when discussing LTOT tapering and discontinuation, providers underscored how benefits outweighed the harms, citing patients' improved well-being and pain management with tapering or alternatives. Patients did not foresee benefits to potential LTOT tapers or discontinuation and were worried about pain management in the absence of LTOT. When discussing non-opioid pain treatments, participants emphasized that they were adjunctive to opioid therapy rather than a replacement (except for cannabis). Providers described the importance of mental health services to manage pain, which differed from patients who focused on treatments to improve strength and mobility and reduce pain. CONCLUSIONS Patients emphasized the benefits of continuing LTOT for pain management and well-being, which differed from providers' emphasis on the benefits of discontinuing LTOT. Patient and provider differences are important for informing patient-centered care and decisions around continuing, tapering, or discontinuing LTOT.
Collapse
Affiliation(s)
- Andrea L Nevedal
- Department of Veterans Affairs Health Care System, VA Center for Clinical Management Research, Ann Arbor, MI, 48105, USA.
| | - Christine Timko
- Department of Veterans Affairs Health Care System, Center for Innovation to Implementation, Palo Alto, CA, 94304, USA
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Stanford, CA, 94305, USA
| | - Mai Chee Lor
- Department of Veterans Affairs Health Care System, Center for Innovation to Implementation, Palo Alto, CA, 94304, USA
| | - Katherine J Hoggatt
- San Francisco VA Health Care System, San Francisco, CA, 94121, USA
- Department of Medicine, University of California, San Francisco, San Francisco, CA, 94143, USA
| |
Collapse
|
16
|
Monette PJ, Schwartz AW. Optimizing Medications with the Geriatrics 5Ms: An Age-Friendly Approach. Drugs Aging 2023; 40:391-396. [PMID: 37043166 PMCID: PMC10092911 DOI: 10.1007/s40266-023-01016-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2023] [Indexed: 04/13/2023]
Abstract
Polypharmacy is a common problem among older adults, as they are more likely to have multiple chronic conditions and may experience fragmentation of care among specialists. The Geriatrics 5Ms framework offers a person-centered approach to address polypharmacy and optimize medications, including deprescribing when appropriate. The elements of the Geriatrics 5Ms, which align with the approach of the Age-Friendly Health Systems initiative, include consideration of Medications, Mind, Mobility, Multicomplexity, and What Matters Most. Each M domain impacts and is impacted by medications, and learning about the patient's goals through questions guided by the Geriatrics 5Ms may inform an Age-Friendly medication optimization plan. While research on the implementation of each of the elements of the Geriatrics 5Ms shows benefit, further research is needed to study the impact of this framework in clinical practice.
Collapse
Affiliation(s)
| | - Andrea Wershof Schwartz
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA.
- New England Geriatrics Research Education and Clinical Center and Geriatrics and Extended Care, VA Boston Healthcare System, and Brigham and Women's Hospital, 150 South Huntington #182, Boston, MA, 02130, USA.
| |
Collapse
|
17
|
Watson NF, Benca RM, Krystal AD, McCall WV, Neubauer DN. Alliance for Sleep Clinical Practice Guideline on Switching or Deprescribing Hypnotic Medications for Insomnia. J Clin Med 2023; 12:jcm12072493. [PMID: 37048577 PMCID: PMC10095217 DOI: 10.3390/jcm12072493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023] Open
Abstract
Determining the most effective insomnia medication for patients may require therapeutic trials of different medications. In addition, medication side effects, interactions with co-administered medications, and declining therapeutic efficacy can necessitate switching between different insomnia medications or deprescribing altogether. Currently, little guidance exists regarding the safest and most effective way to transition from one medication to another. Thus, we developed evidence-based guidelines to inform clinicians regarding best practices when deprescribing or transitioning between insomnia medications. Five U.S.-based sleep experts reviewed the literature involving insomnia medication deprescribing, tapering, and switching and rated the quality of evidence. They used this evidence to generate recommendations through discussion and consensus. When switching or discontinuing insomnia medications, we recommend benzodiazepine hypnotic drugs be tapered while additional CBT-I is provided. For Z-drugs zolpidem and eszopiclone (and not zaleplon), especially when prescribed at supratherapeutic doses, tapering is recommended with a 1–2-day delay in administration of the next insomnia therapy when applicable. There is no need to taper DORAs, doxepin, and ramelteon. Lastly, off-label antidepressants and antipsychotics used to treat insomnia should be gradually reduced when discontinuing. In general, offering individuals a rationale for deprescribing or switching and involving them in the decision-making process can facilitate the change and enhance treatment success.
Collapse
|
18
|
Weir KR, Bonner C, Naganathan V, Tam CWM, Rigby D, McLachlan AJ, Jansen J. Supporting conversations about medicines and deprescribing: GPs' perspectives on a Medicines Conversation Guide. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2023; 31:102-105. [PMID: 36413580 DOI: 10.1093/ijpp/riac088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/20/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To explore GP perspectives on a Medicines Conversation Guide to support deprescribing communication. METHODS Semistructured interviews with GPs from Australia (n = 32). Participants were purposively sampled with varying experiences and locations. Transcribed audio recordings of interviews were coded using framework analysis. KEY FINDINGS Most GPs stated they would use the Guide in consultation with an older patient to discuss medications. The strengths of the Guide included empowering the patient voice on an important topic. Limitations included time and complex concepts. CONCLUSIONS Overall, the Medicines Conversation Guide was perceived by GPs to be a useful communication tool to support discussions about deprescribing with patients.
Collapse
Affiliation(s)
- Kristie Rebecca Weir
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Carissa Bonner
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing (CERA), Department of Geriatric Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Chun Wah Michael Tam
- Primary and Integrated Care Unit, South Western Sydney Local Health District, Liverpool, New South Wales, Australia.,School of Population Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Debbie Rigby
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane City, Queensland, Australia
| | - Andrew J McLachlan
- Centre for Education and Research on Ageing (CERA), Department of Geriatric Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, Australia
| | - Jesse Jansen
- Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
19
|
Pilla SJ, Meza KA, Schoenborn NL, Boyd CM, Maruthur NM, Chander G. A Qualitative Study of Perspectives of Older Adults on Deintensifying Diabetes Medications. J Gen Intern Med 2023; 38:1008-1015. [PMID: 36175758 PMCID: PMC10039184 DOI: 10.1007/s11606-022-07828-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/16/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND While many older adults with type 2 diabetes have tight glycemic control beyond guideline-recommended targets, deintensifying (stopping or dose-reducing) diabetes medications rarely occurs. OBJECTIVE To explore the perspectives of older adults with type 2 diabetes around deintensifying diabetes medications. DESIGN This qualitative study used individual semi-structured interviews, which included three clinical scenarios where deintensification may be indicated. PARTICIPANTS Twenty-four adults aged ≥65 years with medication-treated type 2 diabetes and hemoglobin A1c <7.5% were included (to thematic saturation) using a maximal variation sampling strategy for diabetes treatment and physician specialty. APPROACH Interviews were independently coded by two investigators and analyzed using a grounded theory approach. We identified major themes and subthemes and coded responses to the clinical scenarios as positive (in favor of deintensification), negative, or ambiguous. KEY RESULTS Participants' mean age was 74 years, half were women, and 58% used a sulfonylurea or insulin. The first of four major themes was fear of losing control of diabetes, which participants weighed against the benefits of taking less medication (Theme 2). Few participants viewed glycemic control below target as a reason for deintensification and a majority would restart the medication if their home glucose increased. Some participants were anchored to their current diabetes treatment (Theme 3) driven by unrealistic views of medication benefits. A trusting patient-provider relationship (Theme 4) was a positive influence. In clinical scenarios, 8%, 4%, and 75% of participants viewed deintensification positively in the setting of poor health, limited life expectancy, and high hypoglycemia risk, respectively. CONCLUSIONS Optimizing deintensification requires patient education that describes both individualized glycemic targets and how they will change over the lifespan. Deintensification is an opportunity for shared decision-making, but providers must understand patients' beliefs about their medications and address misconceptions. Hypoglycemia prevention may be a helpful framing for discussing deintensification.
Collapse
Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Kayla A Meza
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cynthia M Boyd
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Geetanjali Chander
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
20
|
Perrine E, Damiaens A, Patey AM, Grimshaw JM, Spinewine A. Barriers and enablers towards benzodiazepine-receptor agonists deprescribing in nursing homes: A qualitative study of stakeholder groups. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 9:100258. [PMID: 37124470 PMCID: PMC10130691 DOI: 10.1016/j.rcsop.2023.100258] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/08/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Background Despite recommendations to deprescribe chronic benzodiazepine receptor agonists (BZRA) among older adults, the prevalence of their use in Belgian nursing homes (NHs) remains above 50%. The use of a behavioral science approach, starting with the evaluation of barriers and enablers for BZRA deprescribing, has the potential to decrease BZRA prescribing. Objectives To identify barriers and enablers for BZRA deprescribing perceived by the different stakeholders involved in nursing home care in Belgium. Methods In a purposive sample of 6 NHs, we conducted face-to-face interviews with general practitioners (GPs), and focus groups with other healthcare providers (HCPs), including nurses, pharmacists, occupational therapists, physical therapists, and with NH residents and relatives. All interviews with HCPs were analyzed through deductive thematic analysis, using the theoretical domains framework (TDF) as the coding framework. Residents' and relatives' interviews were analyzed using an inductive thematic approach. Results We interviewed 13 GPs, 35 other HCPs, 22 nursing home residents, and 5 relatives. Overall, 9 TDF domains were identified as most relevant among HCPs interviewed: Skills, Beliefs about capabilities, Goals, Memory attention and decision processes, Environmental context and resources, Social influences, Knowledge, Social/professional role and identity, and Beliefs about consequences. Five additional themes emerged from residents' and relatives' interviews: knowledge on medications used, communication with NH staff and GPs, perceived efficacy and necessity of BZRA, influence of the environment, and reluctance towards BZRA deprescribing. Some domains and themes differ between stakeholders (e.g., knowledge), while others match between groups (e.g., environmental aspects). Conclusion BZRA deprescribing is influenced by knowledge and skills gaps, automatic BZRA refilling, competing priorities, social challenges, environmental factors and poor nursing home residents involvement. Targeting these barriers will be a key step for implementation of BZRA deprescribing.
Collapse
|
21
|
Green AR, Aschmann H, Boyd CM, Schoenborn N. Association between willingness to deprescribe and health outcome priorities among U.S. older adults: Results of a national survey. J Am Geriatr Soc 2022; 70:2895-2904. [PMID: 35661991 PMCID: PMC9588518 DOI: 10.1111/jgs.17917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/04/2022] [Accepted: 05/07/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND It is not known whether older adults' willingness to deprescribe is associated with their health outcome priorities related to medications. METHODS A cross-sectional survey was conducted from March-April 2020 using a nationally representative online panel. The survey presented two vignettes: (1) a preventive medicine; and (2) a symptom-relief medicine. Participants were asked whether they would be willing to stop each medicine if their doctor recommended it, and to rate their level of agreement with two health outcome priorities statements: "I am willing to accept the risk of future side effects … to feel better now," and "I would prefer to take fewer medicines, even if … I may not live as long or may have bothersome symptoms sometimes." Ordinal logistic regression was used to examine associations between willingness to stop each medicine, baseline characteristics and health outcome priorities. RESULTS Of 1193 panel members ≥65 years invited to participate, 835 (70%) completed the survey. Mean (SD) age was 73 years; 496 (59%) had taken a statin and 124 (15%) a prescription sedative-hypnotic. 507 (61%) were willing to stop preventive medicines; 276 (33%) were maybe willing. 419 (50%) were willing to stop symptom-relief medicines; 380 (46%) were maybe willing. Prioritizing fewer medicines was associated with higher odds of being willing to stop symptom-relief medicines (aOR 1.43 [95% CI 1.02-2.00]) and preventive medicines (aOR 1.52 [95% CI 1.05-2.18]). Prioritizing now over future was associated with lower odds of being willing to stop symptom-relief medicines (aOR 0.62 [95% CI 0.39-1.00]). Current/prior use of statins was associated with lower willingness to stop preventive medicines (aOR 0.66 [95% CI 0.48-0.91]). CONCLUSIONS Older adults' health outcome priorities related to medication use are associated with their willingness to consider deprescribing. Future research should determine how best to elicit patients' health outcome priorities to facilitate goal-concordant decisions about medication use.
Collapse
Affiliation(s)
- Ariel R. Green
- Division of Geriatric Medicine and GerontologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Hélène Aschmann
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCaliforniaUSA,Epidemiology, Biostatistics and Prevention InstituteUniversity of ZurichZurichSwitzerland
| | - Cynthia M. Boyd
- Division of Geriatric Medicine and GerontologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA,Department of Health Policy and ManagementJohns Hopkins University Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Nancy Schoenborn
- Division of Geriatric Medicine and GerontologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| |
Collapse
|
22
|
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
|
23
|
O'Donnell LK, Ibrahim K. Polypharmacy and deprescribing: challenging the old and embracing the new. BMC Geriatr 2022; 22:734. [PMID: 36068485 PMCID: PMC9450314 DOI: 10.1186/s12877-022-03408-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Lisa Kouladjian O'Donnell
- Departments of Clinical Pharmacology and Ageing, Kolling Institute, Royal North Shore Hospital, Faculty of Medicine and Health, The University of Sydney, NSW, St Leonards, Australia.
| | - Kinda Ibrahim
- Academic Geriatric Medicine, Faculty of Medicine, University Hospital Southampton, University of Southampton, Southampton, UK. .,Applied Research Collaboration Wessex, The National Institute of Health and Care Research (NIHR), University of Southampton, Southampton, UK.
| |
Collapse
|
24
|
Armistead LT, Sanders KA, Larson CK, Busby-Whitehead J, Ferreri SP. A-TAPER: A Framework for Deprescribing Medications effectively. Res Social Adm Pharm 2021; 18:3358-3361. [PMID: 34930683 DOI: 10.1016/j.sapharm.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/30/2021] [Accepted: 11/29/2021] [Indexed: 11/28/2022]
Abstract
Inappropriate medication use creates avoidable safety issues for older adults. Deprescribing medications that are high risk and/or of minimal benefit is important for reducing morbidity and adverse effects, especially in this population. A variety of deprescribing resources and algorithms are available, but a singular framework to effectively approach and implement the deprescribing of unnecessary medications in practice does not exist. An interprofessional team of pharmacists, geriatricians, and researchers developed a framework to guide providers in deprescribing medications. This framework is represented by the acronym A-TAPER, which stands for Assess medication use, Talk about risks versus benefits, select Alternatives, Plan next steps, Engage patient, and Reduce dose. Within this framework, comprehensive, medication-specific deprescribing toolkits can be created.
Collapse
Affiliation(s)
- L T Armistead
- UNC Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599-7574, USA.
| | - K A Sanders
- UNC Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599-7574, USA.
| | - C K Larson
- UNC School of Medicine, Division of Geriatric Medicine, 5003 Old Clinic Bldg. Chapel Hill, NC, 27599-7550, USA.
| | - J Busby-Whitehead
- UNC School of Medicine, Division of Geriatric Medicine, 5003 Old Clinic Bldg. Chapel Hill, NC, 27599-7550, USA; UNC Center for Aging and Health, 5003 Old Clinic Bldg. Chapel Hill, NC, 27599-7550, USA.
| | - S P Ferreri
- UNC Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599-7574, USA.
| |
Collapse
|
25
|
Turner JP. Can Recent Health Crises Create Opportunities for Deprescribing? Sr Care Pharm 2021; 36:422-425. [PMID: 34452650 DOI: 10.4140/tcp.n.2021.422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Justin P Turner
- Faculty of Pharmacy University of Montreal Centre de Recherche Institut Universitaire de Gériatrie de Montréal Montréal, QC, Canada
| |
Collapse
|
26
|
Lundby C, Pottegård A. Considerations regarding choice of primary outcome in clinical trials in deprescribing. Br J Clin Pharmacol 2021; 88:3032-3034. [PMID: 34363621 DOI: 10.1111/bcp.14990] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Carina Lundby
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark.,Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark.,ODIN, Odense Deprescribing INitiative, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Anton Pottegård
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark.,Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark.,ODIN, Odense Deprescribing INitiative, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| |
Collapse
|