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Worz C. Cost-Consequence Analysis of Deprescribing to Optimize Health Outcomes for Frail Older People: A Within-Trial Analysis. J Am Med Dir Assoc 2024; 25:105018. [PMID: 38944464 DOI: 10.1016/j.jamda.2024.105018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/03/2024] [Indexed: 07/01/2024]
Affiliation(s)
- Chad Worz
- Chief Executive, ASCP, Alexandria, VA
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Cole JA, Gonçalves-Bradley DC, Alqahtani M, Barry HE, Cadogan C, Rankin A, Patterson SM, Kerse N, Cardwell CR, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2023; 10:CD008165. [PMID: 37818791 PMCID: PMC10565901 DOI: 10.1002/14651858.cd008165.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, so that many medicines may be used to achieve better clinical outcomes for patients. This is the third update of this Cochrane Review. OBJECTIVES To assess the effects of interventions, alone or in combination, in improving the appropriate use of polypharmacy and reducing medication-related problems in older people. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 13 January 2021, together with handsearching of reference lists to identify additional studies. We ran updated searches in February 2023 and have added potentially eligible studies to 'Characteristics of studies awaiting classification'. SELECTION CRITERIA For this update, we included randomised trials only. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy (four or more medicines) in people aged 65 years and older, which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people). DATA COLLECTION AND ANALYSIS Four review authors independently reviewed abstracts of eligible studies, and two authors extracted data and assessed the risk of bias of the included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS We identified 38 studies, which includes an additional 10 in this update. The included studies consisted of 24 randomised trials and 14 cluster-randomised trials. Thirty-six studies examined complex, multi-faceted interventions of pharmaceutical care (i.e. the responsible provision of medicines to improve patients' outcomes), in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists, nurses and geriatricians, and most were conducted in high-income countries. Assessments using the Cochrane risk of bias tool found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low. It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool) (mean difference (MD) -5.66, 95% confidence interval (CI) -9.26 to -2.06; I2 = 97%; 8 studies, 947 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs) (standardised mean difference (SMD) -0.19, 95% CI -0.34 to -0.05; I2 = 67%; 9 studies, 2404 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIM (risk ratio (RR) 0.81, 95% CI 0.68 to 0.98; I2 = 84%; 13 studies, 4534 participants; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.48, 95% CI -1.05 to 0.09; I2 = 92%; 3 studies, 691 participants; low-certainty evidence), however it must be noted that this effect estimate is based on only three studies, which had serious limitations in terms of risk of bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPO (RR 0.50, 95% CI 0.27 to 0.91; I2 = 95%; 7 studies, 2765 participants; very low-certainty evidence). Pharmaceutical care may make little or no difference to hospital admissions (data not pooled; 14 studies, 4797 participants; low-certainty evidence). Pharmaceutical care may make little or no difference to quality of life (data not pooled; 16 studies, 7458 participants; low-certainty evidence). Medication-related problems were reported in 10 studies (6740 participants) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies. This also applied to studies examining adherence to medication (nine studies, 3848 participants). AUTHORS' CONCLUSIONS It is unclear whether interventions to improve appropriate polypharmacy resulted in clinically significant improvement. Since the last update of this review in 2018, there appears to have been an increase in the number of studies seeking to address potential prescribing omissions and more interventions being delivered by multidisciplinary teams.
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Affiliation(s)
- Judith A Cole
- Clinical Trial Service Unit, University of Oxford, Oxford, UK
| | | | | | | | - Cathal Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Audrey Rankin
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | | | - Ngaire Kerse
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Chris R Cardwell
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Cristin Ryan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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Guttier MC, Silveira MPT, Tavares NUL, Krause MC, Bielemann RM, Gonzalez MC, Tomasi E, Demarco FF, Bertoldi AD. Difficulties in the use of medications by elderly people followed up in a cohort study in Southern Brazil. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2023; 26:e230020. [PMCID: PMC10000017 DOI: 10.1590/1980-549720230020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
Objective: This study aimed to assess the need for help by elderly people to take their medications, the difficulties related to this activity, the frequency of forgotten doses, and factors associated. Methods: Cross-sectional study conducted with a cohort of elderly people (60 years and over — “COMO VAI?” [How do you do?] study), where the need for help to properly take medication and the difficulties faced in using them were evaluated. The Poisson regression model was used to estimate the crude and adjusted prevalence ratios (PR) of the outcomes and respective 95% confidence intervals according to the characteristics of the sample. Results: In total, 1,161 elderly people were followed up. The prevalence of participants who reported requiring help with medication was 15.5% (95%CI 13.5–17.8), and the oldest subjects, with lower educational levels, in worse economic situations, on four or more medications and in bad self-rated health were the ones who needed help the most. Continuous use of medication was reported by 83.0% (95%CI 80.7–85.1) of the sample and most participants (74.9%; 95%CI 72.0–77.5) never forgot to take their medications. Conclusion: The need for help to use medications was shown to be influenced by social and economic determinants. Studies assessing the difficulties in medication use by the elderly are important to support policies and practices to improve adherence to treatment and the rational use of medications.
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Affiliation(s)
- Marília Cruz Guttier
- Universidade Federal de Pelotas, Programa de Pós-Graduação em Epidemiologia –Pelotas (RS), Brasil
| | - Marysabel Pinto Telis Silveira
- Universidade Federal de Pelotas, Instituto de Biologia, Departamento de Fisiologia e Farmacologia, Programa de Pós-Graduação Multicêntrico em Ciências Fisiológicas – Pelotas (RS), Brasil
| | | | | | - Renata Moraes Bielemann
- Universidade Federal de Pelotas, Programa de Pós-Graduação em Nutrição e Alimentos – Pelotas (RS), Brasil
| | - Maria Cristina Gonzalez
- Universidade Católica de Pelotas, Programa de Pós-Graduação em Saúde e Comportamento – Pelotas (RS), Brasil
| | - Elaine Tomasi
- Universidade Federal de Pelotas, Programa de Pós-Graduação em Epidemiologia –Pelotas (RS), Brasil
| | - Flavio Fernando Demarco
- Universidade Federal de Pelotas, Programa de Pós-Graduação em Epidemiologia –Pelotas (RS), Brasil
| | - Andréa Dâmaso Bertoldi
- Universidade Federal de Pelotas, Programa de Pós-Graduação em Epidemiologia –Pelotas (RS), Brasil
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Lukacena KM, Keck JW, Freeman PR, Harrington NG, Huffmyer MJ, Moga DC. Patients' attitudes toward deprescribing and their experiences communicating with clinicians and pharmacists. Ther Adv Drug Saf 2022; 13:20420986221116465. [PMID: 36003624 PMCID: PMC9393353 DOI: 10.1177/20420986221116465] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 07/12/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose: Developing effective deprescribing interventions relies on understanding
attitudes, beliefs, and communication challenges of those involved in the
deprescribing decision-making process, including the patient, the primary
care clinician, and the pharmacist. The objective of this study was to
assess patients’ beliefs and attitudes and identify facilitators of and
barriers to deprescribing. Methods: As part of a larger study, we recruited patients ⩾18 years of age taking ⩾3
chronic medications. Participants were recruited from retail pharmacies
associated with the University of Kentucky HealthCare system. They completed
an electronic survey that included demographic information, questions about
communication with their primary care clinician and pharmacists, and the
revised Patients’ Attitudes Toward Deprescribing (rPATD) questionnaire. Results: Our analyses included 103 participants (n = 65 identified as
female and n = 74 as White/Caucasian) with a mean age of
50.4 years [standard deviation (SD) = 15.5]. Participants reported taking an
average of 8.4 daily medications (SD = 6.1). Most participants reported
effective communication with clinicians and pharmacists (66.9%) and
expressed willingness to stop one of their medications if their clinician
said it was possible (83.5%). Predictors of willingness to accept
deprescribing were older age [odds ratio (OR) = 2.99, 95% confidence
interval (CI) = 1.45–6.2], college/graduate degree (OR = 55.25, 95%
CI = 5.74–531.4), perceiving medications as less appropriate (OR = 8.99, 95%
CI = 1.1–73.62), and perceived effectiveness of communication with the
clinician or pharmacist (OR = 4.56, 95% CI = 0.85–24.35). Conclusion: Adults taking ⩾3 chronic medications expressed high willingness to accept
deprescribing of medications when their doctor said it was possible.
Targeted strategies to facilitate communication within the patient–primary
care clinician–pharmacist triad that consider patient characteristics such
as age and education level may be necessary ingredients for developing
successful deprescribing interventions. Plain Language Summary Are patients willing to accept stopping medications? Sometimes, medicines that a patient takes regularly become inappropriate. In
other words, the risks of adverse effects might be greater than a medicine’s
potential benefits. The decision to stop such medicines should involve the
patient and consider their preferences. We surveyed a group of patients
taking multiple medicines to see how they felt about having those medicines
stopped. We also asked patients whether and how much they talk to their
primary care clinician and pharmacists about their medicines. To qualify for
this study, patients had to be at least 18 years old and to take three or
more medicines daily; they also needed to speak English. Participants
provided demographic information and answered questions about their
medicines, their communication with primary care clinicians and pharmacists,
and their feelings about having one or more of their medicines stopped. We
recruited 107 people and were able to use responses from 103 of them. Their
average age was 50 years; 65 of them identified as female, and 75 identified
as White/Caucasian. Most of our participants mentioned having conversations
with primary care clinicians and pharmacists and said they would be willing
to stop a medication if their clinician said it was possible. Older
participants, those with more years of education, those who thought their
medications might lead to side effects, and those who communicated with
their clinician or pharmacists were more willing to have one of their
medicines stopped. Our results indicate that patient characteristics and communication with
clinicians and pharmacists are factors to consider when designing
interventions to reduce the use of inappropriate medicines.
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Affiliation(s)
- Kaylee M Lukacena
- Center for Social and Behavioral Science, Office of the Vice Chancellor for Research and Innovation, University of Illinois Urbana-Champaign, Urbana, IL, USA
| | - James W Keck
- Department of Family and Community Medicine, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Nancy Grant Harrington
- Department of Communication, College of Communication and Information, University of Kentucky, Lexington, KY, USA
| | - Mark J Huffmyer
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Daniela C Moga
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA. Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA
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Scheel J, Luttenberger K, Graessel E, Kratzer A, Donath C. Predictors of falls and hospital admissions in people with cognitive impairment in day-care: role of multimorbidity, polypharmacy, and potentially inappropriate medication. BMC Geriatr 2022; 22:682. [PMID: 35982409 PMCID: PMC9387045 DOI: 10.1186/s12877-022-03346-3] [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: 12/09/2021] [Accepted: 07/28/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Multimorbidity, polypharmacy, and potentially inappropriate medication (PIM) pose challenges for the care of people with cognitive impairment. The aim of the present study is to explore whether multimorbidity, polypharmacy, and PIM predict falls and hospital admissions in a sample of people with cognitive impairment in day-care centers in Germany. METHODS We used data from the German day-care study (multicenter longitudinal study, n = 433). Multimorbidity was defined as ≥ 2 chronic diseases. Polypharmacy was defined as prescriptions to ≥ 5 drugs. Potentially inappropriate medication was defined as scoring on the PRISCUS list. Binary logistic regression analyses were computed to determine whether multimorbidity, polypharmacy, and potentially inappropriate medication at t0 predicted falls and hospital admissions as outcomes at t1 (six months later). RESULTS The rate of multimorbidity and polypharmacy was 87.8% and 60.3%, respectively. 15.9% of the people with cognitive impairment received PIM / PRISCUS-listed drugs, 43.6% ACB-listed drugs, and 52.7% CNS depressant drugs. Falls and hospital admissions during follow-up were prevalent in 19.4% and 24.7% of the people with cognitive impairment. Both were significantly predicted by the total number of drugs (falls: OR = 1.152, p = 0.001, overall model: p < 0.001; hospital admissions: OR = 1.103, p = 0.020, overall model: p = 0.001), even if regression analyses were controlled for the number of comorbidities. CONCLUSIONS Polypharmacy and potentially inappropriate medication are highly prevalent in people with cognitive impairment in German day-care centers. The number of drugs and appropriateness of medication seem to be crucial for the risk of falls and hospital admissions. Polypharmacy and PIM should be critically reviewed by healthcare providers and avoided as much as and whenever possible. TRIAL REGISTRATION ISRCTN16412551, 30 July 2014, registered partly retrospectively.
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Affiliation(s)
- Jennifer Scheel
- grid.5330.50000 0001 2107 3311Department of Psychiatry and Psychotherapy, Center for Health Services Research in Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054 Erlangen, Germany
| | - Katharina Luttenberger
- grid.5330.50000 0001 2107 3311Department of Psychiatry and Psychotherapy, Center for Health Services Research in Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054 Erlangen, Germany
| | - Elmar Graessel
- grid.5330.50000 0001 2107 3311Department of Psychiatry and Psychotherapy, Center for Health Services Research in Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054 Erlangen, Germany
| | - André Kratzer
- grid.5330.50000 0001 2107 3311Department of Psychiatry and Psychotherapy, Center for Health Services Research in Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054 Erlangen, Germany
| | - Carolin Donath
- grid.5330.50000 0001 2107 3311Department of Psychiatry and Psychotherapy, Center for Health Services Research in Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054 Erlangen, Germany
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DAL Ş, UÇAR N, ALTIPARMAK Ö, SANCAR M, OKUYAN B. Medication Review in Turkish Older Adults at Community Pharmacy: A Pilot Study by Using Medication Appropriateness Index. CLINICAL AND EXPERIMENTAL HEALTH SCIENCES 2022. [DOI: 10.33808/clinexphealthsci.1012114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: The study aimed to evaluate medication review in older adults (≥65 years) at a community pharmacy by identifying the prevalence of potentiality inappropriate medication and calculating medication appropriateness index.
Methods: This descriptive study was carried out in a community pharmacy for six months. The older adults (≥65 years) using one or more medications were included. During clinical pharmacist-led medication review; the medication appropriateness index was calculated for each medication of older adults. Potentially inappropriate medications were evaluated according to the 2019 American Geriatrics Society Beers Criteria®.
Result: Among a hundred older adults, 46.0% were female. The median age of the patients was 75.5 (IQR, 68.0-78.8). The median number of medications was 9.0 (7.0-10.0). Polypharmacy has been detected in 97.0% of the patients. At least one potentially inappropriate medication was detected in 63.0% of them. The median score of medication appropriateness index score was 53.0 (IQR: 38.6-67.9).
Conclusion: To best our knowledge, this is the first study of clinical pharmacist-led medication review by calculating the medication appropriateness index carried out at a community pharmacy in Turkey. There was a high rate of potentially inappropriate medication with a higher score of medication appropriateness in older adults. This study highlights the importance of medication review led by the clinical pharmacist at community pharmacy to optimize medication usage in older adults.
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How to Improve Healthcare for Patients with Multimorbidity and Polypharmacy in Primary Care: A Pragmatic Cluster-Randomized Clinical Trial of the MULTIPAP Intervention. J Pers Med 2022; 12:jpm12050752. [PMID: 35629175 PMCID: PMC9144280 DOI: 10.3390/jpm12050752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/19/2022] [Accepted: 04/26/2022] [Indexed: 11/24/2022] Open
Abstract
(1) Purpose: To investigate a complex MULTIPAP intervention that implements the Ariadne principles in a primary care population of young-elderly patients with multimorbidity and polypharmacy and to evaluate its effectiveness for improving the appropriateness of prescriptions. (2) Methods: A pragmatic cluster-randomized clinical trial was conducted involving 38 family practices in Spain. Patients aged 65–74 years with multimorbidity and polypharmacy were recruited. Family physicians (FPs) were randomly allocated to continue usual care or to provide the MULTIPAP intervention based on the Ariadne principles with two components: FP training (eMULTIPAP) and FP patient interviews. The primary outcome was the appropriateness of prescribing, measured as the between-group difference in the mean Medication Appropriateness Index (MAI) score change from the baseline to the 6-month follow-up. The secondary outcomes were quality of life (EQ-5D-5 L), patient perceptions of shared decision making (collaboRATE), use of health services, treatment adherence, and incidence of drug adverse events (all at 1 year), using multi-level regression models, with FP as a random effect. (3) Results: We recruited 117 FPs and 593 of their patients. In the intention-to-treat analysis, the between-group difference for the mean MAI score change after a 6-month follow-up was −2.42 (95% CI from −4.27 to −0.59) and, between baseline and a 12-month follow-up was −3.40 (95% CI from −5.45 to −1.34). There were no significant differences in any other secondary outcomes. (4) Conclusions: The MULTIPAP intervention improved medication appropriateness sustainably over the follow-up time. The small magnitude of the effect, however, advises caution in the interpretation of the results given the paucity of evidence for the clinical benefit of the observed change in the MAI. Trial registration: Clinicaltrials.gov NCT02866799.
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Tremblay Z, Mumbere D, Laurin D, Sirois C, Furrer D, Poisblaud L, Carmichael PH, Farrell B, Tourigny A, Giguere A, Vedel I, Morais J, Kröger E. Health Impacts and Characteristics of Deprescribing Interventions in Older Adults: Protocol for a Systematic Review and Meta-analysis. JMIR Res Protoc 2021; 10:e25200. [PMID: 34889771 PMCID: PMC8704115 DOI: 10.2196/25200] [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: 10/21/2020] [Revised: 08/05/2021] [Accepted: 09/03/2021] [Indexed: 12/05/2022] Open
Abstract
Background Deprescribing, a relatively recent concept, has been proposed as a promising solution to the growing issues of polypharmacy and use of medications of questionable benefit among older adults. However, little is known about the health outcomes of deprescribing interventions. Objective This paper presents the protocol of a study that aims to contribute to the knowledge on deprescribing by addressing two specific objectives: (1) describe the impact of deprescribing in adults ≥60 years on health outcomes or quality of life; and (2) determine the characteristics of effective interventions in deprescribing. Methods Primary studies targeting three concepts (older adults, deprescribing, and health or quality of life outcomes) will be included in the review. The search will be performed using key international databases (MEDLINE, EMBASE, CINAHL, Ageline, PsycInfo), and a special effort will be made to identify gray literature. Two reviewers will independently screen the articles, extract the information, and evaluate the quality of the selected studies. If methodologically feasible, meta-analyses will be performed for groups of intervention studies reporting on deprescribing interventions for similar medications, used for similar or identical indications, and reporting on similar outcomes (eg, benzodiazepines used against insomnia and studies reporting on quality of sleep or quality of life). Alternatively, the results will be presented in bottom-line statements (objective 1) and a matrix outlining effective interventions (objective 2). Results The knowledge synthesis may be limited by the availability of high-quality clinical trials on deprescribing and their outcomes in older adults. Additionally, analyses will likely be affected by studies on the deprescribing of different types of molecules within the same indication (eg, different pharmacological classes and medications to treat hypertension) and different measures of health and quality of life outcomes for the same indication. Nevertheless, we expect the review to identify which deprescribing interventions lead to improved health outcomes among seniors and which of their characteristics contribute to these outcomes. Conclusions This systematic review will contribute to a better understanding of the health outcomes of deprescribing interventions among seniors. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42015020866; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42015020866 International Registered Report Identifier (IRRID) PRR1-10.2196/25200
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Affiliation(s)
- Zoë Tremblay
- Faculté de pharmacie, Université Laval, Québec, QC, Canada
| | - David Mumbere
- Faculté de pharmacie, Université Laval, Québec, QC, Canada
| | | | | | - Daniela Furrer
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale Nationale, Québec, QC, Canada
| | - Lise Poisblaud
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale Nationale, Québec, QC, Canada
| | - Pierre-Hugues Carmichael
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale Nationale, Québec, QC, Canada
| | - Barbara Farrell
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - André Tourigny
- Faculté de médecine, Université Laval, Québec, QC, Canada
| | - Anik Giguere
- Faculté de médecine, Université Laval, Québec, QC, Canada
| | - Isabelle Vedel
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - José Morais
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Edeltraut Kröger
- Faculté de pharmacie, Université Laval, Québec, QC, Canada.,Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale Nationale, Québec, QC, Canada.,Faculty of Medicine, McGill University, Montreal, QC, Canada
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Lee EH, Park JO, Cho JP, Lee CA. Prioritising Risk Factors for Prescription Drug Overdose among Older Adults in South Korea: A Multi-Method Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115948. [PMID: 34206039 PMCID: PMC8198076 DOI: 10.3390/ijerph18115948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 11/17/2022]
Abstract
Older adults are vulnerable to drug overdose. We used a multi-method approach to prioritise risk factors for prescription drug overdose among older adults. The study was conducted in two stages. First, risk factors for drug overdose were classified according to importance and changeability through literature review, determined through 2-phase expert surveys. Second, prescription drug overdose cases during 2011–2015 were selected from a national cohort; the prevalence of ‘more important’ or ‘more changeable’ factors determined in stage one was investigated. Scores were assigned according to the Basic Priority Rating Scale formula, reflecting the problem size and seriousness and intervention effectiveness. In the first stage, polypharmacy, old-old age, female sex, chronic disease, psychiatric disease, and low socioeconomic status (SES) were selected as risk factors. In the second stage, 93.9% of cases enrolled had chronic medical disease; 78.3% were using multiple drugs. Low SES was more prevalent than other risk factors. As per the scoring formula, chronic medical disease, polypharmacy, psychiatric disease, low SES, female sex, and old-old age were the most important risk factors in order of priority. Patients with chronic medical disease and those using multiple medications should be prioritised in overdose prevention interventions among older adults.
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Affiliation(s)
- Eun-Hae Lee
- Division of Injury Prevention and Control, Korea Disease Control and Prevention Agency, Cheongju-si 28159, Korea;
| | - Ju-Ok Park
- Department of Emergency Medicine, Hallym University, Dongtan Sacred Heart Hospital, Hwaseong-si 18450, Korea;
| | - Joon-Pil Cho
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon 16499, Korea;
| | - Choung-Ah Lee
- Department of Emergency Medicine, Hallym University, Dongtan Sacred Heart Hospital, Hwaseong-si 18450, Korea;
- Correspondence: ; Tel.: +82-31-8086-2611; Fax: +82-31-8086-2614
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Shahmoradi L, Safdari R, Ahmadi H, Zahmatkeshan M. Clinical decision support systems-based interventions to improve medication outcomes: A systematic literature review on features and effects. Med J Islam Repub Iran 2021; 35:27. [PMID: 34169039 PMCID: PMC8214039 DOI: 10.47176/mjiri.35.27] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Indexed: 01/24/2023] Open
Abstract
Background: Clinical decision support systems (CDSSs) interventions were used to improve the life quality and safety in patients and also to improve practitioner performance, especially in the field of medication. Therefore, the aim of the paper was to summarize the available evidence on the impact, outcomes and significant factors on the implementation of CDSS in the field of medicine. Methods: This study is a systematic literature review. PubMed, Cochrane Library, Web of Science, Scopus, EMBASE, and ProQuest were investigated by 15 February 2017. The inclusion requirements were met by 98 papers, from which 13 had described important factors in the implementation of CDSS, and 86 were medicated-related. We categorized the system in terms of its correlation with medication in which a system was implemented, and our intended results were examined. In this study, the process outcomes (such as; prescription, drug-drug interaction, drug adherence, etc.), patient outcomes, and significant factors affecting the implementation of CDSS were reviewed. Results: We found evidence that the use of medication-related CDSS improves clinical outcomes. Also, significant results were obtained regarding the reduction of prescription errors, and the improvement in quality and safety of medication prescribed. Conclusion: The results of this study show that, although computer systems such as CDSS may cause errors, in most cases, it has helped to improve prescribing, reduce side effects and drug interactions, and improve patient safety. Although these systems have improved the performance of practitioners and processes, there has not been much research on the impact of these systems on patient outcomes.
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Affiliation(s)
- Leila Shahmoradi
- Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Safdari
- Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Ahmadi
- OIM Department, Aston Business School, Aston University, Birmingham B4 7ET, United Kingdom
| | - Maryam Zahmatkeshan
- Noncommunicable Diseases Research Center, School of Medicine, Fasa University of Medical Sciences, Fasa, Iran
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11
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Syafhan NF, Al Azzam S, Williams SD, Wilson W, Brady J, Lawrence P, McCrudden M, Ahmed M, Scott MG, Fleming G, Hogg A, Scullin C, Horne R, Ahir H, McElnay JC. General practitioner practice-based pharmacist input to medicines optimisation in the UK: pragmatic, multicenter, randomised, controlled trial. J Pharm Policy Pract 2021; 14:4. [PMID: 33397509 PMCID: PMC7784025 DOI: 10.1186/s40545-020-00279-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/24/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Changing demographics across the UK has led to general practitioners (GPs) managing increasing numbers of older patients with multi-morbidity and resultant polypharmacy. Through government led initiatives within the National Health Service, an increasing number of GP practices employ pharmacist support. The purpose of this study is to evaluate the impact of a medicines optimisation intervention, delivered by GP practice-based pharmacists, to patients at risk of medication-related problems (MRPs), on patient outcomes and healthcare costs. METHODS A multi-centre, randomised (normal care or pharmacist supplemented care) study in four regions of the UK, involving patients (n = 356) from eight GP practices, with a 6-month follow-up period. Participants were adult patients who were at risk of MRPs. RESULTS Median number of MRPs per intervention patient were reduced at the third assessment, i.e. 3 to 0.5 (p < 0.001) in patients who received the full intervention schedule. Medication Appropriateness Index (MAI) scores were reduced (medications more appropriate) for the intervention group, but not for control group patients (8 [4-13] to 5 [0-11] vs 8 [3-13] to 7 [3-12], respectively; p = 0.001). Using the intention-to-treat (ITT) approach, the number of telephone consultations in intervention group patients was reduced and different from the control group (1 [0-3] to 1 [0-2] vs 1 [0-2] to 1 [0-3], p = 0.020). No significant differences between groups were, however, found in unplanned hospital admissions, length of hospital stay, number of A&E attendances or outpatient visits. The mean overall healthcare cost per intervention patient fell from £1041.7 ± 1446.7 to £859.1 ± 1235.2 (p = 0.032). Cost utility analysis showed an incremental cost per patient of - £229.0 (95% CI - 594.6, 128.2) and a mean QALY gained of 0.024 (95% CI - 0.021 to 0.065), i.e. indicative of a health status gain at a reduced cost (2016/2017). CONCLUSION The pharmacist service was effective in reducing MRPs, inappropriateness of medications and telephone consultations in general practice in a cost-effective manner. TRIAL REGISTRATION ClinicalTrials.Gov, NCT03241498. Registered 7 August 2017-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03241498.
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Affiliation(s)
- Nadia Farhanah Syafhan
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, BT9 7BL, UK
- Department of Clinical Pharmacy, Faculty of Pharmacy, Universitas Indonesia, Depok, Indonesia
| | - Sayer Al Azzam
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, BT9 7BL, UK
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | | | | | | | | | | | - Mustafa Ahmed
- Fern House Surgery, Essex, UK
- Douglas Grove Surgery, Essex, UK
| | | | - Glenda Fleming
- Medicines Optimisation Innovation Centre (MOIC), Antrim, UK
| | - Anita Hogg
- Medicines Optimisation Innovation Centre (MOIC), Antrim, UK
| | - Claire Scullin
- Medicines Optimisation Innovation Centre (MOIC), Antrim, UK
| | - Robert Horne
- School of Pharmacy, University College London, London, UK
| | | | - James C McElnay
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, BT9 7BL, UK.
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12
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Michie S, Johnston M, Rothman AJ, de Bruin M, Kelly MP, Carey RN, Bohlen LEC, Groarke HNK, Anderson NC, Zink S. Developing an evidence-based online method of linking behaviour change techniques and theoretical mechanisms of action: a multiple methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09010] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background
Many global health challenges may be targeted by changing people’s behaviour. Behaviours including cigarette smoking, physical inactivity and alcohol misuse, as well as certain dietary behaviours, contribute to deaths and disability by increasing the risk of cancers, cardiovascular diseases and diabetes. Interventions have been designed to change these health behaviours with a view to reducing these health risks. However, the effectiveness of these interventions has been quite variable and further information is needed to enhance their success. More information is needed about the specific processes that underlie the effectiveness of intervention strategies.
Aim
Researchers have developed a taxonomy of 93 behaviour change techniques (i.e. the active components of an intervention that bring about behavioural change), but little is known regarding their potential mechanisms of action (i.e. the processes through which a behaviour change technique affects behaviour). We therefore aimed to examine links between behaviour change techniques and mechanisms of action.
Method
First, we conducted a literature synthesis study of 277 behaviour change intervention studies, from which we extracted information on links, described by authors, between behaviour change techniques and mechanisms of action, and identified an average of 10 links per intervention report. Second, behaviour change experts (n = 105) were engaged in a three-round consensus study in which they discussed and rated their confidence in the presence/absence of ‘links’ and ‘non-links’ between commonly used behaviour change techniques (n = 61) and a set of mechanisms of action (n = 26). Ninety links and 460 ‘non-links’ reached the pre-set threshold of 80% agreement. To enhance the validity of these results, a third study was conducted that triangulated the findings of the first two studies. Discrepancies and uncertainties between the studies were included in a reconciliation consensus study with a new group of experts (n = 25). The final results identified 92 definite behaviour change technique–mechanism of action links and 465 definite non-links. In a fourth study, we examined whether or not groups of behaviour change techniques used together frequently across interventions revealed shared theoretical underpinnings. We found that experts agreed on the underlying theory for three groups of behaviour change techniques.
Results
Our results are potentially useful to policy-makers and practitioners in selecting behaviour change techniques to include in behaviour change interventions. However, our data do not demonstrate that the behaviour change techniques are effective in targeting the mechanism of action; rather, the links identified may be the ‘best bets’ for interventions that are effective in changing mechanisms of action, and the non-links are unlikely to be effective. Researchers examining effectiveness of interventions in either primary studies or evidence syntheses may consider these links for further investigation.
Conclusion
To make our results usable by researchers, practitioners and policy-makers, they are available in an online interactive tool, which enables discussion and collaboration (https://theoryandtechniquetool.humanbehaviourchange.org/); accessed 1 March 2020. This work, building on previous work to develop the behaviour change technique taxonomy, is part of an ongoing programme of work: the Human Behaviour Change Project (www.humanbehaviourchange.org/; accessed 1 March 2020).
Funding
This project was funded by the Medical Research Council via its Methodology Panel: ‘Developing methodology for designing and evaluating theory-based complex interventions: an ontology for linking behaviour change techniques to theory’ (reference MR/L011115/1).
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Affiliation(s)
- Susan Michie
- Centre for Behaviour Change, University College London, London, UK
| | - Marie Johnston
- Institute of Applied Health Sciences, College of Life Sciences and Medicine, University of Aberdeen, Aberdeen, UK
| | | | - Marijn de Bruin
- Institute of Applied Health Sciences, College of Life Sciences and Medicine, University of Aberdeen, Aberdeen, UK
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, the Netherlands
| | - Michael P Kelly
- Primary Care Unit, Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Rachel N Carey
- Centre for Behaviour Change, University College London, London, UK
| | - Lauren EC Bohlen
- Centre for Behaviour Change, University College London, London, UK
- Department of Kinesiology, College of Health Sciences, University of Rhode Island, Kingston, RI, USA
| | - Hilary NK Groarke
- Department of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Niall C Anderson
- Centre for Behaviour Change, University College London, London, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Silje Zink
- Centre for Behaviour Change, University College London, London, UK
- National Advisory Unit on Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
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13
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Domínguez-Alonso JA, Conde-Estévez D, Bosch D, Pi-Figueras M, Tusquets I. Breast cancer, placing drug interactions in the spotlight: is polypharmacy the cause of everything? Clin Transl Oncol 2021; 23:65-73. [PMID: 32449126 DOI: 10.1007/s12094-020-02386-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/10/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Breast cancer is the most prevalent and lethal cancer among women. Forty-one percent of cases occur in people ≥ 70 years, hindering their treatment given its comorbidities and polypharmacy (PP). Potential drug-drug interactions (PDDI) were analyzed in elderly breast cancer patients between daily and oncospecific treatments and their associations with Age, BMI, Mini Nutritional Assessment (MNA), Frailty categorization, PP, and adverse effects. PATIENTS/METHODS A cohort of 77 patients ≥ 70 years with breast cancer who underwent a Comprehensive Geriatric Assessment (CGA) were included. Clinical characteristics were collected using medical records. PDDI between treatments were analyzed using two databases. Data were assessed using linear regression, Chi-square, Mann-Whitney U, and Kruskal-Wallis tests. Finally, a multivariate logistic regression model was built and tested to predict adverse effects. RESULTS From 719 PDDI, 530 (74%) were moderate (r2 = 0.72) and the median number of drugs during oncospecific treatment (r2 = 0.73) was 9 (range 3-26). Overall, 59 patients (77%) had adverse effects associated with Frailty categorization and MNA (p < 0.05). The distribution of major, moderate, minor, and total PDDI was associated with PP at CGA and during oncospecific treatment (p < 0.05). Moreover, it was verified that Frailty categorization protects from adverse effects given the intervention made at CGA. CONCLUSIONS CGA should be applied in oncologic elderly patients to assess clinical outcomes and categorize them according to their frailty but also to analyze PDDI. Furthermore, we encourage the use of the model in clinical practice for predicting the occurrence of adverse effects, improving therapeutic conciliation.
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Affiliation(s)
| | | | - David Bosch
- Departament de Dinàmica de la Terra i de l'Oceà, Facultat de Ciències de la Terra, Universitat de Barcelona, Barcelona, Spain
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Gruzdeva AA, Khokhlov AL, Ilyin MV. Risk management strategy for preventing the reduced treatment effectiveness from the position of drug interactions and polypharmacy in patients with coronary heart disease. RESEARCH RESULTS IN PHARMACOLOGY 2020. [DOI: 10.3897/rrpharmacology.6.60164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: In modern clinical practice, various drug combinations are widely used, especially in cardiological patients. The existing clinical recommendations necessitate using organ protective agents, especially with a patient having a comorbid pathology and with an ineffective monotherapy. In some cases, drug interaction decreases the effectiveness of pharmacotherapy and increases the risk of developing adverse events (AE).
The purpose of the study was to analyze the modern pharmacotherapy of patients with coronary heart disease (CHD), identify polypharmacy of treatment, evaluate its significance for the treatment process, and determine ways to solve the problem of using a multi-component system of pharmacotherapy risk management.
Materials and methods: The study involved 156 patients with CHD, among whom 39 received more than 8 drugs at a time.
Results and discussion: In these patients, the evaluation of drug interactions revealed 580 variants (48 were dangerous, 428 – significant, 104 – insignificant). The administration of a therapy to comorbid patients, taking into account possible changes in the activity of cytochrome P450 isoenzymes, is one of the promising ways to improve the safety of a combined pharmacotherapy.
Conclusion: It was revealed that with a mutated cytochrome P450 most of processes of drug biotransformation occurs. And there is a greater risk of developing AE against the background of polypragmasia in polymorbid patients, which makes it possible to individually adjust the dose of beta-blockers, thus affecting the frequency of their development. The choice of management measures should be determined considering all the areas of personalized medicine, including pharmacogenetic predictors, pharmacoepidemiological data, pharmacoeconomic effectiveness, the development of adverse reactions, polypragmasia, and medical and social risk factors.
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Pagès A, Roland C, Qassemi S, Abdeljalil AB, Houles M, Romain M, Toulza O, Belloc A, McCambridge C, Voisin T, Cestac P, Juillard-Condat B. Impact of a Pharmacist-included Mobile Geriatrics team intervention on potentially inappropriate drug prescribing: protocol for a prospective feasibility study (PharMoG study). BMJ Open 2020; 10:e040917. [PMID: 33268421 PMCID: PMC7713213 DOI: 10.1136/bmjopen-2020-040917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Research has shown that potentially inappropriate drug prescription (PIDP) is highly prevalent in older people. The presence of PIDPs is associated with adverse health outcomes. This study aims to evaluate the impact of a PHARmacist-included MObile Geriatrics (PharMoG) team intervention on PIDPs in older patients hospitalised in the medical, surgical and emergency departments of a university hospital. METHODS AND ANALYSIS The PharMoG study is a prospective, interventional, single-centre feasibility study describing the impact of a PharMoG team on PIDPs in older hospitalised patients. Pharmacist intervention will be a treatment optimisation (clinical medication review) based on a combination of explicit and implicit criteria to detect PIDPs. The primary outcome is the acceptance rate of the mobile team's proposed treatment optimisations related to PIDPs, measured at the patient's discharge from the department. This pharmacist will work in cooperation with the physician of the mobile geriatric team. After the intervention of the mobile geriatric team, the proposals for improving therapy will be sent to the hospital medical team caring for the patient and to the patient's attending physician. The patient will be followed for 3 months after discharge from the hospital. ETHICS AND DISSEMINATION This study was approved by the South-West and Overseas Territories II Ethics Committee. Oral consent must be obtained prior to participation, either from the patient or from the patient's representative (trusted person and/or a family member). The results will be presented at national and international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04151797.
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Affiliation(s)
- Arnaud Pagès
- Department of Pharmacy, Toulouse University Hospital, Toulouse, France
- Institute of Aging, Gérontopôle, INSPIRE project, Toulouse University Hospital, Toulouse, France
- Centre for Epidemiology and Population Health Research (CERPOP), UMR 1027, Inserm, University of Toulouse (UPS), Toulouse, France
| | - Christel Roland
- Department of Pharmacy, Toulouse University Hospital, Toulouse, France
| | - Soraya Qassemi
- Department of Pharmacy, Toulouse University Hospital, Toulouse, France
| | | | - Mathieu Houles
- Department of Geriatrics, Toulouse University Hospital, Toulouse, France
| | - Marjolaine Romain
- Department of Geriatrics, Toulouse University Hospital, Toulouse, France
| | - Olivier Toulza
- Department of Geriatrics, Toulouse University Hospital, Toulouse, France
| | - Audrey Belloc
- Department of Research and Innovation, Toulouse University Hospital, Toulouse, France
| | | | - Thierry Voisin
- Centre for Epidemiology and Population Health Research (CERPOP), UMR 1027, Inserm, University of Toulouse (UPS), Toulouse, France
- Department of Geriatrics, Toulouse University Hospital, Toulouse, France
| | - Philippe Cestac
- Department of Pharmacy, Toulouse University Hospital, Toulouse, France
- Centre for Epidemiology and Population Health Research (CERPOP), UMR 1027, Inserm, University of Toulouse (UPS), Toulouse, France
| | - Blandine Juillard-Condat
- Department of Pharmacy, Toulouse University Hospital, Toulouse, France
- Centre for Epidemiology and Population Health Research (CERPOP), UMR 1027, Inserm, University of Toulouse (UPS), Toulouse, France
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Stadlbauer V, Engertsberger L, Komarova I, Feldbacher N, Leber B, Pichler G, Fink N, Scarpatetti M, Schippinger W, Schmidt R, Horvath A. Dysbiosis, gut barrier dysfunction and inflammation in dementia: a pilot study. BMC Geriatr 2020; 20:248. [PMID: 32690030 PMCID: PMC7372911 DOI: 10.1186/s12877-020-01644-2] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 07/09/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Dementia is an increasing public health threat worldwide. The pathogenesis of dementia has not been fully elucidated yet. Inflammatory processes are hypothesized to play an important role as a driver for cognitive decline but the origin of inflammation is not clear. We hypothesize that disturbances in gut microbiome composition, gut barrier dysfunction, bacterial translocation and resulting inflammation are associated with cognitive dysfunction in dementia. METHODS To test this hypothesis, a cohort of 23 patients with dementia and 18 age and sex matched controls without cognitive impairments were studied. Gut microbiome composition, gut barrier dysfunction, bacterial translocation and inflammation were assessed from stool and serum samples. Malnutrition was assessed by Mini Nutritional Assessment Short Form (MNA-SF), detailed information on drug use was collected. Microbiome composition was assessed by 16S rRNA sequencing, QIIME 2 and Calypso 7.14 tools. RESULTS Dementia was associated with dysbiosis characterized by differences in beta diversity and changes in taxonomic composition. Gut permeability was increased as evidenced by increased serum diamine oxidase (DAO) levels and systemic inflammation was confirmed by increased soluble cluster of differentiation 14 levels (sCD14). BMI and statin use had the strongest impact on microbiome composition. CONCLUSION Dementia is associated with changes in gut microbiome composition and increased biomarkers of gut permeability and inflammation. Lachnospiraceae NK4A136 group as potential butyrate producer was reduced in dementia. Malnutrition and drug intake were factors, that impact on microbiome composition. Increasing butyrate producing bacteria and targeting malnutrition may be promising therapeutic targets in dementia. TRIAL REGISTRATION NCT03167983 .
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Affiliation(s)
- Vanessa Stadlbauer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria. .,Center of Biomarker Research in Medicine (CBmed), Graz, Austria.
| | - Lara Engertsberger
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Irina Komarova
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Nicole Feldbacher
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.,Center of Biomarker Research in Medicine (CBmed), Graz, Austria
| | - Bettina Leber
- Department of Surgery, Division of Transplantation Surgery, Medical University of Graz, Graz, Austria
| | - Gerald Pichler
- Department of Neurology, Geriatric Health Centers Graz, Albert Schweitzer Hospital, Graz, Austria
| | - Nicole Fink
- Department of Neurology, Geriatric Health Centers Graz, Albert Schweitzer Hospital, Graz, Austria
| | - Monika Scarpatetti
- Department of Neurology, Geriatric Health Centers Graz, Albert Schweitzer Hospital, Graz, Austria
| | - Walter Schippinger
- Department of Neurology, Geriatric Health Centers Graz, Albert Schweitzer Hospital, Graz, Austria
| | - Reinhold Schmidt
- Clinical Division of Neurogeriatrics, Department of Neurology, Medical University of Graz, Graz, Austria
| | - Angela Horvath
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.,Center of Biomarker Research in Medicine (CBmed), Graz, Austria
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Cadogan CA, Rankin A, Lewin S, Hughes CM. Application of the intervention Complexity Assessment Tool for Systematic Reviews within a Cochrane review: an illustrative case study. HRB Open Res 2020; 3:31. [PMID: 32596632 PMCID: PMC7309054 DOI: 10.12688/hrbopenres.13044.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 12/03/2022] Open
Abstract
Background: The intervention Complexity Assessment Tool for Systematic Reviews (iCAT_SR) has been developed to facilitate detailed assessments of intervention complexity in systematic reviews. Worked examples of the tool’s application are needed to promote its use and refinement. The aim of this case study was to apply the iCAT_SR to a subset of 20 studies included in a Cochrane review of interventions aimed at improving appropriate polypharmacy in older people. Methods: Interventions were assessed independently by two authors using the six core iCAT_SR dimensions: (1) ‘Target organisational levels/categories’; (2) ‘Target behaviour/actions’; (3) ‘Active intervention components’; (4) ‘Degree of tailoring’; (5) ‘Level of skill required by intervention deliverers’; (6) ‘Level of skill required by intervention recipients’. Attempts were made to apply four optional dimensions: ‘Interaction between intervention components’; ‘Context/setting’; ‘Recipient/provider factors’; ‘Nature of causal pathway’. Inter-rater reliability was assessed using Cohen’s Kappa coefficient. Disagreements were resolved by consensus discussion. The findings are presented narratively. Results: Assessments involving the core iCAT_SR dimensions showed limited consistency in intervention complexity across included studies, even when categorised according to clinical setting. Interventions were delivered across various organisational levels and categories (i.e. healthcare professionals and patients) and typically comprised multiple components. Intermediate skill levels were required by those delivering and receiving the interventions across all studies. A lack of detail in study reports precluded application of the iCAT_SR’s optional dimensions. The inter-rater reliability was substantial (Cohen's Kappa = 0.75) Conclusions: This study describes the application of the iCAT_SR to studies included in a Cochrane systematic review. Future intervention studies need to ensure more detailed reporting of interventions, context and the causal pathways underlying intervention effects to allow a more holistic understanding of intervention complexity and facilitate replication in other settings. The experience gained has helped to refine the original guidance document relating to the application of iCAT_SR.
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Affiliation(s)
- Cathal A Cadogan
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Audrey Rankin
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Simon Lewin
- Division of Health Services, Norwegian Institute of Public Health, Oslo, Norway.,Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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Ruangritchankul S, Peel NM, Shafiee Hanjani L, Gray LC. The Changes in Medication Prescribing Among the Older People with Cognitive Impairment in the Acute Care Setting. Clin Interv Aging 2020; 15:865-876. [PMID: 32606626 PMCID: PMC7292256 DOI: 10.2147/cia.s252432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/18/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Most older people with cognitive impairment usually have multiple comorbidities. In the last decade, the guidelines for the management of chronic diseases have been changed, leading to changes in the patterns of medication prescribing and in the prevalence of drug-related problems (DRPs). The main objectives were to explore the changes in medication use and in the prevalence of polypharmacy (PP), the use of potentially inappropriate medications (PIMs) and drug-drug interactions (DDIs) among older hospitalized adults with cognitive impairment in a 5-year period. PATIENTS AND METHODS Older hospitalized patients with cognitive impairment diagnosed by cognitive performance scale (CPS) score of 2 or more at tertiary hospital in Brisbane, Australia in 2009 and 2015 to 2016 were enrolled. Prescribed medication use, and exposures to PP, PIM and/or DDI were evaluated at two time points. The associated factors with patients exposed to >1 criteria of PP, PIM or DDI were analyzed by using logistic regression analyses. RESULTS The median number of prescribed medications was not significantly different between the two periods. The number of medications use as dermatological agents and analgesics substantially increased over 5 years. In contrast, there was a decrease in prescription of drugs for acid-related disorders, drugs used in diabetes, and mineral supplements. Most of the participants were exposed to at least one of PP, PIM or DDI. In multivariate regression analysis, the presence of diabetes diagnosis was a risk factor associated with increased exposure to >1 criteria of PP, PIM or DDI. CONCLUSION The patterns of many prescribed medications use have altered in a 5-year period. The present study confirms that the majority of older adults with cognitive impairment admitted in an acute care setting are prone to PP, PIM and DDI. Comprehensive medication reviews should be undertaken in clinical care of older patients with cognitive impairment.
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Affiliation(s)
- Sirasa Ruangritchankul
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nancye M Peel
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Leila Shafiee Hanjani
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Leonard C Gray
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Potentially inappropriate medications in older patients based on Beers criteria: a cross-sectional study of a family medicine practice in Saudi Arabia. BJGP Open 2020; 4:bjgpopen20X101009. [PMID: 32019777 PMCID: PMC7330182 DOI: 10.3399/bjgpopen20x101009] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/03/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The use of potentially inappropriate medications (PIMs) is an important issue in older patients who are at risk of adverse drug events. AIM To determine the prevalence of PIM use, according to Beers criteria, among an older population (aged ≥65 years) in a large family medicine setting, and to identify the associated risks. DESIGN & SETTING A prospective cross-sectional study of patients aged ≥65 years was conducted from June 2017 to June 2018 at the Family and Community Medicine (FCM) clinics of King Saud Medical City (KSMC) in Riyadh, Saudi Arabia. METHOD This cross-sectional study included patients aged ≥65 years who were seen at new appointments or followed-up at the FCM clinics of KSMC in Riyadh, Saudi Arabia. Data were collected by extensive face-to-face interviews and from the patients' medical records. RESULTS A total of 270 older patients aged 72.41 ±6.23 years (mean ±standard deviation [SD]) were included in the present study. The prevalence of PIMs was 60.7% (n = 164). Multivariate analyses identified three independent variables associated with PIMs: incremental age per 5 years (odds ratio [OR] 1.47, 95% confidence intervals [CI] = 1.15 to 1.88; P = 0.002), female sex (OR 1.95, 95% CI = 1.10 to 3.42; P = 0.021), and polypharmacy (OR 8.21, 95% CI = 4.58 to 14.7; P<0.001). The most common PIMs used were 39.4% related to proton pump inhibitors (PPI), 25.2% to diuretics (other than spironolactone), 10.6% to non-steroidal anti-inflammatory drugs (NSAIDs), and 8.7% to aspirin use. CONCLUSION This study showed high prevalence of PIMs. Increasing age, female sex, and polypharmacy were found to be significant risk factors for PIM use. The frequency of morbidities was not significantly different among patients with PIMs compared to those without PIMs, except for hypertension and osteoarthritis, which were more common in the PIMs group. The present study reinforces the importance of comprehensive medication management and reviews.
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Ferguson C, Thomson W, Smith M, Kerse N, Peri K, Gribben B. Medication taking in a national sample of dependent older people. Res Social Adm Pharm 2020; 16:299-307. [DOI: 10.1016/j.sapharm.2019.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 05/01/2019] [Accepted: 05/19/2019] [Indexed: 01/17/2023]
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Lee EJ, Patel A, Acedillo RR, Bachynski JC, Barrett I, Basile E, Battistella M, Benjamin D, Berry D, Blake PG, Chan P, Bohm CJ, Clemens KK, Cook C, Dember L, Dirk JS, Dixon S, Fowler E, Getchell L, Gholami N, Goldstein C, Hahn E, Hogeterp B, Huang S, Hughes M, Jardine MJ, Kalatharan S, Kilburn S, Lacson E, Leonard S, Liberty C, Lindsay C, MacRae JM, Manns BJ, McCallum J, McIntyre CW, Molnar AO, Mustafa RA, Nesrallah GE, Oliver MJ, Pandes M, Pandeya S, Parmar MS, Rabin EZ, Riley J, Silver SA, Sontrop JM, Sood MM, Suri RS, Tangri N, Tascona DJ, Thomas A, Wald R, Walsh M, Weijer C, Weir MA, Vorster H, Zimmerman D, Garg AX. Cultivating Innovative Pragmatic Cluster-Randomized Registry Trials Embedded in Hemodialysis Care: Workshop Proceedings From 2018. Can J Kidney Health Dis 2019; 6:2054358119894394. [PMID: 31903190 PMCID: PMC6933546 DOI: 10.1177/2054358119894394] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 10/24/2019] [Indexed: 12/12/2022] Open
Abstract
Hemodialysis is a life-sustaining treatment for persons with kidney failure. However, those on hemodialysis still face a poor quality of life and a short life expectancy. High-quality research evidence from large randomized controlled trials is needed to identify interventions that improve the experiences, outcomes, and health care of persons receiving hemodialysis. With the support of the Canadian Institutes of Health Research and its Strategy for Patient-Oriented Research, the Innovative Clinical Trials in Hemodialysis Centers initiative brought together Canadian and international kidney researchers, patients, health care providers, and health administrators to participate in a workshop held in Toronto, Canada, on June 2 and 3, 2018. The workshop served to increase knowledge and awareness about the conduct of innovative, pragmatic, cluster-randomized registry trials embedded into routine hemodialysis care and provided an opportunity to discuss and build support for new trial ideas. The workshop content included structured presentations, facilitated group discussions, and expert panel feedback. Partnerships and promising trial ideas borne out of the workshop will continue to be developed to support the implementation of future large-scale trials.
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Affiliation(s)
| | | | - Rey R. Acedillo
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
| | | | | | - Erika Basile
- Office of Human Research Ethics, Western
University, London, ON, Canada
| | - Marisa Battistella
- Department of Pharmacy, University
Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy,
University of Toronto, ON, Canada
| | - Derek Benjamin
- Royal Victoria Regional Health Centre,
Barrie, ON, Canada
| | - David Berry
- Algoma Regional Renal Program, Sault
Area Hospital, Sault Ste. Marie, ON, Canada
| | - Peter G. Blake
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
| | - Patricia Chan
- Division of Nephrology, Department of
Medicine, Michael Garron Hospital, Toronto, ON, Canada
| | - Clara J. Bohm
- Department of Internal Medicine, Max
Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Kristin K. Clemens
- ICES, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
- Division of Endocrinology and
Metabolism, Department of Medicine, Western University, London, ON, Canada
- St. Joseph’s Health Care London, ON,
Canada
| | - Charles Cook
- Transplant Ambassador Program, Grand
River Hospital, Kitchener, ON, Canada
| | - Laura Dember
- Renal, Electrolyte and Hypertension
Division, Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Stephanie Dixon
- ICES, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
| | | | | | | | - Cory Goldstein
- Rotman Institute of Philosophy,
Western University, London, ON, Canada
| | | | | | - Susan Huang
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
| | | | - Meg J. Jardine
- Innovation & Kidney Research, The
George Institute for Global Health, UNSW Sydney, Newtown, NSW, Australia
| | | | | | | | | | | | | | - Jennifer M. MacRae
- Division of Nephrology, Department of
Medicine, University of Calgary, AB, Canada
| | - Braden J. Manns
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Janice McCallum
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
- Renal Services, London Health Sciences
Centre, ON, Canada
| | - Christopher W. McIntyre
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
- Department of Medical Biophysics,
Schulich School of Medicine and Dentistry, Western University, London, ON,
Canada
| | - Amber O. Molnar
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
| | - Reem A. Mustafa
- Division of Nephrology and
Hypertension, Department of Internal Medicine, University of Kansas Medical Center,
Kansas City, USA
| | - Gihad E. Nesrallah
- Division of Nephrology, Department of
Medicine, Humber River Hospital, Toronto, ON, Canada
| | - Matthew J. Oliver
- Division of Nephrology, Department of
Medicine, University of Toronto, ON, Canada
| | | | | | | | | | | | - Samuel A. Silver
- Division of Nephrology, Kingston
Health Sciences Center, Queen’s University, Kingston, ON, Canada
| | - Jessica M. Sontrop
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
| | - Manish M. Sood
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, University of Ottawa, ON, Canada
| | - Rita S. Suri
- Division of Nephrology, Department of
Medicine, McGill University, Montreal, QC, Canada
- Canadian Nephrology Trials Network,
Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Centre,
Winnipeg, MB, Canada
- Department of Internal Medicine,
University of Manitoba, Winnipeg, Canada
| | - Daniel J. Tascona
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
- Orillia Soldiers’ Memorial Hospital,
ON, Canada
| | | | - Ron Wald
- St. Michael’s Hospital, Toronto, ON,
Canada
- Division of Nephrology, Department of
Medicine, University of Toronto, ON, Canada
| | - Michael Walsh
- Division of Nephrology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute,
Hamilton, ON, Canada
| | - Charles Weijer
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
- Rotman Institute of Philosophy,
Western University, London, ON, Canada
| | - Matthew A. Weir
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
| | - Hans Vorster
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
| | - Deborah Zimmerman
- Division of Nephrology, Department of
Medicine, University of Ottawa, ON, Canada
| | - Amit X. Garg
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
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Lester E, Dykstra M, Grant C, Fawcett V, Tsang B, Widder S. High-risk medications in older patients with trauma: a cross-sectional study of risk mitigation. Can J Surg 2019; 62:100-104. [PMID: 30907565 DOI: 10.1503/cjs.017117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background The Beers Criteria for Potentially Inappropriate Medication Use inOlder Adults is a framework that can assess the nature of high-risk medication use. The objective of this study was to use the Beers Criteria to assess the prevalence and nature of polypharmacy, the magnitude of medication changes during the hospital stay and the impact of Beers Criteria medications on outcomes in older patients with trauma. Methods We used the Alberta Trauma Registry to conduct a retrospective review of patients aged 65 years or older with major trauma (Injury Severity Score ≥ 12) who were admitted to a level 1 trauma centre between January 2013 and December 2014. We analyzed changes in medication prescriptions during the hospital stay using descriptive statistics and assessed the association between Beers Criteria medications and relevant outcomes using multivariable regression analysis. Results There was no significant change in the number of Beers Criteria medications prescribed before and after admission. The adjusted odds ratio for 30-day mortality for each additional Beers Criteria medication prescribed was 2.02 (95% confidence interval [CI] 1.16–3.51) versus 1.24 (95% CI 1.04–1.59) for each additional medication of any type. The corresponding adjusted incidence rate ratios for length of stay were 1.15 (95% CI 1.03–1.30) versus 1.05 (95% CI 1.01–1.10). Conclusion Beers Criteria medications were not discontinued during trauma admissions. Using the Beers Criteria as a process indicator for quality improvement in trauma care may provide interdisciplinary trauma teams an opportunity to audit patient medications and stop potentially harmful medications in a vulnerable population.
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Affiliation(s)
- Erica Lester
- From the Department of Surgery, University of Alberta, Edmonton, Alta
| | - Mark Dykstra
- From the Department of Surgery, University of Alberta, Edmonton, Alta
| | - Chantalle Grant
- From the Department of Surgery, University of Alberta, Edmonton, Alta
| | - Vanessa Fawcett
- From the Department of Surgery, University of Alberta, Edmonton, Alta
| | - Bonnie Tsang
- From the Department of Surgery, University of Alberta, Edmonton, Alta
| | - Sandy Widder
- From the Department of Surgery, University of Alberta, Edmonton, Alta
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Toivo T, Airaksinen M, Dimitrow M, Savela E, Pelkonen K, Kiuru V, Suominen T, Uunimäki M, Kivelä SL, Leikola S, Puustinen J. Enhanced coordination of care to reduce medication risks in older home care clients in primary care: a randomized controlled trial. BMC Geriatr 2019; 19:332. [PMID: 31775650 PMCID: PMC6882364 DOI: 10.1186/s12877-019-1353-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 11/11/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND As populations are aging, a growing number of home care clients are frail and use multiple, complex medications. Combined with the lack of coordination of care this may pose uncontrolled polypharmacy and potential patient safety risks. The aim of this study was to assess the impact of a care coordination intervention on medication risks identified in drug regimens of older home care clients over a one-year period. METHODS Two-arm, parallel, cluster randomized controlled trial with baseline and follow-up assessment at 12 months. The study was conducted in Primary Care in Lohja, Finland: all 5 home care units, the public healthcare center, and a private community pharmacy. PARTICIPANTS All consented home care clients aged > 65 years, using at least one prescription medicine who were assessed at baseline and at 12 months. INTERVENTION Practical nurses were trained to make the preliminary medication risk assessment during home visits and report findings to the coordinating pharmacist. The coordinating pharmacist prepared the cases for the triage meeting with the physician and home care nurse to decide on further actions. Each patient's physician made the final decisions on medication changes needed. Outcomes were measured as changes in medication risks: use of potentially inappropriate medications and psychotropics; anticholinergic and serotonergic load; drug-drug interactions. RESULTS Participants (n = 129) characteristics: mean age 82.8 years, female 69.8%, mean number of prescription medicines in use 13.1. The intervention did not show an impact on the medication risks between the original intervention group and the control group in the intention to treat analysis, but the per protocol analysis indicated tendency for effectiveness, particularly in optimizing central nervous system medication use. Half (50.0%) of the participants with a potential need for medication changes, agreed on in the triage meeting, had none of the medication changes actually implemented. CONCLUSION The care coordination intervention used in this study indicated tendency for effectiveness when implemented as planned. Even though the outcome of the intervention was not optimal, the value of this paper is in discussing the real world experiences and challenges of implementing new practices in home care. TRIAL REGISTRATION ClinicalTrials.gov (NCT02545257). Registered September 9 2015.
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Affiliation(s)
- Terhi Toivo
- Faculty of Pharmacy, Division of Pharmacology and Pharmacotherapy, Clinical Pharmacy Group, University of Helsinki, Viikinkaari 5 E, P.O. BOX 56, 00014 Helsinki, Finland
| | - Marja Airaksinen
- Faculty of Pharmacy, Division of Pharmacology and Pharmacotherapy, Clinical Pharmacy Group, University of Helsinki, Viikinkaari 5 E, P.O. BOX 56, 00014 Helsinki, Finland
| | - Maarit Dimitrow
- Faculty of Pharmacy, Division of Pharmacology and Pharmacotherapy, Clinical Pharmacy Group, University of Helsinki, Viikinkaari 5 E, P.O. BOX 56, 00014 Helsinki, Finland
| | - Eeva Savela
- 1st Pharmacy of Lohja, Laurinkatu 37-41 A, 08100 Turku, Finland
| | | | - Valtteri Kiuru
- City of Lohja, Services for Aged Residents, PL 71, 08101 Lohja, Finland
| | - Tuula Suominen
- City of Lohja, Services for Aged Residents, PL 71, 08101 Lohja, Finland
| | - Mira Uunimäki
- City of Lohja, Services for Aged Residents, PL 71, 08101 Lohja, Finland
| | - Sirkka-Liisa Kivelä
- Faculty of Pharmacy, Division of Pharmacology and Pharmacotherapy, Clinical Pharmacy Group, University of Helsinki, Viikinkaari 5 E, P.O. BOX 56, 00014 Helsinki, Finland
- Institute of Clinical Medicine, Department of Family Medicine, University of Turku, 20014 University of Turku, Finland
| | - Saija Leikola
- 1st Pharmacy of Lohja, Laurinkatu 37-41 A, 08100 Turku, Finland
| | - Juha Puustinen
- Faculty of Pharmacy, Division of Pharmacology and Pharmacotherapy, Clinical Pharmacy Group, University of Helsinki, Viikinkaari 5 E, P.O. BOX 56, 00014 Helsinki, Finland
- Satakunta Hospital District, Satakunta Central Hospital, Unit of Neurology, Sairaalantie 3, 28500 Pori, Finland
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Effects of discontinuation of chronic medication in primary care: a systematic review of deprescribing trials. Br J Gen Pract 2019; 68:e663-e672. [PMID: 30249607 DOI: 10.3399/bjgp18x699041] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 08/20/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Polypharmacy is becoming more prevalent and evaluation of appropriateness of medication use is increasingly important. The primary care physician often conducts the deprescribing process; however, there are several barriers to implementing this. AIM To examine the feasibility and safety of discontinuation of medication, with a focus on studies that have been conducted in the community, that is, primary care (or general practice) and nursing homes. DESIGN AND SETTING This systematic review included randomised controlled trials published in 2005-2017, which studied withdrawal of long-term drugs prescribed in primary care settings and compared continuing medication with discontinuing. METHOD PubMed and EMBASE searches were conducted and the extracted data included the number of patients who successfully stopped medication and the number of patients who experienced relapse of symptoms or restarted medication. RESULTS A total of 27 studies reported in 26 papers were included in this review. The number of participants in the studies varied from 20 to 2471 and the mean age of participants ranged from 50.3 years to 89.2 years. The proportion of patients who successfully stopped their medication varied from 20% to 100%, and the range of reported relapse varied from 1.9% to 80%. CONCLUSION Only a few studies have examined the success rate and safety of discontinuing medication in primary care, and these studies are very heterogeneous. Most studies show that deprescribing and cessation of long-term use seem safe; however, there is a risk of relapse of symptoms. More research is needed to advise physicians in making evidence-based decisions about deprescribing in primary care settings.
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Al-Musawe L, Martins AP, Raposo JF, Torre C. The association between polypharmacy and adverse health consequences in elderly type 2 diabetes mellitus patients; a systematic review and meta-analysis. Diabetes Res Clin Pract 2019; 155:107804. [PMID: 31376400 DOI: 10.1016/j.diabres.2019.107804] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/22/2019] [Accepted: 07/29/2019] [Indexed: 02/08/2023]
Abstract
AIM To summarize the existing literature concerning the association between polypharmacy and adverse health consequences in elderly patients with type 2 diabetes mellitus. METHODS We searched four literature databases (PubMed/Medline, ScienceDirect and Web of Science) through April 2019. We included all studies that addressed the association between polypharmacy and all-cause of mortality, glycemic control, macrovacular complications, hospitalization, potentially inappropriate medicines, drug-drug interactions and fall. A statistical program OpenMeta [Analyst] was used. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with a random effects model. I2 statistics was performed to assess heterogeneity. RESULTS Out of sixteen studies, three studies were used for meta-analysis. A statistically significant association was found between polypharmacy and all-cause mortality (OR = 1.622, 95% CI (1.606-1.637) P < 0.001), and myocardial infarction (OR = 1.962, 95% CI (1.942-1.982), P < 0.001. Non-statistically significant association with evidence of moderate heterogeneity was found between polypharmacy and stroke (OR = 1.335; 95% CI (0.532-3.346), P = 0.538, I2 = 45%), and hospitalization (OR = 1.723; 95% CI (0.983-3.021), P = 0.057, I2 = 57%). CONCLUSIONS Pooled risk estimates reveal that polypharmacy is associated with increased all-cause mortality, macrovacular complications and hospitalization using categorical definitions. These findings assert the need for interventions that optimize the balance of benefits and harms in medicines prescribing.
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Affiliation(s)
- Labib Al-Musawe
- Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal.
| | | | - Joao Filipe Raposo
- Nova Medical School, New University of Lisbon, Lisbon, Portugal; Portuguese Diabetes Association (APDP), Lisbon, Portugal
| | - Carla Torre
- Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal
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Price ML, Surr CA, Gough B, Ashley L. Experiences and support needs of informal caregivers of people with multimorbidity: a scoping literature review. Psychol Health 2019; 35:36-69. [PMID: 31321995 DOI: 10.1080/08870446.2019.1626125] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: Describe and synthesise existing published research on the experiences and support needs of informal caregivers of people with multimorbidity.Design: Scoping literature review. Primary database and secondary searches for qualitative and/or quantitative English-language research with an explicit focus on informal carers of people with multimorbidity (no date restrictions). Quality appraisal of included papers. Thematic analysis to identify key themes in the findings of included papers.Results: Thirty-four papers (reporting on 27 studies) were eligible for inclusion, the majority of which were rated good quality, and almost half of which were published from 2015 onwards. The review highlights common difficulties for informal carers of people with multiple chronic illnesses, including practical challenges related to managing multiple health care teams, appointments, medications and side effects, and psychosocial challenges including high levels of psychological symptomatology and reduced social connectedness. Current gaps in the literature include very few studies of interventions which may help support this caregiver group.Conclusion: Interest in this research area is burgeoning. Future work might fruitfully examine the potential benefits of audio-recorded health care consultations, and digitally delivered psychosocial interventions such as online peer support forums, for supporting and enhancing the caring activities and wellbeing of this caregiver group.
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Affiliation(s)
- Mollie L Price
- School of Social Sciences, Leeds Beckett University, Leeds, UK
| | - Claire A Surr
- School of Health and Community Studies, Leeds Beckett University, Leeds, UK
| | - Brendan Gough
- School of Social Sciences, Leeds Beckett University, Leeds, UK
| | - Laura Ashley
- School of Social Sciences, Leeds Beckett University, Leeds, UK
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Mortazavi SS, Shati M, Malakouti SK, Khankeh HR, Mehravaran S, Ahmadi F. Physicians' role in the development of inappropriate polypharmacy among older adults in Iran: a qualitative study. BMJ Open 2019; 9:e024128. [PMID: 31122964 PMCID: PMC6538096 DOI: 10.1136/bmjopen-2018-024128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES The use of unnecessary or excessive medications (inappropriate polypharmacy) is a major health challenge among older adults which is driven by several factors. This study aims to provide in-depth descriptions of the physician's role in the development of inappropriate polypharmacy among older adults in Iran. DESIGN Qualitative content analysis of interviews, field notes and other relevant documents available (eg, medical records). Data collection and analyses were done concurrently to guide the sampling process. SETTING Three purposively selected referral hospitals in Tehran, Iran. PARTICIPANTS A total of 7 physicians, 10 older adults, 3 caregivers and 3 pharmacists with a median age of 54 (IQR 23) years were recruited through convenience sampling. RESULTS Emerged categories included misdiagnosis, inappropriate prescribing, insufficient patient education, poor communication, unprofessional behaviour and limited perspectives which highlight the role of physicians in the development of inappropriate polypharmacy among older adults in Iran under the main concept of poor medical practice. CONCLUSION This study provides valuable insight on the role of physicians in the development of inappropriate polypharmacy among the elderly in the healthcare setting in Iran by exploring the viewpoints of physicians, patients, caregivers and pharmacists. Physicians can be an influential factor in tackling this challenge through proper diagnosis, prescription, patient education and follow-up. In Iran, physicians' practice styles are affected by potentially adverse factors such as the novelty of geriatric medicine, lack of a referral system, patient unfamiliarity with the system and lack of a monitoring system for multiple prescriptions. Furthermore, clinics tend to be overcrowded and visit fees can be low; in this setting, lack of physician assistants leads to limited time allocation to each patient and physician dissatisfaction with their income.
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Affiliation(s)
- Seyede Salehe Mortazavi
- School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mohsen Shati
- Mental Health Research Center, School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Kazem Malakouti
- School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Khankeh
- Department of Nursing, University of Social Welfare and Rehabilitation Sciences (USWR), Tehran, Iran
| | - Shiva Mehravaran
- Department of Ophthalmology, Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, USA
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Soler O, Barreto JOM. Community-Level Pharmaceutical Interventions to Reduce the Risks of Polypharmacy in the Elderly: Overview of Systematic Reviews and Economic Evaluations. Front Pharmacol 2019; 10:302. [PMID: 31001117 PMCID: PMC6454558 DOI: 10.3389/fphar.2019.00302] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 03/11/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Patients over 65 years of age taking multiple medications face several risks, and pharmaceutical interventions can be useful to improve quality of care and reduce those risks. However, there is still no consensus on the effectiveness of these interventions aimed at promoting changes in clinical, epidemiological, economic, and humanistic outcomes for various service delivery, organizational, financial, and implementation-based interventions. The objective of this overview of systematic reviews was to summarize evidence on the effectiveness of community-level pharmaceutical interventions to reduce the risks associated with polypharmacy in the population over 65 years of age. Method: This overview used a previously described protocol to search for systematic review articles, with and without meta-analysis, and economic evaluations, without any language or time restrictions, including articles published up to May 2018. The following databases were searched: the Cochrane Library, Epistemonikos, Health Evidence, Health Systems Evidence, Virtual Health Library, and Google Scholar. The basic search terms used were "elderly," "polypharmacy," and "pharmaceutical interventions." The findings for outcomes of interest were categorized using a taxonomy for health policies and systems. Equity-related questions were also investigated. The studies were evaluated for methodological quality and produced a narrative synthesis. Results: A total of 642 records were retrieved: 50 from Health Evidence, 197 from Epistemonikos, 194 from Cochrane, 116 from Health Systems Evidence, and 85 from the Virtual Health Library. Of these, 16 articles were selected: 1 overview of systematic reviews, 12 systematic reviews, and 3 economic evaluations. There is evidence of improvement in clinical, epidemiological, humanistic, and economic outcomes for various types of community-level pharmaceutical interventions, but differences in observed outcomes may be due to study designs, primary study sample sizes, risk of bias, difficulty in aggregating data, heterogeneity of indicators and quality of evidence included in the systematic reviews that were assessed. It is necessary to optimize the methodological designs of future primary and secondary studies. Conclusion: Community-level pharmaceutical interventions can improve various clinical, epidemiological, humanistic and economic outcomes and potentially reduce risks associated with polypharmacy in the elderly population.
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Affiliation(s)
- Orenzio Soler
- School of Pharmacy, Health Science Institute, Federal University of Pará, Belém, Brazil
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Vasilevskis EE, Shah AS, Hollingsworth EK, Shotwell MS, Mixon AS, Bell SP, Kripalani S, Schnelle JF, Simmons SF. A patient-centered deprescribing intervention for hospitalized older patients with polypharmacy: rationale and design of the Shed-MEDS randomized controlled trial. BMC Health Serv Res 2019; 19:165. [PMID: 30871561 PMCID: PMC6416929 DOI: 10.1186/s12913-019-3995-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/06/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Polypharmacy is prevalent among hospitalized older adults, particularly those being discharged to a post-care care facility (PAC). The aim of this randomized controlled trial is to determine if a patient-centered deprescribing intervention initiated in the hospital and continued in the PAC setting reduces the total number of medications among older patients. METHODS The Shed-MEDS study is a 5-year, randomized controlled clinical intervention trial comparing a patient-centered describing intervention with usual care among older (≥50 years) hospitalized patients discharged to PAC, either a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IPR). Patient measurements occur at hospital enrollment, hospital discharge, within 7 days of PAC discharge, and at 60 and 90 days following PAC discharge. Patients are randomized in a permuted block fashion, with block sizes of two to four. The overall effectiveness of the intervention will be evaluated using total medication count as the primary outcome measure. We estimate that 576 patients will enroll in the study. Following attrition due to death or loss to follow-up, 420 patients will contribute measurements at 90 days, which provides 90% power to detect a 30% versus 25% reduction in total medications with an alpha error of 0.05. Secondary outcomes include the number of medications associated with geriatric syndromes, drug burden index, medication adherence, the prevalence and severity of geriatric syndromes and functional health status. DISCUSSION The Shed-MEDS trial aims to test the hypothesis that a patient-centered deprescribing intervention initiated in the hospital and continuing through the PAC stay will reduce the total number of medications 90 days following PAC discharge and result in improvements in geriatric syndromes and functional health status. The results of this trial will quantify the health outcomes associated with reducing medications for hospitalized older adults with polypharmacy who are discharged to post-acute care facilities. TRIAL REGISTRATION This trial was prospectively registered at clinicaltrials.gov ( NCT02979353 ). The trial was first registered on 12/1/2016, with an update on 09/28/17 and 10/12/2018.
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Affiliation(s)
- Eduard E. Vasilevskis
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Avantika S. Shah
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
| | | | | | - Amanda S. Mixon
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Susan P. Bell
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN USA
| | - Sunil Kripalani
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - John F. Schnelle
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Sandra F. Simmons
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
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Weeks WB, Mishra MK, Curto D, Petersen CL, Cano P, Hswen Y, Serra SV, Elwyn G, Godfrey MM, Soro PS, Tomás JF. Comparing Three Methods for Reducing Psychotropic Use in Older Demented Spanish Care Home Residents. J Am Geriatr Soc 2019; 67:1444-1453. [PMID: 30848834 DOI: 10.1111/jgs.15855] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 02/02/2019] [Accepted: 02/07/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND/OBJECTIVE In nursing homes across the world, and particularly in Spain, there are concerns that psychotropic medications are being overused. For older Spanish nursing home residents who had dementia, we sought to evaluate the association between applying interventions designed to reduce inappropriate psychotropic medication use and subsequent psychotropic use. DESIGN Retrospective, propensity score-matched, controlled, patient-level observational analysis. SETTING A total of 45 nursing homes in Spain. PARTICIPANTS A total of 1653 nursing home residents, aged 70 to 99 years, who had dementia and were prescribed an antipsychotic, anxiolytic, or antidepressant medication, 606 of whom received an intervention; the remainder served as propensity score-matched controls. INTERVENTION Team Rounds, Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria, or a Patient Decision Aid. MEASUREMENTS At 2 and 4 weeks following intervention: change from baseline drug class-specific milligram-equivalent daily dose (MEDD); at 2 weeks: patient falls and restraint use. RESULTS Within each intervention/drug-class cohort, intervention patients and matched controls had similar baseline demographic characteristics, Charlson scores, lengths of admission, and drug class-specific MEDDs. Compared to controls, patients exposed to Team Rounds experienced a 23.3% (95% confidence interval [CI] = 13.9%-32.8%) reduction in antipsychotic and a 23.1% (95% CI = 18.3%-28.0%) reduction in anxiolytic MEDDs; those exposed to Patient Decision Aids had a 24.8% (95% CI = 15.6%-33.9%) reduction in antipsychotic and a 31.8% (95% CI = 25.5%-38.2%) reduction in anxiolytic MEDDs; and those exposed to STOPP/START application had a 27.7% (95% CI = 22.4%-33.0%) reduction in antipsychotic and a 39.5% (95% CI = 35.5%-43.5%) reduction in anxiolytic MEDDs. Intervention-associated antidepressant MEDD reductions were statistically significant but less dramatic. Interventions were associated with higher rates of medication discontinuation, but not higher rates of deaths, patient falls, or physical restraints. CONCLUSION We found strong evidence that the interventions we studied were associated with reduced psychotropic use without commensurate harms, suggesting that such interventions should be incorporated into Spanish nursing home care models. Public reporting of psychotropic medication use in Spanish care homes may encourage care homes to regularly monitor psychotropic medication use and implement such instruments. J Am Geriatr Soc, 2019.
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Affiliation(s)
- William B Weeks
- Dartmouth Institute, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Manish K Mishra
- Dartmouth Institute, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | | | - Curtis L Petersen
- Dartmouth Institute, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | | | - Yulin Hswen
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts
| | | | - Glyn Elwyn
- Dartmouth Institute, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Marjorie M Godfrey
- Dartmouth Institute, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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Kouladjian O'Donnell L, Gnjidic D, Chen TF, Hilmer SN. Integration of an electronic Drug Burden Index risk assessment tool into Home Medicines Reviews: deprescribing anticholinergic and sedative medications. Ther Adv Drug Saf 2019; 10:2042098619832471. [PMID: 30858967 PMCID: PMC6402056 DOI: 10.1177/2042098619832471] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 01/30/2019] [Indexed: 01/31/2023] Open
Abstract
Background: Our aim in this research was to establish whether integrating an electronically generated calculation and report on the Drug Burden Index (DBI) in the Home Medicines Review (HMR) setting is an accurate, feasible and useful risk assessment tool to assess risk of anticholinergic and sedative medications; and to establish whether the intervention of DBI together with HMR is associated with a reduced use of anticholinergic and sedative medications in older community-dwelling adults in Australia. Methods: An interventional feasibility study was conducted. Accredited clinical pharmacists (APs) were recruited to participate. Each AP was educated on implementation of the DBI into HMR practice and given access to the DBI Calculator© web-based software to generate the DBI report for inclusion in HMR reports for general practitioners (GPs). APs recruited patients (⩾65 years) who were referred to them for HMRs. Patients were sent a letter about their DBI exposure, and a prompt to visit their GP to discuss their medication management options. GPs, APs and patients were asked to evaluate the feasibility and utility of the DBI report. A medication inventory was collected from patients at the time of the HMR and at 3 months to determine whether the intervention affected deprescribing of medications with anticholinergic and sedative effects. Results: Regarding the feasibility of the DBI report as a risk assessment tool within HMR, 89% of APs and 67% of GPs agreed that it would be feasible. The DBI Calculator© was potentially inaccurate, as 26% of DBI scores were underestimated and 7% were overestimated (at baseline). At 3 months, the median (interquartile range) DBI for patients (n = 100) significantly decreased from 0.82 (0–1.33) to 0.67 (0–1.29) (p = 0.014). Additionally, of patients with a DBI > 0 (n = 66), 36.4% had their DBI score decrease, and 6.1% had a score increase. Conclusion: This study demonstrated that integration of the DBI Calculator© into HMR is a feasible and useful method to prompt deprescribing of anticholinergic and sedative medications in older adults. There is potential for the accuracy of the web-based platform to be improved. Registration of trial: Name: Feasibility study of the Drug Burden Index with Home Medicines Review. Website: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368523 Trial ID: ACTRN 12615000539538.
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Affiliation(s)
- Lisa Kouladjian O'Donnell
- Departments of Clinical Pharmacology and Aged Care, Level 13 Kolling Building, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065, Australia
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and Health and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Timothy F Chen
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Sarah N Hilmer
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Sydney, NSW, Australia NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Sydney Medical School University of Sydney, NSW, Australia
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Santos NSD, Marengo LL, Moraes FDS, Barberato Filho S. Interventions to reduce the prescription of inappropriate medicines in older patients. Rev Saude Publica 2019; 53:7. [PMID: 30726488 PMCID: PMC6390643 DOI: 10.11606/s1518-8787.2019053000781] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/06/2018] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE: Identify and critically evaluate systematic reviews addressing the effectiveness of interventions to reduce the number of prescriptions of potentially inappropriate medication to older patients. METHODS: This is an overview of systematic reviews. The studies were searched and selected from Medline, Cochrane Library, Embase, CINAHL, Virtual Health Library, and Web of Science databases, combining the terms aged, prescriptions, inappropriate prescribing and potentially inappropriate medication list with their entry terms and other related descriptors, published by June 2017. This study included systematic reviews with or without meta-analysis that addressed the effectiveness of any intervention or combined interventions to reduce the number of prescriptions of potentially inappropriate medications to older patients, without restriction in terms of design, language or date of publication of primary studies. AMSTAR – A MeaSurement Tool to Assess systematic Reviews – was used to evaluate the methodological quality of selected systematic reviews. Study selection and the methodological quality evaluation were performed by two independent evaluators, who resolved any divergence by consensus. The main findings were grouped into thematic categories, defined after a content analysis and discussed qualitatively as narrative synthesis. RESULTS: This study analyzed 24 systematic reviews. In terms of study design and methodological quality evaluation, most were systematic reviews of randomized controlled clinical trials and studies of moderate quality, respectively. The interventions were analyzed in five thematic categories: medication review services, pharmaceutical interventions, computerized systems, educational interventions, and others. The interventions analyzed showed good results and most of them helped reduce the number of prescriptions of potentially inappropriate medication to older patients. CONCLUSIONS: The systematic reviews included in this overview showed potential benefits of different interventions. However, it was not possible to determine the most effective intervention. Combined interventions are likely to provide better results than isolated interventions.
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Affiliation(s)
| | - Lívia Luize Marengo
- Universidade de Sorocaba. Programa de Pós-Graduação em Ciências Farmacêuticas. Sorocaba, SP, Brasil
| | - Fabio da Silva Moraes
- Universidade de Sorocaba. Programa de Pós-Graduação em Ciências Farmacêuticas. Sorocaba, SP, Brasil
| | - Silvio Barberato Filho
- Universidade de Sorocaba. Programa de Pós-Graduação em Ciências Farmacêuticas. Sorocaba, SP, Brasil
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Cole CP, Routledge P. An evaluation of rational prescribing in hospital outpatient practice in Sierra Leone and assessment of affordability of a prescription as an outcome. Pan Afr Med J 2018; 31:174. [PMID: 31086626 PMCID: PMC6488262 DOI: 10.11604/pamj.2018.31.174.16729] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 10/16/2018] [Indexed: 11/23/2022] Open
Abstract
Introduction Medicines are the most frequently used intervention in healthcare. Rational and cost-effective prescribing is especially important in countries where access to effective medicines may be challenged by affordability issues. This study describes the prescribing patterns of doctors in government hospitals in Freetown, Sierra Leone, considering the scope for rationalising prescribing and reducing cost to the patient. Methods A descriptive, retrospective, cross-sectional study was conducted at four hospitals, using selected World Health Organisation (WHO) indicators applied to 600 prescriptions, after systematic random sampling. The data was analysed using SPSS.16 and the Index of Rational Drug Prescrib-ing (IRDP) calculated. The Spearman's rank coefficient was used to examine possible associations between the number of medicines prescribed as generics and from the National Essential Medicines List (NEML) and cost of the prescription respectively. Affordability was determined from the average number of days of work required to purchase a prescription, based on the minimum wage of the lowest paid government worker in Sierra Leone. Results The mean number of medicines per prescription from the four hospitals was 4.37(range 4.18-4.56) with 57% prescribed generically and 64% from the NEML. An antibiotic and injection were found on 72% and 26% of prescriptions respectively. The overall IRDP was 2.65/5. The aver-age cost per prescription was Le. 29,376.30 ($6.78), equivalent to 43 days of work of the lowest paid government worker. Conclusion In this study, opportunities were identified for significant rationalisation and improvement in cost-effective prescribing.
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Affiliation(s)
- Christine Princess Cole
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmaceutical Sciences, College of Medicine and Allied Health Sciences, University of Sierra Leone, Sierra Leone
| | - Philip Routledge
- Pharmacology, Therapeutics & Toxicology, School of Medicine, Cardiff University, Wales, United Kingdom.,All Wales Therapeutics and Toxicology Centre, University Hospital Llandough, Penarth, Wales, United Kingdom
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Pan Y, Nicolazzo JA. Impact of aging, Alzheimer's disease and Parkinson's disease on the blood-brain barrier transport of therapeutics. Adv Drug Deliv Rev 2018; 135:62-74. [PMID: 29665383 DOI: 10.1016/j.addr.2018.04.009] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 01/17/2018] [Accepted: 04/07/2018] [Indexed: 01/01/2023]
Abstract
Older people are at a greater risk of medicine-induced toxicity resulting from either increased drug sensitivity or age-related pharmacokinetic changes. The scenario is further complicated with the two most prevalent age-related neurodegenerative diseases, Alzheimer's disease (AD) and Parkinson's disease (PD). With aging, AD and PD, there is growing evidence of altered structure and function of the blood-brain barrier (BBB), including modifications to tight junctions and efflux transporters, such as P-glycoprotein. The subsequent impact on CNS drug exposure and risk of neurotoxicity from systemically-acting medicines is less well characterized. The purpose of this review, therefore, is to provide an overview of the multiple changes that occur to the BBB as a result of aging, AD and PD, and the impact that such changes have on CNS exposure of drugs, based on studies conducted in aged rodents or rodent models of disease, and in elderly people with and without AD or PD.
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Affiliation(s)
- Yijun Pan
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, 399 Royal Parade, Parkville, Victoria 3052, Australia
| | - Joseph A Nicolazzo
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, 399 Royal Parade, Parkville, Victoria 3052, Australia.
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Samaranayaka S, Walker RJ, Samaranayaka A, Derrett S, Schollum JWB. Medication Exposure and Health Outcomes in Older Patients with End-Stage Kidney Disease: A Prospective Study Undertaken in New Zealand. Drugs Aging 2018; 35:1005-1015. [PMID: 30194650 DOI: 10.1007/s40266-018-0582-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND The impact of multiple medication exposure on health outcomes among older patients with end-stage kidney disease (ESKD) is unknown. OBJECTIVE The objective of this study was to identify the impact of medicine exposure on hospitalisation rates and mortality in a prospective longitudinal observational study of older dialysis patients. METHODS Patient demographics, medication use, hospitalisation, mortality and co-morbidity data were collected through the prospective longitudinal cohort study DOS65 + (Dialysis Outcomes in those aged ≥ 65 years Study) (n = 225). Medication exposure was measured by the total number of individual medications and the number of predetermined 'medication groups'. Associations between medications prescribed at recruitment and health outcomes as measured by hospitalisation and mortality were assessed by univariate and multivariable regression analyses. RESULTS Older ESKD patients were exposed to a median of ten (0-20) medications and eight (0-15) medication groups. Multivariate analyses estimate each additional medication increased mortality risk by 8% (relative risk [RR] = 1.08; 95% confidence interval [CI] 1.07-1.09); each medication group increased mortality risk by 11% (RR = 1.11; 95% CI 1.09-1.12). Similar trends were observed for hospitalisation. Certain medication groups were associated with reduced hospitalisation rates, namely angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (RR = 0.62; 95% CI 0.53-0.72) and dihydropyridines (RR = 0.64; 95% CI 0.54-0.76). Warfarin, gastric acid suppressants, diuretics and β-blockers were associated with increased hospitalisation rates. Warfarin was associated with an increased mortality rate (RR = 1.40; 95% CI 1.19-1.65). CONCLUSIONS Multiple medication exposure was prevalent in this older ESKD population, and was associated with an increased risk of mortality and hospitalisation. While this study is not able to determine the cause of these relationships, review of medication use is warranted in this population. TRIAL REGISTRATION ACTRN12611000024943.
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Affiliation(s)
- Sashika Samaranayaka
- Department of Medicine, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Robert J Walker
- Department of Medicine, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, New Zealand.
| | - Ari Samaranayaka
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Sarah Derrett
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - John W B Schollum
- Department of Medicine, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, New Zealand
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Rankin A, Cadogan CA, Patterson SM, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2018; 9:CD008165. [PMID: 30175841 PMCID: PMC6513645 DOI: 10.1002/14651858.cd008165.pub4] [Citation(s) in RCA: 196] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing. This is the second update of this Cochrane Review. OBJECTIVES To determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 7 February 2018, together with handsearching of reference lists to identify additional studies. SELECTION CRITERIA We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older, prescribed polypharmacy (four or more medicines), which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people). DATA COLLECTION AND ANALYSIS Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS We identified 32 studies, 20 from this update. Included studies consisted of 18 randomised trials, 10 cluster randomised trials (one of which was a stepped-wedge design), two non-randomised trials and two controlled before-after studies. One intervention consisted of computerised decision support (CDS); and 31 were complex, multi-faceted pharmaceutical-care based approaches (i.e. the responsible provision of medicines to improve patient's outcomes), one of which incorporated a CDS component as part of their multi-faceted intervention. Interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists and geriatricians, and all were conducted in high-income countries. Assessments using the Cochrane 'Risk of bias' tool, found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low.It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool), mean difference (MD) -4.76, 95% CI -9.20 to -0.33; 5 studies, N = 517; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs), (standardised mean difference (SMD) -0.22, 95% CI -0.38 to -0.05; 7 studies; N = 1832; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIMs, (risk ratio (RR) 0.79, 95% CI 0.61 to 1.02; 11 studies; N = 3079; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.81, 95% CI -0.98 to -0.64; 2 studies; N = 569; low-certainty evidence), however it must be noted that this effect estimate is based on only two studies, which had serious limitations in terms of risk bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPOs (RR 0.40, 95% CI 0.18 to 0.85; 5 studies; N = 1310; very low-certainty evidence). Pharmaceutical care may make little or no difference in hospital admissions (data not pooled; 12 studies; N = 4052; low-certainty evidence). Pharmaceutical care may make little or no difference in quality of life (data not pooled; 12 studies; N = 3211; low-certainty evidence). Medication-related problems were reported in eight studies (N = 10,087) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies. AUTHORS' CONCLUSIONS It is unclear whether interventions to improve appropriate polypharmacy, such as reviews of patients' prescriptions, resulted in clinically significant improvement; however, they may be slightly beneficial in terms of reducing potential prescribing omissions (PPOs); but this effect estimate is based on only two studies, which had serious limitations in terms of risk bias.
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Affiliation(s)
- Audrey Rankin
- Queen's University BelfastSchool of Pharmacy97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
| | - Cathal A Cadogan
- Royal College of Surgeons in IrelandSchool of PharmacyDublinIreland
| | - Susan M Patterson
- No affiliationIntegrated Care40 Dunmore RoadBallynahinchNorthern IrelandUKBT24 8PR
| | - Ngaire Kerse
- University of AucklandDepartment of General Practice and Primary Health CarePrivate Bag 92019AucklandNew Zealand
| | - Chris R Cardwell
- Queen's University BelfastCentre for Public HealthSchool of MedicineDentistry and Biomedical SciencesBelfastNorthern IrelandUKBT12 6BJ
| | - Marie C Bradley
- National Cancer Institute9609 Medical Center DriveRockvilleMDUSA20850
| | - Cristin Ryan
- Trinity College DublinSchool of Pharmacy and Pharmaceutical Sciences111 St Stephen’s GreenDublin 2Ireland
| | - Carmel Hughes
- Queen's University BelfastSchool of Pharmacy97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
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Rose O, Richling I, Voigt K, Gottschall M, Köberlein-Neu J. Patient selection and general practitioners' perception of collaboration in medication review. Res Social Adm Pharm 2018; 15:521-527. [PMID: 30139537 DOI: 10.1016/j.sapharm.2018.06.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 06/19/2018] [Accepted: 06/28/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Implementation of collaborative Medication Review (MR) into routine care faces several barriers. OBJECTIVE The study aim was to gain information on patient selection for a MR by general practitioners (GPs). GP selection was compared to objective selection criteria on identifying patients, who would benefit from a MR the most. A secondary objective of this study was to get insight into GPs perception on interprofessional collaboration with pharmacists. METHODS GPs were interviewed for a qualitative study on expected outcomes of MR in former study patients. They were asked to select patients, for whom they expected a major benefit from the MR. Results were compared to objective selection criteria, obtained from the WestGem study. Further interviews were done on aspects of patient selection and perception of interprofessional collaboration, results were presented descriptively. RESULTS The study covered 6 GPs with 78 former study patients. GPs would have chosen 45 out of the 78 patients (57.7%) for a MR. According to changes in the Medication Appropriateness Index, 24 of these patients had a greater benefit from the MR. Patient selection by the number of prescribed drugs had reached a higher specificity at a cut-off of 9 drugs, compared to selection by the GP (67% vs. 61.5%). GPs mentioned medication safety, certain diseases, polymedication, multimorbidity as selection criteria. Increasing quality of therapy and better insight into the patient's drug regimen was appreciated by the GPs as perceived personal advantage of the MR. GPs preferred to have a MR initiated by themselves, but appraised concise interprofessional collaboration with pharmacists. CONCLUSIONS Patient selection for MR should take objective parameters into account and combine them with subjective impressions. GPs preferred the initiation of a MR by themselves but expressed a positive attitude towards collaboration with a pharmacist afterwards. Recommendations should be relevant and concise.
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Affiliation(s)
- Olaf Rose
- College of Pharmacy, Department of Pharmacotherapy & Translational Research, College of Pharmacy, University of Florida, USA.
| | - Ina Richling
- College of Pharmacy, Department of Pharmacotherapy & Translational Research, College of Pharmacy, University of Florida, USA
| | - Karen Voigt
- Department of General Practice/Medical Clinic III, Medical School, Technische Universität Dresden, Dresden, Germany
| | - Mandy Gottschall
- Department of General Practice/Medical Clinic III, Medical School, Technische Universität Dresden, Dresden, Germany
| | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, Germany
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Cardwell K, Clyne B, Moriarty F, Wallace E, Fahey T, Boland F, McCullagh L, Clarke S, Finnigan K, Daly M, Barry M, Smith SM. Supporting prescribing in Irish primary care: protocol for a non-randomised pilot study of a general practice pharmacist (GPP) intervention to optimise prescribing in primary care. Pilot Feasibility Stud 2018; 4:122. [PMID: 30002869 PMCID: PMC6034254 DOI: 10.1186/s40814-018-0311-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/19/2018] [Indexed: 11/10/2022] Open
Abstract
Background Prescribing for patients taking multiple medicines (i.e. polypharmacy) is challenging for general practitioners (GPs). Limited evidence suggests that the integration of pharmacists into the general practice team could improve the management of these patients. The aim of this study is to develop and test an intervention involving pharmacists, working within GP practices, to optimise prescribing in Ireland, which has a mixed public and private primary healthcare system. Methods This non-randomised pilot study will use a mixed-methods approach. Four general practices will be purposively sampled and recruited. A pharmacist will join the practice team for 6 months. They will participate in the management of repeat prescribing and undertake medication reviews (which will address high-risk prescribing and potentially inappropriate prescribing, deprescribing and cost-effective and generic prescribing) with adult patients. Pharmacists will also provide prescribing advice regarding the use of preferred drugs, undertake clinical audits, join practice team meetings and facilitate practice-based education. Throughout the 6-month intervention period, anonymised practice-level medication (e.g. medication changes) and cost data will be collected. A nested Patient Reported Outcome Measure (PROM) study will be undertaken during months 4 and 5 of the 6-month intervention period to explore the impact of the intervention in older adults (aged ≥ 65 years). For this, a sub-set of 50 patients aged ≥ 65 years with significant polypharmacy (≥ 10 repeat medicines) will be recruited from each practice and invited to a medication review with the pharmacist. PROMs and healthcare utilisation data will be collected using patient questionnaires, and a 6-week follow-up review conducted. Acceptability of the intervention will be explored using pre- and post-intervention semi-structured interviews with key stakeholders. Quantitative and qualitative data analysis will be undertaken and an economic evaluation conducted. Discussion This non-randomised pilot study will provide evidence regarding the feasibility and potential effectiveness of general practice-based pharmacists in Ireland and provide data on whether a randomised controlled trial of this intervention is indicated. It will also provide a deeper understanding as to how a pharmacist working as part of the general practice team will affect organisational processes and professional relationships in a mixed public and private primary healthcare system.
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Affiliation(s)
- Karen Cardwell
- 1Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - B Clyne
- 1Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - F Moriarty
- 1Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - E Wallace
- 1Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - T Fahey
- 1Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - F Boland
- 1Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - L McCullagh
- 2Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland
| | - S Clarke
- 3Health Service Executive Medicines Management Programme, Dublin, Ireland
| | - K Finnigan
- 3Health Service Executive Medicines Management Programme, Dublin, Ireland
| | - M Daly
- 3Health Service Executive Medicines Management Programme, Dublin, Ireland
| | - M Barry
- 2Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland.,3Health Service Executive Medicines Management Programme, Dublin, Ireland
| | - S M Smith
- 1Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
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Resnick B, Galik E, Boltz M, Holmes S, Fix S, Vigne E, Zhu S, Lewis R. Polypharmacy in Assisted Living and Impact on Clinical Outcomes. THE CONSULTANT PHARMACIST : THE JOURNAL OF THE AMERICAN SOCIETY OF CONSULTANT PHARMACISTS 2018; 33:321-330. [PMID: 29880094 PMCID: PMC6311411 DOI: 10.4140/tcp.n.2018.321] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The purpose of this study was to describe medication use and polypharmacy in assisted living settings. We hypothesized that: 1) age, gender, race, setting, multi-morbidity, and cognitive status would influence polypharmacy; and 2) polypharmacy would be associated with falls, emergency room visits, and hospitalizations. DESIGN This was a descriptive study using data from a larger study testing the Dissemination and Implementation of Function Focused Care for Assisted Living (FFC-AL-EIT). SETTING Participants were recruited from 26 assisted living settings. PARTICIPANTS A total of 242 individuals for cohort 1 consented and completed baseline data collection. INTERVENTIONS Data were obtained from participant medical records, observations, and input from staff. MAIN OUTCOME MEASURE(S) Age, gender, race, ethnicity, comorbidities, cognitive status, medications, falls, emergency room visits, hospitalizations, function based on the Barthel Index and physical activity using the MotionWatch 8. RESULTS Participants had a mean age of 86.86 (standard deviation [SD] = 7.0), the majority were women (n = 179, 74%) and white (n = 233, 96%), with five (SD = 2) diagnoses. The mean number of drugs was seven (SD = 3.56), and 51% were exposed to polypharmacy. The mean Barthel Index score was 63.06 (SD = 20.20), and they engaged in 111,353 (SD = 87,262) counts of activity daily. Fifty-eight residents fell at least once (24%), 22 were sent to the hospital (9%), and 32 (13%) to the emergency room. Neither hypothesis was supported. CONCLUSION Continued research is needed to explore the factors that influence polypharmacy. Identification of these factors will help guide deprescribing so that medication management does not harm older adults physically or cause unnecessary financial burden.
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Affiliation(s)
- Barbara Resnick
- University of Maryland School of Nursing, Baltimore, Maryland, USA
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Tegegn HG, Tefera YG, Erku DA, Haile KT, Abebe TB, Chekol F, Azanaw Y, Ayele AA. Older patients' perception of deprescribing in resource-limited settings: a cross-sectional study in an Ethiopia university hospital. BMJ Open 2018; 8:e020590. [PMID: 29678983 PMCID: PMC5914769 DOI: 10.1136/bmjopen-2017-020590] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To assess older patients' attitude towards deprescribing of inappropriate medications. DESIGN This was an institutional-based, quantitative, cross-sectional survey. SETTING Outpatient clinics of the University of Gondar Referral and Teaching Hospital in Ethiopia. PARTICIPANTS Patients aged 65 or older with at least one medication were enrolled in the study from 1 March to 30 June 2017. Excluded patients were those who had severe physical or psychological problems and who refused to participate. MAIN OUTCOME MEASURES Older patients' attitude towards deprescribing was measured using a validated instrument, 'the revised Patients' Attitudes towards Deprescribing' (rPATD) tool for older patients. Data were collected on sociodemographic characteristics and clinical data such as comorbidity and polypharmacy, and the main outcome was older patients' willingness to deprescribe inappropriate medications. RESULTS Of the 351 eligible participants, 316 patients completed the survey. Of the 316 patients, 54.7% were men and were taking a median of 3 (IQR: 2-4) medications daily. Overall, most of the participants (92.1%; 95% CI 89% to 95%) were satisfied with the medications they were taking; however, still a significant number of participants (81.6%; 95% CI 77% to 86%) were willing to stop one or more of their medications if possible and agreed by their doctors. This willingness was correlated with seven items of the rPATD, including a strong correlation with the overall satisfaction of patients with the medications taken. CONCLUSION Many older patients have shown their willingness to reduce one or more of their medications if their doctors said it was possible. Healthcare providers should be proactive in discussing and evaluating potentially inappropriate medications for better clinical decision making.
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Affiliation(s)
| | | | - Daniel Asfaw Erku
- Department of Clinical Pharmacy, University of Gondar, Gondar, Ethiopia
| | - Kaleab Taye Haile
- Department of Pharmaceutics and Social Pharmacy, University of Gondar, Gondar, Ethiopia
| | - Tamrat Befekadu Abebe
- Department of Clinical Pharmacy, University of Gondar, Gondar, Ethiopia
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institute, Solna, Sweden
| | - Fasil Chekol
- Department of Clinical Pharmacy, University of Gondar, Gondar, Ethiopia
| | - Yonas Azanaw
- Department of Clinical Pharmacy, University of Gondar, Gondar, Ethiopia
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Van der Linden L, Hias J, Walgraeve K, Flamaing J, Spriet I, Tournoy J. Clinical Pharmacy Services on Geriatric Care Wards: Catch 22 of Implementation and Research. Drugs Aging 2018; 35:375-377. [PMID: 29671214 DOI: 10.1007/s40266-018-0547-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium. .,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Louvain, Belgium.
| | - Julie Hias
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium
| | - Karolien Walgraeve
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Louvain, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Louvain, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Louvain, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Louvain, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Louvain, Belgium
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Abstract
Background: HIV-positive individuals (HIV+) on antiretrovirals commonly take enough other medications to cross a threshold for polypharmacy but little is known about associated outcomes. We asked whether non-antiretroviral polypharmacy is associated with hospitalization and mortality and whether associations differ by HIV status. Methods: Data on HIV+ and uninfected individuals in the US Veterans Affairs Healthcare System were analyzed. Eligible HIV+ were on antiretrovirals with suppressed HIV-1 RNA and uninfected individuals received at least one medication. We calculated average non-antiretroviral medication count for fiscal year 2009. As there is no established threshold for non-antiretroviral polypharmacy, we considered more than two and at least five medications. We followed for hospitalization and mortality (fiscal year 2010–2015), adjusting for age, sex, race/ethnicity and VACS Index. Results: Among 9473 HIV+ and 39 812 uninfected individuals respectively, non-antiretroviral polypharmacy was common (>2: 67, 71%; ≥5: 34, 39%). VACS Index discriminated risk of hospitalization (c-statistic: 0.62, 0.60) and mortality (c-statistic: 0.72, 0.70) similarly in both groups. After adjustment, more than two (hazard ratio 1.51, 95% CI 1.46–1.55) and at least five non-antiretrovirals (hazard ratio 1.52, 95% CI 1.49–1.56) were associated with hospitalization with no interaction by HIV status. Risk of mortality associated with more than two non-antiretrovirals interacted with HIV status (P = 0.002), but not for at least five (adjusted hazard ratio 1.43, 95% CI 1.36–1.50). For both groups and both outcomes, average medication count demonstrated an independent, dose response, association. Conclusion: Neither severity of illness nor demographics explain a dose response, association of non-antiretroviral polypharmacy with adverse health outcomes among HIV+ and uninfected individuals.
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Battistella M, Jandoc R, Ng JY, McArthur E, Garg AX. A Province-wide, Cross-sectional Study of Demographics and Medication Use of Patients in Hemodialysis Units Across Ontario. Can J Kidney Health Dis 2018; 5:2054358118760832. [PMID: 29568537 PMCID: PMC5858734 DOI: 10.1177/2054358118760832] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/12/2017] [Indexed: 01/05/2023] Open
Abstract
Background: Hemodialysis patients are at an increased risk of polypharmacy as they have the highest
pill burden of all chronically ill patient populations, with an estimated average of 12
medications per day. Objectives: The aim of this study was to evaluate prescribing patterns of outpatient medications in
patients receiving in-center hemodialysis. This was done to identify potential candidate
medications for future quality improvement initiations to optimize prescribing. Design: We conducted a descriptive retrospective cross-sectional study in the province of
Ontario, Canada, using several linked health care databases housed at the Institute for
Clinical Evaluative Sciences (ICES). Setting: We considered outpatient medications dispensed to patients eligible for the Ontario
Drug Benefit program. Patients: Patients were receiving chronic in-center hemodialysis at one of the 69 facilities in
the province of Ontario, Canada as of October 1, 2013. Measurements: We assessed whether any of our 28 study medications of interest were recently dispensed
(within the prior 120 days), the type of prescribing physician, and the associated
medication costs. The 28 included medications of interest (ie, proton pump inhibitors,
benzodiazepines) were selected because they may not have a true indication for dialysis
patients and/or there are safety concerns with their use in this population. Results are
presented as median (25th, 75th percentile). Methods: We conducted this study at ICES according to a prespecified protocol approved by the
Research Ethics Board at Sunnybrook Health Sciences Centre (Toronto, Ontario). Results: A total of 3094 patients on chronic in-center hemodialysis received a study drug of
interest (age: 76.5 years [SD: 7.3]), 44% women). Patients were dispensed 11 (8, 14)
unique medication products with more than two-thirds of patients dispensed 9 or more
different medications. The median number of annual health care visits was 7 (3-15) with
more than half the cohort receiving prescriptions from 3 or more specialists. The 10
most commonly dispensed study medications cost more than 3 million dollars in direct
costs in 1 year. Limitations: Our study was also subjected to some limitations of health care databases. Conclusions: Polypharmacy is frequent in in-center hemodialysis patients. To decrease polypharmacy
and its associated negative outcomes, health care providers need to implement tools to
optimize medication use and deprescribe medications that lack evidence for efficacy and
safety in hemodialysis patients. Therefore, strategies to improve prescribing and
discontinue ineffective medications warrant testing for better patient outcomes and
reduced health care costs.
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Affiliation(s)
- Marisa Battistella
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada.,Faculty of Pharmacy, University of Toronto, Ontario, Canada
| | - Racquel Jandoc
- Institute for Clinical Evaluative Sciences, London, Ontario, Canada
| | - Jeremy Y Ng
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada.,Faculty of Pharmacy, University of Toronto, Ontario, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, London, Ontario, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Department of Medicine, Western University, London, Ontario, Canada
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Holden RJ, Srinivas P, Campbell NL, Clark DO, Bodke KS, Hong Y, Boustani MA, Ferguson D, Callahan CM. Understanding older adults' medication decision making and behavior: A study on over-the-counter (OTC) anticholinergic medications. Res Social Adm Pharm 2018; 15:53-60. [PMID: 29559218 DOI: 10.1016/j.sapharm.2018.03.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/29/2018] [Accepted: 03/05/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Older adults purchase and use over-the-counter (OTC) medications with potentially significant adverse effects. Some OTC medications, such as those with anticholinergic effects, are relatively contraindicated for use by older adults due to evidence of impaired cognition and other adverse effects. OBJECTIVE To inform the design of future OTC medication safety interventions for older adults, this study investigated consumers' decision making and behavior related to OTC medication purchasing and use, with a focus on OTC anticholinergic medications. METHODS The study had a cross-sectional design with multiple methods. A total of 84 adults participated in qualitative research interviews (n = 24), in-store shopper observations (n = 39), and laboratory-based simulated OTC shopping tasks (n = 21). Simulated shopping participants also rank-ordered eight factors on their importance for OTC decision making. RESULTS Findings revealed that many participants had concerns about medication adverse effects, generally, but were not aware of age-related risk associated with the use of anticholinergic medications. Analyses produced a map of the workflow of OTC-related behavior and decision making as well as related barriers such as difficulty locating medications or comparing them to an alternative. Participants reported effectiveness, adverse effects or health risks, and price as most important to their OTC medication purchase and use decisions. A persona analysis identified two types of consumers: the habit follower, who frequently purchased OTC medications and considered them safe; and the deliberator, who was more likely to weigh their options and consider alternatives to OTC medications. CONCLUSION A conceptual model of OTC medication purchase and use is presented. Drawing on study findings and behavioral theories, the model depicts dual processes for OTC medication decision making - habit-based and deliberation-based - as well as the antecedents and consequences of decision making. This model suggests several design directions for consumer-oriented interventions to promote OTC medication safety.
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Affiliation(s)
- Richard J Holden
- Department of BioHealth Informatics, Indiana University School of Informatics and Computing - Indianapolis, IN, USA; Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA.
| | - Preethi Srinivas
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA
| | - Noll L Campbell
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Purdue University College of Pharmacy - Lafayette, IN, USA
| | - Daniel O Clark
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Indiana University School of Medicine - Indianapolis, IN, USA
| | - Kunal S Bodke
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA
| | - Youngbok Hong
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Indiana University Herron School of Art and Design - Indianapolis, IN, USA
| | - Malaz A Boustani
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Indiana University School of Medicine - Indianapolis, IN, USA; Indiana University Center for Health Innovation and Implementation Science, Indiana CTSI - Indianapolis, IN, USA
| | - Denisha Ferguson
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA
| | - Christopher M Callahan
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Indiana University School of Medicine - Indianapolis, IN, USA
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Tangiisuran B, Tye SC, Leow MY, Awang R. Comparison of nurses and general caregivers' knowledge, attitude, and practice on medication administration process and their distress level in long-term care facilities across Penang, Kuala Lumpur, and Selangor of Malaysia. Aging Clin Exp Res 2018; 30:183-191. [PMID: 28527134 DOI: 10.1007/s40520-017-0772-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 05/05/2017] [Indexed: 02/06/2023]
Abstract
AIM Comparing nurses and general caregivers' knowledge, attitude, and practices (KAP) on medication administration process in long-term care (LTC) setting and an assessment of their stress, anxiety, and depression (SAD) level. METHODS A cross-sectional survey was conducted among nurses and general caregivers working in LTC using a validated questionnaire. Consisting of demographic characteristics (Section 1); 40 questions on KAP (Section 2); and assessment of Depression, Anxiety, and Stress Scale (DASS-21) (Section 3). RESULTS 155 formally paid staffs in 26 LTC facilities were recruited. Nurses scored significantly higher in the knowledge section compared to caregivers (12.4 ± 1.7 vs. 4.5 ± 3.8; P < 0.001); better attitude (41.5 ± 4.8 vs. 30.8 ± 7.3; P < 0.001); and better practice (65.2 ± 8.5 vs. 40.3 ± 10.9; P < 0.001), respectively. SAD scores reveal that caregivers had significantly higher level of stress, anxiety, and depression compared to the nurses. DISCUSSION General caregivers exhibit poorer knowledge on aspects pertaining to posology, appropriate methods of drug administration, and side effects of common drugs used by the elderly. Compared to nurses, the general caregivers also reported poorer medication administration practices; including not checking labels and expiry dates prior to administration, and not providing basic information about medication therapy to the residents. However, both nurses and general caregivers reported positive attitudes in their role as caregivers. They take pride and satisfaction in their occupation providing support to the elderly. CONCLUSION General caregivers demonstrated lesser knowledge, poorer attitude, and practices towards medication administration processes, in addition to higher SAD score in LTC facilities.
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Affiliation(s)
- Balamurugan Tangiisuran
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Penang, Malaysia.
| | - Sok Cin Tye
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Penang, Malaysia
| | - May Yen Leow
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Penang, Malaysia
| | - Rahmat Awang
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia, 11800, Penang, Malaysia
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Lang PO, Bourgue C, Csajka C. Détection des prescriptions inappropriées, les critères STOPP/START. ACTUALITES PHARMACEUTIQUES 2018. [DOI: 10.1016/j.actpha.2017.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lechner A, Lahmann N, Neumann K, Blume-Peytavi U, Kottner J. Dry skin and pressure ulcer risk: A multi-center cross-sectional prevalence study in German hospitals and nursing homes. Int J Nurs Stud 2017; 73:63-69. [DOI: 10.1016/j.ijnurstu.2017.05.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/15/2017] [Accepted: 05/16/2017] [Indexed: 12/23/2022]
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Lutz BH, Miranda VIA, Bertoldi AD. Potentially inappropriate medications among older adults in Pelotas, Southern Brazil. Rev Saude Publica 2017; 51:52. [PMID: 28658367 PMCID: PMC5493363 DOI: 10.1590/s1518-8787.2017051006556] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 02/21/2016] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To assess the use of potentially inappropriate medications among older adults. METHODS This is a population-based cross-sectional study with 1,451 older individuals aged 60 years or more in the city of Pelotas, State of Rio Grande do Sul, Brazil, in 2014. We have investigated the use of medications in the last 15 days. Using the Beers criteria (2012), we have verified the use of potentially inappropriate medications and their relationship with socioeconomic and demographic variables, polypharmacy, self-medication, and burden of disease. RESULTS Among the 5,700 medications used, 5,651 could be assessed as to being inappropriate. Of these, 937 were potentially inappropriate for the older adults according to the 2012 Beers criteria (16.6%). Approximately 42.4% of the older adults studied used at least one medication considered as potentially inappropriate. The group of medications for the nervous system accounted for 48.9% of the total of the potentially inappropriate medications. In the adjusted analysis, the variables female, advanced age, white race, low educational level, polypharmacy, self-medication, and burden of disease were associated with the use of potentially inappropriate medications. CONCLUSIONS It is important to known the possible consequences of the use of medication among older adults. Special attention should be given to the older adults who use polypharmacy. Specific lists should be created with more appropriate medications for the older population in the National Essential Medicine List. OBJETIVO Avaliar o uso de medicamentos potencialmente inadequados entre idosos. MÉTODOS Estudo transversal de base populacional com 1.451 idosos com 60 anos ou mais em Pelotas, RS, em 2014. Investigou-se o uso de medicamentos nos últimos 15 dias. Utilizando os critérios de Beers (2012), verificou-se a potencial inadequação dos medicamentos e sua relação com variáveis socioeconômicas e demográficas, polifarmácia, automedicação e carga de doença. RESULTADOS Dentre os 5.700 medicamentos utilizados, 5.651 puderam ser avaliados quanto à inadequação. Destes, 937 eram potencialmente inadequados para idosos segundo os critérios de Beers de 2012 (16,6%). Cerca de 42,4% dos idosos usaram no mínimo um medicamento considerado potencialmente inapropriado. O grupo de medicamentos para o sistema nervoso correspondeu a 48,9% do total de medicamentos potencialmente inadequados. Na análise ajustada, as variáveis sexo feminino, idade avançada, cor da pele branca, baixa escolaridade, polifarmácia, automedicação e carga de doença mostraram-se associadas ao uso de medicamentos potencialmente inadequados. CONCLUSÕES É importante que sejam bem conhecidas as possíveis consequências do uso de medicamentos entre idosos. Atenção especial deve ser dada aos idosos que fazem uso de polifarmácia. É necessário existir listas específicas com medicamentos mais adequados para uso em idosos na Relação Nacional de Medicamentos Essenciais.
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Affiliation(s)
- Bárbara Heather Lutz
- Programa de Pós-Graduação em Epidemiologia. Universidade Federal de Pelotas. Pelotas, RS, Brasil.,Departamento de Medicina Social. Faculdade de Medicina. Universidade Federal de Pelotas. Pelotas, RS, Brasil
| | | | - Andréa Dâmaso Bertoldi
- Programa de Pós-Graduação em Epidemiologia. Universidade Federal de Pelotas. Pelotas, RS, Brasil.,Departamento de Medicina Social. Faculdade de Medicina. Universidade Federal de Pelotas. Pelotas, RS, Brasil
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Moga DC, Abner EL, Rigsby DN, Eckmann L, Huffmyer M, Murphy RR, Coy BB, Jicha GA. Optimizing medication appropriateness in older adults: a randomized clinical interventional trial to decrease anticholinergic burden. Alzheimers Res Ther 2017; 9:36. [PMID: 28535785 PMCID: PMC5442667 DOI: 10.1186/s13195-017-0263-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 05/04/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND The complexity of medication therapy in older adults with multiple comorbidities often leads to inappropriate prescribing. Drugs with anticholinergic properties are of particular interest because many are not recognized for this property; their use may lead to increased anticholinergic burden resulting in significant health risks, as well as negatively impacting cognition. Medication therapy management (MTM) interventions showed promise in addressing inappropriate medication use, but the effectiveness of targeted multidisciplinary team interventions addressing anticholinergic medications in older populations is yet to be determined. METHODS We conducted an 8-week, parallel-arm, randomized trial to evaluate whether a targeted patient-centered pharmacist-physician team MTM intervention ("targeted MTM intervention") reduced the use of inappropriate anticholinergic medications in older patients enrolled in a longitudinal cohort at University of Kentucky's Alzheimer's Disease Center. Study outcomes included changes in the medication appropriateness index (MAI) targeting anticholinergic medications and in the anticholinergic drug scale (ADS) score from baseline to the end of study. RESULTS Between October 1, 2014 and September 30, 2015 we enrolled and randomized 50 participants taking at least one medication with anticholinergic properties. Of these, 35 (70%) were women, 45 (90%) were white, and 33 (66%) were cognitively intact (clinical dementia rating [CDR] = 0); mean age was 77.7 ± 6.6 years. At baseline, the mean MAI was 12.6 ± 6.3; 25 (50%) of the participants used two or more anticholinergics, and the mean ADS score was 2.8 ± 1.6. After randomization, although no statistically significant difference was noted between groups, we identified a potentially meaningful imbalance as the intervention group had more participants with intact cognition, and thus included CDR in all of the analyses. The targeted MTM intervention resulted in statistically significant CDR adjusted differences between groups with regard to improved MAI (change score of 3.6 (1.1) for the MTM group as compared with 1.0 (0.9) for the control group, p = 0.04) and ADS (change score of 1.0 (0.3) for the MTM group as compared with 0.2 (0.3) for the control group, p = 0.03). CONCLUSIONS Our targeted MTM intervention resulted in improvement in anticholinergic medication appropriateness and reduced the use of inappropriate anticholinergic medications in older patients. Our results show promise in an area of great importance to ensure optimum outcomes for medications used in older adults. TRIAL REGISTRATION ClinicalTrials.gov NCT02172612 . Registered 20 June 2014.
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Affiliation(s)
- Daniela C. Moga
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, 789 S Limestone Street, Room 241, Lexington, KY 40536 USA
- Department of Epidemiology, College of Public Health, University of Kentucky, 111 Washington Avenue, Lexington, KY 40536 USA
- Sanders-Brown Center on Aging, 800 South Limestone Street, Lexington, KY 40536 USA
| | - Erin L. Abner
- Department of Epidemiology, College of Public Health, University of Kentucky, 111 Washington Avenue, Lexington, KY 40536 USA
- Sanders-Brown Center on Aging, 800 South Limestone Street, Lexington, KY 40536 USA
| | - Dorinda N. Rigsby
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, 789 S Limestone Street, Room 241, Lexington, KY 40536 USA
| | - Lynne Eckmann
- PRO2RX LLC Pharmacy Consulting Services, 336 Romany Rd, Lexington, KY 40502 USA
| | - Mark Huffmyer
- PRO2RX LLC Pharmacy Consulting Services, 336 Romany Rd, Lexington, KY 40502 USA
| | - Richard R. Murphy
- Sanders-Brown Center on Aging, 800 South Limestone Street, Lexington, KY 40536 USA
- Department of Neurology, College of Medicine, University of Kentucky, 740 South Limestone Street, Lexington, KY 40536 USA
| | - Beth B. Coy
- Sanders-Brown Center on Aging, 800 South Limestone Street, Lexington, KY 40536 USA
| | - Gregory A. Jicha
- Sanders-Brown Center on Aging, 800 South Limestone Street, Lexington, KY 40536 USA
- Department of Neurology, College of Medicine, University of Kentucky, 740 South Limestone Street, Lexington, KY 40536 USA
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Sirois C, Laroche ML, Guénette L, Kröger E, Cooper D, Émond V. Polypharmacy in multimorbid older adults: protocol for a systematic review. Syst Rev 2017; 6:104. [PMID: 28526062 PMCID: PMC5438541 DOI: 10.1186/s13643-017-0492-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 05/02/2017] [Indexed: 03/20/2023] Open
Abstract
BACKGROUND Polypharmacy, the concurrent use of multiple medications, consistently evokes a negative connotation, notably because it is associated with a plethora of adverse events. Nonetheless, the number of individuals exposed to polypharmacy is increasing steeply, especially for older people with multiple diseases. There is a need to carefully study the phenomenon at the population scale to full assess the associated health outcomes. Yet, this reveals a complex task because there exists no consensus indicator of polypharmacy. In fact, the definitions of polypharmacy are heterogeneous and its predisposing factors and associated outcomes are not well defined. The goal of this systematic review is to summarize the literature on polypharmacy in multimorbid individuals aged 65 years and over, targeting three objectives: (1) to identify the definitions of polypharmacy that are used in the context of multimorbidity among older individuals (≥65 years); (2) to ascertain predisposing and concurrent factors associated with polypharmacy; and (3) to describe positive and negative outcomes of polypharmacy among older individuals, including hospitalizations, mortality and costs. METHODS We will include publications from 2004 to 2016 that target four concepts: polypharmacy, older individuals, multimorbidity and positive/negative outcomes. The search will be performed using EBM Reviews, Embase, Global Health, MEDLINE, AgeLine, CINAHL, Health Policy Reference Center, Public Affairs Index, SocINDEX and Google Scholar. Two independent reviewers will screen the articles, extract the information and evaluate the methodological quality of included studies. The results will be presented in tables and narrative summaries will be performed. We will perform meta-analyses (objective 3) if the heterogeneity is not important. DISCUSSION This review will help describe the various ways of conceptualizing polypharmacy and how it is associated with health outcomes. We have selected outcomes most relevant for public surveillance performed with administrative databases. Other positive and negative outcomes have been associated with polypharmacy but may not be included in the review. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014014989.
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Affiliation(s)
- Caroline Sirois
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Québec, Canada. .,Centre d'excellence sur le vieillissement de Québec, Centre de recherche du CHU de Québec, Québec, Canada. .,Institut national de santé publique du Québec, Québec, Canada. .,Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec, Québec, Canada. .,Centre d'excellence sur le vieillissement de Québec, Hôpital du St-Sacrement, 1050 Chemin Ste-Foy, Local L2-28, Québec, (Qc) G1S 4L8, Canada.
| | - Marie-Laure Laroche
- Service de Pharmacologie, Toxicologie et Pharmacovigilance, Centre Régional de Pharmacovigilance, de Pharmacoépidémiologie et d'information sur les médicaments, Centre Hospitalier Universitaire de Limoges, Limoges, France.,Faculté de Médecine, Université de Limoges, Limoges, France
| | - Line Guénette
- Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec, Québec, Canada.,Faculté de pharmacie, Université Laval, Québec, Canada
| | - Edeltraut Kröger
- Centre d'excellence sur le vieillissement de Québec, Centre de recherche du CHU de Québec, Québec, Canada.,Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec, Québec, Canada.,Faculté de pharmacie, Université Laval, Québec, Canada
| | - Dan Cooper
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Québec, Canada.,Faculté de pharmacie, Université Laval, Québec, Canada
| | - Valérie Émond
- Institut national de santé publique du Québec, Québec, Canada
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