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McInerney BE, Cross AJ, Alderman CP, Bhat R, Boyd CM, Brandt N, Cossette B, Desforges K, Dowd LA, Frank C, Hartikainen S, Herrmann N, Hilmer SN, Jack L, Jordan S, Kitamura CR, Koujiya E, Lampela P, Macfarlane S, Manias E, Martin C, Martínez-Velilla N, Moriarty F, Onder G, Quirke T, Silvius JL, Soulsby N, Stafford AC, Steinman MA, Sun W, Taguchi R, Todd A, Trenaman SC, Yap KZ, Zhao M, Bell JS, Turner JP. Top 10 Signs and Symptoms of Psychotropic Adverse Drug Events to Monitor in Residents of Long-Term Care Facilities. J Am Med Dir Assoc 2024; 25:105118. [PMID: 38950588 DOI: 10.1016/j.jamda.2024.105118] [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: 11/10/2023] [Revised: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVES To produce a consensus list of the top 10 signs and symptoms suggestive of adverse drug events (ADEs) for monitoring in residents of long-term care facilities (LTCFs) who use antipsychotics, benzodiazepines, or antidepressants. DESIGN A 3-round Delphi study. SETTING AND PARTICIPANTS Geriatricians, psychiatrists, pharmacologists, general practitioners, pharmacists, nurses, and caregivers from 13 Asia Pacific, European, and North American countries. METHODS Three survey rounds were completed between April and June 2023. In Round 1, participants indicated their level of agreement on a 9-point Likert scale on whether 41 signs or symptoms identified in a systematic review should be routinely monitored. Participants considered signs and symptoms that reduce quality of life or cause significant harm, are observable or measurable by nurses or care workers, and can be assessed at a single time point. Round 1 statements were included in a list for prioritization in Round 3 if ≥ 70% of participants responded ≥7 on the Likert scale. Statements were excluded if ≤ 30% of participants responded ≥7. In Round 2, participants indicated their level of agreement with statements that did not reach initial consensus, plus amended statements based on Round 1 participant feedback. Round 2 statements were included in Round 3 if ≥ 50% of the participants responded ≥7 on the Likert scale. In Round 3, participants prioritized the signs and symptoms. RESULTS Forty-four participants (93.6%) completed all 3 rounds. Four of 41 signs and symptoms reached consensus for inclusion after Round 1, and 9 after Round 2. The top 10 signs and symptoms prioritized in Round 3 were recent falls, daytime drowsiness or sleepiness, abnormal movements (eg, shaking or stiffness), confusion or disorientation, balance problems, dizziness, postural hypotension, reduced self-care, restlessness, and dry mouth. CONCLUSIONS AND IMPLICATIONS The top 10 signs and symptoms provide a basis for proactive monitoring for psychotropic ADEs.
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Affiliation(s)
- Brigid E McInerney
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia.
| | - Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | | | - Ravi Bhat
- Department of Rural Health, The University of Melbourne, Melbourne, Australia
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, MD, USA
| | - Nicole Brandt
- Lamy Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Benoit Cossette
- Faculte de medecine et des sciences de la sante, Universite de Sherbrooke, Canada
| | | | - Laura A Dowd
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Chris Frank
- Department of Medicine, Queen's University, Kingston, Canada
| | - Sirpa Hartikainen
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | | | - Sarah N Hilmer
- Kolling Institute, Northern Sydney Local Health District and The University of Sydney, Sydney, Australia
| | - Leanne Jack
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Brisbane, Australia
| | - Sue Jordan
- Faculty of Medicine, Health and Life Science, Swansea University, Swansea, Wales, United Kingdom
| | | | - Eriko Koujiya
- Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Pasi Lampela
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Stephen Macfarlane
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Elizabeth Manias
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Christine Martin
- Advocate and Caregiver for Relative in Residential Care, North Vancouver, British Columbia, Canada
| | - Nicolás Martínez-Velilla
- Navarre Health Service (SNS-O), Navarre University Hospital (HUN), Department of Geriatrics, Navarrabiomed, Navarre Public University (UPNA), Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Graziano Onder
- Department of Geriatrics, Università Cattolica del Sacro Cuore and Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - Tara Quirke
- Dementia Training Study Centre, University of Wollongong, Queensland, Australia
| | - James L Silvius
- Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Andrew C Stafford
- Curtin Medical School & enAble Institute, Curtin University, Perth, Australia
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, CA, USA
| | - Winnie Sun
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada
| | - Reina Taguchi
- Research Department, Institute for Health Economics and Policy, Tokyo, Japan
| | - Adam Todd
- School of Pharmacy, Newcastle University, Newcastle, United Kingdom
| | - Shanna C Trenaman
- College of Pharmacy, Faculty of Health, Dalhousie University, Halifax, Canada
| | - Kai Zhen Yap
- Faculty of Science, Department of Pharmacy and Pharmaceutical Sciences, National University of Singapore, Singapore
| | - Meng Zhao
- School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Justin P Turner
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
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Nair KV, Santoro JD. The Neurologist's Guide to Drug Pricing in the United States. Continuum (Minneap Minn) 2024; 30:1259-1271. [PMID: 39088295 DOI: 10.1212/con.0000000000001456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
ABSTRACT As newer, innovative neurology drugs enter the US health care system, neurologists should consider the cost of these treatments in addition to their efficacy, safety, and tolerability. To do so thoughtfully requires an understanding of how prescription drugs are priced in the United States. The process of drug pricing is linked to the distribution supply chain and the many stakeholders involved. Stakeholders include pharmaceutical manufacturers; wholesalers; pharmacies; pharmacy benefit managers; payers, including health insurers; hospital systems; neurologists and other clinicians; and patients. Drug pricing has taken center stage as the Inflation Reduction Act of 2022 has set maximum out-of-pocket expenses for Medicare beneficiaries for the first time in the program's history and limits drug price increases for a select group of Medicare Part D drugs. This article describes the US drug distribution supply chain and its stakeholders and introduces key drug pricing terms; a brief description of how rebates are generally estimated will also be discussed. Finally, as newer neurology outpatient drugs enter the market, the "value" of drugs will be described through cost-effectiveness terminology and their utility for the clinical neurologist.
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Grant S, Smart R. ROMPER: The RAND/USC OPTIC Method for Policy Expert Ratings. MethodsX 2024; 12:102751. [PMID: 38799036 PMCID: PMC11127521 DOI: 10.1016/j.mex.2024.102751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 05/07/2024] [Indexed: 05/29/2024] Open
Abstract
We developed an expert panel approach for identifying expert views on the effectiveness and implementability of population-level policy interventions. ROMPER-the RAND/USC OPTIC Method for Policy Expert Ratings-involves an online, three-round, modified-Delphi process:•Experts rate and comment on policies according to domains of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework.•To identify consensus on policy effectiveness and implementability, expert ratings are analyzed using the Inter-Percentile Range Adjusted for Symmetry (IPRAS) technique from the RAND/UCLA Appropriateness Method and visualized using a forest plot. To explain consensus, expert comments are analyzed using reflexive thematic analysis and reported following the Standards for Reporting Qualitative Research.•To provide actionable information for decisionmakers, each policy is summarized in a "Policy Profile" adapted from GRADEPro Evidence-to-Decision tables.We validated ROMPER in two studies that successfully recruited the targeted sample size, retained experts through all three rounds, and examined consensus on which policies are (not) effective and implementable. ROMPER protocols, materials, data, and code are openly available on the Open Science Framework with Creative Commons licensing for replication and reuse. ROMPER provides a validated, replicable, open access approach for eliciting expert views on both policy effectiveness and implementability-and for summarizing (lack of) consensus specifically for policymakers.
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Affiliation(s)
- Sean Grant
- RAND Corporation, 1776 Main St, Santa Monica, CA 90401, USA
- HEDCO Institute for Evidence-Based Educational Practice, College of Education, University of Oregon, 1215 University of Oregon, Eugene, OR 97403-1215, USA
| | - Rosanna Smart
- RAND Corporation, 1776 Main St, Santa Monica, CA 90401, USA
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Tyack Z, Carter H, Allen M, Senanayake S, Warhurst K, Naicker S, Abell B, McPhail SM. Multicomponent processes to identify and prioritise low-value care in hospital settings: a scoping review. BMJ Open 2024; 14:e078761. [PMID: 38604625 PMCID: PMC11015208 DOI: 10.1136/bmjopen-2023-078761] [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: 08/11/2023] [Accepted: 01/15/2024] [Indexed: 04/13/2024] Open
Abstract
OBJECTIVES This scoping review mapped and synthesised original research that identified low-value care in hospital settings as part of multicomponent processes. DESIGN Scoping review. DATA SOURCES Electronic databases (EMBASE, PubMed, CINAHL, PsycINFO and Cochrane CENTRAL) and grey literature were last searched 11 July and 3 June 2022, respectively, with no language or date restrictions. ELIGIBILITY CRITERIA We included original research targeting the identification and prioritisation of low-value care as part of a multicomponent process in hospital settings. DATA EXTRACTION AND SYNTHESIS Screening was conducted in duplicate. Data were extracted by one of six authors and checked by another author. A framework synthesis was conducted using seven areas of focus for the review and an overuse framework. RESULTS Twenty-seven records were included (21 original studies, 4 abstracts and 2 reviews), originating from high-income countries. Benefit or value (11 records), risk or harm (10 records) were common concepts referred to in records that explicitly defined low-value care (25 records). Evidence of contextualisation including barriers and enablers of low-value care identification processes were identified (25 records). Common components of these processes included initial consensus, consultation, ranking exercise or list development (16 records), and reviews of evidence (16 records). Two records involved engagement of patients and three evaluated the outcomes of multicomponent processes. Five records referenced a theory, model or framework. CONCLUSIONS Gaps identified included applying systematic efforts to contextualise the identification of low-value care, involving people with lived experience of hospital care and initiatives in resource poor contexts. Insights were obtained regarding the theories, models and frameworks used to guide initiatives and ways in which the concept 'low-value care' had been used and reported. A priority for further research is evaluating the effect of initiatives that identify low-value care using contextualisation as part of multicomponent processes.
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Affiliation(s)
- Zephanie Tyack
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Hannah Carter
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Michelle Allen
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sameera Senanayake
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Kym Warhurst
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Mater Misericordiae Ltd, South Brisbane, Queensland, Australia
| | - Sundresan Naicker
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Bridget Abell
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Metro South Health, Brisbane, Queensland, Australia
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. Implementation considerations of deprescribing interventions: A scoping review. J Intern Med 2024; 295:436-507. [PMID: 36524602 DOI: 10.1111/joim.13599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.
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Affiliation(s)
- Jinjiao Wang
- Elaine, Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Harriet J. Kitzman Center for Research Support, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- UR Medicine Home Care, University of Rochester Medical Center, Rochester, New York, USA
- University of Rochester Medical Center, Finger Lakes Geriatric Education Center, Rochester, New York, USA
| | - Kobi Nathan
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Donna M Fick
- Ross and Carol Nese College of Nursing, Penn State University, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Department of Medicine, Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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De Las Salas R, Vaca-González C, Eslava-Schmalbach J, Torres-Espinosa C, Figueras A. Tackling potentially inappropriate prescriptions in older adults: development of deprescribing criteria by consensus from experts in Colombia, Argentina, and Spain. BMC Geriatr 2023; 23:682. [PMID: 37864147 PMCID: PMC10588094 DOI: 10.1186/s12877-023-04271-9] [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: 09/29/2022] [Accepted: 09/04/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Potentially inappropriate medication use is prevalent among older adults in primary care, leading to increased morbidity, adverse drug reactions, hospitalizations, and mortality. This study aimed to develop and validate a tool for identifying PIMs in older adults within the primary care setting. The tool is composed of a list of criteria and was created based on consensus among experts from three Spanish-speaking countries, including two from Latin America. METHODS A literature review was conducted to identify existing tools, and prescription patterns were evaluated in a cohort of 36,111 older adults. An electronic Delphi method, consisting of two rounds, was used to reach a formal expert consensus. The panel included 18 experts from Spain, Colombia, and Argentina. The content validity index, validity of each content item, and Kappa Fleiss statistical measure were used to establish reliability. RESULTS Round one did not yield a consensus, but a definitive consensus was reached in round two. The resulting tool consisted of a list of 5 general recommendations per disease, along with 33 criteria related to potential problems, recommendations, and alternative therapeutic options. The overall content validity of the tool was 0.87, with a Kappa value of 0.69 (95% CI 0.64-0.73; Substantial). CONCLUSIONS The developed criteria provide a novel list that allows for a comprehensive approach to pharmacotherapy in older adults, intending to reduce inappropriate medication use, ineffective treatments, prophylactic therapies, and treatments with an unfavorable risk-benefit ratio for the given condition. Further studies are necessary to evaluate the impact of these criteria on health outcomes.
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Affiliation(s)
- Roxana De Las Salas
- Department of Nursing, Km5 Via Puerto Colombia, Universidad del Norte, Barranquilla, Colombia.
| | - Claudia Vaca-González
- Faculty of Science, Department of Pharmacy, Universidad Nacional de Colombia, Carrera 45 N° 26-85, Bogota, Colombia
| | - Javier Eslava-Schmalbach
- Faculty of Medicine, Department of Surgery, Universidad Nacional de Colombia, Carrera 45 N° 26-85, Bogota, Colombia
| | - Catalina Torres-Espinosa
- Faculty of Medicine, Department of Internal Medicine, Universidad Nacional de Colombia, Carrera 45 N° 26-85, Bogota, Colombia
| | - Albert Figueras
- Faculty of Medicine, Autonomus University of Barcelona, Bellaterra (Cerdanyola del Vallès), 08193, Barcelona, Spain
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Platen M, Flessa S, Teipel S, Rädke A, Scharf A, Mohr W, Buchholz M, Hoffmann W, Michalowsky B. Impact of low-value medications on quality of life, hospitalization and costs - A longitudinal analysis of patients living with dementia. Alzheimers Dement 2023; 19:4520-4531. [PMID: 36905286 DOI: 10.1002/alz.13012] [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: 10/18/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 03/12/2023]
Abstract
INTRODUCTION This study aimed to analyze the impact of low-value medications (Lvm), that is, medications unlikely to benefit patients but to cause harm, on patient-centered outcomes over 24 months. METHODS This longitudinal analysis was based on baseline, 12 and 24 months follow-up data of 352 patients with dementia. The impact of Lvm on health-related quality of life (HRQoL), hospitalizations, and health care costs were assessed using multiple panel-specific regression models. RESULTS Over 24 months, 182 patients (52%) received Lvm at least once and 56 (16%) continuously. Lvm significantly increased the risk of hospitalization by 49% (odds ratio, confidence interval [CI] 95% 1.06-2.09; p = 0.022), increased health care costs by €6810 (CI 95% -707€-14,27€; p = 0.076), and reduced patients' HRQoL (b = -1.55; CI 95% -2.76 to -0.35; p = 0.011). DISCUSSION More than every second patient received Lvm, negatively impacting patient-reported HRQoL, hospitalizations, and costs. Innovative approaches are needed to encourage prescribers to avoid and replace Lvm in dementia care. HIGHLIGHTS Over 24 months, more than every second patient received low-value medications (Lvm). Lvm negatively impact physical, psychological, and financial outcomes. Appropriate measures are needed to change prescription behaviors.
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Affiliation(s)
- Moritz Platen
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Steffen Flessa
- Department of General Business Administration and Health Care Management, University of Greifswald, Friedrich-Loeffler-Straße 70, Greifswald, Germany
| | - Stefan Teipel
- German Center for Neurodegenerative Diseases (DZNE), site Rostock, Gehlsheimer Str. 20, Rostock, Germany
- Department of Psychosomatic Medicine, University Hospital Rostock, Gehlsheimer Str. 20, Rostock, Germany
| | - Anika Rädke
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Annelie Scharf
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Wiebke Mohr
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Maresa Buchholz
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Wolfgang Hoffmann
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
- Institute for Community Medicine, Section Epidemiology of Health Care and Community Health, University Medicine Greifswald (UMG), Ellernholzstrasse 1-2, Greifswald, Germany
| | - Bernhard Michalowsky
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
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McCarthy C, Flood M, Clyne B, Smith SM, Wallace E, Boland F, Moriarty F. Medication changes and potentially inappropriate prescribing in older patients with significant polypharmacy. Int J Clin Pharm 2023; 45:191-200. [PMID: 36385206 DOI: 10.1007/s11096-022-01497-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/01/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Number of medicines and medicines appropriateness are often used as outcome measures to evaluate the effectiveness of deprescribing interventions. AIM The aim of this study was to evaluate changes in prescribing, potentially inappropriate prescriptions (PIP) and prescribing of low-value medicines in older people with multimorbidity and significant polypharmacy. METHOD This study was a retrospective secondary analysis of prescription data from a cluster randomised controlled trial involving 404 participants aged ≥ 65 years and prescribed ≥ 15 repeat medicines from 51 different general practices. For this study, repeat medications at baseline and follow-up (~ 1 year later) were assigned Anatomical Therapeutic Classification (ATC) codes. Outcomes were the most commonly prescribed and potentially inappropriately prescribed drug groups, the most frequently discontinued or initiated drug groups and the number of changes per person between baseline and follow-up. RESULTS There were 7051 medicines prescribed to 404 participants at baseline. There was a median of 17 medicines (IQR 15-19) at baseline and 16 (IQR 14-19) at follow-up. PIP represented 17.1% of prescriptions at baseline and 15.7% (n = 6777) at follow-up. There were reductions in the prescription of most drug groups with the largest reduction in antiplatelet prescriptions. Considering medication discontinuations, initiations and switches, there was a median of five medication changes per person (range 0-30, IQR 3-9) by follow-up. There were 95 low-value prescriptions at baseline reducing to 78 at follow-up. CONCLUSION The number of medication changes per person was not reflected by summarising medication count at two time points, highlighting the complexity of prescribing for patients with polypharmacy. Frequent medication changes has potentially important implications for patients in terms of adherence and medication safety. TRIAL REGISTRY The SPPiRE trial was registered prospectively on the ISRCTN registry (ISRCTN12752680).
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Affiliation(s)
- Caroline McCarthy
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland.
| | - Michelle Flood
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Barbara Clyne
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland.,Department of Public Health and Primary Care, Trinity College Dublin, Dublin 2, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland.,Data Science Centre, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Frank Moriarty
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland.,School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin 2, Ireland
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Smart R, Grant S, Gordon AJ, Pacula RL, Stein BD. Expert Panel Consensus on State-Level Policies to Improve Engagement and Retention in Treatment for Opioid Use Disorder. JAMA HEALTH FORUM 2022; 3:e223285. [PMID: 36218944 PMCID: PMC10041351 DOI: 10.1001/jamahealthforum.2022.3285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Importance In the US, recent legislation and regulations have been considered, proposed, and implemented to improve the quality of treatment for opioid use disorder (OUD). However, insufficient empirical evidence exists to identify which policies are feasible to implement and successfully improve patient and population-level outcomes. Objective To examine expert consensus on the effectiveness and the ability to implement state-level OUD treatment policies. Evidence Review This qualitative study used the ExpertLens online platform to conduct a 3-round modified Delphi process to convene 66 stakeholders (health care clinicians, social service practitioners, addiction researchers, health policy decision-makers, policy advocates, and persons with lived experience). Stakeholders participated in 1 of 2 expert panels on 14 hypothetical state-level policies targeting treatment engagement and linkage, evidence-based and integrated care, treatment flexibility, and monitoring or support services. Participants rated policies in round 1, discussed results in round 2, and provided final ratings in round 3. Participants used 4 criteria associated with either the effectiveness or implementability to rate and discuss each policy. The effectiveness panel (n = 29) considered policy effects on treatment engagement, treatment retention, OUD remission, and opioid overdose mortality. The implementation panel (n = 34) considered the acceptability, feasibility, affordability, and equitability of each policy. We measured consensus using the interpercentile range adjusted for symmetry analysis technique from the RAND/UCLA appropriateness method. Findings Both panels reached consensus on all items. Experts viewed 2 policies (facilitated access to medications for OUD and automatic Medicaid enrollment for citizens returning from correctional settings) as highly implementable and highly effective in improving patient and population-level outcomes. Participants rated hub-and-spoke-type policies and provision of financial incentives to emergency departments for treatment linkage as effective; however, they also rated these policies as facing implementation barriers associated with feasibility and affordability. Coercive policies and policies levying additional requirements on individuals with OUD receiving treatment (eg, drug toxicology testing, counseling requirements) were viewed as low-value policies (ie, decreasing treatment engagement and retention, increasing overdose mortality, and increasing health inequities). Conclusions and Relevance The findings of this study may provide urgently needed consensus on policies for states to consider either adopting or deimplementing in their efforts to address the opioid overdose crisis.
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Affiliation(s)
- Rosanna Smart
- Economics, Sociology, and Statistics Department, RAND Corporation, Santa Monica, California.,Drug Policy Research Center, RAND Corporation, Santa Monica, California
| | - Sean Grant
- Department of Social & Behavioral Sciences, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City.,Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Rosalie Liccardo Pacula
- Sol Price School of Public Policy and Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles
| | - Bradley D Stein
- Behavioral and Policy Sciences Department, RAND Corporation, Pittsburgh, Pennsylvania
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Trenaman SC, Kennie-Kaulbach N, d'Entremont-MacVicar E, Isenor JE, Goodine C, Jarrett P, Andrew MK. Implementation of pharmacist-led deprescribing in collaborative primary care settings. Int J Clin Pharm 2022; 44:1216-1221. [PMID: 35794285 PMCID: PMC9261167 DOI: 10.1007/s11096-022-01449-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022]
Abstract
In many jurisdictions pharmacists share prescribing responsibilities with other members of the primary care team. Responsibility for deprescribing, the healthcare professional supervised withdrawal of medications that are no longer needed, has not been assumed by a specific member of the primary care team. In this commentary we describe implementation of pharmacist-led deprescribing in collaborative primary care settings using the seven components of knowledge translation. Patient and stakeholder engagement shaped the deprescribing intervention. The intervention was implemented in three collaborative primary care clinics in two Canadian provinces. The evaluation included measures of medication appropriateness, patient satisfaction, and healthcare professional satisfaction. Pharmacist-led deprescribing in primary care was acceptable to both patients and healthcare professionals and demonstrated a reduction of medications deemed to confer more risk than benefit. Our findings support successes in pharmacist-led deprescribing. Future work is needed to understand how to successfully implement and evaluate pharmacist-led deprescribing more widely.
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Affiliation(s)
- Shanna C Trenaman
- Department of Medicine (Geriatrics), Dalhousie University, Veterans Memorial Building, 5955 Veterans Memorial Lane, Halifax, NS, B3H 2E1, Canada.
- Geriatric Medicine Research, Dalhousie University / Nova Scotia Health Authority, 1427-5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada.
| | - Natalie Kennie-Kaulbach
- College of Pharmacy, Faculty of Health, Dalhousie University, 5968 College Street, PO Box 15000, Halifax, NS, B3H 4R2, Canada
| | | | - Jennifer E Isenor
- College of Pharmacy, Faculty of Health, Dalhousie University, 5968 College Street, PO Box 15000, Halifax, NS, B3H 4R2, Canada
- Department of Community Health and Epidemiology, Centre for Clinical Research, 5790 University Avenue, Halifax, NS, B3H 1V7, Canada
| | - Carole Goodine
- Horizon Health Network, Doctor Everett Chalmers Hospital, 700 Priestman Street, PO Box 9000, Fredericton, NB, E3B 5N5, Canada
| | - Pamela Jarrett
- Department of Medicine (Geriatrics), Dalhousie University, Veterans Memorial Building, 5955 Veterans Memorial Lane, Halifax, NS, B3H 2E1, Canada
- Horizon Health Network, 400 University Avenue, PO Box 2100, Saint John, NB, E2L 4L2, Canada
| | - Melissa K Andrew
- Department of Medicine (Geriatrics), Dalhousie University, Veterans Memorial Building, 5955 Veterans Memorial Lane, Halifax, NS, B3H 2E1, Canada
- Geriatric Medicine Research, Dalhousie University / Nova Scotia Health Authority, 1427-5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
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11
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The Ambiguous Reality of Prescribing in Geriatric Practice. J Am Med Dir Assoc 2022; 23:976-979. [PMID: 35659943 DOI: 10.1016/j.jamda.2022.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 04/25/2022] [Indexed: 11/20/2022]
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